Professor Derek Bell Acute Internal Medicine Imperial College London. President Royal College of Physicians Edinburgh. Flow again laminar or turbulent

Transcription

1 Professor Derek Bell Acute Internal Medicine Imperial College London President Royal College of Physicians Edinburgh Flow again laminar or turbulent October 2104

2 Overview Health care is complex Recognising complexity is a fundamental to getting it right Avoid oversimplification Avoid complication Use local data Context specific Real-time Avoid (stop) using average times for performance or outcome measures.

3 Overview Occupancy data poorly understood and often misrepresented All understand overcrowding and boarding (outliers) Flow and capacity/demand management are not new to health Often poorly applied Better understanding of inter and intra departmental flow 24/7 and 7/7 Elective flow, unplanned and unplanned to planned. Relate to outcomes including experience.

4 St E Action Effect Diagram Outline of shared aim, contributing factors, actions and measures developed through staff dialogue and visit team feedback. Represents cause and effect relationships and intended to support conversations and planning in regards to improvement. Embrace positivity and empower staff to deliver high quality care to patients: improving patient experience and outcomes and working with family and carers * timely, patient centred care, safe, evidencebased, equitable, efficient Health outcomes 2. Patient experience/ quality of life 3. Staff satisfaction 4. Readmissions All services working together to support appropriate admissions and alternative options Efficient, effective and proactive flow within hospital: right care, right place, right time 7 Improve flow out of hospital Positive working environment that supports staff to collaboratively manage flow 3 5. Compliance to 4 hour standard 6. Admission trend data 7. Boarding 8. Discharge trend data (day of week, time of day) 8 6 Availability of acute services in the community Appropriate use of acute services by GPs Healthcare staff knowledge and ownership of appropriate of services Communication channels Protection of direct assessment areas (JAB) and CDU Direct admission policy Utilisation of robust ambulatory care pathways Robust surgical assessment unit CEPOD theatre access Structured ward Rounds with patients prioritisation Consistent twice daily ward rounds (AMU/ASU) - all patients Consistent 8am ward round starts Increase availability of consultant review over 7 days/week Full utilisation of electronic white boards 7 day services Discharge earlier in the day 8 Physio, OT, pharmacy 7 day/ week Imaging 7 day/week Physio & OT start /finish times (e.g. 8am - 7pm) Near-side patient testing Redesign phlebotomy/ blood tests pathway TTA packs available across hospital Discharging of patients in ward by non consultant medical staff Discharge pathways e.g. CDU, JAB (CT KUB protocol, TIA, First seizure, head injury) Early proactive patient centred discharge planning, MDT approach Increase use of EDD/ definite discharges prediction Communicate EDD & discharge plan with patients/ relatives Ward - Discharge Lounge interface/ referral process Social services, nursing homes &continuing care access Collaborative working with primary and social care Visibility of patient flow information Effective Bed meeting with accountability Accountability and Clarity of roles in patient flow Visible hospital management Positive feedback to staff inc. p t & staff data Priority (based on impact & ability to deliver in short time Potential valuable impact but may take longer Reed J, McNicholas C, Woodcock T, Bell D Designing quality improvement initiatives: the action effect method, a structured approach to identifying and articulating programme theory BMJ Qual Saf. 2014

5 Flow (F) = Quantity (Q) gas liquid vapour/time (t) Patients? Particulate flow? Managing flow is essential to high quality care Understanding flow can help diagnose the system and processes

6 A&E attendance and admissions from A&E age-sex profile, 2013 A&E attendance and hospital admissions from A&E, by recorded patient age-group, 2013, n Notes: (i) excludes CWH UCC area; (ii) results are intended for management information only and are subject to change 6,000 5,500 5,000 4,500 4,000 3,500 3,000 A&E attendance 2,500 2,000 1,500 1,000 Admissions from A&E Male A&E attendance Age group Female A&E attendance Male admissions from A&E Female admissions from A&E

