Whole system improvement in Forth Valley

Whole system improvement in Whole system improvement in Forth ValleyForth Valley

Improvement and support team meeting

15th Jan 2009

ContextContext

• Period of significant change and innovation • National collaborative projects• Integrated healthcare strategy includes new

acute hospital 2010-2011• Consistent bed pressures• Need for step change in results from

improvement activity– Implementation– Measureable benefit– Focus and prioritisation

Lean improvementLean improvement

• It’s about BALANCE and FLOW

Resources (R) =Cycle Time (CT)

Takt Time (TT)

Improvement on the ‘shop floor’ Improvement on the ‘shop floor’

time

Failu

re R

easo

n 1

Failure Count

Failu

re R

easo

n 2

Failu

re R

easo

n 3

Failu

re R

easo

n 4

Failu

re R

easo

n 5

Failu

re R

easo

n 6

3. Routinely act on the most costly failures using:

Concern Cause Countermeasure

Multi-disciplinary team, according to problem

Target

Process performance

# Who When Status

1

2

3

4

~~~~

~~~~

~~~~

~~~~

~~/~~/08

~~/~~/08

~~/~~/08

~~/~~/08

Action

~~~~~~~~~~~~

~~~~~~~~~~~~

~~~~~~~~~~~~

~~~~~~~~~~~~

1. Measure actual v target for key processes

2. Assign reasons for process failure, and count …

ProcessProcess

2 - 4 weeks 1 day 1-2 days 2 days1 - 2 weeks

Phase 1 Phase 3

Analyse the Forth Valley Whole System

Phase 2

Top Team Event Analyse Priority Areas

Phase 4 Phase 5 Phase 6

1 - 2 weeks

Prioritisation Event

Evaluate OptionsPolicy &

Planning Event

2&3 Dec 17&18 Dec12th Nov20th Oct

start

Executive challengeExecutive challenge

• Transition to new models of care across system

• £14.5m - £25m savings by Mar 2011• Maximum 18 week RTT by Dec 2011• Resilient U&E flow = 98% A&E asap• Consistent, safe care:

• HAI down by 30% by 2010

Day Patient In PatientClinic

community services – partnership model with LA

Home Visit

mental health; elderly care

district nursing

health visiting

specialist nursing

AHP (e.g. physio, OT)

other

GP referral

GP referral

GP referral

A&E

CAU

amb care

acutereceiving

unitin-patient

out-patient

diagnostics

rehab

day case

acute services

MIU

SAS

OOH

OOH, urgent & emergency services (community)

NHS 24

Specialist acute care

tertiary services

routinedischarge

complexdischarge

out-reach

refer to GP

refer on-going community care

LocalAuthorities

Partner & Vol organisations

AHP (physio)

sub-contract

GDP

GP

Community Pharmacists

family health services

Optom

GP direct

access

GP direct

access

GP feedback

Forth Valley System Map

7 Forth Valley Planning Event



Home Visit


district nursing

health visiting

specialist nursing


other

GP referral

GP referral

GP referral

A&E

CAU

amb care

acutereceiving

unitin-patient

out-patient

diagnostics

rehab

day case

acute services

MIU

SAS

OOH


NHS 24


tertiary services

routinedischarge

complexdischarge

out-reach

refer to GP


LocalAuthorities

Partner & Volorganisations

AHP (physio)

sub-contract

GDP

GP



Optom

GP direct

access

GP direct

access

GP feedback

1,300,000

962,000

789k OP; 135k IP

~130,000

300,000

65,000

32,000

81,000

80% occ; 294 beds

12,000

50,000

196,000

52,600

27,500

9,600 LOS=3.8 41,000

13,500

26,000 LOS=6.8

25,100

166,000

-

M 4,300




Home Visit


district nursing

health visiting

specialist nursing


other

GP referral

GP referral

GP referral

A&E

CAU

amb care

acutereceiving

unitin-patient

out-patient

diagnostics

rehab

day case

acute services

MIU

SAS

OOH


NHS 24


tertiary services

routinedischarge

complexdischarge

out-reach

refer to GP


LocalAuthorities


AHP (physio)

sub-contract

GDP

GP



Optom

GP direct

access

GP direct

access

GP feedback

963,000

~130,000

330k AHP 32k Nr

300,000

65,000

32,000

81,000

80% occ; 294 beds

28k DP; 17k OP

12,000

50,000

196,000

52,600

27,500

9,600 LOS=3.8 41,000

13,500

26,000 LOS=6.8

25,100

166,000

M 4,300

+12%

+24% (new)

