Making a difference through High Impact Changes

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Making a difference through High Impact Changes

• 26th April 2005

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Key idea focus on reducing variation
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A different way of seeing

• Understanding your system
• Common cause factors
• stable, consistent pattern of variation
• chance, constant causes
• Special cause factors
• assignable
• pattern changes over time

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My trip to work
Upper process limit
Mean
Lower process limit
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• Natural variation
• Inevitable characteristic of any healthcare
  system
• Variation in patient characteristics
• Take steps to manage it

• Artificial variation
• Created by the way the system is managed
• Variation in the way the service is provided
• Take steps to eliminate it

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Identify causes of variation in the system

• Natural (Patient) factors

• Artificial (Service) factors

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Consecutive patients urgent referrals from
primary care time to treatment
350
Consecutive patients
300
Mean 91.7
UPL 226.8
250
200
Days
150
100
50
0
Consecutive patients
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What is causing this variation?

• Natural (patient) factors?
• Artificial (service) factors?

• Estimate what proportion of the problemis
  natural factors and what proportion is artifical
  factors?

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Workforce factors are the single greatest cause
of artificial variation!
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Variation is the key

• Root cause of delays for patients is variability
• not volume
• We create most of the variability
• Reduce variability by creating a steady flow of
  patients through the system at a steady rate
• improve patient experience
• reduce delays
• improve safety
• provide care more efficiently

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Reduction in waiting time
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Reduction in waiting time Community Service A
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Reduction in waiting time Community Service B
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Reduction in waiting time Community Service C
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Focus on reducing variation can mean

• safer care
• quicker care
• more co-ordinated care
• better response to needs
• reduced morbidity and mortality
• less waste
• better value from resources

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East Lancashire Hospitalsinitiatives to improve
flow

• Reconfiguration of medical beds
• sick and quick ward established
• Daily senior review on the medical wards
• Medical outliers eliminated (usually)
• Simple timely discharge training
• ( medical wards)
• COPD outreach team
• Older people's team

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Total Weekly Mortality BlackburnApril 2002 to
December 2004
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Total Community Mortality
projected from 46 weeks data
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Background

• which service redesign improvements make the
  biggest difference?
• what (quantifiable) benefits can potentially be
  made through modernisation?

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Evaluation criteria- how were the 10 chosen?

• improvement for large numbers of patients?
• a gap between current performance and potential
  performance in the area covered by the high
  impact change?
• relate to a topic, specialty or area that is a
  priority for improvement?
• easy for local NHS organisations to interpret and
  implement?

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The Improvement Dividend Framework
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High Impact Change 1

• Treat day surgery
• (rather than inpatient surgery)
• as the norm for elective surgery

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Focus on specific procedures where the evidence
is strong

• 1. The easy ten procedures
• then
• 2. The remaining Audit Commission basket
  procedures
• then
• 3. The remaining British Association of Day
  Surgery procedures

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Ten easyday case procedures
Source HES, Department of Health 2002/3. Drawn
from admissions (FFCE) activity data.
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High Impact Change 2

• Improve patient flow across the NHS system by
  improving access to key diagnostic tests

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Diagnostic tests

• full range of diagnostic tests
• primary and secondary care
• match demand and capacity and enable patients to
  flow through the system
• potential of technological advances wont be
  achieved without this

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Torbay Hospital - CT length of wait
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Improved access to CT scanning

• process redesign
• booking times changed
• flexible start time for staff
• scan by protocol
• improved patient explanation
• role redesign
• radiographers trained to cannulate and inject
  contrast
• support worker employed

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No.2 Improve access to key diagnostic tests

• What might we aim for locally?
• a reduction in outpatient DNA rates for
  diagnostic tests of at least 50.
• in-patient length of stay reduced by at least 0.5
  days if tests can be carried out, and/or results
  can be returned in shorter timescales.
• a reduction in the number of unnecessary X rays
• pilot work suggests around 7 of total number of
  X-rays
• a reduction in waiting time for GP referral to
  first treatment by up to 50 by redesigning
  access to diagnostic tests
• a reduction in waiting time in AE

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High Impact Change 3 4

• Manage variation in patient discharge thereby
  reducing length of stay
• Manage variation in the patient admission process

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Sorting out the system (1) High Impact Change 3

• what is causing discharge variability?
• i.e. variability in capacity of beds?

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Average length of stay by day of admission
Medical admissions
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7.8
8
7.6
7.1
7.0
7
6.5
6.2
6.1
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Average length of stay (days)
5
4
3
2
1
0
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Source Kate Silvester/Richard Lendon/Improvement
Partnership for Hospitals
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Length of Stay
Source Richard Lendon / Improvement Partnership
for Hospitals
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West Middlesex University Hospital NHS Trust -
Average length of stay
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Sorting out the system (2)High Impact Change 4

• What is causing the admission variability?
• i.e. demand for beds?

