Plymouth  Story  Poten&al  for  Huge  Improvement  

(Session  1,  Part  2)

 

Benefits  of  adop&ng  an  ‘A9ending  System’  

Beds Per Day Occupied by Neurology Patients (excluding Patients with Main Diagnosis of Stroke)

10

15

20

25

30

35

40

45

50

31/0

3/05

14/0

4/05

28/0

4/05

12/0

5/05

26/0

5/05

09/0

6/05

23/0

6/05

07/0

7/05

21/0

7/05

04/0

8/05

18/0

8/05

01/0

9/05

15/0

9/05

29/0

9/05

13/1

0/05

27/1

0/05

10/1

1/05

24/1

1/05

08/1

2/05

22/1

2/05

05/0

1/06

19/0

1/06

02/0

2/06

16/0

2/06

02/0

3/06

16/0

3/06

30/0

3/06

13/0

4/06

27/0

4/06

11/0

5/06

25/0

5/06

08/0

6/06

22/0

6/06

06/0

7/06

20/0

7/06

03/0

8/06

17/0

8/06

31/0

8/06

14/0

9/06

28/0

9/06

12/1

0/06

26/1

0/06

09/1

1/06

23/1

1/06

07/1

2/06

21/1

2/06

04/0

1/07

18/0

1/07

01/0

2/07

15/0

2/07

01/0

3/07

15/0

3/07

29/0

3/07

Bed

s O

ccup

ied

at M

idni

ght

No. in bed

Mean

UCL

LCL

Effects  Over  Time  

Quality  

Produc1vity   Culture  

Francis,  Keogh  

QiPP   Berwick  

Need  a  Strategy!  

An  Authen1c  Strategy  would  Unleash…Leadership  Leadership  =  Followership    Followership  =  (Trust  +  Compassion  +  Stability)  +  Hope    

Hope  =  Goal  +  Process  +  Agency    For  leaders  =  create  ACTIVE  HOPE  

This method is WHAT of the PROCESS

Figure 1 Effective Operation management in Health

£

Challenge Value of clinical work

Activity £

C C

Activity

Support Support

S S

S S

Current Approach Limited

Scope

C C

Starting point

Proposed Approach

Clinical Clinical

Value  framework  (1)  

This is very different And very challenging

YOU  CAN  START  ANYWHERE!  1.  How  to  find  opportunity  in  theory  2.  How  to  deliver  results  locally  3.  How  to  deliver  results  more  broadly  

Star&ng  point  is  ALWAYS  -­‐  Mul&ple  symptoms  

Need  a  value  framework  to  orientate  you  

Here  we  are  star&ng  with  department  level  work  

In  Healthcare  –  there  are  lots  of  poten1al  symptoms  One  department’s  data  from  Trust  Databook  

Current approach = tackle as issues arise in isolation Proposed approach = ‘systems – value’ approach to issues

2008  -­‐  Worst  Performer  in  Region  

95

76

76

79

91

93

96

96

99

University Hospitals Bristol

Poole

Taunton And Somerset

North Bristol

Royal Devon And Exeter Healthcare

Northern Devon Healthcare

Plymouth Hospitals 118

105

Salisbury Health Care 107

Yeovil District 111

Royal United Hospital Bath 112

Royal Bournemouth and Christchurch 116

Dorset County Hospital 117

South Devon Health Care

Weston Area Health

Royal Cornwall Hospitals

Cheltenham General Hospital 102

Gloucestershire Royal Hospital 102

Great Western Hospitals

Stroke in-hospital deaths by NHS hospital4

Standardised mortality rate (percent of national average)

In 2008/ 2009, PHT death rate was 18.3% higher than the national average

£2,000  Loss  per  Pa6ent 1.5  pa6ents  per  day  average £1.1  million  annual  loss Poor  Pa6ent  &  Rela6ve  Experience

