Approaching NEAT targets from a policy and research perspective

Andrew Gosbell, ACEM Director of Policy and Research & Deputy CEO

Can overcrowded EDs be totally eliminated from the modern public hospital system?

ED stress points

• Increasing demand for ED services – increasing at rate greater than population growth and with increases in admissions from ED

20.0%

22.0%

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26.0%

28.0%

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40.0%

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Data sources: Australian Institute of Health and Welfare. Australian hospital statistics 2011–12:

Australian Bureau of Statistics. Australian Demographic Statistics

ED stress points • Constrained in-patient bed stock

• Broader health budget limitations

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Data sources: Australian Institute of Health and Welfare. Australian hospital statistics 2011–12:

Australian Bureau of Statistics. Australian Demographic Statistics

ED stress points

• Ageing population

• Increased prevalence of chronic disease (from National Health Survey

data)

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Australian Health Survey: Health Service Usage and Health Related Actions, 2011–12

Admitted to hospital as inpatient

Visited emergency/casualty

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85 years andover

%

Australian Population Growth (proportion by age groups)

2011

2026

2051

Data sources: Australian Bureau of Statistics. Australian Social Trends & Australian Health Survey

ED stress points

• Evolving roles for EDs – Growth in hospital admissions from ED

– Impact on patient care (12% population attend ED but EPs represent only ~4% specialist workforce1)

– Complexity of diagnostic work-ups

– Preventive care

• ED workforce changes – Increasing intern & trainee numbers over next 5-10 years

– HWA EM supply & demand projections unclear

1. AIHW Medical Labour Force Survey 2009

Solving ED overcrowding

Harvard Business School and Harvard Medical School 2012 Forum on Healthcare Innovation:

• identified “process improvements in care delivery” as the number one opportunity for both improving quality and controlling the cost of health care over the next 5 years

http://projects.iq.harvard.edu/forum-on-healthcare-innovation/

From problem to potential solution – National Emergency Access Target

COAG Expert Panel stated the primary aim of NEAT was to 'improve patient safety and quality of care by removing obstacles to patient flow that contribute to emergency department overcrowding‘

So to improve patient access NEAT is not as an end in itself, but ‘a tool to drive clinical service redesign and whole-of-system change, ensuring all obstacles to effective patient flow within a hospital are removed’ with ‘sustainable improvements over the longer term’

Expert Panel Review of Elective Surgery and Emergency Access Targets under the National Partnership Agreement on Improving Public Hospital Services, Report to the Council of Australian Governments , 30 June 2011. http://www.yourhealth.gov.au/internet/yourhealth/publishing.nsf/Content/Expert-Panel-Report/$File/Expert%20Panel%20Report-D0490.pdf

ACEM support for time-based targets

ACEM STATEMENT ON NATIONAL TIME BASED EMERGENCY ACCESS TARGETS IN AUSTRALIA AND NEW ZEALAND (S60)

• Time based targets are not an end in themselves

• Clinically appropriate patient care is paramount

• Targets must drive change throughout hospitals and into the community, and not just in the ED

• Additional resources necessary to achieve improvements

• Increased physical capacity and access to beds required

• Transparent, rigorous and independent monitoring expected

http://www.acem.org.au/media/policies_and_guidelines/S60_Time_Based_Access_Targets.pdf

Schedule C – National Partnership Agreement on Improving Public Hospital Services

C1. The objective and output of this Schedule will be achieved through a four hour NEAT where 90 per cent of all patients presenting to a public hospital ED will either physically leave the ED for admission to hospital, be referred to another hospital for treatment, or be discharged within four hours.

C10. The parties agree that whole-of-hospital engagement in achieving the NEAT will be essential, ensuring that all obstacles to effective patient flow are removed.

http://archive.coag.gov.au/docs/nap_improving_public_hospital_services.pdf

NEAT: why 4 hour 90% target?

