7 day working: can you tame a wicked problem?


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7 day working: can you tame a wicked problem?
Dr John Lowes, Dr Mike Williams, Dr Oliver Dyar
South Devon and Torbay
Presentation from seven day services event held on 20 August 2013

Published in: Health & Medicine
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7 day working: can you tame a wicked problem?

  1. 1. 7 day working: can you tame a wicked problem? Dr John Lowes, Dr Mike Williams, Dr Oliver Dyar Learning from South Devon & Torbay
  3. 3. Simple Build a rowing boat - change a rota
  4. 4. Complicated but tame Design and build a hospital
  5. 5. Wicked – running healthcare delivery services Solutions are difficult to recognise because of the complex interdependencies that surround the problem
  6. 6. Wicked problem 1. ‘Problem’ is ill structured – solutions expose new problems 2. There is no definitive ‘solution’ 3. Solutions are assesses in a social context – many views of what is good as consequences ripple out 5. Every attempt to solve has consequences – spawn new problems 6. Matter of creativity to devise potential solutions; judgement to decide which are valid Rittel, H. & Webber, M. (1973) Dilemmas in a General Theory of Planning. Policy Sciences, 4, 155-169. Conklin, J. (2006) Dialogue mapping – building shared understanding of wicked problems, Chichester, John Wiley & Sons. 4. Problems are unique due to dynamic social context 7. Is a symptom of another problem
  7. 7. Taming Wicked problems Lock down the problem – solvable sub-problem Assert that the problem is solved Specify objective parameters to measure success Give up trying to find good solution – just follow orders Declare there are just a few solution; frame problem as either - or Conklin, J. (2006) Dialogue mapping – building shared understanding of wicked problems, Chichester, John Wiley & Sons. Cast problem as ‘just like’ a solved problem Ignore social complexity
  8. 8. A wicked problem tamed?
  9. 9. 7 day emergency only service Full 7 day for all services 7 day urgent care 7 day urgent plus partial elective
  10. 10. How to respond Simple Complicated (Tame) Wicked Command Manage Lead Just do it Project manage process Engage in dialogue & social change
  11. 11. 7 day force field Currentstate Weekend mortality Perceived costs Senior staff preferences Lack of whole system approach (primary and community services) Recruitment & retention of staff Public & political opinion Media interest Supervision of junior staff Push harder creates stronger push back therefore... enter into dialogue to engage in social process to address emotional values and concerns
  12. 12. Torbay & South Devon Journey South Devon Healthcare NHS Foundation trust 2007 Torbay & South Devon Health & Care Trust 2005 Integrated H & Care Zones 2007 Intermediate care services 2009 Radiology services 2000+ Hospital @Night 2004 T & O service/ #NOF Acute physician model Enhanced recovery in surgery Extended ward round Combined ICO 2014? Joinedup Health & Care Cabinet 2011 System modelling, mapping & understanding Enhanced recovery in medicine Sunday test of change - discharge Weekend working - Trainee Doctors Hospice@ Home Joinedup Leadership Norman Lamb Pioneer Bid Redesigning the front door South Devon & Torbay CCG
  13. 13. Modelling & understanding our system – plan for reality not rhetoric Acute emergency admissions have been rising at ~1.6% per annum
  14. 14. Modelling & understanding our system – 8 mins or 8 hrs to treatment • GPs visit sickest patients 1 - 3pm – then phone for ambulance (HCP calls) • Ambulance prioritise 999 response < 8mins therefore GP call as ‘urgent’ <4 hrs • Patient arrives at hospital late afternoon / evening • Patient’s need subordinated to local optimisation of parts of system Calls per hour by time of day by GPs 2009 - 2011 “Visits are a very inefficient use of GP time.” “Achieving the 999 target is our priority.”
  15. 15. Modelling & understanding our system – junior doctor capacity Junior Doctors estimated clerking capacity (1 hr per pt) cf expected admissions WeekendWeekday
  16. 16. Modelling & understanding our system – primary care 0 5 10 15 20 25 30 35 40 A B C D E GP Survey (July 12 - March 13) (Q12) Failure demand (%) No Call Back “March is always busy but I think that’s because of doctors on holidays. We seem to take our holidays around this time for some reason, I don’t know. “ GP
  17. 17. Problem • Sustained increase in emergency admissions (Highest % unplanned medical) • Low levels of discharge at weekend, particularly on Sundays. • Requirement for additional escalation beds to cope with demand • System has continued to be under significant pressure • Variation in the quality of care inc. safety, patient experience & outcomes Aim • To reduce the variation in care 7 days a week • Sunday test of change – multidisciplinary consultant led ward round • Weekend test of change – timely discharge summaries (ongoing) Sunday test of change: consultant led multi-disciplinary ward round
  18. 18. Sunday test of change: what happened “Flow been much better into the hospital. No significant delays in getting beds” EAU Consultant “ Much calmer on ward area. Patients seen by team over weekend reassurred that they were not forgotten over the weekend” Staff nurse “Greatly reduced number of 2nd calls chasing patient jobs” H@D Findings inc: •Improved team work •Calmer •Empty beds on Mon. •Improved flow •Better organised •Better patient care
  19. 19. Actual discharge rates and forecast savings by increasing discharge rates Note: Discharge rates increase throughout week. It is possible that 7 day working would maintain discharge rates at the higher end of the observed values.
  20. 20. How can we better match the resource of foundation doctors to out of hours demand? 0900 1100 1300 1500 1700 1900 2100 2300 Medical Surgical SURGICAL JOBS Acute reviews PR bleed – EWS 7 Routine reviews Prescribe fluids Take bloods Put in cannula Analgesia MEDICAL JOBS Acute reviews Chest pain – EWS 8 Routine reviews Prescribe fluids Prescribe warfarin Take bloods Examine ear Put in cannula Elevated BM Medical Surgical
  21. 21. F1 ward cover: weekend test of change
  22. 22. F1 ward cover: what actually happened Medical F1 Surgical F1 H@D/H@N Ward staff Patients “Actually managed to finish on time” F1 doctor “I felt like I was on a team with the other F1s, there was more opportunity to ask for help on certain wards, and workload felt more manageable. F1 doctor “No 2nd calls, jobs completed earlier… I felt like I was actually coordinating” H@D “When doctors arrived .. they did all the jobs [medical and surgical] meaning patients were not left for hours in pain or without fluids” Nurse, Allerton ward
  23. 23. Taming a wicked problem – solutions are context specific; methodology is generalisable In Torbay & South Devon during the next 5 years those aged 70-75 will increase by 35%, those over 90 by 20%. Engage in dialogue & social change Project manage process Just do it Lead Manage Command WickedComplicated (Tame) Simple