PuYng  it  all  together:  Stroke  Example  Technical  Analysis  

0

1

2

3

4

5

6

7

8

1-A

pr-0

6 1-

May

-06

1-Ju

n-06

1-

Jul-0

6 1-

Aug

-06

1-Se

p-06

1-

Oct

-06

1-N

ov-0

6 1-

Dec

-06

1-Ja

n-07

1-

Feb-

07

1-M

ar-0

7 1-

Apr

-07

1-M

ay-0

7 1-

Jun-

07

1-Ju

l-07

1-A

ug-0

7 1-

Sep-

07

1-O

ct-0

7 1-

Nov

-07

1-D

ec-0

7 1-

Jan-

08

1-Fe

b-08

Mean Number of admissions

Mean has been 1.5 admissions per day over the past two years

UCL*

Start  with  Demand  

Stroke  Pa6ents  AdmiGed  per  Day

Define  Streams  of  Pa1ents  Many  ways  of  doing  this  Presen6ng  condi6on  (including  severity)

Point  of  admission  e.g.  A&E

Opera6onal  Parameters  e.g.  ALOS

High (8+)

Med (3-7) Low (<3)

2009

499 (84)

83 (14) 18 (3)

ALOS Days

Number of bed days (percent)

Mean LOS

0

20

40

60

80

0 50 100 150 200

ALOS Days

Consecutive patients

Length of stay for patients with ALOS ≥8 days

14

Quality: Interaction of streams

Iden1fy  Hot  Spots  of  resource  consump1on  (Ideally,  quality  then  cost)  

Audit    >  7  day  Length  of  Stay  Stream  Understand  authen&c  cause  of  varia&on  in  performance  

15

* Rehabilitation Stroke Unit ** Frail patients were defined as having medical complexity index of 3, 4, or 5 on a 1-5 scale. 0=No systemic disease other than primary diagnosis ,

1=Premorbid, inactive, and or irrelevant systemic disease, 2=Active, relevant systemic disease not limiting function, 3=Active, systemic disease limiting function, 4=Active, systemic disease severely limiting function, 5=Moribund / terminal intermediate

Home (23%)

RSU (13%)

RSU (11%)

RSU or convalescence (20%)

RSU* or convalescence (17%)

Well (47%)

Frail** (53%)

Mild Moderate Severe

Clinical stroke size

Patient status pre-stroke

Preferred  place  of  discharge  for  6  subgroups  of  pa6ents3  (percent  of  total)

Pathway redesign required (16%)

6  Types  of  Pa1ent  Demand  Six  types  of  pa6ents  were  defined  based  on  pa6ent  status  pre-­‐stroke  and  the  size  of  the  stroke

Basic  Principle  

Iden6fy  Groups

•  e.g.  by  ALOS

Break  Group  Down

•  e.g.  by  Pre-­‐disease  health

Examine  in  Depth

•  Iden6fy  Hot  Spots

Goal  =  Segment  by  Resource  Consump6on,  then…  

Get  granular  on  the  high  ones

Pathway redesign required (16%)

Home (23%)

RSU (13%)

RSU (11%)

RSU or conval- escence (20%)

RSU or conval- escence (17%)

Well (47%)

Frail (53%)

Mild Moderate Severe Clinical stroke size

Patient status pre-stroke

Determining  Improvement  Strategy  

Target Group 1 – Redesign Pathway

Target Group 2 – Improve Operational

Rigour

Improvement  Strategy  The  pathway  was  then  redesigned  for  the  key  segment  (frail  pa&ents  with  severe  stroke),  and  opera&onal  improvements  were  ini&ated  in  the  RSU  for  4  other  pa&ent  segments  

 

