Transcript Patient Flow – NHS Lothian

Improving Capacity Management
and Patient Flow
Chris Stirling
Associate Director of Operations
NHS Lothian
• 3 main acute adults sites
(2010-11)
– RIE – 111,000 attendances (up 3000 from 09-10)
– WGH – 35,865 attendances (including MIU)
– SJH – 47,766 attendances
• RHSC – 37,585 attendances
1-26 May
Apr-11
Mar-11
Feb-11
Jan-11
Dec-10
Nov-10
Oct-10
Sep-10
Aug-10
Jul-10
Jun-10
May-10
Apr-10
Mar-10
Feb-10
Jan-10
Dec-09
Nov-09
Oct-09
Sep-09
Aug-09
Jul-09
Jun-09
May-09
Apr 09
Mar-09
Feb-09
Jan-09
Dec-08
Nov-08
Oct-08
Sep-08
Aug-08
Jul-08
Jun-08
May-08
Apr-08
Mar-08
Feb-08
Jan-08
Dec-07
Nov-07
Oct-07
Sep-07
Aug-07
Jul-07
Jun-07
May-07
Apr-07
Mar-07
Feb-07
80%
97.5%
95%
90%
Target
Lothian
85%
% of Patients Admitted, Discharged or Transferred within 4hours
Lothian performance
NHS Lothian Monthly 4-hour Compliance, February 07 - 26th May 11
100%
Month
EAST Diagnostic visit - March 2010
Many opportunities for improvement in different areas….
•Late discharge by hospital sites
•Mismatch of capacity with demand (beds/staff/sites)
•Reactive/tactical use of capacity
•High levels of boarding
•Lack of pull to downstream beds
•Internal processes – communication issues
•Use of information to support improvement
•Crisis spike – poor for patients and staff
Many actions,
PDSA’s & changes
•
•
•
•
•
•
•
•
•
•
•
•
Refocus on protecting Flow 1 at RIE
Front Door areas – matching staffing capacity with demand
Introduction of protected Primary Assessment Area
Improvement in Older people pathways
Improvements to predictor tool
Introduction of OPAT/Team 65 (MoE in assessment areas)
Change in ED escalation roles (ownership)
CAA – medical sweeps/presence
Wards – earlier decision making, rapid run-downs
Site Emergency Access meetings – new focus
Value stream mapping on patient pathways
Specialty actions plans
Matching capacity and demand
One aspect of capacity –
level
system
Problem
•RIE more pressured than other 2 adult sites
•Reactive practice of redirecting patients from
RIE to WGH/SJH compounding problem
•SAS activity skewed to RIE away from RIE –
affected by variety of factors
End of shift – crews crossing
town away from WGH to get back to
SAS Station for end of shift (near the RIE)
Actions
•Rezoning of GP practices – for GP bed bureau patients to increase activity to
WGH away from RIE to reduce unplanned redirection from RIE. Two tranches.
LMC involvement. Journey time analysis by EAST
•SAS development of sub-stations in North Edinburgh
•SAS partnership working – receiving unit and facilities staff
•Opening of WGH ARAU overnight to relieve capacity pressure at RIE as
Winter response
•Testing with NHS24 use of scheduled appointments for bony injuries
Futher actions still to be resolved for system level capacity changes
•Bed reprofiling within and between sites and between specialties
•Further shift of elective activity profile from Mondays to other days
•Further shift of activity off RIE site
•Additional developments of ambulatory care
•Testing different model of specialty handovers to reduce delays
•Progress with HEAT T10 and alternatives in Primary Care
Downstream flows
Problem
•MoE long lengths of stay & delays in transfer
from acute sites to downstream sites (Liberton,
Royal Victoria, Roodlands, Astley Ainslie)
•Difficulties in matching capacity and demand
between acute sites and downstream sites
•Lack of awareness / responsiveness (pull)
Actions
•Organisational priority - year long lean pathways work on Older people
(general rehab, stroke, orthopaedic rehab, dementia) Multiple
Kaizens/workouts. Ongoing focus.