7 07/11/ /12/ /01/ /02/ /03/ /04/ /05/ /06/ /07/ /08/ /09/ /10/ /11/ /12/ /01/ /02/ /03/ /04/ /05/ /06/ /07/ /08/ /09/ /10/ /11/ /12/ /01/ /02/ /03/ /04/ /05/ /06/ /07/ /08/ /09/ /10/ /11/ /12/ /01/ /02/ /03/ /04/ /05/ /06/ /07/ /08/ /09/ hr ED LoS compliance, % Average daily attendances for week 100% 99% 98% 97% 96% 95% 94% 93% 92% 91% 90% 89% 88% 87% 86% 85% Hospital X: ED attendances 4 hour access Average daily attendances; weekly 4 hr Emergency Department (ED) time in department compliance, % Sources: WSitAE Unify2-derived publications covering unscheduled activity for ED' sites w/e 7th Nov 2011 and w/e 21st Sept Notes: (i) ED' refers to EDs, MIUs and WICs; (ii) unadjusted, XmR-based process control limits with mr screening. Baseline to w/e 30th Dec 2012 (iii) results are intended for management information only and are subject to change. Baseline period Whole system measure System process control variability % 21/09/ Week ending Baseline (process limits) Operating Standard (95%) Average daily attendances for week C2R

8 07/11/ /12/ /01/ /01/ /02/ /03/ /04/ /05/ /06/ /07/ /08/ /09/ /10/ /11/ /12/ /01/ /01/ /02/ /03/ /04/ /05/ /06/ /07/ /08/ /09/ /10/ /11/ /12/ /12/ /01/ /02/ /03/ /04/ /05/ /06/ /07/ /08/ /09/ /10/ /11/ /12/ /12/ /01/ /02/ /03/ /04/ /05/ /06/ /07/ /08/ /09/ hr ED LoS compliance, % Avg daily ED attendance, n 100% 98% 96% 94% 92% 90% 88% 86% 84% 82% 80% 78% 76% 74% 72% 70% 68% 66% 64% 62% 60% Hospital Y : ED attendances Average daily type-1 ED attendance, n; weekly 4 hr ED LoS compliance (type-1), % Sources: WSitAE Unify2-derived publications covering unscheduled activity for ED' sites w/e 7 Nov 2010 to w/e 14 Sep 2014 Notes: (i) ED' refers to EDs, MIUs and WICs; (ii) **unadjusted, XmR-based process control limits recalculated against Wheeler rules 1,4 and 24-pt baseline; (iii) results are intended for management information only and are subject to change 98.7% 97.8% 95.8% 95.7% % % % % % Avg daily ED attendance (w/e 14 Sep 2014): hr ED LoS compliance (w/e 14 Sep 2014): 71.4% Avg 4 hr ED LoS compliance: 89.1%

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13 Number of patients, volume Transition Transition Schematic of flow characteristics across hospital system ED AMU Downstream Ward Needs related = benefit hours 8 hours 2-3days Duration in system, time 4 days - weeks

14 0:00 0:15 0:30 0:45 1:00 1:15 1:30 1:45 2:00 2:15 2:30 2:45 3:00 3:15 3:30 3:45 4:00 4:15 4:30 4:45 5:00 5:15 5:30 5:45 6:00 6:15 6:30 6:45 7:00 7:15 7:30 7: >12 Unscheduled ED' attendance, n Cumulative unscheduled ED' attendance, % St E: ED' LoS distribution for unscheduled ED' attendances, 14 Apr to 8 Jun 2014 Unscheduled ED' attendance, n; ED' LoS in 15 min bins to 8 hr, 8-12 hr, > 12 hr Notes: (i) ED' includes EDs, MIUs, WICs; (ii) results are intended for management information only and are subject to change 3,500 3,325 3,150 2,975 2,800 2,625 2,450 2,275 2,100 1,925 1,750 1,575 1,400 1,225 1, Processes internal and external to ED Resilience of system 100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% ED' LoS, h:mm (15 min bins to 8 hr, 8-12 hr, > 12 hr) Direct discharge Transfer Hospital admission Total