Severe  Stroke  in  Frail  Pa&ents  

m  Highest  resource  consump&on  m  75%  of  beds  were  used  by  the  frail  pa&ents  pre-­‐stroke  

m  Highest  variability  in  bed  occupancy  &  long  length  of  stay  

m  Driven  by  a  lack  of  systema&c  care  planning  

m  Care  not  well-­‐matched  to  pa&ents  m  Variable  treatment  and  feeding  processes,  not  aligned  with  pa&ent  

and  rela&ve  preferences  

RSU  Opera&onal  Rigour  (1)  

m  No  frail  pa&ents  with  severe  strokes  are  sent  to  RSU  

m  Ac&ve  decision  for  frail  pa&ents  with  moderate  stroke  

m  Based  on  clear  triage  rules  and  input  from  acute  care  providers,  rela&ves  and  pa&ents  

m  Previously  well  pa&ents  with  moderate  or  severe  strokes  go  to  the  RSU  

m  Rigorous  monitoring  is  used  to  determine  when  pa&ents  can  be  sent  home  with  enhanced  community  resources  (early  suppor&ve  discharge)  or  to  long-­‐term  placement  (e.g.,  nursing  home)  

RSU  Opera&onal  Rigour  (2)  

m  Rigorous  daily  review  m  Status  of  all  pa&ents  is  reviewed  daily  (discharge  round)  

m  Staffing  adjustment  to  reduce  ALOS  m  A  dedicated  social  worker  was  added  to  the  RSU  to  help  reduce  

ALOS    

m  Consider  ongoing  re-­‐design  m  PHT  is  currently  redesigning  its  RSU  pathway,  assessing  its  op&ons  

for  community  services,  and  reassessing  its  pathway  for  frail  pa&ents  with  mild  strokes  

In under a year, access to and use of the Acute Stroke Unit has become more efficient3

0

0.5

1.0

1.5

2.0

2.5

-12% p.a.

Feb Jan Dec Nov Oct Sep Aug Jul Jun May Apr

0

5

10

15 -6% p.a.

Feb Jan Dec Nov Oct Sep Aug Jul Jun May Apr

0

10

20

30

40

50

60

70

80

90

100

+7% p.a.

Jun May Apr Mar Feb Jan Dec Nov Oct Sep Aug Jul Jun May Apr Mar

2009 2010

Percentage of patients spending at least 90% of their time in the ASU*,3

Percentage

2009 2010

Time required for transfer to ASU3

Hours

2009 2010

Average LOS in ASU3

Days

* This is one of the major indicators in the UK National Stroke Audit; if patients are not spending time in the stroke unit, they are either in the A&E or the medical assessment unit, likely not getting the most appropriate care

20

33

June 2009 April 2009

Acute beds at Derriford Hospital Rehab beds at Mount Gould

1923

May 2009 April 2009

Net acute benefits

• Reimbursement  level:  £4k  per  pa6ent

• New  cost  of  care:  £3k  per  pa6ent,  Savings:  £1k

• 17  beds  released,  implying  net  savings  of  11%  across  system  

Lots  of  Beds  Saved…  Permanently  

PuYng  it  all  together:  Combining  Top-­‐  down  with  Bobom  analysis  Stroke  Project  

mild moderate severe

Well

Frail

Flow stream (a or b) 1,2, or 3

Demand – condition level

Find key Patient groups/condition

Value Requirement

Target Condition Quality Grid

Value offering Current State

Improvement opportunity/ solution

Gap between target and reality Possible improvements

Enterprize design issue

Workforce implication

ROI/BM Quality cost equation

System Conditions

Management Task

Strategic Sub-Condition Analysis

Condition/ Group

Diagnosis Treatment Medical Complication

Functional Stability

Effective “” “”” “”””

Timely

Safe

Holistic

medical MH SC

Well

Frail ** “” “”**

Strategic Sub- patient group Analysis

Ideal treatment for target group

Find key groupings

Quality Matrix

Strategic Decision 1

A3

Strategic Decision 2 Frail/severe

Strategic Decision 3

FS Bottom-up Analysis 1

Bottom-up Analysis 2

Bottom-up Analysis 3

Bottom-up Analysis 4

Bottom-up Analysis 5

Real  Life  Experiences  Making  it  Happen  

(Session  3,  Part  2)

 

(1)  Decision-­‐making  Rights  

Which  Mindset  prevails!

