by Kate Silvester of Heart of England NHS Trust shown at the 1st Global Healthcare Summit on 25th June 2007

1. Training
Clinical Systems Engineers
The Osprey Programme
Kate Silvester BSc MBA FRCOphth
Lean Healthcare Summit
June 2007
K. Silvester 170607
Global Summit Ospreys

2. Agenda:
• Why Osprey?
• What is a clinical systems engineer?
• How are we getting on?
– Dr Steve Allder, Osprey Plymouth
• Where next?
– Advice please!
K. Silvester 170607
Global Summit Ospreys

3. The National Health Service
• 1947: free healthcare at the point of access
– Emergency room (A&E)
– General Practitioner (GP)
• Paid for out of taxation
– £98 Billion budget
– £860 / annum / UK citizen
• 1,000,000 employees
• Administered centrally
– Department of Health through the NHS Executive
• England, Scotland, Wales and Northern Ireland.
– Local services now commissioned by Primary Care Trusts
K. Silvester 170607
Global Summit Ospreys

4. The NHS’ Symptoms
• Long delays:
– NHS is famous for ‘waiting lists’
• ‘Long waits because demand > capacity’
– Increase in resource from £47B to £98 Billion
• Output only increased by 3% (Economist 2004)
– Patients will still wait 18 weeks by Dec 2008
• Wrong diagnosis !
K. Silvester 170607
Global Summit Ospreys

5. NHS has run out of excuses
• We need to understand:
– the system.
– the pathology of the system
– how to put it right
– convince others of what to do
• lead by example
• Peer to Peer
• with statistical kosher evidence
K. Silvester 170607
Global Summit Ospreys

6. Traditional NHS Management
Unit Cost
Clinic
Radiology
Laboratories
Theatres
Admin
Wards
Unit cost
Clinic
Unit cost
Activity
cost
Activity
cost
Activity
cost
Activity
cost
Activity
cost
Activity
cost
Activity
cost
K. Silvester 170607
Global Summit Ospreys

7. Flows in a Healthcare System
A&E
&
EAU
GP
Radiology
Pathology
‘Tests’
Pharmacy or
elsewhere
Home
Follow up
Long term
care
Social
services
NHS
dir
Specialist clinic
Specialist clinic
Specialist clinic
Specialist clinic
rehab > 3 / 52
theatre
1 to 10 days
Day case unit
(inc Endoscopy)
Pre
op
assess
Discharges Deaths
Quick
Sick: specialist ward
theatre
ITU
K. Silvester 170607
Global Summit Ospreys

8. Primary Care Trust’s Spend
by flow through Hospital
PCT expenditure on Flow
0
10,000,000
20,000,000
30,000,000
40,000,000
50,000,000
60,000,000
Elective Non elective New OP FU OP
Patient Flow
£s
This is failure
demand from the
‘green’ process
K. Silvester 170607
Global Summit Ospreys

9. Grouping of diagnostic codes
for top 50% of emergencies
What is the process
for these patients?
Groupings Cumulative Total Cumlative %
IHD/chest pain 758 22.14%
Respiratory infection / disease 1236 36.10%
Abdo pain/appendix 1703 49.74%
Atrial Fibrilation and flutter 1873 54.70%
Poisoning 2029 59.26%
Localised swelling, mass, lump lower limb (DVT)2163 63.17%
# Neck of Femur 2292 66.94%
Syncope & collapse 2420 70.68%
Urinary Tract Infection site unspecified 2544 74.30%
CVA Cerebral Vascular ‘Attack’ 2660 77.69%
Cellulitis of other parts of limb -axilla, hip, shoulder2774 81.02%
Chole/pancreatitis 2881 84.14%
Inf or Cx procedure 2988 87.27%
Miscarriage 3094 90.36%
Heart failure 3188 93.11%
Asthma unspecified 3263 95.30%
Head Injury 3326 97.14%
Senility – ‘off legs’ old age 3375 98.57%
# other parts lower leg - ankle 3424 100.00%
K. Silvester 170607
Global Summit Ospreys

10. Pareto Analysis
50
6
0
1000
2000
3000
4000
5000
W42.1
T42.3
J43.9
G45.9
Q18.1
Z42.1
W41.3
P22.1
Z94.1
H36.9
N26.2
T46.2
W74.1
Z44.9
Patient Type (elective surgical procedure)
CumulativeDemand
Cumulative
Demand: Pareto
50
5
20
80
K. Silvester 170607
Global Summit Ospreys

11. Value Stream Management
Unit Cost
Clinic
Radiology
Laboratories
Theatres
Admin
Wards
Unit cost
Clinic
Unit cost
Activity
cost
Activity
cost
Activity
cost
Activity
cost
Activity
cost
Activity
cost
Activity
cost
RONA
RONA
RONA
RONA
RONA
K. Silvester 170607
Global Summit Ospreys

12. What is a
Clinical Systems Engineer?
• Responsible for ‘healthcare production line’
– from presentation
– to discharge & prevention (death)
• Meets demand
• Timeliness, cost and quality
• Chief Engineer?
K. Silvester 170607
Global Summit Ospreys

