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Supported by and delivering for:
London’s NHS organisations include all of London’s CCGs, NHS England and Health Education England
Taster session:
Patient journey (flow)
Professor Derek Bell and Jane Clegg RN
1
Outline of the taster session
2
Aims and objectives of the session:
• To understand the importance of effective patient flow throughout the whole
pathway including coming into and out of acute settings
By the end of the session we will have:
• Increased awareness of importance of taking a whole system perspective and
considering each step of the patient journey in order to maintain seamless patient
flow, both into and out of acute settings
• Two priority actions and what support is needed locally to take actions forward
Change is part of everyone’s role
3
What is “quality improvement” and how can it transform healthcare?
Paul B Batalden and Frank Davidoff, Qual Saf Health Care. 2007 Feb; 16(1): 2–3.
Whole system’s approach
4
GP in hours GP out of hours NHS 111 Ambulance (999)
Emergency Department
Acute medical/surgical assessment unit
Patient Ward
(any specialty)
High Dependency Unit/ Intensive Therapy Unit
Community Rehabilitation
Hospice Nursing/
Residential Home Care at Home
HOME
Patient journey vs patient flow
Whole system flow
5 Hospital catchment areas are much larger than imagined
Emergency care flow is critical for patient
experience, clinical outcomes & quality of care
6
Assessing & treating patients who require emergency care is time critical for
good patient experience and outcomes
Efficiently managing all patient groups accessing emergency care will
improve patient flow through pathway
For those being admitted, prompt assessment and transfer to appropriate
in-patient area with the correct clinical staff, care team and equipment is
essential to ensure high quality & effective care
Evidence suggests the sooner patients moved to the right clinical
environment, the better the overall outcomes
Why Emergency Flow?
The 4-hour measure: A powerful marker of overall system function
A measure of the percentage of patients being seen by ED within 4hrs
Important measure of overall patient flow and whole system performance
An indicator of quality from a patient perspective
System factors within the control of hospital services are primary drivers to improve flow
Evidence suggests patients with longer waits have poorer clinical outcomes and poorer
patient experience
4hr standard acts as a barometer or pulse, but we need other measures.
NHS Constitution: MINIMUM 95% of patients attending A&E must be seen, treated
and admitted / discharged within 4 hours
UK overall performing poorly
4hr standard progressively deteriorating since September 2013
7
Maroon
axis =
number of
breaches
Blue line =
average
attendance
monthly
Green line =
overall 4hr
performanc
e
1. UK 4 hour
standard not met
at all since
September 2013
2. Gradual continuous
deterioration since
Aug 2013
3. Significant further
deterioration in
performance since
Aug 2015 down to
80% in Mar 201
4. Signs of new
period of
deterioration since
Sep 2016
Analysis Line Graph
Gradual continuous decline in performance since 2013, despite a steady attendance. Worryingly, a
new downward trend since September 2016, with performance down to under 80% in December 2016
Attendance remains
stable within current
accepted variation
Increase in breaches
consistent with
performance decline
Different groups of patients move at different speeds
8
92.8%
82.5%
72.8%
67.9%
70.6%
81.0%
87.9%
82.1%
70.3%
73.0%
88.6%
30%
35%
40%
45%
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
100%
08/0
1/2
012
22/0
1/2
012
05/0
2/2
012
19/0
2/2
012
04/0
3/2
012
18/0
3/2
012
01/0
4/2
012
15/0
4/2
012
29/0
4/2
012
13/0
5/2
012
27/0
5/2
012
10/0
6/2
012
24/0
6/2
012
08/0
7/2
012
22/0
7/2
012
05/0
8/2
012
19/0
8/2
012
02/0
9/2
012
16/0
9/2
012
30/0
9/2
012
14/1
0/2
012
28/1
0/2
012
11/1
1/2
012
25/1
1/2
012
09/1
2/2
012
23/1
2/2
012
06/0
1/2
013
20/0
1/2
013
03/0
2/2
013
17/0
2/2
013
03/0
3/2
013
17/0
3/2
013
31/0
3/2
013
14/0
4/2
013
28/0
4/2
013
12/0
5/2
013
26/0
5/2
013
09/0
6/2
013
23/0
6/2
013
07/0
7/2
013
21/0
7/2
013
04/0
8/2
013
18/0
8/2
013
01/0
9/2
013
15/0
9/2
013
29/0
9/2
013
13/1
0/2
013
27/1
0/2
013
Flow 1 - Non-admitted minors Flow 3 - Medical admissions National standardFlow 2 - Non-admitted majors Flow 4 - Surgical admissions
Hospital 2: weekly 4 hr emergency access performance, 2 Jan 2012 to 27 Oct 2013 Weekly 4 hr ED LoS compliance, by patient flow group, % Notes: (i) excludes planned reviews and ED ward stays; (ii) results are intended for management information only and are subject to change
4 h
r E
D L
oS
co
mp
lian
ce
, %
Different journeys, different days of the week
9
95.5%
60.0%
53.3%
60.0%
82.9%
79.2%
56.8%
52.9% 50.0%
46.2%
95.8%
30%
35%
40%
45%
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
100%08/0
1/2
012
22/0
1/2
012
05/0
2/2
012
19/0
2/2
012
04/0
3/2
012
18/0
3/2
012
01/0
4/2
012
15/0
4/2
012
29/0
4/2
012
13/0
5/2
012
27/0
5/2
012
10/0
6/2
012
24/0
6/2
012
08/0
7/2
012
22/0
7/2
012
05/0
8/2
012
19/0
8/2
012
02/0
9/2
012
16/0
9/2
012
30/0
9/2
012
