Using our data to understand our flow, we were able to highlight the impact of our current system on the timeliness of patient care delivery.
3.2 Innovations in Acute Flow andCapacity Management
Session Outline• Working definition• How we have prioritised flow• How we might want to think about flow in future• What are the issues – why raise our ambition?• Celebrating our existing work & what it tells us• Next Steps
Flow1. a. To move or run smoothly with unbroken continuity, asin the manner characteristic of a fluid.1. b. To issue in a stream; pour forth: Sap flowed from thegash in the tree.2. To circulate, as the blood in the body.3. To move with a continual shifting of the componentparticles: wheat flowing into the bin; traffic flowing throughthe tunnel.
Right treatment area Right time Right team Right care(as efficiently as possible and within available resources)
How we traditionally consider flow• Access targets and standards (point improvements)• Evolved from point improvements to pathway management (unscheduled care / 18 weeks RTT/ cancer/mental health)• Chunking up strategies and goals for the system (i.e. elective and unscheduled)• Focus on improving constraints (delayed discharge)• Strategies having competing impacts (patient boarding)• Insufficient emphasis on individual patient experience?• Insufficient recognition of workforce design on flow and of improvement and workforce relationship?
How we should consider flow?– Access/equity– safety issue– experience– efficiency– 20/20 Vision demands on acute services are such that optimising throughput is critical– Poor flow and inefficient use of capacity can drive up costs and may be compromising efficiency in all parts of the system
Efficiency & Productivity Framework SR10 Aim, Objectives & Scope “To improve the overall quality and efficiency of NHSScotland while ensuring good value for money and achieving financial targets.”Key objectives: Acute Flow & Capacity work-• Quality is not compromised, stream formed to support NHS• NHSScotland will achieve financial Boards to improve/optimise flow balance over the SR10 period, and to challenge unwarranted• NHS Boards are supported in variation. achieving efficiency targets and improving services, and Productive Opportunity (based on• Central co-ordination of McKinsey DoH study and applied support, monitoring, benefits pro-rata up to £300m) realisation and challenge will be available to NHS Boards.
The Problems of Patient Flow – Why raise our game? Marilyn E Rudolph• Peaks and valleys• Resource utilisation• Internal diversion – boarding• Increases in medical errors• Delays in patient care• Boarders and ED diversion (non IP areas)• Left without being seen• Decreased throughput = increased costs?• Increased length of stay• Staff and patient satisfaction
Born this Way? People and ReformReform agenda domains Medical Medical General Nurse Nurse clinicians managers managers managers cliniciansRecognise interconnections Ambivalent Accept Strongly Accept Stronglybetween the clinical and accept rejectResource dimensions of care.Adopt a perspective that Reject Accept Strongly Accept Ambivalentbalances autonomy with accepttransparent accountability.Participate in processes that are Strongly reject Strongly Accept Accept Acceptoriented to bring clinical work rejectwithin the ambit of workprocess control.Accept the multidisciplinary Reject Ambivalent Accept Strongly Acceptand hence team-based nature acceptof clinical service provision.Peter Diegling
National Results & Examples of Flow Improvement across NHS Boards
Median and 90th Percentile Waits for IP/DC Median (days) 90th percentile (days) 120 105 100Wait (days) 80 63 60 35 40 25 20 0 Ju 8 Ju 9 Ju 0 Ju 1 2 M 8 M 9 M 0 M 1 N 8 N 9 N 0 N 1 -0 -0 -1 -1 -1 -0 -0 -1 -1 l-0 l-0 l-1 l-1 ar ar ar ar ar ov ov ov ov M Quarter ending
NHS Tayside: Exploring Improvements for Effective Management of Capacity and Demand• Demand activity calculated for each medical specialty• Reason code tracker completed by each Specialty to ascertain reasons why capacity not achieved• Reason code tracker includes: Patients on EDISON / Patients due for discharge who are placed out with speciality ward for non clinical reasons / Awaiting script / Awaiting tests/investigations (state what) / No bed in receiving hospital• Improvement methodology applied to tailor improvements to each Specialty• Development of Capacity and Flow page on staff intranet which has daily activity info, RAG status for each directorate/CHP, access to escalation plan and action cards• Developing a 7 day acute physician delivered service model to ensure senior clinical decision making at the front door• Interactive whiteboards with real time information•