13. What we need to do
Hierarchies
• People are problem
• Parent to child
• Fire-fighting
• Short term
Functional view
• Focus is organisation
• Waiting list = asset
• Utilisation
• Unit cost
• Quality costs money
Comparative methods based
on averages
(Audit Commission, Monitor,
Dr Foster,)
Batch production
Push systems
Teams
• System is problem
• Adult to adult
• Persistent, consistent,
• Long term
Process view
• Focus is Patient
• Waiting list = liability
• Waste
• Return on Net Assets
• Quality saves time,
money and lives
Variation in one system in
real time
Flow
Pull systems
Human dimensions of change
Systems dynamics
Steady state & dynamic state
Theory of Constraints
Short term optimising of bottlenecks
Statistical Process Control
Lean
Understand Human Body
Processes required to ‘fix’ it
Value streams
Understand demand
Improve flow
Eliminate waste
Leading by exampleK. Silvester 170607
Global Summit Ospreys

14. Who are we?
• Sponsored by 6 Strategic Health Authorities
– ‘Clone Kate’
• 1st batch: 2004 - 06
– 9 doctors:
• General Practice (Primary Care),
• Hospital care (Secondary care)
• Mental Health
• 2nd batch : 2006 - 08
– Mixture of healthcare professionals with clinical
background
K. Silvester 170607
Global Summit Ospreys

15. Osprey Plan
6
months
12
months
May
06
Nov
06
March
08
0
May
07
Nov
07
Improved
Performance
Improved
PerformanceKate
Curriculum
Practice
& experience
Ospreys
Local
Project
teams
Senior
Managers
Senior
Clinicians
data Senior
Managers
Senior
Clinicians
knowledge
confidence
feedback
feedback
feedback
May
08
2 years18
months
K. Silvester 170607
Global Summit Ospreys

16. Queen Mary’s Sidcup
Patients discharge from Hospital
Weekly medical Length Of Stay 80%
3
4
5
6
7
8
3-May-04
17-May-04
31-May-04
14-Jun-04
28-Jun-04
12-Jul-04
26-Jul-04
9-Aug-04
23-Aug-04
6-Sep-04
20-Sep-04
4-Oct-04
18-Oct-04
1-Nov-04
15-Nov-04
29-Nov-04
13-Dec-04
27-Dec-04
10-Jan-05
24-Jan-05
7-Feb-05
21-Feb-05
Weekly readmissions within 28 days of discharge
20
40
60
80
100
120
3-May-04
17-May-04
31-May-04
14-Jun-04
28-Jun-04
12-Jul-04
26-Jul-04
9-Aug-04
23-Aug-04
6-Sep-04
20-Sep-04
4-Oct-04
18-Oct-04
1-Nov-04
15-Nov-04
29-Nov-04
13-Dec-04
27-Dec-04
10-Jan-05
24-Jan-05
7-Feb-05
21-Feb-05
Quality: better ?
No increase in
readmissions
Saving: £1,368,750 p.a.
(based on 30 discharges
per day and hotel costs
£125/day)
Time: average LOS for
80% of medical
patients reduced by >1
day
K. Silvester 170607
Global Summit Ospreys

17. 55
60
65
70
75
80
85
90
95
09-Jul-05
16-Jul-05
23-Jul-05
30-Jul-05
06-Aug-05
23-Oct-05
30-Oct-05
IndividualValue
Crisis team of nurses
(trying to block admissions)
* Consultant Psychiatrists
in front line seeing
1 or 2 emergencies / day
Time:
3 day wait to
same day assessment
Crisis Team cost ++
* Savings: some agency nurse costs,
+ Saved £2M on out of district
placements
Quality: no increase
in suicide rate.
Patients Delighted
Staff ‘Thrilled’
Mental Health: bed occupancy
Bed Occupancy %
K. Silvester 170607
Global Summit Ospreys

18. Osprey Plan
Kate
Senior
Managers
Senior
Clinicians
Curriculum
Practice
& experience
6
months
12
months
Improved
Performance
Improved
Performance
data Senior
ManagersOspreys
Senior
Clinicians
knowledge
confidence
May
06
Nov
06
March
08
0
May
07
Nov
07
Local
Project
teams
feedback
feedback
feedback
May
08
2 years18
months
K. Silvester 170607
Global Summit Ospreys

19. Sorting the System
• Over to Dr. Steve Allder!
– Osprey for Derriford Hospital, Plymouth
K. Silvester 170607
Global Summit Ospreys

20. Summary: What is an Osprey?
Systems
Understanding:
Complexity
& Variation
High
Low
NHS (Project)
Manager
University Lecturer Clinical Systems Engineer
Improvement Advisor:
e.g. Lean / 6 Sigma
‘I’ve hit the target so what
is the problem?’
‘I have never had to deal
with such complexity
before!’
‘Its all very well in theory –
but putting into practice is
another matter!’
I understand the system
+ target improvement
interventions
Measure time, cost & quality
Few tools Lots of toolsApplication of Improvement
Tools and Techniques
K. Silvester 170607
Global Summit Ospreys

21. Batch 2008 -2010?
• University of Warwick Medical School
– Osprey as post graduate programme
– Lots of doctors interested but funding required
– 5 NHS Organisations interested currently
• Advice please!
K. Silvester 170607
Global Summit Ospreys