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Whole system improvement in Whole system improvement in Forth ValleyForth Valley
Improvement and support team meeting15th Jan 2009
ContextContext
• Period of significant change and innovation • National collaborative projects• Integrated healthcare strategy includes new
acute hospital 2010-2011• Consistent bed pressures• Need for step change in results from
improvement activity– Implementation– Measureable benefit– Focus and prioritisation
Lean improvementLean improvement
• It’s about BALANCE and FLOW
Resources (R) =Cycle Time (CT)
Takt Time (TT)
Improvement on the ‘shop floor’ Improvement on the ‘shop floor’
time
Failure
Reaso
n 1
Failure Count
Failure
Reason 2
Failure
Reaso
n 3
Failure
Reason 4
Failure
Reason 5
Failure
Reason 6
3. Routinely act on the most costly failures using:
Concern Cause Countermeasure
Multi-disciplinary team, according to problem
Target
Process performance
# Who When Status
1
2
3
4
~~~~
~~~~
~~~~
~~~~
~~/~~/08
~~/~~/08
~~/~~/08
~~/~~/08
Action~~~~~~~~~~~~
~~~~~~~~~~~~
~~~~~~~~~~~~
~~~~~~~~~~~~
1. Measure actual v target for key processes
2. Assign reasons for process failure, and count …
ProcessProcess
2 - 4 weeks 1 day 1-2 days 2 days1 - 2 weeks
Phase 1 Phase 3
Analyse the Forth Valley Whole System
Phase 2
Top Team Event Analyse Priority Areas
Phase 4 Phase 5 Phase 6
1 - 2 weeks
Prioritisation Event
Evaluate OptionsPolicy &
Planning Event
2&3 Dec 17&18 Dec12th Nov20th Oct
start
Executive challengeExecutive challenge
• Transition to new models of care across system
• £14.5m - £25m savings by Mar 2011• Maximum 18 week RTT by Dec 2011• Resilient U&E flow = 98% A&E asap• Consistent, safe care:
• HAI down by 30% by 2010
Day Patient In PatientClinic
community services – partnership model with LA
Home Visit
mental health; elderly care
district nursing
health visiting
specialist nursing
AHP (e.g. physio, OT)
other
GP referral
GP referral
GP referral
A&E
CAU
amb care
acutereceiving
unitin-patient
out-patient
diagnostics
rehab
day case
acute services
MIU
SAS
OOH
OOH, urgent & emergency services (community)
NHS 24
Specialist acute care
tertiary services
routinedischarge
complexdischarge
out-reach
refer to GP
refer on-going community care
LocalAuthorities
Partner & Vol organisations
AHP (physio)
sub-contract
GDP
GP
Community Pharmacists
family health services
Optom
GP direct
access
GP direct
access
GP feedback
Forth Valley System Map
7 Forth Valley Planning Event
Day Patient In PatientClinic
community services – partnership model with LA
Home Visit
mental health; elderly care
district nursing
health visiting
specialist nursing
AHP (e.g. physio, OT)
other
GP referral
GP referral
GP referral
A&E
CAU
amb care
acutereceiving
unitin-patient
out-patient
diagnostics
rehab
day case
acute services
MIU
SAS
OOH
OOH, urgent & emergency services (community)
NHS 24
Specialist acute care
tertiary services
routinedischarge
complexdischarge
out-reach
refer to GP
refer on-going community care
LocalAuthorities
Partner & Volorganisations
AHP (physio)
sub-contract
GDP
GP
Community Pharmacists
family health services
Optom
GP direct
access
GP direct
access
GP feedback
1,300,000
962,000789k OP; 135k IP
~130,000300,000
65,000
32,000
81,000
80% occ; 294 beds
12,000
50,000
196,000
52,600
27,500
9,600 LOS=3.8 41,000
13,500
26,000 LOS=6.8
25,100
166,000
-
M 4,300
Forth Valley System Map
Day Patient In PatientClinic
community services – partnership model with LA
Home Visit
mental health; elderly care
district nursing
health visiting
specialist nursing
AHP (e.g. physio, OT)
other
GP referral
GP referral
GP referral
A&E
CAU
amb care
acutereceiving
unitin-patient
out-patient
diagnostics
rehab
day case
acute services
MIU
SAS
OOH
OOH, urgent & emergency services (community)
NHS 24
Specialist acute care
tertiary services
routinedischarge
complexdischarge
out-reach
refer to GP
refer on-going community care
LocalAuthorities
Partner & Vol organisations
AHP (physio)
sub-contract
GDP
GP
Community Pharmacists
family health services
Optom
GP direct
access
GP direct
access
GP feedback
963,000
~130,000
330k AHP 32k Nr
300,000
65,000
32,000
81,000
80% occ; 294 beds
28k DP; 17k OP
12,000
50,000
196,000
52,600
27,500
