Steven Allder_Challenging the status quo

Challenging the Status Quo Working collaboratively to make continuous improvement Quality Francis, Keogh Need a Strategy! Productivity QiPP Culture Berwick An Authentic Strategy would Unleash…Leadership Leadership = Followership Followership = (Trust + Compassion + Stability) + Hope Hope = Goal + Process + Agency Value framework (1) Figure Effective Operation management in Health Starting point Support Clinical Support Clinical Activity S C £ S C £ Activity S C S C Challenge Value of clinical work This is very different And very challenging YOU CAN START ANYWHERE! How to find opportunity in theory How to deliver results locally How to deliver results more broadly Starting point is ALWAYS - Multiple symptoms Need a value framework to orientate you Here we are starting with department level work Putting it all together: Stroke Example Technical Analysis In Healthcare – there are lots of potential symptoms One department’s data from Trust Databook 2008 - Worst Performer in Region Plymouth Hospitals 118 Dorset County Hospital 117 Royal Bournemouth and Christchurch 116 Royal United Hospital Bath 112 Yeovil District 111 Salisbury Health Care 107 Great Western Hospitals 105 Gloucestershire Royal Hospital 102 Cheltenham General Hospital 102 Royal Cornwall Hospitals 99 Weston Area Health 96 South Devon Health Care 96 Taunton And Somerset 95 Poole 93 University Hospitals Bristol 91 Royal Devon And Exeter Healthcare 79 North Bristol 76 Northern Devon Healthcare 76 In 2008/ 2009, PHT death rate was 18.3% higher than the national average £2,000 Loss per Patient £1.1 million annual loss Poor Patient & Relative Experience Stroke in-hospital deaths by NHS hospital4 Standardised mortality rate (percent of national average) 1-Feb-08 1-Jan-08 1-Dec-07 1-Nov-07 1-Oct-07 1-Sep-07 1-Aug-07 1-Jul-07 1-Jun-07 1-May-07 1-Apr-07 1-Mar-07 1-Feb-07 1-Jan-07 1-Dec-06 1-Nov-06 1-Oct-06 1-Sep-06 1-Aug-06 1-Jul-06 1-Jun-06 1-Apr-06 1-May-06 Start with Demand Number of admissions Stroke Patients Admitted per Day Mean UCL* Mean has been 1.5 admissions per day over the past two years Determining Improvement Strategy Clinical stroke size Mild Patient status prestroke Moderate Severe Frail (53%) RSU or convalescence (17%) RSU or convalescence (20%) Pathway redesign required (16%) Well (47%) Home (23%) RSU (13%) RSU (11%) Improvement Strategy The pathway was then redesigned for the key segment (frail patients with severe stroke), and operational improvements were initiated in the RSU for other patient segments Severe Stroke in Frail Patients  Highest resource consumption   Highest variability in bed occupancy & long length of stay   75% of beds were used by the frail patients pre-stroke Driven by a lack of systematic care planning Care not well-matched to patients  Variable treatment and feeding processes, not aligned with patient and relative preferences RSU Operational Rigour (1)  No frail patients with severe strokes are sent to RSU  Active decision for frail patients with moderate stroke   Based on clear triage rules and input from acute care providers, relatives and patients Previously well patients with moderate or severe strokes go to the RSU  Rigorous monitoring is used to determine when patients can be sent home with enhanced community resources (early supportive discharge) or to long-term placement (e.g., nursing home) RSU Operational Rigour (2)  Rigorous daily review   Staffing adjustment to reduce ALOS   Status of all patients is reviewed daily (discharge round) A dedicated social worker was added to the RSU to help reduce ALOS Consider ongoing re-design  PHT is currently redesigning its RSU pathway, assessing its options for community services, and reassessing its pathway for frail patients with mild strokes Making it happen Importance of Strategic mandate To use this approach , you need mandate: Defining Technical Solution This felt KEY Overview Establishing Mandate Allows all symptoms to be filtered through same lens TECHNICAL ANALYSIS Stroke Service Line Story JDY Paper Cost Analysis End to End Cost vs Quality Gets you on right path! Strategic Plan ? Plan OTM Start with Quality ASU RSU Home Quality Conformance to Standards Current State A Standards VAS RSU Current State B End to End Data Cost Well Dx AT SP MC Quality Cost Frail LTU Mx FS Standards Standards Mild CT Aspirin G CVA MS Quality Moderate Severe Mild Moderate Severe PS Continue to analyse RSU Home Simple Home Complex CU Palliative WICKED PROBLEM! Other PDSA specifics Monitor and evaluate Palliative (1) Decision-making Rights Which