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Which is most variable Emergency or Planned?
Source Richard Lendon/Improvement Partnership
for Hospitals
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Source Kate Silvester/Richard Lendon/Improvement
Partnership for Hospitals
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No.3 4 Smooth variation in patient discharge
admission process

• What might we aim for locally?
• a 1 day reduction in length of stay for patients
  staying 10 days or less
• resulting in an approximately 10 reduction in
  total bed days used
• an average district general hospital could
  release 10 of its capacity
• increase the throughput of patients within
  existing capacity
• could act as slack
• help to achieve financial balance
• patients discharged home when fit to be
  discharged with no unnecessary delays
• an available bed for all patients at all times
• no on the day cancellations of elective
  patients
• no medical outliers
• the four hour AE target met and surpassed
• reduction in hospital acquired infections

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High Impact Change 5

• Avoid unnecessary follow ups for patients,
  providing necessary follow ups in the right care
  setting

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Avoiding unnecessary follow ups

• 37 million hospital follow ups each year
• 75 of patient did not attends
• patient-led process
• location, method and role redesign

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High Impact Change 6

• Increase the reliability of therapeutic
  interventions through a care bundle approach

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Ventilator Care Bundle

• Original Elements of Care Bundle
• Semi-Recumbent positioning gt30o.(Drakulovic 1999)
• DVT prophylaxis (Cook et al 2001).
• Gastro-intestinal Protection (Yang Lewis 2003).
• Sedation Holds (Kress 2000).
• Tight Control of Blood glucose 4.4-6.1 mils (Van
  den Berghe 2001).

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University Hospitals, Coventry and Warwickshire
NHS TrustBenefits of care bundle approach
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High Impact Change 7

• apply a systematic approach to care for people
  with long term conditions

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Over 65s average length of stay
Over 65s bed days per 1,000 population
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University Hospital Lewisham Admissions for COPD
reduced by 35
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High Impact Change 8

• improve patient access by reducing the number of
  queues

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Endoscopy Unit
73 queues
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Ealing - waiting list for barium enema reduced
from 19 to 9 weeks

• reduced number of queues
• routine/urgent
• inpatient/outpatient
• 5 inpatient slots were reserved but on average
  only 2 were filled

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High Impact Change 9

• Optimise patient flow through service bottlenecks
  using process templates

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Fracture Clinic example Step 1 - create a
template based on what happens 80 of the time
(not including delay)
Book in 2 min.
Xray 5 min.
Book out 2 min.
Plaster 12 min.
See Doctor 10 min.
receptionist
The colour bars represent the time required at
each step as performed by one person, in one
place at one time
doctor
radiographer
plaster room
receptionist
Source Richard Lendon
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Step 23 - create the schedule background
create the schedule
Step two create the schedule background
9.00
8.00 p.m.
Step three create the schedule
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Step 4 - consider available resources

• 2 receptionists
• 2 doctors
• 2 Xray room
• 2 radiographers
• 1 plaster rooms

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How we usually schedule - by the most expensive
resource, in this case the doctor
Source Richard Lendon
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We should be scheduling against the plaster room
- this is the constraint
Source Richard Lendon
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What really happens
wait for doctor
Source Richard Lendon Lucy Vere
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No.9 Optimise patient flow through the service
bottlenecks using process templates

• What might we aim for locally?
• NHS organisations should consider using process
  templates prior to investment in additional
  capacity to ensure that the investment is
  required
• this should become standard NHS practice
• at the level of a single bottleneck (i.e.
  endoscopy, chemotherapy or radiotherapy unit),
  assume a minimum of 10 and ideally 15-20
  improvement in effective capacity.
• combine this with a reduction in the number of
  queues (HIC 8) to get much more dramatic capacity
  gains

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High Impact Change 10

• redesign and extend roles in line with efficient
  patient pathways, to attract and retain an
  effective workforce

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3 high impact areas for role redesign

• Administrative and clerical roles in the clinical
  team
• Assistant Practitioner
• Advanced Practitioner

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Assistant practitioner roles

• Assistant Practitioner in
• Radiology
• Cardiac Catheter Laboratory
• Neurology and Rehabilitation
• Critical Care
• Assistant Clinical Psychologist
• Audiology Associate Practitioner
• Extended Pharmacy Technician
• Cytology Screener

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Introduction of an Endoscopy Technician to the
team
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Implementing Advanced Practitioner Roles in
Radiography reduces waiting times
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Biggest change required is in leadership thinking
Performance

• raises overall level of performance
• less fires break out at this level

high
fire-fighting
service role redesign
Chronic problems
Acute problems
Time
low