9,600 LOS=3.8 41,000
13,500
26,000 LOS=6.8
25,100
166,000
M 4,300
+12%
+24% (new)
-26%
+1.1%
+2%
+3%
1,300,000+5%
Forth Valley System Map
38,000
3,000
Day Patient In PatientClinic
community services – partnership model with LA
Home Visit
mental health; elderly care
district nursing
health visiting
specialist nursing
AHP (e.g. physio, OT)
other
GP referral
GP referral
GP referral
A&E
CAU
amb care
acutereceiving
unitin-patient
out-patient
diagnostics
rehab
day case
acute services
MIU
SAS
OOH
OOH, urgent & emergency services (community)
NHS 24
Specialist acute care
tertiary services
routinedischarge
complexdischarge
out-reach
refer to GP
refer on-going community care
LocalAuthorities
Partner & Vol organisations
AHP (physio)
sub-contract
GDP
GP
Community Pharmacists
family health services
Optom
GP direct
access
GP direct
access
GP feedbackQ
Q
T
Q
T
Q
Q
Solutions to imbalance lie in whole system …
GP referral in-patientout-patient
diagnostics day case
Discharge
refer on-going community care
home
out-patient Pre-Op Theatre
OutpatientsDemand 1000Capacity 793
9.5 wks 16.5 wks
1st OP Appt OutcomeDischarged 24.8%DNA 4%Failed Discharge 1.7%Awaiting Results 8.8%Waiting List DC 4%Ref other Clinics 2.7%IP wtg list 7%Blank/Other 8.8%Further Appt 38.4%
OP – Lost Capacity
Scheduled capacity
80% of demand
Quality Losses 17-42%
Losses = 29%
of capacity
Hips – Sept 08Capacity 363Pts seen 255(overtime 69)DNA 13Unfilled Appt 44Canc Clinic 50
45 wks (83% > 18 wks)
23.4 wks
3.2 Planned Orthopaedics Outpatients
Discharges by day of the weekDischarges by day of the week
0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
Mon Tue Wed Thur Fri Sat Sun
AdmissionsDischarges
19% Sunday
shortfall
Approx 60 bed days a week (£1.6M p.a.)
Opportunity to release Opportunity to release bed capacitybed capacity
ALOS by acute physician
0.01.02.03.04.05.06.07.08.09.0
4012
986
3078
732
3488
920
2247
072
3459
834
2580
302
3582
707
4321
077
3440
735
3132
449
1389
562
3668
661
4040
507
4334
778
2925
211
3098
279
1327
104
2845
793
4040
899
Days
30%
Distribution of acute LOSDistribution of acute LOSAre there 3 themes here ?
LOS All Specialties
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
20000
0-1 2-3 4-5 6-7 8-9 10-11 12-13 14-15 16-17 18-20 >20
LOS
Cou
nt
42%
Generally elderly patients. Avoid admission …
Reduce LOS by improved inpatient and discharge processes
Avoid admission and ambulatory care …
District nurse diary study:District nurse diary study:conclusionsconclusions
• Opportunities to increase productivity– Reducing lost time (eg. admin, meetings etc)– Scheduling domiciliary time more efficiently– Using lower grade staff for routine work– Shifting routine treatment room work to GP practices and phlebotomist– Improving predictive planning with acute services– Balancing nursing resource effectively to meet 7 day a week demand
• Opportunities for released capacity– Increased capacity in treatment rooms to support acute discharge– Increased capacity for anticipatory care– Understanding return on investment of different options
Urgent & Emergency Work-stream
Enabling Work-streams : Leadership & Communication; Information & Metrics; Training; Programme Mgt;
Elective Work-stream
Primary & Community Work-stream
Diagnostics Work-stream
Redesign whole system U&E pathway
Mainstream advanced care planning to reduce inappropriate hospital
admissions
Improve quality of Urgent and Emergency “front door” services
Reduce avoidable unplanned admissions
Systematic improvement in acute
in-patient management
Releasing/developing capacity in primary care and community services
Systematic improvement in LA
supported discharge
Reduce variation in referral management
Systematic improvement of Labs
Increase CT (MRI) productivity / capacity
Articulate the productivity benefits
from 18 week programme
NHS Forth Valley Priority Improvement Work-Streams
Improve ‘home-to-home’ visibility of patient pathway
ConclusionsConclusions
• Whole system perspective was revealing– Increased focus on primary and community care
• Process highlighted the need for good information– Real focus on evidence
• Challenged us about how we prioritise resource use• Produced plans with clarity and shared understanding