 

To  use  this  approach  ,  you  need  mandate:    Defining  Technical  Solu1on  

Stroke Service Line

Story

Cost Analysis End

to End

Cost vs Quality

JDY Paper

Start with Quality

Quality Conformance to Standards Standards

VAS

End to End Data

Well Frail

Current State

A

Cost Quality

Standards

Current State

B

Cost Quality

Standards

Continue to analyse

PDSA specifics

Monitor and

evaluate

Strategic Plan

OTM

ASU RSU

?Plan

RSUHomePalliative

RSU

Mild Moderate Severe Mild Moderate Severe

Home Simple

Home Complex CU Palliative

Dx AT SP MC FS LTUMx

CT Aspirin G CVA MS PS

Establishing Mandate

Overview

Other

WICKED PROBLEM!

This  felt  KEY    Allows  all  symptoms  to  be  filtered  through  same  lens TECHNICAL  ANALYSIS Gets  you  on  right  path!

With  mandate,  you  need:  Clarity  of  Structure  and  Informa1on  

Care Quality Commission/ DoH/RCP

SHA

Peninsula Clinical Network

Peninsula Research Network

Commissioning Provider?

Stroke Commissioning Group

Provider Group Finance Group

Stroke Service Line

Clinical Pathway

CVA

TIACommunity PCT Response Ambulance

Response?Emergency Response ASU MDT Community

Response

Home Home RSU Care Care Pallitative

Demand determined by 100 patient

analysis

ESD for StrokeTrauma Neurological

RSU  Structure  JW

MM

PsychePhysioRSUBevDR OT

RSUSALTRSU

Sisters

1 2 3 4

Trainers

HCA

Sarah7

Tina C6

Jane C6

KE CGDS

Lucy S

Ward Clerk

Discharge

*1

*2

*3

*4

*5 *6 *7

Adam

*8

Sue Ellis

Appreciate  Inter-­‐connectedness  

Complexity  of  Running  a  Single  Department  (1)  You  can  only  slowly  unravel  current  state  

Work

USC SC

I II III New Dx Rx FUTIA1st Fit

N CVA N CVA N CVA

GP C2C RTT Non RTT

IP OT

RTT Non RTT RTT RTT Non

RTT

Attending System CVA Team New OPRed Tops

N CVA

? PIU FU OPs

SA

Clinical Acad ST Reg F2 ST1 ST2

Cons Reg SHO

DRs Nurses

Ward Clin

WM Trained WM SN

Other

Physio OT SALT Diet Psyche

Complexity  of  Running  a  Single  Department  (2)  There  is  limit  to  within  department  improvement  

Resource

Dr

Cons Reg SHO ? CVA SCS

Clinical Acad

MS SE SA SW AMN JZ JH ON CC

Neurology

IP OP

Neurology CVA New FU

IIIIIIIIIIII

5/Day 5 - 10 10 - 35 2/Day 5 - 10 10 - 35

Attending CVA

GP CRCEPI

TIA

RTT NON RTT

11 13 5 25

+ 1 Torbay Input

12 3

A

B

C D E F

4

CombineIn daily clinicFU

5. Combine

6

7

8Specialist

9

J K L M

Right – Left Plan

Sept Dec Mar

1 & 2 Medinet3

4 Monitor 5 Audit

6 Get clear 7 Audit 8 Capture 9 C&D

Medinet

Demand A – M

Issues 1 - 8

Daily Demand

PCT interface issues

(2)  Performance  Management  

Informa1on  and  clarity  of  ac1on  

Performance management is so much easier with a proper plan that talks to the work

mild moderate severe

Well

Frail

Flow stream (a or b) 1,2, or 3

Demand – condition level

Find key Patient groups/condition

Value Requirement

Target Condition Quality Grid

Value offering Current State

Improvement opportunity/ solution

Gap between target and reality Possible improvements

Enterprize design issue

Workforce implication

ROI/BM Quality cost equation

System Conditions Management Task

Strategic Sub-Condition Analysis

Condition/ Group

Diagnosis Treatment Medical Complication

Functional Stability

Effective “” “”” “”””

