South Warwickshire NHS Foundation Trust has taken a whole system approach to improving its emergency care performance. The impact has been felt across the hospital. Mortality has reduced by nine points and medical outliers are down by eight per day. Staff satisfaction levels are now amongst the highest in England, according to the National Satisfaction Survey.
South Warwickshire’s Chief Executive, Glen Burley, explained the Trust’s successful approach to improving emergency care:
"When we became a Foundation Trust, Monitor advised us that our emergency care performance needed to improve. We tried increasing our bed stock and opening up outlier wards but it made no real difference to the problem. Often, when we made improvements in the hospital, we merely shifted the problem from the front door (admission) to the back door (discharge). We realised that the problem was all about system flow and that was what we needed to address in order to achieve lasting change."
The Link between Mortality and Patient FlowIn 2013, the Trust took part in the Health Foundation’s Acute Flow project. This taught it several important lessons.
"We discovered a clear link between mortality and patient flow," said Glen. "It became clear to us that variations were driven by the admission date rather than the discharge date - in other words, getting it right at the first point of contact with patients could vastly improve outcomes. This meant making the right decisions early on, identifying the right specialities and getting patients to the right part of the hospital."
"While emergency demand is relatively predictable, we found that it is the capacity that varies, particularly out of hours. CIP (cost improvement programme) indicators are not always a reliable predictor of outcomes because, while individual departments might appear to be performing well, this does not always equate to the best flow for the patient."
"Our conclusion from all of this was that the key to improving flow, quality and productivity is to align capacity to demand. This also drives down costs. On this basis, we realised that we could only achieve the improvements we wanted to make by ensuring that the entire system worked in harmony with capacity and flow."
So, how did South Warwickshire do that?
Patient Experience
A complaint from a patient called Gerry prompted the Trust to invite him to come in and talk to them about his experience. Gerry spent eight days with them in total, explaining that, whilst his experience of the clinicians was excellent, there was no co-ordinated approach to his care and communication between specialities was poor.
The Trust process mapped Gerry’s journey through the hospital and discovered that, during his entire eight-day stay, there were only 34 hours’ of value-added time. The rest of the time was spent waiting... for decisions, for tests, for results, for To Take Out Medications (TTOs) to be written up. In response, South Warwickshire developed a number of whole system principles which it believes are fundamental to efficient patient flow.
1.Today’s Work Today
One of the areas that South Warwickshire identified as a particular bottleneck was the processing of blood tests. At the time, only 20% of blood results came back the same day. The reason for the delay was that the blood sciences lab had invested in high tech testing equipment which, while it dramatically reduced the cost of blood tests and produced great CIP results, meant that tests tended to be batched. Consequently, most tests were not done on the day that they were taken. The Trust worked with the phlebotomists, blood sciences team and porters to examine what could be done differently.
The solution they came up with was cost-free, immediate and highly effective. The blood sciences lab agreed to process tests as soon as they arrived rather than waiting until they had a batch. The phlebotomists agreed to start work slightly earlier to improve efficiency and the porters made it a priority to shuttle tests to and from the lab. As a result, now 80% of blood tests come back the same day which means that decisions can be made quicker and the need to do repeat blood tests has reduced. An unexpected consequence of this change is that GP blood tests can also be processed more quickly as they no longer tend to clash with the processing of batches of blood tests from the wards.
The hospital applied this same methodology to other areas that tended to cause bottlenecks, particularly radiology, and the results were similar. It also made use of time series data to help it identify the cause of delays in patient flow. This showed that many patients leave A&E and arrive in the Medical Assessment Unit (MAU) just as many of the doctors’ shifts are ending.
In some cases, this meant that patients were not assessed until the following day. In other cases, assessments fell to more junior grade doctors. South Warwickshire tackled the problem by extending the availability of senior decision-makers on MAU so that patient demand was more closely aligned with clinical capacity.
2.Assessment before Admission
Another principle identified as being critical for whole system performance is to assess patients before they are admitted. In MAU for example, each of the admitting specialities now visits the unit on a daily basis to identify their patients and initiate treatment even before the patients come onto the ward. This has resulted in faster treatment, better outcomes and improved teamwork between consultants and MAU physicians.
The Community Emergency Response Team works outside of the hospital to prevent unnecessary admissions by providing emergency support at home for patients. The definition of ‘urgent’ has been refined to mean ‘within hours’ rather than ‘within days’ and the team now works seven days a week.
