On April 24 Ko Awatea welcomed Dr Ian Sturgess, National Clinical Lead for Urgent and Emergency Care in the UK and key driver for the production of the UK Directory of Ambulatory Care
Dr Sturgess hosted a clinical session around Managing Acute Care for People across the Health Care System and shared his experience of the teams he has worked with in supporting improvement and flow. Click here for the PowerPoint presentation.
Some key points from the presentation:
- -Patient flow is not just about productivity and efficiency – it’s about patient safety.
- -Beds are not capacity – beds are where patients wait for the next useful thing to happen.
- -If you add beds to a flow problem you will feel like you are getting better for about 3 months, then 3 to 6 months later it will be a lot worse if you haven’t changed the processes.
- -To bring about change requires a whole system approach.
- -If you have to admit someone – they need to go to the right bed first time every single time and not get moved around the system. If they move out of EC they get picked up by the service,
consistently and confidentially, because if they are not they bounce back.
- -What is true demand in EC? Demand is not activity – it is not the work that you do. Demand is a call on your time to get things done.
- -How do you measure demand out there in the community? You could measure how many dropped calls you get for a same day appointment? Because if you drop a call and a patient doesn’t get answered what do they do? They escalate up to the next level of care. So it’s crucial we understand about demand
- -What you have to be very clear about is what is capacity? In EC and an Assessment Unit capacity is the hours of decision making in the construct of a decision.
- -We need to get better at streamlining processes so you can maximise your capacity. We waste a lot of time doing things that we should not be doing. About 30-50% of your time is wasted when
you are not focusing on true capacity.
- -One of the big challenges is the use of data. There seems to be very little intelligence or use of data.
- -What we are aiming to do is to progressively and appropriately shift care safety and effectively in the community
- -For admitted acute care there are a number of things to think about. Identify the drivers, be clear about governance and leadership, not just the structure but behaviours. You create a
vision for the admitted care process in EC’s and Assessment Units. Identify what has value. And then standardise where appropriate.
- -Standardisation is absolutely crucial. How many people would like to get on an aeroplane where the pilot lands upside down and backwards? Standardisation is appropriate
- -70% of healthcare is highly predictable. Yet we add variance as clinicians, unnecessarily to patient’s pathways – this can increase harm and LOS.
- -Variance mismatch guarantees backlog. Most of this is down to the way we work.
- -ALOS (average length of stay) is not useful as a measure – it tells you nothing unless you deal with bed occupancy.
- -I sometimes hear the excuse that our patients are different – there may be some subtle differences but patients are not that different. It still doesn’t mean you can’t mange flow
- -What I hear a lot of is the problem is with someone else. What you need to remember is when you are pointing a finger at someone else you have 3 fingers pointing straight back at you.
- -If you can’t measure it – you can’t improve it: Lord Kelvin, 1824-1907
- -The methodology we use to help people improve their internal processes is based around what I would want if I was coming into hospital. Not what can I do with my present resources but what I would like in an idealised pathway if coming to hospital
- -The more handovers you have – the slower the flow. How do we minimise this?
- -What constitutes a senior clinical decision, especially when some decisions can be different? We need to standardise the structure of decision making.
- -Every single one of my patients has a Goal Discharge Date. The challenge is to get people using it
- -To improve patient flow – remove redundant steps
- -If you have variation – reduce batching. The biggest batching system is the consultant ward round. Visual work space management and Daily Consultant review can help maintain the daily drum beat
- -Junior doctors write lists of jobs and then go around again to carry them out. Why don’t they do them at the time?