15 AAU stays, n Cumulative AAU stays, % AAU spell LoS distribution, 17 Feb to 13 Apr 2014* stays for *all patients discharged from hospital 17 Feb to 13 Apr 2014, n; AAU spell LoS in 4 hr bins to 168 hr, 168 hr Notes: (i) AAU spell LoS calculated in minutes and excludes transit areas; (ii) results are intended for management information only and are subject to change % 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% AAU LoS, hr (4 hr bins to 168 hr, 168 hr) Transfer to 'other' ward Hospital discharge from 'AMU'/'SAAU' Total

16 AAU stays, n Cumulative AAU stays, % AAU spell LoS distribution, 14 Apr to 8 Jun 2014* stays for *all patients discharged from hospital 14 Apr to 8 Jun 2014, n; AAU spell LoS in 4 hr bins to 168 hr, 168 hr Notes: (i) AAU spell LoS calculated in minutes and excludes transit areas; (ii) results are intended for management information only and are subject to change % 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% AAU LoS, hr (4 hr bins to 168 hr, 168 hr) Transfer to 'other' ward Hospital discharge from 'AMU'/'SAAU' Total

17 0 hr 8 hr 16 hr 1 d 1 d 8 hr 1 hr 16 hr 2 d 2 d 8 hr 2 d 16 hr 3 d 3 d 8 hr 3 d 16 hr 4 d 4 d 8 hr 4 d 16 hr 5 d 5 d 8 hr 5 d 16 hr 6 d 6 d 8 hr 6 d 16 hr 7-14 d d d 28 d Hospital admissions*, n Cumulative hospital* admissions, % St E: hospital LoS distribution for admitted patients*, 14 Apr to 8 Jun 2014 *Hospital discharges excl. same-day non-emergency, 14 Apr to 8 Jun 2014, n; hospital LoS in 8 hr bins to 7 d, 7 d bins to 28 d, 28 d Notes: (i) LoS calculated in minutes, incl. trolleyed ED' LoS and excl. transit areas; (ii) results are intended for management information only and are subject to change 1, % 1,140 1,080 1, % 90% 85% 80% 75% 70% 65% 60% 55% 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Discharge from: Hospital LoS, d (8 hr bins to 7 d, 7d bins to 28 d, > 28 d) AMU'/'SAAU' CDU'/'AECU' 'other' ward (non-emergency) 'other' ward (emergency) All discharges

18 hr 8 hr 16 hr 1 d 1 d 8 hr 1 hr 16 hr 2 d 2 d 8 hr 2 d 16 hr 3 d 3 d 8 hr 3 d 16 hr 4 d 4 d 8 hr 4 d 16 hr 5 d 5 d 8 hr 5 d 16 hr 6 d 6 d 8 hr 6 d 16 hr 7-14 d d d 28 d Feeder systems 2, % 2,800 2,625 2,450 2,275 2,100 1,925 1,750 1,575 80% 60% Interrelated Reservoirs Locks Vessels Rapids v regular flow reduce unnecessary overnight moves 1,400 1,225 40% 1, % % 0:00 4: % 80% 60% 40% 20% 0% % 80% 60% 40% 20% 0% scharge from: ED AMU Ward

19 AAU stays, n Cumulative AAU stays, % St E: AAU spell LoS distribution, 14 Apr to 8 Jun 2014* Stays for *all patients discharged from hospital 14 Apr to 8 Jun 2014, n; AAU spell LoS in 4 hr bins to 168 hr, 168 hr Notes: (i) AAU spell LoS calculated in minutes and excludes transit areas; (ii) results are intended for management information only and are subject to change % 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Transfer to 'other' ward Hospital discharge from 'AMU'/'SAAU' Total Process map Ethnography