NHS Fife Waits230/ 4,8,12 hrs Add. Capacity ~60 / Boarding250 31 (52) A&E Slow Ad Unit Queue 7.7(6.4) 52 (62) pts/d Q Assess. 8.8(6) Home 49(49) Sp Beds ~46/d pts/dImproving Flow and Emergency Access Programme•Work streams = Front Door, Acute Admissions andSpecialty Flow, Community Flow Q•Metrics and PDSA‟s in each work stream Q Community Assess. Assess. Beds/IRT ~20•Front Door examples – • Flow 1 and 2 / 4 hours ~18 • Fast track triage (time to 1st assessment) • Junior check in with Cons (referral rate / clinical safety) • Specialty Review (time to specialty review) NH • Increased Consultant cover at peak times Beds (overall performance at 4 hours)15/6/2012
NHS Greater Glasgow & Clyde Management of Inpatient FlowGlasgow Royal Infirmary – Creation of Emergency Receiving Complex – patients streamed directly to the following areas : • Minor Injury Unit • ED Majors and Resus • Medical Assessment Unit – GP referred medical patients go directly • Impact of the above has demonstrated a significant reduction in breachers and in particular breach reason “wait for bed”
NHS Greater Glasgow & ClydeNHS Board NHS GREATER GLASGOW & CLYDE Hospital GLASGOW ROYAL INFIRMARYNote: When choosing board to view, do not choose (All) as will double count. Select NHS Scotland as board ifwanting to view Scotland level data. ED 4 Hour Breach Reasons by month: October 2010 - April 2012 800 700 Breach Reason 99 Not Known 600 98 Other reason 08 Major incident Monthly ED 4 hr Breaches 07 Clinical reason(s) 500 06 Wait for 1st assessment 05B Wait for diagnostics test(s) - awaiting results 05A Wait for diagnostics test(s) - to be performed 05 Wait for diagnostics test(s) 400 04B Wait for initial A&E treatment - to be completed 04A Wait for initial A&E treatment - to commence 04 Wait for initial A&E treatment 300 03C Wait for a specialist - Wait for Mental Health/Psychiatrist 03B Wait for a specialist - Wait for Medical Specialty 03A Wait for a specialist - Wait for Orthopaedics 03 Wait for a specialist 200 02 Wait for transport 01 Wait for bed 100 0 Source: ISD A&E2 datamart Management May-11 Mar-11 Mar-12 Nov-10 Nov-11 Oct-10 Feb-11 Feb-12 Dec-10 Jan-11 Apr-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Dec-11 Jan-12 Apr-12 information Reports covering October 2010 - April 2012. Data is for management information purposes only and subject to change. Month
NHS Greater Glasgow & Clyde Management of Inpatient Flow Use of Lean methodology• Three teams configured to work at Western Infirmary; Royal Alexandra Hospital; Victoria Infirmary to : – Improve discharge process with increased number of beds available before midday – Improve flow through ED/wards by addressing relationship issues between Medicine and DME
NHS Lothian• Implementation of Real Time Demand and Capacity Management (Resar, et al, 2011)• Estimate of 10-15% in day capacity gains through implementing this methodology• Project/Improvement Manager in place, estimate 6 months for implementation, further 6 for sustainability• Focus on „Discharge Huddles‟ and change in bed meeting process – accuracy of predictions – key issues to „unblock‟
Strategies for Managing Patient Flow S,G.Vaswani, M.C.Long, B.Prenney, E,Litvak• Key principles: – System-wide not silos – Science-based, data-driven – Right structure before improving micro-processes – Compliance review and enforcement• Operations Management – Critical path – minimise delays – Queuing theory – mismatch between demand and resources – Simulation
Natural Variability Artificial Variability• Random • Non-random• Predictable • Non-predictable (driven• Can not be eliminated (or by unknown individual even reduced) priorities)• Must be optimally • Should not be managed managed, must be identified and eliminated
A. N. Other Hospital • Overcrowded • Safety? • Experience? • Waits/Boarding
The Natural Variation The Artificial VariationHospital Hospital – Emergencies only – Electives only – Queuing theory to decide size – Smooth all admissions and and staffing discharges – Run at 80% capacity – Run at 95% capacity