• Consensus view that 4 hour timeframe = reasonable time to deal with the majority of ED patients and is aligned with patient expectations on timeliness of care

• 90% target allows for clinical appropriate LOS>4hrs in some patients

‘Four hours … it is meant to be tight – a stretch target’1

‘the final target of 90% is hard, but doable and safe’2

1. Four Hour Rule Program Progress and Issues Review. December 2011. Perth: Department of Health WA. http://www.health.wa.gov.au/publications/documents/FourHourRule_Review_Stokes.pdf

2. National Emergency Access Target Q&A with Mark Monaghan http://www.ecinsw.com.au/mark-monaghan

NEAT: as a stretch target? Pros:

• an important tool to drive process and system improvements in health care delivery

• focus attention on identified priority areas & promote excellence and innovation

Cons:

• Target fixation = improving outcome metrics rather than the process

• Stretch goals demotivating when seem overwhelming and unattainable

NEAT as public policy • Schedule C of NPA implicitly ends the debate on the serious

consequences of access block and provides a policy imperative to address this issue across the healthcare system

• Ongoing monitoring by NHPA, COAG Reform Council & AIHW is holding hospitals and jurisdictions to account and keeping this healthcare reform issue on the political/public policy agenda

Initial (period 1) NEAT performance

Data sources:

• National Health Reform Agreement - National Partnership Agreement on Improving Public Hospital Services, July

2011, Schedule C34

• Australian Institute of Health and Welfare 2012. Australian hospital statistics 2011–12: emergency department

care. Health services series no. 45. Cat. no. HSE 126. Canberra: AIHW

Initial impressions on level of support for NEAT

Data source: Australasian College for Emergency Medicine (May – 2013). Hospital Data and Accreditation Part 1:

Report of Findings. http://www.acem.org.au/media/publications/Hosp_Data__Accreditation-_Part_1_Report.pdf

DEM perceptions on the overall levels of support for NEAT from:

0%

20%

40%

60%

80%

FACEMs Registrars JuniorDoctors/CMOs

ED Nursing staff Clinical staff inother

departments

Clinicalleadership atyour hospital

Seniormanagement at

your hospital

No-minority support Equally divided support Majority-Unanimous support

Initial system reforms following implementation of NEAT

Data source: Australasian College for Emergency Medicine (May – 2013). Hospital Data and Accreditation Part 1:

Report of Findings. http://www.acem.org.au/media/publications/Hosp_Data__Accreditation-_Part_1_Report.pdf

0%

20%

40%

60%

80%

100%

ED Redesign Additional staffemployed

Hospital redesign Additional acuteinpatient beds

Improved access toradiology

Improved access topathology

Yes No NA

Initial impressions on effect of NEAT

Data source: Australasian College for Emergency Medicine (May – 2013). Hospital Data and Accreditation Part 1:

Report of Findings. http://www.acem.org.au/media/publications/Hosp_Data__Accreditation-_Part_1_Report.pdf

DEM perceptions on the effects of implementation of NEAT

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60%

70%

Disagree-strongly disagree Neutral Agree-strongly agree

Initial impressions on barriers

Top 5 barriers to achieving NEAT, from DEM responses:

• In-patient: Lack of engagement with/ slow review process

(46%)

• Lack of beds/poor bed management practices (40%)

• Lack of staff/VMO (on-call) model (33%)

• Lack of executive/wider hospital support (23%)

• Lack of direct access pathway (21%)

Initial impressions on enablers

Top 5 enabling factors to achieving NEAT, from DEM responses:

• Efficient patient flow processes, e.g. SSU/fast track (26%)

• Senior staff as leaders (21%)

• Global hospital support (19%)

• Proactive/supportive ED staff (19%)

• Specific staff for decision making/medical assessment units

(19%)

Important indicators

Top 5 indicators to be measured to assess safety & effectiveness of NEAT, from DEM responses:

• Representation rates – planned vs unplanned (42%)

• MET call rates (31%)

• Patient satisfaction/complaints (29%)

