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NEAT within the hospital Culture, strategy and how to embed timely quality care
or
Don’t mention the war!
ACI/NSW Health/ECI Seminar, Sydney, 13th December 2013
A/Prof Harvey Newnham,Clinical Program Director Emergency & Acute Medicine,Director of General Medicine,Alfred Health, Melbourne
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How are we doing?
Improved Much the same Worsened No idea
1. Quality of patient care in your sphere of influence in 2013 compared with 2011 is ……………..?
2. In what way do you feel the 4h NEAT approach to date has contributed to quality of care?
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Survey of Directors of Victorian
General Medical Units
September 2013
Certainly has led to increased focus on patient through put and we have implemented some practice change to improve thisFocus on KPI's to the detriment because we are treating a performance measure as an objectiveThe 4 h NEAT target has been a catalyst for some positive changes although there are balancing negative effectsHave noticed very little difference in realityIt has helped focus on what was previously very poor and unpatient centred performance.
Pressure on JMS to discharge patients and to transfer patients to ward regardless of clinical management requirementsIt has been challenging to maintain the high standard of patient care but feel we have achieved this.Shorter ED length of stay and earlier contact with the treating team has lead to benefits overall
There have been stress points with ED at times and some tensions that we have had to resolve Pressure leads to deterioration in behaviours General medicine is looking closer at internal structure and perhaps not filling gaps in other services as it was previously We have been better accepted by ED people
The registrars feel more stressed and there has been some pressure put on them by ED staff which they have found difficult to manage Resources allocated to assist with achieving targets We have had to operate within existing budget It has helped focus on gaps in rostering
Consistent practice, excellent senior staff input, wonderful nurses and junior medical staff with great nursing leadershipVery happy with care once they get in.
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The Zen of HealthcareIt’s not about what happens.
It’s about what you do with what happens.
Modified from Aldous Huxley
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Working in healthcare:
What’s not to like?The people:
Smart,
Experienced,
Committed,
Ultimately want to do the best job they can for our patients
Very substantial Resource
High degree of public, political and administrative Engagement
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Context of NEAT:Essential problems in delivery of careFor many patients we don’t know what to do.
When evidence exists it is often not applied.
Fidelity of execution.
Our health system is tweaking an historical model of care rather than designing its own future
Solution: Design and create a comprehensive system for delivering health care.
Richard Bohmer “Designing Care” 2009
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All just too hard
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Don’t mention the war(However will we win?)
It’s not about 4 hours – pebble in a pond
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It’s not about working harder
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E &TC cubicle occupancy May to August 2011, 2012, 2013
2011
2012 2013
2009
Which department would you prefer to work in?
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Timely Quality Care (TQC) Transforms the way we treat our patients to
ensure they all receive timely, quality care consistent with their clinical needs
Is a whole of health service change that involves everyone (clinicians, managers and support staff)
Changes how we assess and treat our patients from the moment they arrive to the time they are discharged
It is about excellence in patient care
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It is a new paradigm‘It is no longer tenable that a good practitioner can provide the best care other than as part of an effective team within a well organised health care delivery system.’
Translated into medicalese: We can enjoy what we do, use our skills to provide effective care,
have a manageable workload and maintain reasonable remuneration, if we learn how to be part of an effective team.
Management speak: We want everyone to work at the mid-upper level of their
competency. We all need to
• work differently or • be paid less or • get off the bus.