Mindset prevails! With mandate, you need: Clarity of Structure and Information Care Quality Commission/ DoH/RCP SHA Peninsula Clinical Network Commissioning Peninsula Research Network Provider? Stroke Commissioning Group Stroke Service Line Provider Group Clinical Pathway CVA TIA Home Community Home Finance Group Ambulance Response? PCT Response RSU Emergency Response Care Demand determined by 100 patient analysis Trauma ESD for Stroke Neurological ASU Care MDT Pallitative Community Response Appreciate Inter-connectedness Complexity of Running a Single Department (1) You can only slowly unravel current state Work USC I II SC TIA 1st Fit III New Dx Rx IP N CVA N CVA N CVA Team OT CVA GP Attending System FU Red Tops N C2C RTT Non RTT New OP Non RTT RTT ? PIU RTT Non RTT RTT FU OPs CVA SA Clinical Cons Acad ST Reg Reg DRs F2 ST1 SHO ST2 WM Trained WM Ward SN Physio OT SALT Clin Nurses Other Diet Psyche (2) Performance Management Information and clarity of action In under a year, access to and use of the Acute Stroke Unit has become more efficient3 Time required for transfer to ASU3 Hours Percentage of patients spending at least 90% of their time in the ASU*,3 Percentage 2.5 2.0 -12% p.a 1.5 100 1.0 90 0.5 80 70 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb 2009 2010 Average LOS in ASU3 Days 15 +7% p.a 60 50 40 30 -6% p.a 20 10 10 Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun 2009 2010 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb 2009 2010 * 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 Lots of Beds Saved… Permanently Acute beds at Derriford Hospital Net acute benefits Rehab beds at Mount Gould 33 23 19 20 April 2009 June 2009 April 2009 May 2009 •Reimbursement level: £4k per patient •New cost of care: £3k per patient, Savings: £1k •17 beds released, implying net savings of 11% across system How will the priorities for the Care Groups be established? Speciality AE AM AS AU BS CS CD CM AN CC HM CI RT CO CP DM DI EN ED ET GA GM GS GU GC GH GO GY HF HE PS HP IC MO NE NF NL NY NP NX NR NS NM OB OP ON OS OD OR OT PA DP PD PT PL RA RD RH TM TS TI TR UG GE UI UR VS A&E Acute Medicine Anaesthetics Audiological Medicine Breast Surgery Cardiac Surgery Cardiology Child Psychology Chronic Pain Clin Chemistry Clin Haematology Clin Immunology Clinical Oncology Colorectal Surgery Community Paediatrics Dermatology Diabetic Medicine Endocrinology Endoscopy ENT Gastroenterology General Medicine General Surgery GUM Gynae - Colposcopy Suite Gynae - Hysteroscopy Gynaecological Oncology Gynaecology Haemophilia HCE Hepatobiliary & Pancreatic Surgery Hepatology Intensive Care Medical Oncology Neonatology Nephrology Neurology Neuropathology Neurophysiology Neuropsychology Neuroradiology Neurosurgery Nuclear Medicine Obstetrics Ophthalmology Optician Oral Surgery Orthodontics Orthopaedics Orthoptist PAC Paediatric Diabetic Medicine Paediatrics Palliative Medicine Plastic Surgery Radiology Rest Dent Rheumatology Thoracic Medicine Thoracic Surgery TIA Trauma Upper GI Surgery Uro-Gynaecology Uro-Infertility Urology Vascular Surgery Planned Care New FU A Q V A Q V ? ? ? ? ? IP DC A Q V A Q V I II III Total - - - - - - - ? ? ? ? - - - - - - - - - - - - - - - - - Unscheduled Care IP A Q V I II III Total - - - - - - - - - ? ? ? ? ? ? - - - - - - - - ? ? - - - - - - - - - - - - - - - - - ? ? - - - - - - - - - - - - - - - - - Align quality and financial standards developed by programmes to flows - - Prioritise - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ? - ? - - ? - - - - - - - - - - - - - - - - - ? - - - - - - - ? - - ? ? ? ? - - - - ? - - - - - - - - - - - - - - - ? ? - ? ? ? - - ? ? - - - Understand the work different Service Lines do: A value stream analysis at Trust level - ? - ? - A V - - - Total - - - - - - - - - - - - ? - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -Longer stay unscheduled care patients ? - - ? Key Areas ? 40% of beds are occupied by patients who have stayed more than days –this equates to approximately 300 beds -Significant capacity and demand problem across each step of the scheduled care pathway Capacity and demand mismatch ... 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. .. Improvement Strategy The pathway was then redesigned for the key segment (frail patients with severe stroke), and operational improvements were initiated in the RSU for other patient segments... Understand authentic cause of variation in performance in end to end performance Types of Patient Demand Six types of patients were defined based on patient status pre-stroke and the size of the stroke