Improving the flow
Source: NHE Jan/Feb 2017
Glen Burley, chief executive of South Warwickshire NHS FT, explains how his organisation has been able to improve patient flow through its emergency department after taking part in the Flow Cost Quality programme.
Back in December, the Health Foundation published its report ‘The challenge and potential of whole system flow’, which outlined an organising framework and tested methods that local health and social care leaders can use to improve whole system flow.
Whole system flow is described as a “co-ordinated approach across organisations that ensure people, information and resources are in the right place at the right time, to reduce bottlenecks, duplication and avoidable waits”.
Drawing on case studies from across the UK and internationally, the report describes the steps that can be taken at a national level to create an environment to deliver change at scale.
The Health Foundation’s publication also outlines how work at Sheffield Teaching Hospitals NHS FT and South Warwickshire NHS FT through the Flow Cost Quality programme has delivered sustained reductions in emergency care length of stay, bed occupancy and readmissions, while improving safety and the patient experience.
Glen Burley, chief executive of South Warwickshire, who has been at the FT for over a decade, said that it is one of the most important projects the trust has been involved in since he started there.
“Back when I started we were struggling with A&E performance,” he explained. “I know it is a national standard, but it is a good barometer of whether the system is flowing. We put ourselves forward to become a FT, but it took us two attempts to get through because this was one of the performance issues.
“When we were finally authorised [the FT was formed in 2010] we had a side letter from Monitor saying we needed to continue the work we had started and improve A&E performance.”
Plan, do, study, act
As part of the Flow Cost Quality programme, South Warwickshire started by mapping processes and testing changes using a ‘plan, do, study, act’ approach. Innovations included ways of matching consultant availability to variation in demand, and bringing senior clinical assessment closer to the start of the process.
“The study showed, quite dramatically, that there were a lot of patients in the hospital who could have been in community hospitals or other support packages,” said Burley. “It also showed that the costs as well as the appropriateness of treatment were not aligned.
“Right-sizing your system is important to have the right level of capacity in the often least expensive parts but the parts where patients want to be, which is usually at home. Similarly, in the hospital, it was also an important part of that and taking a different approach to delay.”
At the FT there was a particular focus on ensuring support processes were capable and aligned in order to facilitate flow. For instance, the number of same-day blood test results available on ward rounds was increased from less than 15% to more than 80%. Because of these up-to-date results, consultants were able to make quicker and safer clinical decisions for patients.
“We looked at when the patients arrived, and when the demand was. The approach from the Health Foundation was to look at time series data and when patients were hitting different parts of the system,” added Burley. “It showed us that the majority of patients, by the time that they were through the A&E process, were hitting the medical assessment unit late on in the day – often when the consultants weren’t there, and you only had junior doctors so some patients were being pushed into the next day.
“Shifting the availability of the senior decision-making team to match patient flow was an important initiative. It is a constant fine-tuning exercise. Whenever I talk about this to other people, I tell them that you cannot just do this as a one-off exercise and walkaway; you have to revisit it every few months.”
Since taking part in the work, South Warwickshire has reported a fall in mortality rates from 1.11 in 2011-12 to 1.02 in April 2015.
Over the same period, the length of acute stay for all patients fell from 7.7 days to 6.2 days, while the reduction for patients aged over 75 was even greater – down by 3.1 from 12.6 days to 9.5 days. This reduction in length of stay has not, however, been accompanied by an increase in emergency readmission.
“We’ve also been delivering the A&E standard consistently now for the best part of two years,” said Burley, adding that while there has been a few challenges on certain days and weeks this winter “more often than not, we will deliver the standard”.
“I think that the system we have got with the flow right means we can recover well,” he noted. “You can never design a system to perfectly cope with the absolute peaks in demand, but if it is reasonably well structured it recovers quickly.
“The other thing about recovery is that our staff haven’t gone through an entire year of being on their knees with regards to flow. They are used to it running well, so the occasional bad day or week means they can bounce back quite well. There is certainly a resilient, can-do feeling in the way that the system works.”
As well as helping teams at the FT to understand the root cause of problems and test solutions, using a structured approach to flow has been a powerful method for changing the behaviours of those involved. According to the Health Foundation, it can be adapted for use on a whole-system basis by addressing five key areas of work:
- Creating space for the system to come together
- Understanding the ‘current state’
- Collecting and analysing data
- Developing a ‘future state’ plan
- Implementation, evaluation and learning
Improving back-door efficiency
While admitting there is still more work to do on the frontline, South Warwickshire’s CEO stated that there is a lot of work going on to improve the efficiency at the back door as well.
“We run community services in Warwickshire and the community emergency response teams, which are basically district nurses, have the same ‘today’ concept as those in the hospital setting,” he noted. “They do quite a lot to avoid patients having to come to the hospital in the first place.”
Like its counterparts in Sheffield, South Warwickshire has implemented the innovative model known as ‘discharge to assess’, which allows frail older patients to be discharged home as soon as their acute medical needs have been met. This means that within a few hours of the patient’s arrival at home, the trust’s community staff assess their continuing care, equipment and ongoing rehabilitation needs.
“We are leading some work, through the STP, on the out-of-hospital workstream which covers this work,” said Burley. “We have also been doing some work to extend this into the social care side. We have recently taken on the running of the reablement service, which is a local authority group of about 160 staff which provide social care support for those coming out of the hospital.
“They are under our leadership now. What we will be able to do through this, and it is early days, will provide a mix of the health and social care components to them in their own homes. It is a blending of those skills, giving us more ability to deliver home care packages.”
The biggest workstream of the Coventry and Warwickshire STP – which includes Coventry & Rugby CCG, South Warwickshire CCG, Warwickshire North CCG, Coventry & Warwickshire Partnership NHS Trust, George Eliot Hospital NHS Trust, South Warwickshire NHS FT, University Hospitals Coventry & Warwickshire NHS Trust, Coventry City Council, Warwickshire County Council – is the out-of-hospital aspect.
“It is an incredible challenge to project a few years forward an increase in demand and flat resources,” explained Burley. “This not only has the different delivery model in it, it also has some of the health promotion and prevention activities in there.
“I’ve been put in place as chair of the Coventry and Warwickshire A&E delivery board and, for the first time, we are looking at this from a Coventry and Warwickshire perspective — previously I was just a member of the South Warwickshire Systems Resilience Group. They [the STP] are looking at what we have done here [at South Warwickshire] and if can we roll out into the rest of Warwickshire.”
Although Burley says there are still “sticky bits” the STP has to work through with regards to clinical options, partners have already been doing quite a lot of public and primary care engagement with regards to out-of-hospital plans.
“I don’t think it is sensible just to sit in a meeting with the public with a blank piece of paper. You need to have some ideas that are there for people to question and challenge,” he added.
“The most important thing is changing the way that people use the NHS, changing the way people take responsibility for their own care and creating a new model of care that particularly has primary care buy-in and aims to reduce some emergency demand in the system.”
FOR MORE INFORMATION
The Health Foundation’s ‘The challenge and potential of whole system flow’ report can be accessed at:
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