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The Good News
The best innovations happen within the tightest constraints
Paraphrased from Clayton Christensen, in ‘the Innovator’s Prescription’
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Our Timely Quality Care Journey
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Alfred Health
3 hospitals: The Alfred; Caulfield Hospital & Sandringham Hospital Around 900 beds; 90,000 ED presentations, 92,000 inpatient events;
170,000 outpatient attendances. Approximately 5000 equivalent-full-time staff made up by around
7000 people State-wide services for trauma, burns, heart & lung transplants, HIV /
AIDS, hyperbaric service, cystic fibrosis, haemophilia, Melbourne Sexual Health Centre
$900 million per annum Strong General Medicine
Highest bed-day user
The Journey starts:
Harvey H Newnham, Pieter De Villiers Smit, Martin J Keogh, Andrew M Stripp, Peter Cameron MJA 2012 p101
In August and September 2010, four of us (H H N, P De V S, M J K, A M S) undertook an investigative tour of 13 emergency hospitals in the United States and the United Kingdom to observe innovative approaches to patient flow pathways from the emergency department (ED) to inpatient wards and consider their potential for use at Alfred Health
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The Journey towards Timely Quality Care
E&TC and Acute/GenMed in same program
Site visits US & UK 2010
In house conversations
Individual unit developments –
AMU model of care etc, E&TC modifications
Formation of Whole of Hospital TQC Steering Group
Data, and more data
Site visits to Perth Hospitals
Importance of engaging HMOs
Draft principles established for whole of hospital approach
Stakeholder input into principles
Sign off by HOUs of principles
Travelling roadshow by COO
E&TC Design sessions
Launch of daytime TQC Nov 2012
Formation of Hospital at Night steering committee late 2012
–Conversations about hospital at night–Draft principles established–Stakeholder input–Promulgation of hospital at night plan–Launch of hospital at night (ie 24h TQC) Feb 2013
Ongoing monitoring by steering group
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TQC – Craft group specific approaches to implementation
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Leadership Workshop
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Concerns must be voiced and taken seriously
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GENERAL MEDICINE DESIGN WORKSHOP
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Key Whole of Hospital Changes
Trust The Emergency physicians’ decision to admit The inpatient team to promptly provide appropriate
care The investigative/interventional services to deliver in
24 hours (treat in turn) Management to apply resources according to system
design/priorities based on accurate data Adjust rosters/work patterns to ensure staff are available
when required Match bed capacity to the time of highest demand and
ensure patient goes to the correct bed first time admission beds, SAAU’s, MAAU's & Flex beds
Develop safe after hours/overnight teams
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Triage has become Streaming
3 minute assessment maximum ATS allocated (? is it still relevant)
Patients streamed to either: Resus & Trauma: RITZ:
Prioritise Cat 2 & AV to front of queue Everyone else treat-in-turn
Fast Track: Treat-in-turn
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Upfront Senior Decision making for all patients….
RITZ (Rapid Intervention & Treatment Zone)
Consultant led assessment team Determine interim management and
disposition plan “Treat in turn” principle instead of
“triage & wait”
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Safety is OK
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Dr Foster global health comparator
Alfred Health
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Bypass: Our Doors are Always Open
The Alfred
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NEAT 4h KPI July 2011–March 2013
NHPA website Sept 2013
The AlfredTarget 75%
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Patient Access as per NEAT
Acute General Medicine Patient Pathway
*Via call to streaming APT registrar & nurse.
With interim orders DIRECT ADMITfrom community,
clinic or other hospitalvia call to *lead
consultant
RITZ
HOMEor
CH, SH, HITH, private hospital
E & TC
Team ATeam B
Ward 4GMU
4 Identical teams A-DConsultant (8-12/1600*pm)APT (8-1700)BPT (8-2130)2 x Interns (8-4 & 11-1930/2130)Daily consultant ward round
*Lead Consultant
Patient
Team CTeam D
Ward 4AMUStreaming
APTStreaming
nurse
AAU
ESSU Cubicles
As at 2nd December 2013
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TQC GenMed % E&TC Admitted <4hJune-November 2013
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Staff Experience – 12 months on…….
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What NEAT is showing usBefore NEAT
Good Doctor + Experience + Resources = Best Care
Doctor: custodian of knowledge, skills and application of these to the individual patient
Organisation: provider of resources
After NEAT
Health care delivery organisation manages….
Practitioners - typically in multidisciplinary teams
Knowledge base - decision support and practice-based evidence
Processes of care – reduced variation and delays, outcome orientated
to provide best healthcare outcomes at affordable cost
Adapted from Richard Bohmer “Designing Care” 2009
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10 Big Ideas Future Hospital Commission 2013: “the most important statement about the future of British medicine for a generation”
“Hospitals must offer “seven-day care, delivered where patients need it”.
It's time to build a new movement for generalism, not specialism—”generalists are the undervalued champions of …acute hospital service”.
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Major Gaps
Practice-based evidence is in its infancy in our systemCan’t implement change unless monitoring systems are good enough to
learn from mistakes and measure failure
Integration is essentialThe divide between hospital and community care leaves us impotent
regarding demand management
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Where next?PM’s & weekends
Treat-in-Turn expansion Cardiology
Gastroenterology
Patient discharge pathway
Matching staff with workload (volume and time)
New ward governance models
Standardisation of ward rounding
How many admitting units do we need?
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ConclusionsDon’t mention the war – it’s not about the 4 hour KPI!