Strategies for Managing Patient Flow S,G.Vaswani, M.C.Long, B.Prenney, E,Litvak• Artificial Variability – Inadvertence e.g. LoS in HDU awaiting bed – Provider scheduling – „dysfunctional scheduling of elective admissions‟ – Inappropriate management of flows emergency/elective predictions, complexity• Effects „Artificial variability cannot be predicted or managed but must be investigated and eliminated‟ – Compromised quality of care – Decreased patient satisfaction – Decreased staff satisfaction – Operational inefficiency/ high cost of care
Strategies for Managing Patient Flow S,G.Vaswani, M.C.Long, B.Prenney, E,Litvak• Variability MethodologyPeaks in scheduled admissions is artificial variabilitycaused by dysfunctional scheduling of elective admissions – Identify variability – Classify as natural or artificial – Statistical test for randomness – Quantify – as deviation from ideal expected pattern – Eliminate/ significantly decrease – Manage natural variability by stratifying patients
Strategies for Managing Patient Flow S,G.Vaswani, M.C.Long, B.Prenney, E,Litvak• Variability Methodology IHO – Eliminating variability where you can – Optimally managing it where you can‟t – Different types of variability in health care • Clinical variability – illness and response to treatment • Flow variability – when • Professional variability – time taken
Strategies for Managing Patient Flow S,G.Vaswani, M.C.Long, B.Prenney, E,LitvakPhases• Separate flows• Smooth elective and queuing theory to emergencies• Once optimised estimate resource for system
20/20 A Balanced Flow Hospital • Flow = Quality • Separate Flows • Variation Smoothed • Real Time Queuing Theory • Whole System with Integrated Community Teams
Intelligent Flow• Making the flows/processes visible/separating them• Measurement & balancing measures• Patient experience & co-design• Complex adaptive thinking – the whole system• Counter-intuitive - most variation is in elective care and is a supply not a demand problem• Generating the evidence base that poor flow is a patient safety, efficiency and experience issue• Sustainable improvement will require a focus on quality, workforce and governance
NHS Scotland’s Focus on Flow Whole Hospital Acute Flow and Capacity Management
Key Improvement Messages• Separate scheduled and unscheduled patient flows• Eliminate / minimise artificial variability wherever possible• Assign separate resources for scheduled and unscheduled patients• Resources for unscheduled patients should be based on clinically driven maximum acceptable waiting times – match capacity to the profile of demand• Resources for scheduled patients should be based on maximising patient throughput and minimising unnecessary waiting• Only after separation and matching capacity to demand examine fixed resources
Next Steps - 2012• Acute Flow & Capacity Management workstream progresses improvement projects and maintains close links to unscheduled care groups. Overarching improvement context• Acute Flow & Capacity Management Programme Board receives proposals to test/implement a whole systems approach to flow and capacity planning – August 2012• HSCMB, QAB and Efficiency Portfolio Board invited to agree proposals
The Relationship between Flow, Quality and Cost
Question:• If Patient Flow slows down: – do more patients die? – does cost go up?
Agenda• Programme Structure• High level measures – What are we trying to improve?• Patient Flow – Emergency and Elective• The constraints• The policies that need changing• How to make changes happen
Structure for an Improvement Programme DH, SHA, Monitor, Health Commission etc. Board Board GP GP FlowEmergencyPlanned careClinical subspecialtiesMedicine Intermediate careSurgery Community hospitalsPaediatrics A&E Long term care Functional Ambulance Departments Clinics Radiology Pathology Theatres Wards Pharmacy Therapies Transport HR IT Finance Estates Supplies Support functions Seattle Children‟s Hospital
Weekly A&E performance & crude death rate April 2007 to Feb 2011 Dec 07 Dec 08 Dec 09 Dec 10 FoundationWeekly number Status Non elective deferredof A&E breaches death rate What happened In Sept 2009? Non elective deaths / non elective discharges inc deaths by Date of ADMISSION Comments?