20 100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% 45% 40% St E: cumulative hourly hospital inpatient discharge profile, 14 Apr to 8 Jun 2014 Proportion of hospital discharges completed (excl. same-day non-emergency admissions and non-admitted ED' attendances), %, by hour of day, n Note: results are intended for management information only; transit areas considered out of hospital wrt discharge 35% 30% 27.9% 25% 20% 15% 10% 5% 0% 15.2% 12.7% Cumulative hospital discharges from: 'CDU/AECU' 'AMU'/'SAAU' Other ward'

21 100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% 45% 40% 35% 30% St E: cumulative hourly hospital inpatient discharge profile, 14 Apr to 8 Jun 2014 Proportion of hospital discharges completed (excl. same-day non-emergency admissions and non-admitted ED attendances), %, by hour of day, n Note: results are intended for management information only; transit areas considered out of hospital wrt discharge 25% 20% 17.7% 15% 10% 5% 0% 13.1% Discharges (LoS 72 hr) Discharges (LoS > 72 hr)

22 200 St E: daily hospital inpatient arrival and discharge profile, 14 Apr to 8 Jun 2014 Avg daily hospital arrivals and discharges (excl. same-day non-emergency admissions and non-admitted ED attendances), by day of week, n Note: results are intended for management information only; transit areas considered out of hospital wrt discharge Mon Tue Wed Thu Fri Sat Sun Non-emergency admissions Total admissions Total discharges

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24 07/11/ /11/ /12/ /12/ /01/ /01/ /01/ /02/ /02/ /03/ /03/ /04/ /04/ /05/ /05/ /06/ /06/ /07/ /07/ /07/ /08/ /08/ /09/ /09/ /10/ /10/ /11/ /11/ /12/ /12/ /01/ /01/ /01/ /02/ /02/ /03/ /03/ /04/ /04/ /05/ /05/ /06/ /06/ /07/ /07/ /07/ /08/ /08/ /09/ /09/ /10/ /10/ /11/ /11/ /12/ /12/ /12/ /01/ /01/ /02/ /02/ /03/ /03/ /04/ /04/ /05/ /05/ /06/ /06/ /06/ /07/ /07/ /08/ /08/ /09/ /09/ /10/ /10/ /11/ /11/ /12/ /12/ /12/ hr ED LoS compliance, % St E A&E: weekly 4 hr emergency access performance, 1 Nov 2010 to 29 Dec 2013 Weekly overall 4 hr ED LoS compliance, by patient flow group, % Notes: (i) excludes planned reviews, UCC attendances and ED ward stays; (ii) results are intended for management information only and are subject to change 100% 98% 96% 94% 92% 90% 88% 86% 84% 82% 80% 78% 76% 74% 72% 70% 68% 66% 64% 62% 60% 58% 56% 54% 52% 50% 79.8% 81.1% 80.4% 73.9% 71.1% 99.2% 77.9% 81.5% 97.6% 93.2% 91.0% 90.9% Flow 1 - Non-admitted minors Flow 3 - Medical admissions National standard Flow 2 - Non-admitted majors Flow 4 - Surgical admissions

25 07/11/ /11/ /12/ /12/ /01/ /01/ /01/ /02/ /02/ /03/ /03/ /04/ /04/ /05/ /05/ /06/ /06/ /07/ /07/ /07/ /08/ /08/ /09/ /09/ /10/ /10/ /11/ /11/ /12/ /12/ /01/ /01/ /01/ /02/ /02/ /03/ /03/ /04/ /04/ /05/ /05/ /06/ /06/ /07/ /07/ /07/ /08/ /08/ /09/ /09/ /10/ /10/ /11/ /11/ /12/ /12/ /12/ /01/ /01/ /02/ /02/ /03/ /03/ /04/ /04/ /05/ /05/ /06/ /06/ /06/ /07/ /07/ /08/ /08/ /09/ /09/ /10/ /10/ /11/ /11/ /12/ /12/ /12/ hr ED LoS compliance, % St E A&E: weekly Mon 4 hr emergency access performance, 1 Nov 2010 to 29 Dec 2013 Weekly Monday 4 hr ED LoS compliance, by patient flow group, % Notes: (i) excludes planned reviews, UCC attendances and ED ward stays; (ii) results are intended for management information only and are subject to change 100% 98% 96% 94% 92% 90% 88% 86% 84% 82% 80% 78% 76% 74% 72% 70% 68% 66% 64% 62% 60% 58% 56% 54% 52% 50% 70.4% 69.0% 69.0% 68.0% 57.9% 66.7% 100.0% 68.0% 97.3% 96.8% 92.3% 77.8% Flow 1 - Non-admitted minors Flow 3 - Medical admissions National standard Flow 2 - Non-admitted majors Flow 4 - Surgical admissions

