7 day working:

can you tame a wicked problem?

Dr John Lowes, Dr Mike Williams, Dr Oliver Dyar

Learning from South Devon & Torbay

THREE TYPES OF PROBLEM

Simple

Build a rowing boat - change a rota

Complicated but tame

Design and build a hospital

Wicked – running healthcare delivery services

Solutions are difficult to recognise because of the complex interdependencies that surround the problem

Wicked problem

1. ‘Problem’ is ill structured – solutions expose new problems

2. There is no definitive ‘solution’

3. Solutions are assesses in a social context –

many views of what is good as consequences

ripple out

5. Every attempt to solve has consequences –

spawn new problems

6. Matter of creativity to devise potential solutions; judgement

to decide which are valid

Rittel, H. & Webber, M. (1973) Dilemmas in a General Theory of Planning. Policy Sciences, 4, 155-169. Conklin, J. (2006) Dialogue mapping – building shared understanding of wicked problems, Chichester, John Wiley & Sons.

4. Problems are unique due to dynamic social

context

7. Is a symptom of another problem

Taming Wicked

problems

Lock down the problem – solvable

sub-problem

Assert that the problem

is solved

Specify objective parameters to

measure success

Give up trying to find good solution – just

follow orders

Declare there are just a few solution; frame

problem as either - or

Conklin, J. (2006) Dialogue mapping – building shared understanding of wicked problems, Chichester, John Wiley & Sons.

Cast problem as ‘just like’ a solved

problem

Ignore social complexity

A wicked problem tamed?

7 day emergency only service

Full 7 day for all services

7 day urgent care

7 day urgent plus partial

elective

How to respond

Simple Complicated (Tame)

Wicked

Command

Manage

Lead

Just do it

Project manage process

Engage in dialogue & social change

7 day force field

Curre

nt sta

te

Weekend mortality

Perceived costs

Senior staff preferences

Lack of whole system approach (primary and

community services)

Recruitment & retention of staff

Public & political opinion

Media interest

Supervision of junior staff

Push harder creates stronger push back therefore...

enter into dialogue to engage in social process to address emotional values and concerns

Torbay & South Devon Journey South Devon

Healthcare NHS Foundation trust

2007

Torbay & South Devon Health &

Care Trust 2005

Integrated H & Care

Zones 2007

Intermediate care services

2009

Radiology services 2000+

Hospital @Night

2004

T & O service/

#NOF

Acute physician

model

Enhanced recovery

in surgery

Extended ward round

Combined ICO 2014?

Joinedup Health &

Care Cabinet 2011

System modelling, mapping &

understanding

Enhanced recovery

in medicine

Sunday test of

change - discharge

Weekend working -

Trainee Doctors

Hospice@Home

Joinedup Leadership

Norman Lamb

Pioneer Bid

Redesigning the front

door

South Devon & Torbay CCG

Modelling & understanding our system – plan for reality not rhetoric

Acute emergency admissions have been rising at ~1.6% per annum

Modelling & understanding our system – 8 mins or 8 hrs to treatment

• GPs visit sickest patients 1 - 3pm – then phone for ambulance (HCP calls)

• Ambulance prioritise 999 response < 8mins therefore GP call as ‘urgent’ <4 hrs

• Patient arrives at hospital late afternoon / evening

• Patient’s need subordinated to local optimisation of parts of system

Calls per hour by time of day by GPs 2009 - 2011

“Visits are a very inefficient use of GP time.”

“Achieving the 999 target is our priority.”

Modelling & understanding our system – junior doctor capacity

Junior Doctors estimated clerking capacity (1 hr per pt) cf expected admissions

Weekend Weekday

Modelling & understanding our system – primary care

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5

10

15

20

25

30

35

40

A B C D E

GP Survey (July 12 - March 13) (Q12) Failure demand (%)

No

Call Back

“March is always busy but I think that’s because of doctors on holidays. We seem to take our holidays around this time for some reason, I don’t know. “ GP

Problem

• Sustained increase in emergency admissions (Highest % unplanned medical)

• Low levels of discharge at weekend, particularly on Sundays.

• Requirement for additional escalation beds to cope with demand

• System has continued to be under significant pressure

• Variation in the quality of care inc. safety, patient experience & outcomes

Aim

• To reduce the variation in care 7 days a week

• Sunday test of change – multidisciplinary consultant led ward round

• Weekend test of change – timely discharge summaries (ongoing)

Sunday test of change: consultant led multi-disciplinary ward round

Sunday test of change: what happened

“Flow been much better into the hospital. No significant delays in getting beds”

EAU Consultant

“ Much calmer on ward area. Patients seen by team over

weekend reassurred that they were not forgotten over the

weekend” Staff nurse

“Greatly reduced number of 2nd calls chasing patient jobs” H@D

Findings inc: •Improved team work •Calmer •Empty beds on Mon. •Improved flow •Better organised •Better patient care

Actual discharge rates and forecast savings by increasing discharge rates

Note: Discharge rates increase throughout week. It is possible that 7 day working would maintain discharge rates at the higher end of the observed values.

How can we better match the resource of foundation doctors to out of hours demand?

0900

1100

1300

1500

1700

1900

2100

2300

Medical Surgical

SURGICAL JOBS Acute reviews PR bleed – EWS 7 Routine reviews Prescribe fluids Take bloods Put in cannula Analgesia

MEDICAL JOBS Acute reviews Chest pain – EWS 8 Routine reviews Prescribe fluids Prescribe warfarin Take bloods Examine ear Put in cannula Elevated BM

Medical

Surgical

F1 ward cover: weekend test of change

F1 ward cover: what actually happened

Medical F1 Surgical F1

H@D/H@N

Ward staff

Patients

“Actually managed to finish on time” F1 doctor

“I felt like I was on a team with the other F1s, there was more opportunity to ask for help on certain

wards, and workload felt more manageable. F1 doctor

“No 2nd calls, jobs completed earlier… I felt like I was

actually coordinating” H@D

“When doctors arrived .. they did all the jobs [medical and surgical] meaning patients were not left for hours in pain or without fluids” Nurse, Allerton ward

Taming a wicked problem – solutions are context specific; methodology is generalisable

In Torbay & South Devon during the next 5 years those aged 70-75 will increase by 35%, those over 90 by 20%.

Engage in dialogue & social

change

Project manage process

Just do it

Lead

Manage

Command

Wicked Complicated (Tame)

Simple