Foundation What Status happened in deferred September 2009? Weekly Flow Cost Quality Ap 07 to Ap – Jan 11 A&E breaches & Non elective deaths / discharges by date of admission Palliative Infection control Care > %15-64 years excluded admissions Adult Non elective Rami (Rate Adjusted Mortality Index) (excl paeds, obs & midwifery) compared to average for peer group Open new wards Recruit Total Pay costsAgenda for change (elective and non elective) Comments?
What the Warwick and Sheffield teams learned• Plot the dots! – weekly data – reviewed monthly: Board• Monthly 2 hour meeting: – Executives, senior clinicians and Dpt. heads from across the health & social care system • Study, Adjust, Plan, Do – When did the statistically significant changes happen? – Why? » What did WE change?
Understanding Flow DH, SHA, Monitor, Health Commission etc. Board BoardEmergency GP GP FlowPlanned careClinical subspecialtiesMedicineSurgery Intermediate carePaediatrics Community hospitals A&E Long term care Functional Ambulance Departments Clinics Radiology Pathology Theatres Wards Pharmacy Therapies Transport HR IT Finance Estates Supplies Support functions
High Level Emergency System Map Death Hospital CommunityAmbulance Hospitals Accident Assessment and Unit(s) Specialist Intermediate GP Emergency Ward Care (services delivered in the patient‟s home) Permanent place of residence
Relationship between flow in, A&E performance and deaths and emergency admissions Comments?
Closure of Foundation Community Hospital Status deferred Sept 2009 Weekly Flow Cost Quality Ap 07 to Ap – Jan 11 A&E breaches & Non elective deaths / discharges by date of admission Palliative Infection control Care > %15-64 years excluded admissions Adult Non elective Rami (Rate Adjusted Mortality Index) (excl paeds, obs & midwifery) compared to average for peer group Open new wards Recruit Total Pay costsAgenda for change (elective and non elective)
High Level System Map Death Hospital Closed 40 Community bedsAmbulance Hospitals Sept 2009 Accident Assessment and Unit(s) Specialist Intermediate GP Emergency Ward Care (services delivered in the patient‟s home) Permanent place of residence Continuing Health Care funding process changed Oct 2009
Lesson for Boards:Poor A&E performance is due to poor flow OUT – Constraints are under our control
Lesson for Performance Management• Plot the dots! – Trend lines should be removed from Excel – Statistical Process Control • Reveals the voice of the process
What did we learn?• Plot the weekly emergency admissions by age group:• 0 to 15• 16 to 64 Correlates with the high level patient flows• 65 to 79• 80 and plus• Plot Patients-in-Progress (work-in-progress): – very sensitive to changes in demand x LOS: • A&E performance (breaches) • Midnight bed occupancy – See later
Emergency admissions 80 years +Confirms that poor flow is NOT due to increased admissions of patients > 80 years
High Level Emergency System Map Death Hospital CommunityAmbulance Hospitals Accident Assessment and Unit(s) Specialist Intermediate GP Emergency Ward Care (services delivered in the patient‟s home) Permanent place of residence (0 to15) 16 to 64 65 to 79 80 and plus years Warwick Sheffield: GSM
GSM: How Many Bed Nights Do They Stay? Pareto of Bed Nights for Home to Home Patients 100% 90% 80% 70% 60%Cum Freq 50% 40% 30% 20% 10% 0% 0 6 12 18 24 30 36 42 48 54 60 66 72 78 84 90 96 102 108 114 120 126 132 138 144 150 156 164 175 189 205 263 Bed Nights
Day to day Admissions Discharge mismatch NEL Admission Discharge mismatchnumber of NEL patientsadmtted and dicharged 80 70 60 Total NEL admissions (NEL 50 40 + NEL other) 1. 30 Total NEL discharges (NEL 20 + NEL other) Reduce daily 10 0 variation in discharges 7 07 7 7 07 8 8 08 08 08 00 22 00 29 00 12 00 19 00 20 20 20 20 2 2 2 2 2 2/ 2/ 2/ 2/ 2/ 1/ 1/ 1/ 1/ /1 /1 /1 /1 /1 /0 /0 /0 /0 01 15 05 26 date Elective Admission Discharge mismatch Nubmer of elective patients admitted and discharged 80 70 60 50 40 EL admissions 2. Smooth 30 EL discharges 20 Variation in 10 0 PLANNED 01/12/2007 08/12/2007 15/12/2007 22/12/2007 29/12/2007 05/01/2008 12/01/2008 19/01/2008 26/01/2008 Elective Admissions date