-26%

+1.1%

+2%

+3%

1,300,000

+5%


38,000

3,000



Home Visit


district nursing

health visiting

specialist nursing


other

GP referral

GP referral

GP referral

A&E

CAU

amb care

acutereceiving

unitin-patient

out-patient

diagnostics

rehab

day case

acute services

MIU

SAS

OOH


NHS 24


tertiary services

routinedischarge

complexdischarge

out-reach

refer to GP


LocalAuthorities


AHP (physio)

sub-contract

GDP

GP



Optom

GP direct

access

GP direct

access

GP feedbackQ

Q

T

Q

T

Q

Q

Solutions to imbalance lie in whole system …

GP referral

in-patientout-patient

diagnostics day case

Discharge


home

out-patient Pre-Op Theatre

OutpatientsDemand 1000Capacity 793

9.5 wks 16.5 wks

1st OP Appt OutcomeDischarged 24.8%DNA 4%Failed Discharge 1.7%Awaiting Results 8.8%Waiting List DC 4%Ref other Clinics 2.7%IP wtg list 7%Blank/Other 8.8%Further Appt 38.4%

OP – Lost Capacity

Scheduled capacity

80% of demand

Quality Losses

17-42%

Losses = 29%

of capacity

Hips – Sept 08Capacity 363Pts seen 255(overtime 69)DNA 13Unfilled Appt 44Canc Clinic 50

45 wks (83% > 18 wks)

23.4 wks

3.2 Planned Orthopaedics Outpatients

Discharges by day of the weekDischarges by day of the week

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

Mon Tue Wed Thur Fri Sat Sun

Admissions

Discharges

19% Sunday

shortfall

Approx 60 bed days a week (£1.6M p.a.)

Opportunity to release Opportunity to release bed capacitybed capacity

ALOS by acute physician

0.01.02.03.04.05.06.07.08.09.0

4012

986

3078

732

3488

920

2247

072

3459

834

2580

302

3582

707

4321

077

3440

735

3132

449

1389

562

3668

661

4040

507

4334

778

2925

211

3098

279

1327

104

2845

793

4040

899

Day

s

30%

Distribution of acute LOSDistribution of acute LOSAre there 3 themes here ?

LOS All Specialties

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

20000

0-1 2-3 4-5 6-7 8-9 10-11 12-13 14-15 16-17 18-20 >20

LOS

Co

un

t

42%

Generally elderly patients. Avoid admission …

Reduce LOS by improved inpatient and discharge processes

Avoid admission and ambulatory care …

District nurse diary study:District nurse diary study:conclusionsconclusions

• Opportunities to increase productivity– Reducing lost time (eg. admin, meetings etc)– Scheduling domiciliary time more efficiently– Using lower grade staff for routine work– Shifting routine treatment room work to GP practices and

phlebotomist– Improving predictive planning with acute services– Balancing nursing resource effectively to meet 7 day a week demand

• Opportunities for released capacity– Increased capacity in treatment rooms to support acute discharge– Increased capacity for anticipatory care– Understanding return on investment of different options

Urgent & Emergency Work-stream

Enabling Work-streams : Leadership & Communication; Information & Metrics; Training; Programme Mgt;

Elective Work-stream

Primary & Community Work-stream

Diagnostics Work-stream

Redesign whole system U&E pathway

Mainstream advanced care planning to reduce inappropriate hospital

admissions

Improve quality of Urgent and Emergency “front door” services

Reduce avoidable unplanned admissions

Systematic improvement in acute

in-patient management

Releasing/developing capacity in primary care and community services

Systematic improvement in LA

supported discharge

Reduce variation in referral management

Systematic improvement of Labs

Increase CT (MRI) productivity / capacity

Articulate the productivity benefits

from 18 week programme

NHS Forth Valley Priority Improvement Work-Streams

Improve ‘home-to-home’ visibility of patient pathway

ConclusionsConclusions

• Whole system perspective was revealing– Increased focus on primary and community care

• Process highlighted the need for good information– Real focus on evidence

• Challenged us about how we prioritise resource use• Produced plans with clarity and shared understanding

Documents

Whole system improvement in Forth Valley