14/1
0/2
012
28/1
0/2
012
11/1
1/2
012
25/1
1/2
012
09/1
2/2
012
23/1
2/2
012
06/0
1/2
013
20/0
1/2
013
03/0
2/2
013
17/0
2/2
013
03/0
3/2
013
17/0
3/2
013
31/0
3/2
013
14/0
4/2
013
28/0
4/2
013
12/0
5/2
013
26/0
5/2
013
09/0
6/2
013
23/0
6/2
013
07/0
7/2
013
21/0
7/2
013
04/0
8/2
013
18/0
8/2
013
01/0
9/2
013
15/0
9/2
013
29/0
9/2
013
13/1
0/2
013
27/1
0/2
013
Flow 1 - Non-admitted minors Flow 3 - Medical admissions National standardFlow 2 - Non-admitted majors Flow 4 - Surgical admissions
Hospital 2: weekly Monday 4 hr emergency access performance, 2 Jan 2012 to 27 Oct 2013 Weekly Monday 4 hr ED LoS compliance, by patient flow group, % Notes: (i) excludes planned reviews and ED ward stays; (ii) results are intended for management information only and are subject to change
4 h
r E
D L
oS
co
mp
lian
ce
, %
People moving more slowly at weekends…
Movement across the whole hospital
10
A single component of the patient journey
11
A patient at home has infective symptoms and will need a course of antibiotics.
He/she will not require hospital admission.
A patient at home has infective symptoms and will need a course of antibiotics.
He/she will not require hospital admission.
Table Discussion 1
12
Table 1
In your tables consider the following scenarios during normal working hours:
An elderly woman has fallen at home and has a painful hip. She is unable to walk
and so her neighbour has called an ambulance.
An elderly woman has fallen at home and has a painful hip. She is unable to walk
and so her neighbour has called an ambulance.
Table 2
A patient is going home after a 5-day admission post surgery and is awaiting
discharge letter and prescription…
A patient is going home after a 5-day admission post surgery and is awaiting
discharge letter and prescription…
Table 3
A man with terminal metastatic disease who is at home and has become acutely
confused. He is known to local hospice team and hospital palliative care team
A man with terminal metastatic disease who is at home and has become acutely
confused. He is known to local hospice team and hospital palliative care team
Table 4
Discuss the potential steps in these patient’s journey ..
Patients don’t actually flow… they can get held up..
13
What’s within your sphere of influence?
14
The Challenge
15
Increasing demands to improve quality increasing change initiatives at the point of care
Many initiatives fail
Reports of change fatigue due to:
Volume;
Associated workload (lack of capacity);
Lack of involvement;
Lack of perceived value of change
Four
Ideas to
Find
Time for
Improve-
ment
Copyright © 2017 NIHR CLAHRC NWL
Setting an
Improvement
Rhythm
Focusing on
“Highly
Adoptable
Improvement”
Use
Orchestrated
Testing
Stopping doing
things that don’t
work or don’t
work work well
1 2
3 4
The half-life concept
Setting time-based improvement targets
17
The half-life concept focuses goal setting around the length of time
it will take to reduce defects (or close a gap) by 50 percent.
“half-life” accommodates the notion of perfection, yet accepts that
it is achievable only in infinite time.“
if the goal is to achieve 98% and current operational performance
is 93% then gap is 5% so how long to achieve 2.5% as first stage –
set achievable time trajectory based on data
Effective framework for long-term planning
Maximally Adoptable Improvement
18
Change initiatives that do
not add additional
workload & have high
perceived value are:
more likely to be
adopted
cause less workplace
burden
achieve the intended
outcomes
Hypothesis
Understanding the data
19
• Notice the seasonality
• What is influencing the performance?
• This graph alone tells you about overall flow, but doesn’t tell you what’s
happening…
A patient at home has infective symptoms and will need a course of antibiotics.
He/she will not require hospital admission.
A patient at home has infective symptoms and will need a course of antibiotics.
He/she will not require hospital admission.
Table Discussion 2:
20
Table 1
In your tables consider the following scenarios during normal working hours:
An elderly woman has fallen at home and has a painful hip. She is unable to walk
and so her neighbour has called an ambulance.
An elderly woman has fallen at home and has a painful hip. She is unable to walk
and so her neighbour has called an ambulance.
Table 2
A patient is going home after a 5-day admission post surgery and is awaiting
discharge letter and prescription…
A patient is going home after a 5-day admission post surgery and is awaiting
discharge letter and prescription…
Table 3
A man with terminal metastatic disease who is at home and has become acutely
confused. He is known to local hospice team and hospital palliative care team
A man with terminal metastatic disease who is at home and has become acutely
confused. He is known to local hospice team and hospital palliative care team
Table 4
1. What would be necessary to improve your understanding of the patient
journey? Use the scenario that you’ve worked on as exemplar.
2. What support could the collaborative best provide you?
Improving the patient experience/journey..
21
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