In-day mismatch betweenEmergency admissions and Specialist capacity Time of Arrival into A&E Time of Departure out of A&E to Main Hospital450400 Patients admitted when capacity is not350300250200150 available100 50 0 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Assessment units are storage units to When is the Specialist Capacity available? hold the patients until the specialist capacity X junior is available the staff + following day Minimal Y Minimal capacity specialist capacity consultants?00.00 06.00 12.00 18.00 23.59
Assessment Process at April 2009 Up to 24 4 hours. Up to 12 hours overnight hours post arrival at hospitalArrive History & Requests Perform tests Perform testsAt Triage Nursing examination Test & Obs‟ & imaging & imagingA&E & initial imaging treatment Senior review Transfer to Assessment Unit Nursing History & Senior Review Obs examination Plan definitive treatment ? A&E Assessment Unit = value
What do we need to do instead? Pull patients forward into the working day:450 Time of Arrival into A&E Time of Departure out of A&E to Main Hospital •Stop making them wait 3:59 minutes…..400 •Stop duplication350300250200150100 50 0 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 The specialty capacity needs to be available: Right decisions On time 08:00 21:00 Every time Specialists available In full Seeing patients on wards Minimal Discharging patients capacity Admitting patients00.00 06.00 12.00 18.00 23.59
„Future‟ Assessment Process (Now current as at April 2012) 2 hours Transfer to Appropriate History & Senior specialistArrive Plan Requests specialist area Nursing examination Perform tests ReviewAt for Test & including home Obs‟ & initial & imaging Plan definitiveA&E diagnosis imaging with PT/OT /SS treatment treatment home assessment at home 1 hour Safe ambulatory care process now possible
All admissions from A&E by hour Mondays May to Oct 08 8 7 Reduce daily 6 variation in discharges 5 MaxAdmission Min 4 Avg Av + 1 SD Av +2 SD 3 2 1 0 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Hour of arrival What is the rate of production required?
Improving Flow (front end)• Pooled junior docs – A&E, MAU and specialty on call – Staggered start times on A&E/MAU = Increased availability from 08:00 to 10:00• MAU consultants continuous flow • Speciality take every day: admissions • Heartbeat system for tracking patients• Wards – Consultant ward round every day: discharges
Functional departments DH, SHA, Monitor, Health Commission etc. Board Board GP GP FlowEmergencyPlanned careClinical subspecialtiesMedicine Intermediate careSurgery Community hospitalsPaediatrics A&E Long term care Functional Ambulance Departments Clinics Radiology Pathology Theatres Wards Pharmacy Therapies Transport HR IT Finance Estates Supplies Support functions
Do this hour‟s work this hour:• Emergency Blood turnaround: – Bottleneck for emergency samples = centrifuges Change: • Now a centrifuge starts every 3 minutes whether full or not• IP blood monitoring on wards – Bottleneck: Phlebotomists & transport to lab Change: • Porters running between phleb‟s and lab • Steady flow of samples into lab • all results back by 10:30 a.m. for ward rounds
1 year later• Warwick• Focus on: – A&E, – Assessment units and wards – Diagnostics – Ward rounds – TTOs
Foundation Close Status Community Dec 2010: flow improvements start deferred Hsp Sept 09 Increased % 16 to 64 years Flow doesn‟t recover from Sept 2009 bed + staff closures Infection control Palliative Care excluded Reduction in death rate Nobody addressed the CHC admin delays Acquire causing the Community long LOS services Open new wards Organisation RecruitAgenda for change change disrupted the Admin flow even more Comments?