26 St E Hospital High level system overview and balance measures (8 weeks)

27 08/04/ /05/ /06/ /07/ /07/ /08/ /09/ /10/ /11/ /12/ /01/ /02/ /03/ /04/ /05/ /06/ /06/ /07/ /08/ /09/ /10/ /11/ /12/ /01/ /02/ /03/ /04/ /05/ /06/2014 Emergency readmission within 7 days, % Avg daily inpatient discharges*, n 15% St E: emergency readmission within 7 days, w/e 8 Apr 2012 to 18 May 2014 Proportion of inpatient discharges* readmitted as an emergency %; avg daily inpatient discharges*, n Notes: (i) ED refers to EDs, MIUs and WICs; (ii) *excludes same-day non-emergency stays, in-hospital deaths and hospital transfers; (iii) **unadjusted, XmR-based process control limits recalculated against Wheeler rules 1,4 and (iii) changes in rates may be the result of a number of factors, incl. shifts in underlying case-mix and clinical practice; (iv) results are intended for management information only and are subject to change % 13% 12% % % 9% 8% % 9.2% 9.8% % 120 7% 6% 5% 4% 4.7% % % 40 2% 1% 20 0% 0

28 Patient Numbers Optimal maximum occupancy Schematic of Demand and capacity per day by clinical department % 90.00% Most headroom needed and when 80.00% 70.00% 60.00% % 40.00% % % 10.00% 0 ED AMU Specialty Wards Rehabilitation 0.00%

29 What needs to happen Recognise complexity Patient, behaviours and context and system Recognise unscheduled care is a whole system issue Develop capacity to understand and monitor flow Individual Organisational Responsibility Individual Departmental Organisational Link flow to capacity (physical and human) and demand Not getting it right affects patient outcome and staff experience

30 Summary Improve patient flow securing links in the chain Flow and capacity are dynamic Influenced by system and processes By hour by day by week In day capacity Weekend capacity Optimise admission between ED and AMU/ASU and AMU to sub-specialty inpatient wards Improve continuity of patient care Optimise physical and staff capacity doing today s work today Move from TGIF Happy Mondays Real time

31 Avg hourly AAU admissions and discharges, n St E: hourly AAU admission and discharge profile, 14 Apr to 8 Jun 2014 Avg hourly T01(AMU)/T6AU(SAAU) bed admissions and discharges/transfers, n, by hour of day Note: results are intended for management information only; transit areas considered out of hospital wrt discharge Hour of day Transfers from 'CDU'/'AECU'/'other' wards Transfers to 'other' wards' All admissions/transfers to 'AMU'/'SAAU' (spell) All discharges/transfers from 'AMU'/'SAAU' (spell)

