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NEAT within the hospital Culture, strategy and how to embed timely quality care or Don ’ t mention the war! ACI/NSW Health/ECI Seminar, Sydney , 13 th December 2013. A/Prof Harvey Newnham, Clinical Program Director Emergency & Acute Medicine, Director of General Medicine,

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slide1

NEAT within the hospitalCulture, strategy and how to embed timely quality careorDon’t mention the war!ACI/NSW Health/ECI Seminar, Sydney, 13th December 2013

A/Prof Harvey Newnham,

Clinical Program Director Emergency & Acute Medicine,

Director of General Medicine,

Alfred Health, Melbourne

how are we doing
How are we doing?

No idea

Improved

Much the same

Worsened

1. Quality of patient care in your sphere of influence in 2013 compared with 2011 is ……………..?

2. In what way do you feel the 4h NEAT approach to date has contributed to quality of care?

slide4

Certainly has led to increased focus on patient through put and we have implemented some practice change to improve this

Focus on KPI's to the detriment because we are treating a performance measure as an objective

The 4 h NEAT target has been a catalyst for some positive changes although there are balancing negative effects

Have noticed very little difference in reality

It has helped focus on what was previously very poor and unpatient centred performance.

slide5

Pressure on JMS to discharge patients and to transfer patients to ward regardless of clinical management requirements

It has been challenging to maintain the high standard of patient care but feel we have achieved this.

Shorter ED length of stay and earlier contact with the treating team has lead to benefits overall

slide6

There have been stress points with ED at times and some tensions that we have had to resolve

Pressure leads to deterioration in behaviours

General medicine is looking closer at internal structure and perhaps not filling gaps in other services as it was previously

We have been better accepted by ED people

slide7

The registrars feel more stressed and there has been some pressure put on them by ED staff which they have found difficult to manage

Resources allocated to assist with achieving targets

We have had to operate within existing budget

It has helped focus on gaps in rostering

slide8

Consistent practice, excellent senior staff input, wonderful nurses and junior medical staff with great nursing leadership

Very happy with care once they get in.

the zen of healthcare
It’s not about what happens.
  • It’s about what you do with what happens.
The Zen of Healthcare

Modified from Aldous Huxley

working in healthcare what s not to like
The people:
    • Smart,
    • Experienced,
    • Committed,
    • Ultimately want to do the best job they can for our patients
  • Very substantialResource
  • High degree of public, political and administrativeEngagement
Working in healthcare:What’s not to like?

We can't fail

context of neat essential problems in delivery of care
Context of NEAT:Essential problems in delivery of care

For many patients we don’t know what to do.

When evidence exists it is often not applied.

Fidelity of execution.

Our health system is tweaking an historical model of care rather than designing its own future

Solution: Design and create a comprehensive system for delivering health care.

Richard Bohmer “Designing Care” 2009

timely quality care tqc
Timely Quality Care (TQC)

Itis about excellence in patient care

Transforms the way we treat our patients to ensure they all receive timely, quality care consistent with their clinical needs

Is a whole of health service change that involves everyone (clinicians, managers and support staff)

Changes how we assess and treat our patients from the moment they arrive to the time they are discharged

it is a new paradigm
‘It is no longer tenable that a good practitioner can provide the best care other than as part of an effective team within a well organised health care delivery system.’
  • Translated into medicalese:
    • We can enjoy what we do, use our skills to provide effective care, have a manageable workload and maintain reasonable remuneration, if we learn how to be part of an effective team.
  • Management speak:
    • We want everyone to work at the mid-upper level of their competency.
    • We all need to
      • work differently or
      • be paid less or
      • get off the bus.
It is a new paradigm
the good news
The best innovations happen within the tightest constraintsThe Good News

Paraphrased from Clayton Christensen, in ‘the Innovator’s Prescription’

slide23

Alfred Health

  • 3 hospitals: The Alfred; Caulfield Hospital & Sandringham Hospital
  • Around 900 beds; 90,000 ED presentations, 92,000 inpatient events; 170,000 outpatient attendances.
  • Approximately 5000 equivalent-full-time staff made up by around 7000 people
  • State-wide services for trauma, burns, heart & lung transplants, HIV / AIDS, hyperbaric service, cystic fibrosis, haemophilia, Melbourne Sexual Health Centre
  • $900 million per annum
  • Strong General Medicine
    • Highest bed-day user
the journey starts
The Journey starts:

In August and September 2010, four of us (H H N, P De V S, M J K, A M S) undertook an investigative tour of 13 emergency hospitals in the United States and the United Kingdom to observe innovative approaches to patient flow pathways from the emergency department (ED) to inpatient wards and consider their potential for use at Alfred Health

Harvey H Newnham, Pieter De Villiers Smit, Martin J Keogh, Andrew M Stripp, Peter Cameron MJA 2012 p101

the journey towards timely quality care
E&TC and Acute/GenMed in same program

Site visits US & UK 2010

In house conversations

Individual unit developments –

AMU model of care etc, E&TC modifications

Formation of Whole of Hospital TQC Steering Group

Data, and more data

Site visits to Perth Hospitals

Importance of engaging HMOs

Draft principles established for whole of hospital approach

Stakeholder input into principles

Sign off by HOUs of principles

Travelling roadshow by COO

E&TC Design sessions

Launch of daytime TQC Nov 2012

Formation of Hospital at Night steering committee late 2012

Conversations about hospital at night

Draft principles established

Stakeholder input

Promulgation of hospital at night plan

Launch of hospital at night (ie 24h TQC) Feb 2013

Ongoing monitoring by steering group

The Journey towards Timely Quality Care
slide30

Key Whole of Hospital Changes

  • Trust
    • The Emergency physicians’ decision to admit
    • The inpatient team to promptly provide appropriate care
    • The investigative/interventional services to deliver in 24 hours (treat in turn)
    • Management to apply resources according to system design/priorities based on accurate data
  • Adjust rosters/work patterns to ensure staff are available when required
  • Match bed capacity to the time of highest demand and ensure patient goes to the correct bed first time
    • admission beds, SAAU’s, MAAU's & Flex beds
  • Develop safe after hours/overnight teams
slide31

Triage has become Streaming

  • 3 minute assessment maximum
  • ATS allocated (? is it still relevant)
  • Patients streamed to either:
    • Resus & Trauma:
    • RITZ:
      • Prioritise Cat 2 & AV to front of queue
      • Everyone else treat-in-turn
    • Fast Track:
      • Treat-in-turn
slide32

Upfront Senior Decision making for all patients….

RITZ (Rapid Intervention & Treatment Zone)

  • Consultant led assessment team
  • Determine interim management and disposition plan
  • “Treat in turn” principle instead of “triage & wait”
slide36

The Alfred

Target 75%

NHPA website Sept 2013

acute general medicine patient pathway
Acute General Medicine Patient Pathway

*Lead

Consultant

Streaming

nurse

Streaming

APT

Ward 4AMU

Ward 4GMU

Team C

Team D

Team A

Team B

DIRECT ADMIT

from community, clinic or other hospital

via call to *lead consultant

HOME

or

CH, SH, HITH,

private hospital

AAU

4 Identical teams A-D

Consultant (8-12/1600*pm)

APT (8-1700)

BPT (8-2130)

2 x Interns (8-4 & 11-1930/2130)

Daily consultant ward round

*Via call to streaming

APT registrar & nurse.

With interim orders

ESSU

Cubicles

RITZ

E & TC

As at 2nd December 2013

Patient

what neat is showing us
What NEAT is showing us

Before NEAT

Good Doctor + Experience + Resources = Best Care

Doctor: custodian of knowledge, skills and application of these to the individual patient

Organisation: provider of resources

After NEAT

Health care delivery organisation manages….

Practitioners - typically in multidisciplinary teams

Knowledge base - decision support and practice-basedevidence

Processes of care – reduced variation and delays, outcome orientated

to provide best healthcare outcomes at affordable cost

Adapted from Richard Bohmer “Designing Care” 2009

slide42
10 Big IdeasFuture Hospital Commission 2013: “the most important statement about the future of British medicine for a generation”

“Hospitals must offer “seven-day care, delivered where patients need it”.

It's time to build a new movement for generalism, not specialism—”generalists are the undervalued champions of …acute hospital service”.

major gaps
Major Gaps

Practice-based evidence is in its infancy in our system

Can’t implement change unless monitoring systems are good enough to learn from mistakes and measure failure

Integration is essential

The divide between hospital and community care leaves us impotent regarding demand management

where next
Where next?