• Morbidity/mortality (27%)

• Critical incident/error reporting (17%)

Where to next with NEAT…

• NEAT metrics show that to meet target improved performance required in ED and especially the broader hospital

• Based on 2011-12 national average data for admission rates and access time performance:

• 90% = %admitted x %admitted<4hr + (1-%admitted) x %discharged<4hr

target

current

to meet target

discharge

admit

> 4hrs

Discharges perform at 95% or better

Admits perform at 75% or better

10%

90%

64%

Discharges at 78% Admits at 29%

Data source: Australian Institute of Health and Welfare 2012. Australian hospital statistics 2011–12: emergency

department care. Health services series no. 45. Cat. no. HSE 126. Canberra: AIHW

NEAT solutions

• Based on data/evidence and implemented with broad clinician buy-in

• Areas for consideration include:

– Emergency Department activities

– Hospital systems:

• Bed management

• Admission processes

• Discharge planning & processes

– Community actions

• Primary & secondary care options

• Preventive medicine

ED solutions & ACEM support

• Demand management – Review of Guidelines for Constructing an Emergency Medicine Medical Workforce (G23)

• Workforce numbers and roles – Workforce baseline data studies

– ‘ED Top of Scope of Practice’ Project

• Quality & safety of patient care – Quality standards project

– Patient safety project

– ACEM Quality Framework for Emergency Departments (P28)

– EMER (Emergency Medicine Events Register) Project

• ED design – Review of Guidelines for Emergency Department Design (G15)

Workforce baseline data studies

• Analysis of current staffing levels and rostering at all reporting

EDs in Australia to ascertain existing resource management

strategies.

• Includes all ED medical staff : FACEMs, non-specialist

medical staff, trainees and ED nurse practitioners.

• Aims to evaluate staffing levels in relation to demand for

service within Australian EDs in order to:

• establish the best practice for effective utilisation of ED

resources

• inform forecasting for future workforce needs

‘Emergency Department: Top of Scope of Practice’ Project

• To inform optimum use of the Emergency Department (ED) team so as to:

• better meet current and future ED demand in Australia

• facilitate the achievement of NEAT and other performance indicators

• improve the patient experience of the ED

• inform planning for the future ED workforce.

• By identifying and articulating:

• the specialised skills and knowledge that Emergency Physicians (of

different levels) have

• how Emergency Physicians are currently using these skills and

knowledge

• whether Emergency Physicians are working at the top of their scope of

practice, and if not, how this can be facilitated in the ED

• whether other ED staff are enabled to work at the top of their scope of

practice

Quality Standards and Patient Safety Projects

• Quality standards:

• within the context of the ACEM Quality Framework, to

develop detailed quality standards which include

objectives and criteria that can be audited and clinical

indicators that can be monitored, for implementation in all

EDs across Australia

• Patient safety:

• to establish a group of patient safety and diagnostic error

experts amongst the fellowship and promote the

reduction of clinical error in the context of emergency

medicine

Emergency Medicine Events Register (EMER)

• ED-specific near miss and adverse event reporting system. being piloted across a

number of EDs

• Key elements of EMER are:

• it is quick, intuitive, easy to use, and specially designed for EDs,

• it is anonymous, data protected by Qualified Privilege.

• the system can identify problem areas & patient safety deficiencies in EDs

that can be used to support arguments for better equipment, improved

staffing, system changes

• pilot sites receive aggregated data identifying key features of collected data

• ‘burst reporting’ capabilities (NEAT issues included in pilot)

• CPD points for reporting: 1 point per 2 incidents, up to a total of 50 points per

year,

• dedicated time and expertise at the back-end (once data is collected) to

analyse data, feedback results to the profession, and publish findings, and

help drive future improvements in patient safety and preventative strategies in

Australasian EDs

www.emer.org.au

NEAT & whole of system…

• Initial performance results (period 1) indicate that admitted patients is where most gains are to be made so focus should be on whole of hospital

• Access block causes lie outside the ED, and….

