Supported by and delivering for:

London’s NHS organisations include all of London’s CCGs, NHS England and Health Education England

Taster session:

Patient journey (flow)

Professor Derek Bell and Jane Clegg RN

1

Outline of the taster session

2

Aims and objectives of the session:

• To understand the importance of effective patient flow throughout the whole

pathway including coming into and out of acute settings

By the end of the session we will have:

• Increased awareness of importance of taking a whole system perspective and

considering each step of the patient journey in order to maintain seamless patient

flow, both into and out of acute settings

• Two priority actions and what support is needed locally to take actions forward

Change is part of everyone’s role

3

What is “quality improvement” and how can it transform healthcare?

Paul B Batalden and Frank Davidoff, Qual Saf Health Care. 2007 Feb; 16(1): 2–3.

Whole system’s approach

4

GP in hours GP out of hours NHS 111 Ambulance (999)

Emergency Department

Acute medical/surgical assessment unit

Patient Ward

(any specialty)

High Dependency Unit/ Intensive Therapy Unit

Community Rehabilitation

Hospice Nursing/

Residential Home Care at Home

HOME

Patient journey vs patient flow

Whole system flow

5 Hospital catchment areas are much larger than imagined

Emergency care flow is critical for patient

experience, clinical outcomes & quality of care

6

Assessing & treating patients who require emergency care is time critical for

good patient experience and outcomes

Efficiently managing all patient groups accessing emergency care will

improve patient flow through pathway

For those being admitted, prompt assessment and transfer to appropriate

in-patient area with the correct clinical staff, care team and equipment is

essential to ensure high quality & effective care

Evidence suggests the sooner patients moved to the right clinical

environment, the better the overall outcomes

Why Emergency Flow?

The 4-hour measure: A powerful marker of overall system function

A measure of the percentage of patients being seen by ED within 4hrs

Important measure of overall patient flow and whole system performance

An indicator of quality from a patient perspective

System factors within the control of hospital services are primary drivers to improve flow

Evidence suggests patients with longer waits have poorer clinical outcomes and poorer

patient experience

4hr standard acts as a barometer or pulse, but we need other measures.

NHS Constitution: MINIMUM 95% of patients attending A&E must be seen, treated

and admitted / discharged within 4 hours

UK overall performing poorly

4hr standard progressively deteriorating since September 2013

7

Maroon

axis =

number of

breaches

Blue line =

average

attendance

monthly

Green line =

overall 4hr

performanc

e

1. UK 4 hour

standard not met

at all since

September 2013

2. Gradual continuous

deterioration since

Aug 2013

3. Significant further

deterioration in

performance since

Aug 2015 down to

80% in Mar 201

4. Signs of new

period of

deterioration since

Sep 2016

Analysis Line Graph

Gradual continuous decline in performance since 2013, despite a steady attendance. Worryingly, a

new downward trend since September 2016, with performance down to under 80% in December 2016

Attendance remains

stable within current

accepted variation

Increase in breaches

consistent with

performance decline

Different groups of patients move at different speeds

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92.8%

82.5%

72.8%

67.9%

70.6%

81.0%

87.9%

82.1%

70.3%

73.0%

88.6%

30%

35%

40%

45%

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

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012

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Flow 1 - Non-admitted minors Flow 3 - Medical admissions National standardFlow 2 - Non-admitted majors Flow 4 - Surgical admissions

Hospital 2: weekly 4 hr emergency access performance, 2 Jan 2012 to 27 Oct 2013 Weekly 4 hr ED LoS compliance, by patient flow group, % Notes: (i) excludes planned reviews and ED ward stays; (ii) results are intended for management information only and are subject to change

4 h

r E

D L

oS

co

mp

lian

ce

, %

Different journeys, different days of the week

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95.5%

60.0%

53.3%

60.0%

82.9%

79.2%

56.8%

52.9% 50.0%

46.2%

95.8%

30%

35%

40%

45%

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%08/0

1/2

012

22/0

1/2

012

05/0

2/2

012

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2/2

012

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3/2

012

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012

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6/2

012

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012

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7/2

012

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8/2

012

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8/2

012

02/0

9/2

012

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9/2

012

30/0

9/2

012

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0/2

012

28/1

0/2

012

11/1

1/2

012

25/1

1/2

012

09/1

2/2

012

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2/2

012

06/0

1/2

013

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1/2

013

03/0

2/2

013

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2/2

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03/0

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17/0

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013

13/1

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013

27/1

0/2

013

Flow 1 - Non-admitted minors Flow 3 - Medical admissions National standardFlow 2 - Non-admitted majors Flow 4 - Surgical admissions

