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Key priorities to drive and deliver sustainable improvements. Vincent Connolly Clinical Lead ECIST. Emergency Care is a ‘wicked problem’. A social or cultural problem that is difficult or impossible to solve because: of incomplete or contradictory knowledge;

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emergency care is a wicked problem
Emergency Care is a ‘wicked problem’
  • A social or cultural problem that is difficult or impossible to solve because:
  • of incomplete or contradictory knowledge;
  • of the number of people/opinions involved;
  • of the large economic burden; and
  • of the interconnected nature of this and other problems

Russell L. Ackoff wrote about complex problems as: "Every problem interacts with other problems and is therefore part of a set of interrelated problems, a system of problems…. I choose to call such a system a mess."

care coordination
Care Coordination

The health system delivered the required care, but was it in a time frame that suited the patient, carer or staff ?

average demand average capacity variation mismatch queue
Average demand = Average capacity Variation mismatch = queue





Can’t pass

unused capacity

forward to next week

Reducing waiting times in the NHS: is lack of capacity the problem?

Bevan et al Clinician in Management (2004) 12:


Organise beds to improve patient flow

  • Arrange beds around patient streams:
  • Clinical Decision Unit (CDU) / Ambulatory Emergency Care (AEC), Acute Assessment Unit (AAU), short stay, specialty, complex discharge
  • Minimise handovers
  • Combat outliers
admit but where
Admit – but where?

Stroke Unit

Respiratory Unit

Gastro- Intestinal Unit

Acute Rehabilitation Unit

Decision to admit

Acute Bed Pool

two nights

Metabolic Unit

Critical care

Cardiac Unit

in reach case management
‘In-reach’ Case Management

Stroke Unit

Respiratory Unit

Gastro- Intestinal Unit

Acute Rehabilitation Unit

Decisionto admit

Acute Bed Pool

two nights

Metabolic Unit

Specialist “in-reach”

Critical care

Cardiac Unit

outreach model of care
Outreach Model of Care

Stroke Unit

Respiratory Unit

Gastro- Intestinal Unit


Acute Rehabilitation Unit

Acute Bed Pool

two nights

Decision to admit


Metabolic Unit

Critical care

Cardiac Unit

the right people are more important than the right system as long as it is
The right people are more important than the right system as long as it is
  • Well described
  • Addresses patient care requirements
  • Everybody understands their role
  • Appropriate support from other services
  • Location is fit for purpose
  • Adequately scoped
  • Supported by staff
managing the streams
Managing the Streams

Identify the stream

  • Short stay Sick specialty Sick general Complex
  • Allocate early to teams skilled in that stream


Short stay – manage to the hour

Maximise ambulatory care


Clarity of specialty criteria

Specialty case management plan at

Handover – no delays

Green bed days vs. red bed days


Number of patients

Minimise handover

Decompensation risk

Early assertive management

Green bed days vs. red bed days


Complex needs – how

much is decompensation?

Detect early and design

simple rules for discharge

































Length of stay (days)

pareto analysis
Pareto Analysis

5% of demand:

Red stream: Rare Strangers

Cumulative Demand



50% of demand

= 7% of types:

Green stream: ‘Runners’







Short Stay


Sick General

Sick Specialty

Glenday Sieve

los cumulative profile excl paeds obstetrics and midwifery zero los
LOS Cumulative ProfileExcl Paeds, Obstetrics and Midwifery, Zero LOS

ANHST Top 25

50% = 3 midnights 2 midnights

80% = 10 midnights 7 midnights

95% = 29 midnights 23 midnights


Cumulative OBD by LOS Excl Paeds, Obstetrics and Midwifery , Zero LOS


<50% = 3 midnights 10.8%

<80% = 10 midnights 35.3%

<95% = 29 midnights 69.4%

>95% = >29 midnights 30.6%

focus on discharge
Focus on discharge

Simulation of patient flows in A&E and elective surgery Discharge Priority: reducing length of stay and bed occupancy

Michael Allen, Mathew Cooke & Steve Thornton, Clinical Systems Improvement 2010

Consistently prioritising discharge activities can significantly reduce length of stay in elective or emergency clinical care pathways.

Prioritising discharge activities only when beds are full may have little impact on patient throughput or average length of stay.

Increasing beds may increase length of stay with no benefit to patient throughput.


Focus on discharge

  • Every patient should be reviewed every day by a senior decision maker
  • Use expected date of discharge (EDD) to support case management for all inpatients
  • Ensure all patients have criteria for discharge
  • Implement morning check-outs so that patients are ‘home for coffee’
  • Focus on early supported discharge
which type of doctor
Which type of doctor?