PM’s & weekends

Treat-in-Turn expansion

Cardiology

Gastroenterology

Patient discharge pathway

Matching staff with workload (volume and time)

New ward governance models

Standardisation of ward rounding

How many admitting units do we need?

conclusions
Conclusions
  • Don’t mention the war – it’s not about the 4 hour KPI!
  • It’s not about working harder -
  • It is about leadership, teamwork, design, and reducing variation
  • Hospitals are full of smart people, we need to create the environment/culture that allows them to achieve their potential
  • It is about quality and excellence in care – quality saves time and money
  • It is a journey that your staff have to travel with you
  • Let’s get the job done and move on to address the bigger issues
acknowledgements
Acknowledgements
  • Martin Keogh – Services Director, Emergency and Acute Medicine
  • Andrew Stripp – Chief Operating Officer
  • De Villiers Smit – Director Emergency Services
  • Peter Hunter – Program Director of Aged Care and Rehabilitation
  • Andrew Way – CEO
  • Bill Johnson – Program Director Surgical Services
  • Amy McKimm – Redesign manager
  • Many, many others
genmed team staffing dec 2013

A

A

A

A

A

A

B

B

B

B

B

B

C

C

C

C

C

C

D

D

D

D

D

D

GenMed Team Staffing Dec 2013+

WEEKDAYS

WEEKENDS

CON

INTERN

CON

APT

BPT

INTERN

BPT

8am

A

12pm

1pm

5pm

7.30pm

9.30pm

slide51

Re-thinking E&TC Practices & Processes

  • Completely change triage
    • Move from triage to streaming model
  • More timely care to reduce E&TC occupancy
    • Upfront senior clinical decision making
    • “Treat in turn” instead of “triage and wait
  • New team structures
    • Clarity of Roles & Responsibilities
  • E&TC to use their authority to admit
    • Reduce need for negotiation & delay
what has this been about
What has this been about?
  • Enhancing access to care for acute patients and making access to care a central component of excellent clinical care.
  • Replacing processes that are burdened with waste and protectionism, and thereby reducing morbidity, length of stay and mortality.
slide54

What has this been about?

  • Creating a more effective system to cope with increasing demand.
  • Instilling the concept that hospital beds are a valuable resource that we as clinicians have a responsibility to utilise in the most efficient way possible.
key achievements wa program
Key achievements – WA Program
  • Implementation of large scale, statewide change program
  • Establishment of redesign capacity across the system
  • Invested over $40M in solutions
  • Leading the nation in emergency access reform
where are we now
Where are we now?
  • In terms of numbers and targets, the WA State NEAT performance in high 70‘s, with our tertiary site performance stalled or deteriorated slightly.
where are we now1
Where are we now?
  • From a hospital clinician perspective it has created an improved work environment that persists despite challenges in maintaining tertiary performance.
  • The concept of the need to flow patients efficiently has been embedded to a significant degree. It is part of our language now.
what happened in 2012
What happened in 2012?

Transition from project teams to hospital executive ownership.

Consequent lack of drive of solutions and solution review.

Significant ED demand.

Ministerial focus on NEST.

so what did we do about this performance trajectory
So what did we do about this performance trajectory?

We attempted to rally managerial and clinician engagement, however we were struggling to know where to start.

The Minister for Health commissioned an external review –The Bell Review.

the bell review
The Bell Review
  • Daily accountability /core business
  • Data
  • Bed management structure/ outliers/ the clinician’s role
  • Consultant lead service-weekend performance
  • Align multi-professional teams for timely treatment and decision making
  • ED discharge stream perfomance, decreased patient moves within ED.
the bell review1
The Bell Review

Capacity audit analysis. 25-30%, half of which is under hospital control.

Simplified points of access to specialties.

Acute unit structure and staffing. “a safe haven”, with focus on inclusion rather than exclusion criteria.

Appropriate IT solutions

the bell review2
The Bell Review
  • Essentially, the take home message was that if you want this to be successful, you have to get serious and run it like a professional business should run.
what has happened since
What has happened since
  • Executive restructuring was already occurring in several of our tertiary sites. This is occurring across all tertiary sites now.
  • This includes leadership training, greater time allocation to divisional heads, JDF changes to incorporate NEAT accountability (eg FSH).
what has happened since1
What has happened since
  • Bed management disassembling and increased clinician involvement.
  • Services to provide seven day structure –endpoint being equivalent discharge rates to weekdays
slide71

Data/CapPlan utilisation for daily clinician bed management.

  • Some real accountability and ownership is being seen at a hospital level.
some general observations to consider
Some general observations to consider
  • ED versus Inpatient reform.
  • Flogging the discharge stream
  • The admission stream dilemma.
  • Direct admissions, inpatient occupancy and the core role of the ED
  • The future of NEAT
  • The ministerial drive effect