Hospital 2: weekly Monday 4 hr emergency access performance, 2 Jan 2012 to 27 Oct 2013 Weekly Monday 4 hr ED LoS compliance, by patient flow group, % Notes: (i) excludes planned reviews and ED ward stays; (ii) results are intended for management information only and are subject to change

4 h

r E

D L

oS

co

mp

lian

ce

, %

People moving more slowly at weekends…

Movement across the whole hospital

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A single component of the patient journey

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A patient at home has infective symptoms and will need a course of antibiotics.

He/she will not require hospital admission.

A patient at home has infective symptoms and will need a course of antibiotics.

He/she will not require hospital admission.

Table Discussion 1

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Table 1

In your tables consider the following scenarios during normal working hours:

An elderly woman has fallen at home and has a painful hip. She is unable to walk

and so her neighbour has called an ambulance.

An elderly woman has fallen at home and has a painful hip. She is unable to walk

and so her neighbour has called an ambulance.

Table 2

A patient is going home after a 5-day admission post surgery and is awaiting

discharge letter and prescription…

A patient is going home after a 5-day admission post surgery and is awaiting

discharge letter and prescription…

Table 3

A man with terminal metastatic disease who is at home and has become acutely

confused. He is known to local hospice team and hospital palliative care team

A man with terminal metastatic disease who is at home and has become acutely

confused. He is known to local hospice team and hospital palliative care team

Table 4

Discuss the potential steps in these patient’s journey ..

Patients don’t actually flow… they can get held up..

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What’s within your sphere of influence?

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The Challenge

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Increasing demands to improve quality increasing change initiatives at the point of care

Many initiatives fail

Reports of change fatigue due to:

Volume;

Associated workload (lack of capacity);

Lack of involvement;

Lack of perceived value of change

Four

Ideas to

Find

Time for

Improve-

ment

Copyright © 2017 NIHR CLAHRC NWL

Setting an

Improvement

Rhythm

Focusing on

“Highly

Adoptable

Improvement”

Use

Orchestrated

Testing

Stopping doing

things that don’t

work or don’t

work work well

1 2

3 4

The half-life concept

Setting time-based improvement targets

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The half-life concept focuses goal setting around the length of time

it will take to reduce defects (or close a gap) by 50 percent.

“half-life” accommodates the notion of perfection, yet accepts that

it is achievable only in infinite time.“

if the goal is to achieve 98% and current operational performance

is 93% then gap is 5% so how long to achieve 2.5% as first stage –

set achievable time trajectory based on data

Effective framework for long-term planning

Maximally Adoptable Improvement

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Change initiatives that do

not add additional

workload & have high

perceived value are:

more likely to be

adopted

cause less workplace

burden

achieve the intended

outcomes

Hypothesis

Understanding the data

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• Notice the seasonality

• What is influencing the performance?

• This graph alone tells you about overall flow, but doesn’t tell you what’s

happening…

A patient at home has infective symptoms and will need a course of antibiotics.

He/she will not require hospital admission.

A patient at home has infective symptoms and will need a course of antibiotics.

He/she will not require hospital admission.

Table Discussion 2:

20

Table 1

In your tables consider the following scenarios during normal working hours:

An elderly woman has fallen at home and has a painful hip. She is unable to walk

and so her neighbour has called an ambulance.

An elderly woman has fallen at home and has a painful hip. She is unable to walk

and so her neighbour has called an ambulance.

Table 2

A patient is going home after a 5-day admission post surgery and is awaiting

discharge letter and prescription…

A patient is going home after a 5-day admission post surgery and is awaiting

discharge letter and prescription…

Table 3

A man with terminal metastatic disease who is at home and has become acutely

confused. He is known to local hospice team and hospital palliative care team

A man with terminal metastatic disease who is at home and has become acutely

confused. He is known to local hospice team and hospital palliative care team

Table 4

1. What would be necessary to improve your understanding of the patient

journey? Use the scenario that you’ve worked on as exemplar.

2. What support could the collaborative best provide you?

Improving the patient experience/journey..

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