‘It takes time to break from historical methods of doing things (in the ED and the hospital as a whole) especially when we are tackling deeply ingrained cultures of practice within the hospital at large. Emergency medicine has a history of being flexible and rapidly adaptive to new requirements and creating novel solutions to problems; however specialty units and the hospital as a whole needs time. This is clearly seen in most facilities whereby discharge rate compliance with NEAT is the first to improve and admission rate compliance with NEAT lags behind.’1

• But….

‘Emergency Department workforce engaged and believe in targets - drivers of change’1

1. Australasian College for Emergency Medicine (May – 2013). Hospital Data and Accreditation Part 1: Report of Findings.

http://www.acem.org.au/media/publications/Hosp_Data__Accreditation-_Part_1_Report.pdf

NEAT where to next…

• Need to further promote “whole-of-hospital ownership” of NEAT = it is a hospital performance metric, not an ED target

• Engagement of senior clinical leaders to champion NEAT within hospital and, in particular, improve buy-in from clinical staff within hospital in-patient departments

http://youtu.be/MNLNDsIN_TM

NEAT – need for research & evidence to inform implementation

• Over 100 strategies1 identified in terms of leading practices to address the patient experience in the Emergency Department and beyond

• What are best-practice improvements for rapid and safe patient flow while ensuring high quality care?

• How can these models be generalised and promulgated to other settings?

1. Leading Practices in Emergency Department. Patient Experience. Prepared for the Ontario Hospital Association by InfoFinders

http://www.oha.com/KnowledgeCentre/Library/Documents/Leading%20Practices%20in%20Emergency%20Department%20Patient%20Experience.pdf

Whole-of-System resources

• NSW Health Whole of Hospital Program http://www.health.nsw.gov.au/wohp/Pages/default.aspx

• NZ Health Improvement and Innovation Resource Centre http://www.hiirc.org.nz/section/9088/shorter-stays-in-ed/

• Emergency Care Institute NSW National Emergency Access Target Resources http://www.ecinsw.com.au/neat

NEAT politics

• Political drivers vs evidence

• Buy-in and understanding

• A national target that is implemented by state governments

• Increasing health care costs vs budget constraints

NEAT: research questions?

• Is the target improving patient outcomes?

• Is the target effectively driving whole-of-system reform?

• Is a uniform target appropriate for all hospital settings?

• Is the balance right? Can 4hrs/90% give sustainable improvements in patient flow and quality of patient care?

For NEAT to meet its primary goal:

• Whole-of-system reform involves cultural change that is a fundamental requirement for success = transformational change is challenging and must have top-down support and commitment to ensure it is sustainable

• Leadership from all levels is essential

– Ministers and Health Depts. must remain engaged and fully supportive of process and outcomes

– Local Hospital Network executives and Hospital CEOs need to facilitate change management processes in partnership with clinicians

• Clinical engagement required to ensure ownership of changes and implementation of best-practice solutions

• Innovation encouraged to address local needs

• Trustworthy communication, including performance feedback

ACEM & NEAT:

• Continue to support target, informed by developing evidence base, as a means to an end

• Advocate for political engagement and policy commitment, from across the entire health care community, to enable and ensure sustained whole-of-system reforms

• Promote best practice outcomes both within ED and across healthcare system

• Promote the use broad range of performance indicators that measure quality and safety of patient outcomes (not just time!)

• Advocate for ongoing resourcing of initiatives that enable improved flow and quality patient outcomes

NEAT – the ends are worth it….

‘Somebody on the Orient Express gets killed and the question is, who killed him? The answer is, everybody on the train killed him.

And the answer about who killed healthcare is: the status quo.’1

1. Regina E. Herzlinger – Nancy R. McPherson Professor of Business Administration at Harvard Business School at Harvard Business School and Harvard Medical School 2012 Forum on Healthcare Innovation

Questions / discussion