USING A SYSTEMATIC APPROACH TO DELIVER SUSTAINABLE CHANGE IN PATIENT FLOW

Mairead Mc CormickDeputy Chief Operating OfficerUrgent & Emergency careBarking, Havering, Redbridge university hospitals Trust

CONTEXT

Barking, Havering and Redbridge is a challenged health economy with long standing poor performance on emergency pathway, previous problems in maternity, and current 18 week RTT issues. BHRT was placed in special measures in January 2014 .

• Local population size-750,000• 3 Main local boroughs Barking

& Dagenham, Havering and Redbridge + Essex

• 2 sites- Queen’s & King George• Emergency attendances

285,000 per year and 55,300 admissions

• Approx 180 ambulances per day

THE DRIVERS FOR CHANGE

SPECIAL MEASURES

THE HELP!

• Analysed• Scrutinised• Deep dives, high fives, staying alive• Intensive support, another report!!!!!!• Regulation, irritations, speculations!!• Process mapping, number crunching, benchmarking…..• Assurance, Assurance, Assurance

WHAT DID WE KNOW FROM THE DATA

• We had a significant vacancy factor across all professional groups and exceptional in the Emergency department and assessment areas

• We were admitting too many people-(ED Conversion rate 29% from attendance to admission)

• Our length of stay for medical specialities was a significant outlier against national HES data (range 4-12 days against conditions)

• Our delayed transfers of care (DTOC) were occupying 10% of the bed base

• 80% of our bed base had a LOS greater than 2 midnights• We had approximately 30-40 outliers every day

WHAT DID WE KNOW FROM THE SOFTER INTELLIGENCE

• The whole system did not own the 4 hour access standard• The ED accepted the blame culture for poor performance and had

become desensitised to breaches including black breaches and 12 hour breaches

• The rest of the hospital and whole system had not taken responsibility for the 4 hour standard

• The daily bed meetings were issue focused with little attention to solutions and lacked structure.

• The special measures label encouraged a victim mentality• There had been little investment in staff development and capability

was a significant problem

GETTING A GRIP

• What do we need to do immediately to stabilise?• Have I got the right people in the room that can make it happen?• What have we done already? Has it worked? If not why not?• What are the reports telling us? Themes? Have we REALLY

implemented the actions and have we measured outcomes?• What will have the highest impact and what should we do first, second,

third…..and so on• What is the medium to long term plans?• What is our vision/strategy?

PROVOKE A REACTION/CREATE AWARENESS

THE FULL CAPACITY PROTOCOL

CONSISTENT APPROACH

Daily operational /bed meetingsWhat are you trying to achieve?

Structure, rhythm, informed actions, capture & accountability

DEMAND & CAPACITYKeep it simple!

What does that mean for me? What do I have to achieve today?

LENGTH OF STAYThe ECIST review > 7 days> 14 days > 20 days

Weekly/monthly intense reviews. Do we know what is within our gift to fix? Do we know how we would like our partners to support?Is it working

OutliersZero tolerance

Who can influence this?

Measurement Has it worked?How has it worked?Is it worth doing tomorrow?Is it worth doing everyday

DEMAND & CAPACITY

Discharge Targets by Ward Gold Silver BronzeWard AM Daily AM Daily AM DailyAmber A 4 7 3 6 2 5Amber B 4 7 3 6 2 5Bluebell A 4 6 3 5 2 4Bluebell B 4 6 3 5 2 4CCU 4 5 3 4 2 3Clementine A 4 6 3 5 2 4Clementine B 4 6 3 5 2 4Cornflower B 6 12 4 11 3 9Harvest A 4 5 3 4 2 3Harvest B 3 4 2 3 1 2Mandarin A 4 7 3 6 2 5Mandarin B 4 7 3 6 2 5Ocean A 5 7 3 6 2 5Ocean B 6 8 4 7 3 5Sahara A 4 6 3 5 2 4Sahara B 4 7 3 6 2 5Sky A 5 7 3 6 2 5Sunrise A 4 5 3 4 2 3Sunrise B 4 5 3 4 2 3Tropical Lagoon 6 14 4 12 3 10

These targets are subject to change in line with significant fluctuations in demand.