It’s not about working harder -
• It is about leadership, teamwork, design, and reducing variation
• Hospitals are full of smart people, we need to create the environment/culture that allows them to achieve their potential
It is about quality and excellence in care – quality saves time and money
It is a journey that your staff have to travel with you
Let’s get the job done and move on to address the bigger issues
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Acknowledgements
Martin Keogh – Services Director, Emergency and Acute Medicine
Andrew Stripp – Chief Operating Officer
De Villiers Smit – Director Emergency Services
Peter Hunter – Program Director of Aged Care and Rehabilitation
Andrew Way – CEO
Bill Johnson – Program Director Surgical Services
Amy McKimm – Redesign manager
Many, many others
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GenMed Team Staffing Dec 2013+
8am
12pm
5pm
7.30pm
9.30pm
WEEKDAYS WEEKENDS
APT BPT INTERN BPTCONCONA B C DA A B C D A B C D A B C D A B C D A B C D
1pm
INTERN
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“Culture Eats Strategy for Breakfast”
Pre TQC Post TQC
You can’t remove triage Don’t bring back triage
That’s ED’s problem The hospital working more as a team
I was the wall Thanks for the referral I’ll see them on the ward
At night I see what’s on my list and just get on with it
We have a night team and meet at 9 for handover
Frequent unnecessary overnight calls to on-call staff
The After Hours Clinical Lead can decide
What training overnight Its great to get support, mentoring and education after hours
I would never ask a registrar to do one of my jobs
I’m not alone.
This is just about government targets ???? not so sure now
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Re-thinking E&TC Practices & Processes
Completely change triage Move from triage to streaming model
More timely care to reduce E&TC occupancy
Upfront senior clinical decision making “Treat in turn” instead of “triage and wait
New team structures Clarity of Roles & Responsibilities
E&TC to use their authority to admit Reduce need for negotiation & delay
Time based targets five years on: The WA perspective
and other lessons.
Dr Mark Monaghan
What has this been about?
Enhancing access to care for acute patients and making access to care a central component of excellent clinical care.
Replacing processes that are burdened with waste and protectionism, and thereby reducing morbidity, length of stay and mortality.
Creating a more effective system to cope with increasing demand.
Instilling the concept that hospital beds are a valuable resource that we as clinicians have a responsibility to utilise in the most efficient way possible.
What has this been about?
Key achievements – WA Program
Implementation of large scale, statewide change program
Establishment of redesign capacity across the system
Invested over $40M in solutions Leading the nation in emergency access reform
Where are we now?
In terms of numbers and targets, the WA State NEAT performance in high 70‘s, with our tertiary site performance stalled or deteriorated slightly.
Where are we now?
From a hospital clinician perspective it has created an improved work environment that persists despite challenges in maintaining tertiary performance.
The concept of the need to flow patients efficiently has been embedded to a significant degree. It is part of our language now.
A quick scan of the data
Presentation numbers compared to ED hours of care
Access block and mortality
Beds saved for ED presentations at Tertiary hospitals
What happened in 2012?
Transition from project teams to hospital executive ownership.
Consequent lack of drive of solutions and solution review.
Significant ED demand. Ministerial focus on NEST.
So what did we do about this performance trajectory?
We attempted to rally managerial and clinician engagement, however we were struggling to know where to start.
The Minister for Health commissioned an external review –The Bell Review.
The Bell Review
Daily accountability /core business Data Bed management structure/ outliers/ the
clinician’s role Consultant lead service-weekend performance Align multi-professional teams for timely
treatment and decision making ED discharge stream perfomance, decreased
patient moves within ED.
The Bell Review
Capacity audit analysis. 25-30%, half of which is under hospital control.
Simplified points of access to specialties. Acute unit structure and staffing. “a safe haven”,
with focus on inclusion rather than exclusion criteria.
Appropriate IT solutions
The Bell Review
Essentially, the take home message was that if you want this to be successful, you have to get serious and run it like a professional business should run.
What has happened since
Executive restructuring was already occurring in several of our tertiary sites. This is occurring across all tertiary sites now.
This includes leadership training, greater time allocation to divisional heads, JDF changes to incorporate NEAT accountability (eg FSH).
What has happened since
Bed management disassembling and increased clinician involvement.
Services to provide seven day structure –endpoint being equivalent discharge rates to weekdays
Data/CapPlan utilisation for daily clinician bed management.
Some real accountability and ownership is being seen at a hospital level.
Some general observations to consider
ED versus Inpatient reform. Flogging the discharge stream The admission stream dilemma. Direct admissions, inpatient occupancy and the
core role of the ED The future of NEAT The ministerial drive effect
Thanks