High qualityHigh quality safe acute services safe acute services

Professor Derek BellProfessor Derek BellDirector NIHR CLAHRC for NW LondonDirector NIHR CLAHRC for NW LondonImperial College LondonImperial College LondonChelsea and Westminster HospitalChelsea and Westminster Hospital

Characteristics Characteristics

• Safe Safe • EffectiveEffective• Patient Centred Patient Centred

• Quality Quality • InnovativeInnovative• Prevention Prevention • Productive Productive

• Value Value

Patient perception of quality by Patient perception of quality by waiting time in acute care waiting time in acute care

5

ED Door to medical team time 30-day adjusted mortality 30-day adjusted mortality

5.8 6.48.6

12.6

17.4

0.0

4.0

8.0

12.0

16.0

20.0

<2.5 hr <4 hr < 6 hr < 9 hr >9 hr

All c

ause

mor

talit

y (%

)

P < 0.0001

7

QUARTERLY A&E WAITING TIMES (ENGLAND 2005-2010)QUARTERLY A&E WAITING TIMES (ENGLAND 2005-2010)

Percentage less than 4hrs: Percentage less than 4hrs: Seasonally AdjustedSeasonally Adjusted

Where are we?Where are we?• Managing the target – delivering high quality careManaging the target – delivering high quality care

– Flow Flow – Capacity – demand Capacity – demand – VariationVariation– Quality agenda Quality agenda

• Hitting the target (standard) – missing the pointHitting the target (standard) – missing the point– Gaming Gaming

• Tail gunningTail gunning• Boarding but not …….Boarding but not …….

• Missing the target (standard) missing the point Missing the target (standard) missing the point – GamingGaming– Bringing back old practise Bringing back old practise – Ignoring quality Ignoring quality

NHS London review NHS London review Upping our game Upping our game • Benchmarking exerciseBenchmarking exercise

• Review Consultant coverReview Consultant cover– 7/7 extended day cover – 12 hours dedicated on site 7/7 extended day cover – 12 hours dedicated on site – Twice daily Consultant ward rounds – all patients Twice daily Consultant ward rounds – all patients

– All patients in AMU footprint to be seen twice dailyAll patients in AMU footprint to be seen twice daily– Daily review all wards 7/7Daily review all wards 7/7

• Direct access to AMU from primary care Direct access to AMU from primary care

• Prompt access to diagnostics and reports Prompt access to diagnostics and reports

High valueHigh value

• High qualityHigh quality– OutcomesOutcomes– Patient experiencePatient experience– Avoid harmAvoid harm

• Cost effectiveCost effective

– Low variability – consistentLow variability – consistent

– TimelyTimely

– Right person right staff right placeRight person right staff right place

Elective and emergency Elective and emergency

• Synergy Synergy √√√√ √√√√

• Competition ----Competition ----

• Avoid reactive bed / flow management Avoid reactive bed / flow management

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All Admissions All Discharges

SystemStressed System

Recovery

‘‘System Stress’ – Admission and Discharge Profile for all specialties

SummarySummary

• We all need to;We all need to;

– address the governance issuesaddress the governance issues– control patient flow within the systemcontrol patient flow within the system– ensure we provide continuity of care (rotas and reviews)ensure we provide continuity of care (rotas and reviews)– design improved 7/7 safer systems design improved 7/7 safer systems – monitor performance and standardsmonitor performance and standards

– Avoid Safari and MartiniAvoid Safari and Martini– Right place right person first time – all the time Right place right person first time – all the time

Patient flow groupsPatient flow groups- must be whole system !- must be whole system !• Emergency careEmergency care

– Minor injury and Minor injury and illnessillness

– Short stay Short stay emergency emergency admissions admissions (<48hrs)(<48hrs)

– In-patient medicineIn-patient medicine– In-patient surgeryIn-patient surgery

• Planned carePlanned care– Out-patientsOut-patients– Day case and Short Day case and Short

staystay– In-patient electiveIn-patient elective– Complex elective Complex elective

(e.g Intensive (e.g Intensive Care)Care)

– RehabilitationRehabilitation• Not ageist ?Not ageist ?

Findings Systematic review of acute careFindings Systematic review of acute careScott et al Scott et al Mortality - 2 hospitals showed significant reductions in all-cause hospital mortality (44%

relative reduction over 5 yrs in 1).

Length of stay - 4 hospitals showed consistent reduction in LoS of 1-2.5 days.

Direct discharge rates(DDR): 3 hospitals increased their DDR (24, 48 and 72 hrs). One hospital increased DDR24 by 25%.

Downstream Redistribution: 3 hospitals found improved usage of downstream wards.Readmission: No hospital found increased RRs. One hospital halved their RR.Economic: Only economic analysis - saving of 4039 bed days over 12/12, resulting in

estimated cost benefit of €1 714 152.Patient and Staff Satisfaction: One hospital found near universal satisfaction with new

system. Other found mixed feelings, especially amongst nursing staff who reported much higher levels of stress.

Multi-professional teams better