Acute Physician

General Physician

  • Specific training
  • Focus on acute med
  • Assessment & 1st 48 hours
  • Will develop acute med
  • Out of hours
  • Generic training
  • Holistic approach
  • Long ward rounds
  • Office hours
the doctor needs to have
The doctor needs to have:
  • Team worker
  • Humility
  • Discipline
  • Measures performance
  • Service improvement
  • Challenges the orthodoxy
  • Accepts and embraces peer challenge
  • Concerned about quality not volume
  • Can describe the system
  • Builds service around the needs of patients
  • Focus on decisions, tasks and workflows to optimise care
  • Sort out the high variation
  • Reconfigure the supporting infrastructure to match the redesigned clinical processes
  • Design structures and processes to help learning from daily work
  • Fixing Healthcare from Inside and Out, Harvard Business Review
does daily senior review work
Does daily senior review work?

Twice weekly consultant ward rounds compared with twice daily ward rounds


  • Over study period, no change in length of stay on ‘control’ wards
  • Average length of stay (ALOS) on study wards fell from 10.4 – 5.3
  • The impact of twice-daily consultant ward rounds on the length of stay in two general medical wards
  • No deterioration in other indicators (readmissions, mortality, bed occupancy)

The impact of twice-daily consultant ward rounds on the length of

stay in two general medical wards

Aftab Ahmad, Tejpal S Purewal, Dushyant Sharma and Philip J Weston

Clinical Medicine 2011, Vol 11, No 6: 524–8

continuity of care and regular reviews
Continuity of care and regular reviews
  • Hospitals with two or more AMU ward rounds per day on weekdays AND admitting consultants working blocks of more than one day had a lower adjusted case fatality rate.
  • Where the admitting consultant was present for more than four hours, seven days per week they had a lower 28 day readmission rate

RCP Taskforce 2007

internal professional standards for aau
Internal Professional Standards for AAU
  • Time to first review 15 mins
  • Completion of clerk in Two hours
  • Middle grade review in Four hours
  • Consultant Two-three hours day time, 12 hours out of hours
  • Diagnostics within Four hours
  • Referral response half a day
quality measures
Quality measures
  • Mortality
  • Mortality & morbidity (M&M) meetings
  • 24 hour discharge rate
  • Delivery of Internal Professional Standards (IPS)
  • Readmissions seven days
  • Adverse events
  • A&E flow
  • Patient experience
admission avoidance early discharge strong evidence weak evidence
Admission avoidance & early dischargeStrong evidenceWeak evidence

Admission prevention from nursing homes

Ambulatory emergency care (e.g. 60-90% reduction in overnight stays for pulmonary embolism (PE))

Improve urgent access to primary care

Intermediate care in-reach to emergency department (ED) and assessment units

Assertive case management of frail patients with dementia

Continuity of care with a GP

Hospital at home as an alternative to admission

Assertive case management in mental health

Early senior review in A&E

Multidisciplinary interventions and tele-monitoring in heart failure

Integration of primary and secondary care

GPs in ED

Walk in centres (WICs) and urgent care centres (UCCs) (unless co-located with EDs with integrated governance)

Public education

Pharmacist home-based medication review

(Unfocussed) intermediate care

Community-based case management (generic conditions)

Early discharge to hospital at home on readmissions

Nurse-led interventions pre- and post-discharge for patients with chronic obstructive pulmonary disease (COPD)

Telemedicine (except for heart failure)

crude mortality
Crude Mortality

An example of success

No of patients with LoS > 14 days

A&E - Time to be seen

A&E – Wait to treatment time

Hospital Falls

Ward cardiac arrests

the ten commandments
The Ten Commandments
  • Ensure timely access and continuity in primary care
  • There should be early senior review of all patients along all parts of the pathway, to maintain the momentum of care – there should be a senior review of every inpatient’s care plan every day
  • Get patients on the right pathways – Concentrate on patient flow
  • Work together across the whole system to systematically and predictably – implement internal professional standards – to minimise variation
  • Plan and manage capacity to meet demand
  • Avoid unnecessary overnight stays – implement ambulatory emergency care
  • There should be a relentless focus on discharge
  • Develop clear models of care for assertive management of the frail elderly
  • Measure the effect and impact of interventions using SPC and follow up with further improvements
  • Remember this will all be delivered by people so talk, engage, lead, follow & LISTEN