•Development of expanded community rehab and reablement services to
support earlier discharge and pull from hospital/community. Ortho-rehab
LOS reduced
•Establishment of OPAT/Team 65 improving early selection of MoE patients
and “pull” from front door areas
•Improved communication between acute/downstream sites – more reliable
matching of capacity with demand
•70% increase in throughput on relevant wards since 2009, reduction in LoS
•Further action using Change Fund
Then
LUHD: Daily Emergency Access Report
19227
Trajecto
ry chart
target
for this
Month
4-Hour Emergency Access Standard April 2010
Date
ED* daily
attendance
Daily 4hour
breaches
Breaches
for month
to date
Daily
compliance
achieved
ED*
attendance
for month to
date
Thu 01-Apr-10
Fri 02-Apr-10
Sat 03-Apr-10
Sun 04-Apr-10
Mon 05-Apr-10
Tue 06-Apr-10
Wed 07-Apr-10
Thu 08-Apr-10
Fri 09-Apr-10
629
659
658
653
708
625
625
578
620
52
30
49
47
39
72
65
30
31
52
82
131
178
217
289
354
384
415
91.73%
95.45%
92.55%
92.80%
94.49%
88.48%
89.60%
94.81%
95.00%
629
1288
1946
2599
3307
3932
4557
5135
5755
91.73%
93.63%
93.27%
93.15%
93.44%
92.65%
92.23%
92.52%
92.79%
Compliance
for month to
date
Sat 10-Apr-10
626
10
425
98.40%
6381
93.34%
Sun 11-Apr-10
Mon 12-Apr-10
Tue 13-Apr-10
Wed 14-Apr-10
Thu 15-Apr-10
Fri 16-Apr-10
Sat 17-Apr-10
Sun 18-Apr-10
Mon 19-Apr-10
Tue 20-Apr-10
Wed 21-Apr-10
Thu 22-Apr-10
671
709
626
616
589
627
599
604
695
650
621
595
5
25
16
16
4
41
13
24
29
14
8
9
430
455
471
487
491
532
545
569
598
612
620
629
99.25%
96.47%
97.44%
97.40%
99.32%
93.46%
97.83%
96.03%
95.83%
97.85%
98.71%
98.49%
7052
7761
8387
9003
9592
10219
10818
11422
12117
12767
13388
13983
93.90%
94.14%
94.38%
94.59%
94.88%
94.79%
94.96%
95.02%
95.06%
95.21%
95.37%
95.50%
Fri 23-Apr-10
Sat 24-Apr-10
Sun 25-Apr-10
Mon 26-Apr-10
Tue 27-Apr-10
Wed 28-Apr-10
Thu 29-Apr-10
Fri 30-Apr-10
556
645
658
770
644
676
621
674
8
21
16
30
31
20
40
40
637
658
674
704
735
755
795
835
98.56%
96.74%
97.57%
96.10%
95.19%
97.04%
93.56%
94.07%
14539
15184
15842
16612
17256
17932
18553
19227
95.62%
95.67%
95.75%
95.76%
95.74%
95.79%
95.71%
95.66%
98%
Current number of
breaches for this
month
835
Max number of breaches for
compliance with 4-hour
emergency access standard
382
Colour Code
98% Trajectory and above
95% Below current trajectory position
<95% Remedial performance
83
288
220
8
59
26
58
3
34
56
Initial Reasons For breaches
Clinical exception
Wait for 1st assessment
Wait for bed
Wait for diag test start
Wait for diag test result
Wait for NHS transport
Wait for non NHS transport
Wait for specialist
Wait for treatment to start
Wait for treatment to end
Other (please specify)
No reason recorded
835
Total attendances
19227
%
0.4%
1.5%
1.1%
0.0%
0.3%
0.1%
0.3%
0.0%
0.2%
0.3%
Now
LUHD: Daily Emergency Access Report
20254
Trajector
y chart
target
for this
Month
4-Hour Emergency Access Standard April 2011
Date
ED* daily
attendance
Daily 4hour
breaches
Breaches
for month
to date
Daily
compliance
achieved
ED*
attendance
for month to
date
Fri 01-Apr-11
Sat 02-Apr-11
679
667
26
20
26
46
96.17%
97.00%
679
1346
96.17%
96.58%
Sun 03-Apr-11
Mon 04-Apr-11
Tue 05-Apr-11
Wed 06-Apr-11
Thu 07-Apr-11
Fri 08-Apr-11
Sat 09-Apr-11
734
762
685
687
692
670
667
13
34
47
46
11
45
24
59
93
140
186
197
242
266
98.23%
95.54%
93.14%
93.30%
98.41%
93.28%
96.40%
2080
2842
3527
4214
4906
5576
6243
97.16%
96.73%
96.03%
95.59%
95.98%
95.66%
95.74%
Compliance
for month to
date
Sun 10-Apr-11
724
15
281
97.93%
6967
95.97%
Mon 11-Apr-11
Tue 12-Apr-11
Wed 13-Apr-11
Thu 14-Apr-11
Fri 15-Apr-11
Sat 16-Apr-11
Sun 17-Apr-11
Mon 18-Apr-11
Tue 19-Apr-11
Wed 20-Apr-11
Thu 21-Apr-11
Fri 22-Apr-11
752
622
602
588
642
626
672
739
623
616
654
624
16
30
28
5
10
10
12
15
8
9
11
7
297
327
355
360
370
380
392
407
415
424
435
442
97.87%
95.18%
95.35%
99.15%
98.44%
98.40%
98.21%
97.97%
98.72%
98.54%
98.32%
98.88%
7719
8341
8943
9531
10173
10799
11471
12210
12833
13449
14103
14727
96.15%
96.08%
96.03%
96.22%
96.36%
96.48%
96.58%
96.67%
96.77%
96.85%
96.92%
97.00%
Sat 23-Apr-11
Sun 24-Apr-11
Mon 25-Apr-11
Tue 26-Apr-11
Wed 27-Apr-11
Thu 28-Apr-11
Fri 29-Apr-11
Sat 30-Apr-11
670
676
750
720
697
629
656
729
13
13
5
16
29
30
11
12
455
468
473
489
518
548
559
571
98.06%
98.08%
99.33%
97.78%
95.84%
95.23%
98.32%
98.35%
15397
16073
16823
17543
18240
18869
19525
20254
97.04%
97.09%
97.19%
97.21%
97.16%
97.10%
97.14%
97.18%
98%
Current number of
breaches for this
month
571
Max number of breaches for
compliance with 4-hour
emergency access standard
382
Colour Code
98% Trajectory and above
95% Below current trajectory position
<95% Remedial performance
78
102
200
6
44
16
62
2
29
32
Initial Reasons For breaches
Clinical exception
Wait for 1st assessment
Wait for bed
Wait for diag test start
Wait for diag test result
Wait for NHS transport
Wait for non NHS transport
Wait for specialist
Wait for treatment to start
Wait for treatment to end
Other (please specify)
No reason recorded
571
Total attendances
20254
%
13.7%
17.9%
35.0%
1.1%
7.7%
2.8%
10.9%
0.4%
5.1%
5.6%
• Significant issues still remain
• Performance at RIE still not achieving 98%
• Crisis spike still present
• Lowering the water level…
…exposes more rocks!