THE OPERATIONAL/BED MEETING IS A CRITICAL FACTOR IN ACHIEVING PATIENT FLOW

A quorum shall consist of COO/deputy COO or DM to chair A representative from each division A site/bed manager and JAD representative

Daily meetings 8.30am, 12 midday and 4pm Daily patient mapping with ward managers on MRU and ERU at 11.30 and 18.30 and on assessment units @ KGH

The current position will be electronically displayed to include full bed state at both sites, staffing issues, number of patients in discharge lounge. There will be discussion on the position and an agreed action plan which will be captured electronically with named responsible leads.

Members unable to attend must send a deputy who is briefed and able to make decisions on their behalf. Decisions will be made following discussion within the ops meetings and direction given by the chair. In escalation these decisions will be taken by a director following review of position

1. All information regarding bed state will be pre populated in advance of the meeting and displayed electronically. This information will be populated by a site manager

2. A summary of the current bed position will be given for both sites against a bed predictor based on the rolling 6 weeks and working on the MEAN predictor. The discharge status of bed required using bronze, silver or gold will be agreed as a discharge target for each ward.

3. Identify if there are any patients from critical care for step down and ensure that step-down is facilitated to provide critical care capacity as either 1 bed on both sites or 2 on 1 site

4. Check status of ring fenced beds and escalation capacity; overnight recovery/ departure lounge at Queens, ADCU/ Erica day room, observation ward at KGH

5. Review action log from previous meeting and either close actions if complete or review status

6. Staffing issues will be raised and entered with agreed actions written on action log. 7. Infection control issues to be discussed and actions agreed. 8. Check that an ED consultant has discussed all current patients with DTA’s who

have been referred by juniors and the probability of reversed decision to admit 9. At Queens agree immediate actions to release capacity in ED and SAU,MRU and

ERU assessment units within next hour working on the principles of 4 trolley spaces in SAU, 3 in ERU and 4 in MRU. Aim for 8pm is to have all patients moved from assessment units onto inpatient beds other than cat B’s and provide 11 MRU, 9 ERU, and 5 surgical spaces to support adequate flow at night.

10. Check if there are any patients in SAU/ERU/MRU that currently have a bed allocated and not moved yet. Identify a manager with advice from clinical staff to co-ordinate this immediately

11. At KGH agree immediate actions to release capacity in ED, MAU and URR. Aim at

BHRUT | Queen's Hospital | Bed State Report

Date 09/02/2015 HOSPITAL OVERVIEW ED OVERVIEW STAFFING OVERVIEW

08:30 12:00 16:00 08:30 12:00 16:00 Area Role Morning Evening OvernightPredictor 101 101 101 Resus 3 5 A&E Nurses 4T 5T 0

Outliers 29 29 0 Majors 25 25 Doctors T2 T2x2T1 T1 & T2

Beds Closed (infection) 0 0 0 Majors Lite 8 7 Other Nurses 9T 5T 1T

Def. D/C 1 5 0 Paeds 3 8 Doctors FY1 Admissions 8 23 0 UCC 16

Empty 7 6 0 Total 39 61 0 RINGFENCED Ringfence 0 2 0 DTAs 17 5 08:30 12:00 16:00Shortfall -85 -67 -101 Breaches since

midnight 8 14 CCU

? D/C 29 34 0 Ortho Net Shortfall -56 -33 -101

Time of next 12 Hr 11:36 16:28 HASU

Site Status Black Black Select EPAU 2 Staffing Status Red Red Select Bipap Site D/C Status Gold Gold Gold MandB

AMBULANCE TURNAROUNDTime period Emergency department role Speciality receiving unit’s

role Reporting arrangements

Standard Operational Practice Rapid assessment cubicles receiving all ambulance patients within 15mins

On arrival ambulance crews to be greeted and patient registered Destination for patient identified Transfer to rapid assessment area within 15mins and senior ED Doctor to undertake rapid assessment. Aim for consultant delivered where possible

Respond to all referrals within 30mins and stream to either ambulatory or receiving units within 4 hour standard

Standard operational reports should report no unnecessary patient delays in off loading

Escalation to Consultant and ED matron (in hours) Reg and NIC OOHRapid assessment cubicles full with all 5 patients waiting for majors/Resus cubicle >30minsand/or >3 patients arriving by ambulance within 10mins Stage 1 surge

Consultant to review patients in rapid assessment and downgrade to minors lite or ambulatory if possible.Senior nurse and Doctor to commence reverse triage of all patients in majors and identify 4 or more suitable for seated area in majors 

