Improving Capacity Management and Patient Flow

Chris StirlingAssociate 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

Lothian performance

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

RIE(A&E) Average Attendances by Arrival time/Nurse & CSW Individuals on Floor Per Half Hour - Mondays

Tue 10th Nov 09 - Mon 10th May 10

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Avg Attendances Nurse Cover

Trial of Acute Practitioner through the night.

Reduce number of coordinators from 3 to 2 when appropriate to facilitate increased direct nursing care

Nursing shift moved forward to extend evening cover

One aspect of capacity – system level

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 crossingtown 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

LUHD: Daily Emergency Access Report 19227

4-Hour Emergency Access Standard April 2010

Trajectory chart target for this Month

        98%

DateED* daily

attendance

Daily 4-hour

breaches

Breaches for month

to date

Daily compliance

achieved

ED* attendance

for month to date

Compliance for month to

date

Current number of breaches for this

month835

Max number of breaches for compliance with 4-hour

emergency access standard382

Thu 01-Apr-10 629 52 52 91.73% 629 91.73% Colour Code

Fri 02-Apr-10 659 30 82 95.45% 1288 93.63%   98% Trajectory and above

Sat 03-Apr-10 658 49 131 92.55% 1946 93.27%   95% Below current trajectory position

Sun 04-Apr-10 653 47 178 92.80% 2599 93.15%   <95% Remedial performance

Mon 05-Apr-10 708 39 217 94.49% 3307 93.44%

Tue 06-Apr-10 625 72 289 88.48% 3932 92.65%

Wed 07-Apr-10 625 65 354 89.60% 4557 92.23%

Thu 08-Apr-10 578 30 384 94.81% 5135 92.52%

Fri 09-Apr-10 620 31 415 95.00% 5755 92.79%

Sat 10-Apr-10 626 10 425 98.40% 6381 93.34%

Sun 11-Apr-10 671 5 430 99.25% 7052 93.90%   Initial Reasons For breaches %

Mon 12-Apr-10 709 25 455 96.47% 7761 94.14% 83 Clinical exception   0.4%

Tue 13-Apr-10 626 16 471 97.44% 8387 94.38% 288 Wait for 1st assessment 1.5%

Wed 14-Apr-10 616 16 487 97.40% 9003 94.59% 220 Wait for bed     1.1%

Thu 15-Apr-10 589 4 491 99.32% 9592 94.88% 8 Wait for diag test start   0.0%

Fri 16-Apr-10 627 41 532 93.46% 10219 94.79% 59 Wait for diag test result 0.3%

Sat 17-Apr-10 599 13 545 97.83% 10818 94.96% 26 Wait for NHS transport   0.1%

Sun 18-Apr-10 604 24 569 96.03% 11422 95.02%   Wait for non NHS transport  

Mon 19-Apr-10 695 29 598 95.83% 12117 95.06% 58 Wait for specialist   0.3%

Tue 20-Apr-10 650 14 612 97.85% 12767 95.21% 3 Wait for treatment to start 0.0%

Wed 21-Apr-10 621 8 620 98.71% 13388 95.37% 34 Wait for treatment to end 0.2%

Thu 22-Apr-10 595 9 629 98.49% 13983 95.50% 56 Other (please specify)   0.3%

Fri 23-Apr-10 556 8 637 98.56% 14539 95.62%   No reason recorded    

Sat 24-Apr-10 645 21 658 96.74% 15184 95.67% 835

Sun 25-Apr-10 658 16 674 97.57% 15842 95.75%

Mon 26-Apr-10 770 30 704 96.10% 16612 95.76% Total attendances 19227

Tue 27-Apr-10 644 31 735 95.19% 17256 95.74%

Wed 28-Apr-10 676 20 755 97.04% 17932 95.79%

Thu 29-Apr-10 621 40 795 93.56% 18553 95.71%

Fri 30-Apr-10 674 40 835 94.07% 19227 95.66%

Then

LUHD: Daily Emergency Access Report 20254

4-Hour Emergency Access Standard April 2011

Trajectory chart target for this Month

        98%

DateED* daily

attendance

Daily 4-hour

breaches

Breaches for month

to date

Daily compliance

achieved

ED* attendance

for month to date

Compliance for month to

date

Current number of breaches for this

month571

Max number of breaches for compliance with 4-hour

emergency access standard382

Fri 01-Apr-11 679 26 26 96.17% 679 96.17% Colour Code

Sat 02-Apr-11 667 20 46 97.00% 1346 96.58%   98% Trajectory and above

Sun 03-Apr-11 734 13 59 98.23% 2080 97.16%   95% Below current trajectory position

Mon 04-Apr-11 762 34 93 95.54% 2842 96.73%   <95% Remedial performance

Tue 05-Apr-11 685 47 140 93.14% 3527 96.03%

Wed 06-Apr-11 687 46 186 93.30% 4214 95.59%

Thu 07-Apr-11 692 11 197 98.41% 4906 95.98%

Fri 08-Apr-11 670 45 242 93.28% 5576 95.66%

Sat 09-Apr-11 667 24 266 96.40% 6243 95.74%

Sun 10-Apr-11 724 15 281 97.93% 6967 95.97%

Mon 11-Apr-11 752 16 297 97.87% 7719 96.15%   Initial Reasons For breaches %

Tue 12-Apr-11 622 30 327 95.18% 8341 96.08% 78 Clinical exception   13.7%

Wed 13-Apr-11 602 28 355 95.35% 8943 96.03% 102 Wait for 1st assessment 17.9%

Thu 14-Apr-11 588 5 360 99.15% 9531 96.22% 200 Wait for bed     35.0%

Fri 15-Apr-11 642 10 370 98.44% 10173 96.36% 6 Wait for diag test start   1.1%

Sat 16-Apr-11 626 10 380 98.40% 10799 96.48% 44 Wait for diag test result 7.7%

Sun 17-Apr-11 672 12 392 98.21% 11471 96.58% 16 Wait for NHS transport   2.8%

Mon 18-Apr-11 739 15 407 97.97% 12210 96.67%   Wait for non NHS transport  

Tue 19-Apr-11 623 8 415 98.72% 12833 96.77% 62 Wait for specialist   10.9%

Wed 20-Apr-11 616 9 424 98.54% 13449 96.85% 2 Wait for treatment to start 0.4%

Thu 21-Apr-11 654 11 435 98.32% 14103 96.92% 29 Wait for treatment to end 5.1%

Fri 22-Apr-11 624 7 442 98.88% 14727 97.00% 32 Other (please specify)   5.6%

Sat 23-Apr-11 670 13 455 98.06% 15397 97.04%   No reason recorded    

Sun 24-Apr-11 676 13 468 98.08% 16073 97.09% 571

Mon 25-Apr-11 750 5 473 99.33% 16823 97.19%

Tue 26-Apr-11 720 16 489 97.78% 17543 97.21% Total attendances 20254

Wed 27-Apr-11 697 29 518 95.84% 18240 97.16%

Thu 28-Apr-11 629 30 548 95.23% 18869 97.10%

Fri 29-Apr-11 656 11 559 98.32% 19525 97.14%

Sat 30-Apr-11 729 12 571 98.35% 20254 97.18%

Now

• Significant issues still remain• Performance at RIE still not achieving 98%• Crisis spike still present

• Lowering the water level……exposes more rocks!