Timely

Safe

Holistic

medical MH SC

Well

Frail ** “” “”**

Strategic Sub- patient group Analysis

Ideal treatment for target group

Find key groupings

Quality Matrix

Strategic Decision 1

A3

Strategic Decision 2

Well/moderate SC

Strategic Decision 3 Timely Rx

Bottom-up Analysis 1

Bottom-up Analysis 2

Bottom-up Analysis 3 Bottom-up

Analysis 4 Bottom-up Analysis 5

LEADERSHIP TASK

Planned Care Unscheduled Care TotalNew FU IP DC IP

Speciality A Q V A Q V A Q V A Q V A Q V A VI II III Total I II III Total

AE A&E - - - - - - - - -AM Acute Medicine ? ? -AS Anaesthetics ? ? ? ? ? - -AU Audiological Medicine - - - - - - - - - - - - - -BS Breast Surgery - -CS Cardiac SurgeryCD CardiologyCM Child Psychology - - - - - - - - - - - - - -AN Chronic Pain -CC Clin Chemistry ? ? - - - - - - - - - - - - - -HM Clin HaematologyCI Clin Immunology - - -RT Clinical OncologyCO Colorectal SurgeryCP Community Paediatrics - - - - - - - - - - - - - -DM Dermatology - -DI Diabetic Medicine - ?EN Endocrinology - - - - - - -ED Endoscopy -ET ENTGA GastroenterologyGM General Medicine - - - - - - - -GS General SurgeryGU GUM ? ? - - - - - - - - - - - - - -GC Gynae - Colposcopy Suite - - - - - - - - - - - - - -GH Gynae - Hysteroscopy - - - - - - - - - - - - - -GO Gynaecological OncologyGY GynaecologyHF Haemophilia ? ? - - - - - - - - - - - - -HE HCEPS Hepatobiliary & Pancreatic Surgery ? ? - - - - - -HP HepatologyIC Intensive Care - - - - - - - - - - - - -MO Medical OncologyNE Neonatology - -NF NephrologyNL NeurologyNY Neuropathology - - - - ? ? ? ? ? ? - - - - - ?NP Neurophysiology - -NX Neuropsychology - - - - - - - - - - - - - -NR Neuroradiology - - - - ? - ? - -NS NeurosurgeryNM Nuclear Medicine ? ? - - - - - - - - - - - - - -OB Obstetrics - - - - - - - - -OP Ophthalmology - - - -ON Optician - - - - - - - - - - - - - -OS Oral SurgeryOD Orthodontics ? ? ? ? ? - - - - -OR Orthopaedics - - - - -OT Orthoptist ? - - - - - - - - - - - - -PA PAC - - - - - -DP Paediatric Diabetic Medicine ? ? - - - - - - - - - - - - - - ?PD PaediatricsPT Palliative Medicine - - - - - - - -PL Plastic SurgeryRA Radiology ? ? ? - - ? - -RD Rest Dent - - - - - - -RH Rheumatology -TM Thoracic MedicineTS Thoracic SurgeryTI TIA ? ? - - - - - - - - - - - - - -TR Trauma - - - - - - - - -UG Upper GI SurgeryGE Uro-Gynaecology - - - -UI Uro-Infertility - - - - -UR UrologyVS Vascular Surgery

How  will  the  priori&es  for  the  Care  Groups  be  established?    

1.   Understand  the  work  different  Service  Lines  do:  A  value  stream  analysis  at  Trust  level  

2.   Align  quality  and  financial  standards  developed  by  programmes  to  flows  

3.   Priori1se  

 

 Key  Areas  

 -­‐ Longer  stay  unscheduled  care  pa&ents  40%  of  beds  are  occupied  by  pa2ents  who  have  stayed  more  than  7  days  –this  equates  to  approximately  300  beds  

 -­‐ Significant  capacity  and  demand  problem  across  each  step  of  the  scheduled  care  pathway  Capacity  and  demand  mismatch  

 

Where  do  we  spend  our  money?  (NHS  Plymouth  Programme  Budge2ng  data  2010/11)