Specialities to proactively respond as above and map admission against discharge and receive patients from ED

 

Rapid assessment remains full with all 5 patients waiting > 30mins despite actions above Stage 2 surge

Escalation to Speciality leads, Matrons and General managersED seniors to continue with above and ensure continuous re-assessment to support reverse triage into chairs in majors and downgrades to majors lite or discharge. Consultant to ensure that all patients referred have been discussed and reviewed

Each speciality to retrieve 1 patient from ED with DTA and transfer to dedicated waiting area identified to support stage 2 surge.Full capacity protocol initiated

Full capacity protocol alert to clinical and managerial leads and all wards informed Ambulance service alerted and identified leads for co-ordination between acute trust and service

Escalation to Executive LeadsRapid assessment cubicles remain full with 1 or more patients waiting > 1 hour Stage 3 surge plan

ED seniors to provide senior rounding as above and keep senior clinical leads and operational managers informed of new risks

Full capacity protocol continued and nominated speciality consultant to be placed in ED as per internal major incident 

All external partners alerted as per major incident plans.

AMBULANCE TURNAROUND

Admission Rate

OUTLIERS

It is within the gift of the clinical teams to remove outliers Take the control away from bed managers Manage your own demand by creating your own capacity There will always be someone lying on your ward that is a lower risk

than your outlier. Manage that risk! Patient mapping= the right patient, in the right bed

Jan Feb Mar April0

20406080

201320142015

THE IMPACT OF ECIST RECOMMENDATIONS

2014-04

2014-05

2014-06

2014-07

2014-08

2014-09

2014-10

2014-11

2014-12

2015-01

2015-02

2015-03

2015-04

2015-05

2015-06

2015-07

2015-08

2015-09

2015-10

2015-11

2015-12

2016-01

2016-02

2016-03

20.00%21.00%22.00%23.00%24.00%25.00%26.00%27.00%28.00%29.00%

Admission Rate

2015-04 2015-05 2015-06 2015-07 2015-08 2015-09 2015-10 2015-11 2015-12 2016-01 2016-020

100200300400500600700800900

1000

Ambulatory Care Activity

LENGTH OF STAY REVIEWSPrimary Code

Fit

F3 Waiting for community hospital placement or any other bedded intermediate/reablement care

32

F8 Waiting for patient/family choice 18 F9 Waiting for HNA/DST assessment 15 F16 Waiting for internal assessments results before discharge

14

F11 Ready for home today 13 F10 Waiting for OT/Physiotherapy assessment 13 F4 Waiting for continuing health care panel decision

10

F6 Waiting for equipment/adaptations 10 F20 Waiting for residential or nursing home, social care or self funder (placement identified and awaiting date)

8

F5 Waiting for continuing health care placement package of care FT full CHC

7

F14 Discharge planned for tomorrow - what is stopping them going today?

5

F2 Waiting for transfer to Acute Hospital for treatment - tertiary fit to travel

5

F18 Waiting for Start restart Domiciliary Care Package - long term packages

4

F12 Waiting for completion of section 5 4 F21 No clear plan of clinical care and or what is needed for discharge

4

F1 Waiting return to other Acute Hosp - fit to travel

3

F22 Safeguarding 3 F17 Waiting for external agency assessment - MH,RH,NH , extra care accom

2

F23 Waiting for hospice care 2 F15 Waiting for social care reablement or home based intermediate care

2

F7 Housing needs / homeless 1 F13Waiting for internal transfer - ward to ward

1

F19 Out of county borough assessments 1 Total 177

External Help requiredSetting

expectations. The 3 letters!

THE DEMAND CHALLENGE

Admission Rate

REDIRECTION

2015-06 2015-07 2015-08 2015-09 2015-10 2015-11 2015-12 2016-01 2016-02 2016-03 2016-04 2016-05 2016-06 2016-07 2016-0870.00%

75.00%

80.00%

85.00%

90.00%

95.00%

100.00%

ED 4 Hour Performance - All Types

NEXT STEPS

• Pilot schemes with CCG and local authorities to manage medically fit cohort

• Deep dive in areas where LOS is an outlier against HES data• Full approval for redirection away from the Emergency department• Reconfiguration of both sites• Development of new models of care from VANGUARD scheme• Continue to develop the enhanced urgent care model on both sites

using the advanced care practitioner workforce model.