South Warwickshire has also implemented an effective Ambulatory Emergency Care approach. As the system has become established, rather than sticking to particular Ambulatory Care pathways, every patient is now considered as potentially ambulatory unless there are clear indications to the contrary
3.The Frailty Specialist Service
Alongside the Community Emergency Response Team, the hospital has introduced a range of measures to ensure it avoids admitting frail, elderly patients unless absolutely necessary. In MAU, for example, there is now a dedicated frailty unit and there is also a specialist elderly care physician in A&E, with specialist multidisciplinary support.
4.Discharge to Assess
Not only is it important to avoid admitting elderly patients where appropriate, it is also critical to patient flow to be able to discharge in a timely way. South Warwickshire believes that assessing an individual’s ongoing care needs while they are still in an acute care setting is both inefficient and costly. It developed the Discharge to Assess initiative to enable patients to be discharged into their own homes, nursing homes or community hospitals to await assessment, once they have no medical need to remain in hospital.
The average age of patients using Discharge to Assess is 80 years and there are three main pathways:
Pathway 1 is for patients who are able to return home with additional rehabilitation support. Around 40 patients a week use this service.
Pathway 2 is for patients who cannot be discharged home but who have the potential to go home once they have received rehabilitation. Around 23 patients a week use this service.
Pathway 3 is for patients who are likely to need ongoing care in a residential home and who may be eligible for continuing health care funding. Around five patients a week use this service.
Rehabilitation support can be provided for up to six weeks once patients are at home and there are care coordinators who ensure a seamless transition of care from the hospital to community settings. Care coordinators are primarily nursing staff, but they also include occupational therapists and social workers.
The Trust has access to 30 temporary community nursing home beds, available for up to six weeks. These beds are funded by the Clinical Commissioning Group, commissioned by the local authority and case managed by the Trust. Two GP practices are commissioned to be linked to these 30 nursing home beds and provide care to patients during the six weeks. This is regarded as a critical success factor.
The service doesn’t only support timely discharge from the hospital, but it also maintains the patient’s independence wherever possible and reduces the need for long-term care packages. A multidisciplinary rehabilitation team, including GPs, nurses and physiotherapists, is available to provide care in patients’ own homes seven days a week, seven hours a day.
Discharge to Assess helps to speed up the flow of patients through the hospital and improves outcomes and patient experience, as individuals are able to return home quicker without having to wait in a hospital bed while their ongoing care needs are assessed. Although the service means that patients are being discharged earlier, it has not led to an increase in readmissions. The proportion of patients who need continuing health care funding following Discharge to Assess is roughly half of that for those who do not use the service.
Impact of the Whole System Approach
- South Warwickshire’s pioneering whole system approach has produced a range of positive impacts. Mortality rates have improved by nine points, down from a baseline of 1.11 in 2011/12 to 1.02 in April 2015.
- Performance against the 4-hour emergency access standard is up from a baseline of 93.5% in 2011/12 to 95.4% in April 2015, an increase of 1.9%. Length of stay for acute patients is down by 1.5 days, from 7.7 days in 2011/12 to 6.2 days in April 2015. The reduction in length of stay for patients over 75 is even greater, down by 3.1 days from 12.6 days in 2011/12 to 9.5 days in April 2015.
- The average number of medical outliers is down by an average of eight per day, from 12 in 2011/12 to just 4 in April 2015.
- Staff satisfaction levels have increased steadily. South Warwickshire is now one of the top 10 trusts nationally for staff satisfaction, contributing to greater levels of engagement and motivation. Glen points out that this has also made recruitment and retention of staff far easier.
- South Warwickshire has learned a number of important lessons by taking a whole system approach which it is keen to share with others.
- Focus on action not explanation or escalation. Glen believes it is important to empower staff to do the things that will make a difference. He said: "In previous winters, I spent too many days in escalation meetings. Ultimately, giving staff the tools and confidence to make a difference is what will change things."
- Transformation takes time! At first performance indicators took a dip at South Warwickshire but as the whole-system approach became established, things improved dramatically.
- Be brave! Deconstruction is needed before reconstruction can occur.
- Get the narrative right. South Warwickshire found that patient stories were a particularly powerful way of getting the message across, as was stressing the link between patient flow and mortality. Glen points out that solutions that work well in other areas will always require fine-tuning for the individual locality. "You need to have local ownership and a solution that works for your individual circumstances," said Glen. "You also need to allow headroom for the inevitable bad days and a commitment to keeping going."
Glen Burley is the Chief Executive of South Warwickshire NHS Foundation Trust and Senior Responsible Office for the Emergency Care Improvement Programme
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