1 Year later• SheffieldGeriatric and stroke medicine – Focus on reducing the admin constraints (policies) – Check List and CHC assessment process • 42 page document • 18 man hours of work • Min time (LOS) = 30 days+ – Home assessment at home on day of discharge • Referral to Social Services by physio to social services • SS package in place within 48 hours (Upper process limit) – Home of choice: • out to residential home, CHC afterwards
Lessons for executive support services DH, SHA, Monitor, Health Commission etc.. Board BoardEmergency GP GP FlowPlanned careClinical subspecialtiesMedicineSurgery Intermediate carePaediatrics Community hospitals A&E Long term care Functional Ambulance Departments Clinics Radiology Pathology Theatres Wards Pharmacy Therapies Transport HR IT Finance Estates Supplies Support functions
Lessons for executive support services• HR: – Systems thinking and improvement science for A4C 8 & above – Match staff capacity to patient demand: 7/7, 365 – Heads of functions = responsibility for end-to-end process Focus is on Flow, WIP incurred accountable to the Dpt. concerned.• IT – Information in real time – Time series data• Estates: – Reduce transport and motion – Co-location of process resources• Supplies – Just-in-time
Pareto analysis of the pay costs in one Trust for one month by employee. 50% of cost Role of senior managers is to improve process flow 20% of staff through the most expensive value adding staff =clinicians
Change the Finance ParadigmEconomies of Scale Economies of Flow Capacity Nu,ber of Patients Patients/hr treated successfully Land lives „saved‟ Demand Patients /hr Activity £5 £2 x PbR £1 /hr /hr £1 income Dpt 1 Dpt 2 Dpt 3 Dpt 4 Dpt 5 Dpt 6 /hr £2 £1 /hr /hr /hr Dpt 1 Dpt 2 Dpt 3 Dpt 4 Dpt 5 Dpt 6 Department Cost Activity = waste = unit cost constraint So focus is on improving value delivered and incomeDrives Dpt manager to This depends on moving resources to support the constraintdo more activity at less cost The constraint should be the most expensive resourceAcquires „new business‟ in the process = in Dpt 2.But what happens to flow? How can we optimise productivity through the most expensive resource?
Finance• John Darlington‟s paper• http://www.leanuk.org/downloads/LS_2010/paper_lean_b usiness_case.pdf
Get Everyone on Board Patient‟s experience of waste DiscussionHistory Full Endoscopy Discharge Nil by Rest & Check Cross with cardiacExamination blood & Transfuse With Plan mouth dehydrate FBC match centreAssessment Count Breath test 8 hours And Rx 4 hours for 20 5 minutes 40 mins Re stent30 minutes 5 minutes 30 minutes 15 minutes hours 15 minutes Value adding 34 hours = 18% of time value adding Non Value adding 8 days x 24 hours 82% of time and resource wasted Poor quality experience and outcome From a Poor Quality System
The Doctors can lead the change…..• Very complex system: – Like a human body!• Understand – Anatomy – Physiology (flows) – Plot the dots: BP, temp, pulse, resp‟s …. – Diagnosis – Treatment (releave the constraints) – Look for changes in the pattern of variation (SPC)
Get the Managers on Board• Top Down Command and Control is impossible: – Not possible for one person to understand whole end- to-end process or System.• Facilitate Big Room Meetings – Get the everyone in a room – Listening to each other – Conversations based on facts: – Study, Adjust, Plan, Do, – Monthly and Weekly reviews
Summary• Quality is a System property• Track patient flow (WIP), death rate and cost over time. – Increasing cost doesn‟t always improve flow – Reducing cost can have grave consequences• Improve processes to reduce delays and inventory (WIP) – Match staff capacity to patient demand – Do this hour‟s work this hour• Shift from: – Unit Costing: Dpt cost/activity – to Flow Accounting: throughput at constraint/total process cost – The constraints are policies or availability of staff, not beds.
What have we learned ?• Nuggets• Niggles• Nice-if• NoNos