32 10/02/ :00 13/02/ :00 16/02/ :00 19/02/ :00 22/02/ :00 25/02/ :00 28/02/ :00 03/03/ :00 06/03/ :00 09/03/ :00 12/03/ :00 15/03/ :00 18/03/ :00 21/03/ :00 24/03/ :00 27/03/ :00 30/03/ :00 02/04/ :00 05/04/ :00 08/04/ :00 11/04/ :00 14/04/ :00 17/04/ :00 20/04/ :00 23/04/ :00 26/04/ :00 29/04/ :00 02/05/ :00 05/05/ :00 08/05/ :00 11/05/ :00 14/05/ :00 17/05/ :00 20/05/ :00 23/05/ :00 26/05/ :00 29/05/ :00 01/06/ :00 04/06/ :00 07/06/ :00 Occupancy, n St E: hourly hospital bed occupancy, 4 Feb to 8 Jun 2014 Hospital admitted patient occupancy at start of each hour, n Notes: (i) *excludes ED and transit areas, e.g. discharge lounge; (ii) results are intended for management information only and are subject to change 1,100 1,075 1,050 1,025 1, , , Total 800 Outliers 134

33 07/11/ /12/ /01/ /01/ /02/ /03/ /04/ /05/ /06/ /07/ /08/ /09/ /10/ /11/ /12/ /01/ /01/ /02/ /03/ /04/ /05/ /06/ /07/ /08/ /09/ /10/ /11/ /12/ /12/ /01/ /02/ /03/ /04/ /05/ /06/ /07/ /08/ /09/ /10/ /11/ /12/ /12/ /01/ /02/ /03/ /04/ /05/ /06/ /07/ /08/2014 'Decision to admit' to admission from ED' 4 hr, % Avg daily admissions from ED', n 100% 99% 98% 97% 96% 95% 94% 93% 92% 91% 90% 89% 88% 87% 86% 85% 84% 83% 82% 81% 80% London: hospital admissions from ED' Average daily admissions from ED', n; weekly 'decision to admit' to admission: 4 hr, %; and > 12 hr, n Sources: WSitAE Unify2-derived publications covering unscheduled activity for ED' sites w/e 7 Nov 2010 to w/e 31 Aug 2014 Notes: (i) ED' refers to EDs, MIUs and WICs; (ii) **unadjusted, XmR-based process control limits recalculated against Wheeler rules 1,4 and 24-pt baseline; (iii) results are intended for management information only and are subject to change 1, % 99.1% 1,588 1, % 1,894 1, % 1, % % 1, , % 1, ,500 3, % 2, % 2,000 1,703 1,500 1, Avg daily admissions from ED' (w/e 31 Aug 2014): 1,703 'Decision to admit' to admission from ED' > 12 hr (w/e 31 Aug 2014): 0 'Decision to admit' to admission from ED' 4 hr (w/e 31 Aug 2014): 93.5% Upper/lower/natural process limits** Avg 'decision to admit' to admission from ED' 4 hr: 95.9% No operating standard

34 19 18 St E: hourly hospital inpatient arrival and discharge profile, 17 Feb to 13 Apr 2014 Avg hourly hospital arrivals and discharges (excl. same-day non-emergency admissions and non-admitted ED* attendances), by hour of day, n Note: results are intended for management information only; transit areas considered out of hospital wrt discharge Non-emergency admissions Total admissions Total discharges

35 11/01/ /03/ /05/ /07/ /09/ /11/ /01/ /03/ /05/ /07/ /09/ /11/ /01/ /03/ /05/ /07/ /09/ /11/ /01/ /03/ /05/ /07/ /09/ /11/ /01/ /03/ /05/ /07/ /09/ /11/ /01/ /03/ /05/ hr ED' LoS compliance, % St E: weekly 4 hr emergency access performance, 5 Jan 2009 to 8 Jun 2014 Weekly 4 hr ED* LoS compliance, by patient flow group, % Notes: (i) ED' includes EDs, trolleyed assessment units and MIUs; (ii) results are intended for management information only and are subject to change 100% 98.2% 95% 92.1% 90% 97.1% 95.2% 89.9% 85% 80% 75% 74.4% 70% 77.0% 76.4% 65% 65.7% 65.4% 60% 60.3% 55% 50% Flow 1 - Non-admitted minors Flow 2 - Non-admitted majors Flows 3 & 4 - Admissions from ED'