'Understanding the admitted flow streams and how to optimise patient journeys’

Dr Ian Sturgess

Director, IMP Healthcare Consultancy Ltd

What are we trying to achieve? Getting patients better faster and safer

Safety

Reliability Flow

Ideal Care

Improving outcomes • No avoidable deaths • No harm • No unnecessary pain • No waste • No delays • No feelings of helplessness • No inequality • Getting everyone on the

‘same page’ • NOT - ‘Hitting the target but

missing point’

The Patient’s Perspective in Admitted Emergency care

I expect what to know and know what to expect from day 0: • What is wrong with me?

= Competent assessment • What is going to happen today and tomorrow?

= End to end case management plan • What needs to be achieved to get me home?

= Clinical criteria for discharge • When is this going to happen?

= Expected date of discharge

‘No decisions about me without me’

Occupied Beds = Work in Progress or Inventory Patients Waiting for the next useful thing to happen

Do you use average LOS to ‘measure’ improvement?

What is the Goal for Admitted Emergency care?

To maximise PbR Tariff ? - No To treat patients safely? - Yes but what else? To get patients back home having achieved an improvement in their acute condition without causing any harm? - Yes but a bit long Deliver EDD and CCD? - Yes – the ‘Goal’

Short Stay Unit

Home

Social care

D+T - OPA

IC Specialist units

MAU - Decision to admit

Churn

Handover

Handover

Handover

Handover

Traditional Model for Acute Care

GP referrals

A+E Referrals

Handover

Expected Date of Discharge (EDD) and Clinical Criteria for Discharge (CCD)

• Use EDD and CCD to support Care Coordination = the Goal. – When setting an EDD do not build in the delays that exist

within the system (clinical length of stay only) – Set the clinical (incl functional) criteria for discharge – EDD can be changed for (real) clinical reasons only – EDD + CCD are the (case management) goal

• Communicate Plan, EDD and Criteria for discharge

– Creating the expectation • Clinical Team • Patient and family

– Identify the constraints to delivery of the EDD and CCD • Focus on the key one (TOC) of each of: • Internal • External

Pareto Analysis

20%

20

80 60% of demand

\

19%

1% of demand: Red stream: Rare Strangers

Sick Specialty 25% OBD

0

100%

Cumulative Demand

LOS

Sick General/frail 55% OBD

Short Stay 10% OBD

Complex

Managing the Streams – Short stay Sick specialty Sick Frail Complex – Allocate early to teams skilled in that stream

0

50

100

150

200

250

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59

Length of stay (days)

Num

ber o

f pat

ient

s

Clarity of specialty criteria Specialty case management plan at

Handover – no delays Green bed days vs red bed days

Short stay – manage to the hour Maximise ambulatory care

Complex needs – how much is decompensation? Detect early and design

simple rules for discharge

Minimise handover Decompensation risk

Early assertive management Green bed days vs red bed days

Segmentation by LOS – 1 – Short Stay Short Stay – Requires decision makers

• Locus of control = Internal: • 65-70% of Medical take with LOS < 3 days • Big impact on within day and day to day variation in demand

– hourly drum beat • Needs - Generalist skills + standardisation (decision making

and case management) • Common Constraints

• Senior decision making and diagnostics available 8 a.m. to 10 p.m.

Segmentation by LOS – 2 – Sick Specialty Sick Specialty: Need specialist skills

• Locus of control = Internal: • Needs - Specialty specific standardisation • Variation in diagnoses and treatment – specialty

specific – pull from point of access • Common Constraints

• Specialist decision maker availability – attending model • Specialist diagnostic/intervention

Segmentation by LOS – 3 – Sick Frail + general

Sick frail/general • Require planners and decision makers

• Loci of control = Internal and External: • Frequently frail older people • Needs - Identify early (at admission), CGA on

admission and assertive case management • Main constraints

– Early de-compensation – minimise handovers/moves – ‘Over working’ through multiple in-hospital assessments – Frequently externalised to Social Services Delays

Integrated Flow – Frailty – Stranded Patient

Daily Board Rounds Key principle - focus on the processes and outcome not structure 1. Nursing and Medical Director:

– Set the principle – ‘drum beat and constraints’

2. Clinical Director – Describe and standardise the process - inclusivity – Consider ‘Attending Model’ – but focus on behaviours – Ensure peer review – with supportive challenge

3. Ward senior clinicians – Consultants, Ward Manager and AHP leads – Deliver the process – create ‘safe competition’ between wards – Identify the constraints

4. Trust Exec and Non Execs – Walk the floor – go and watch daily board rounds! – Embed within safety walk rounds

5. Management of ‘disruptive behaviours’ – Make it a ‘red rule’ – Are you prepared to have those difficult conversations?

What are we trying to achieve? Getting patients better faster and safer

Safety

Reliability Flow

Ideal Care

Improving outcomes • No avoidable deaths • No harm • No unnecessary pain • No waste • No delays • No feelings of helplessness • No inequality • Getting everyone on the

‘same page’ • NOT - ‘Hitting the target but

missing point’