High quality safe acute services Professor Derek Bell

High quality safe acute services Professor Derek Bell Director NIHR CLAHRC for NW London Imperial College London Chelsea and Westminster Hospital

Characteristics • Safe • Effective • Patient Centred • • Quality Innovative Prevention Productive • Value

Patient perception of quality by waiting time in acute care Percentage rating care positively by time examined by a nurse or doctor 89% (n=39143) 82% 98% waiting 95% to be 71% 52% No wait (17% of patients) 1 -30 minutes (43% of patients) 31 -60 minutes (26% of patients) Between 1 Between 2 Over 4 and 2 hours and 4 hours (3% (17% of (11% of of patients)

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ED Door to medical team time 30 -day adjusted mortality P < 0. 0001

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oct-dec 2010 jul-sep 2010 apr-jun 2010 jan-mar 2010 91 oct-dec 2009 92 jul-sep 2009 93 apr-jun 2009 jan-mar 2009 oct-dec 2008 jul-sep 2008 apr-jun 2008 jan-mar 2008 oct-dec 2007 jul-sep 2007 apr-jun 2007 jan-mar 2007 oct-dec 2006 jul-sep 2006 apr-jun 2006 jan-mar 2006 oct-dec 2005 jul-sep 2005 apr-jun 2005 jan-mar 2005 Seasonally Adjusted Percentage QUARTERLY A&E WAITING TIMES (ENGLAND 2005 -2010) Percentage less than 4 hrs: Seasonally Adjusted 100 99 98 97 96 95 94 Seasonally adjusted % less than 4 h Mean Process limit 90

Where are we? • Managing the target – delivering high quality care – Flow – Capacity – demand – Variation – Quality agenda • Hitting the target (standard) – missing the point – Gaming • Tail gunning • Boarding but not ……. • Missing the target (standard) missing the point – Gaming – Bringing back old practise – Ignoring quality

NHS London review Upping our game • Benchmarking exercise • Review Consultant cover – 7/7 extended day cover – 12 hours dedicated on site – Twice daily Consultant ward rounds – all patients – All patients in AMU footprint to be seen twice daily – Daily review all wards 7/7 • Direct access to AMU from primary care • Prompt access to diagnostics and reports

High value • High quality – Outcomes – Patient experience – Avoid harm • Cost effective – Low variability – consistent – Timely – Right person right staff right place

Elective and emergency • Synergy √√√√ • Competition ---- • Avoid reactive bed / flow management

‘System Stress’ – Admission and Discharge Profile for all specialties

Summary • We all need to; – – – address the governance issues control patient flow within the system ensure we provide continuity of care (rotas and reviews) design improved 7/7 safer systems monitor performance and standards – Avoid Safari and Martini – Right place right person first time – all the time

Patient flow groups - must be whole system ! • Emergency care – Minor injury and illness – Short stay emergency admissions (<48 hrs) – In-patient medicine – In-patient surgery • Planned care – – Out-patients Day case and Short stay – In-patient elective – Complex elective (e. g Intensive Care) – Rehabilitation • Not ageist ?

Findings Systematic review of acute care Scott et al Mortality - 2 hospitals showed significant reductions in all-cause hospital mortality (44% relative reduction over 5 yrs in 1). Length of stay - 4 hospitals showed consistent reduction in Lo. S of 1 -2. 5 days. Direct discharge rates(DDR): 3 hospitals increased their DDR (24, 48 and 72 hrs). One hospital increased DDR 24 by 25%. Downstream Redistribution: 3 hospitals found improved usage of downstream wards. Readmission: No hospital found increased RRs. One hospital halved their RR. Economic: Only economic analysis - saving of 4039 bed days over 12/12, resulting in estimated cost benefit of € 1 714 152. Patient and Staff Satisfaction: One hospital found near universal satisfaction with new system. Other found mixed feelings, especially amongst nursing staff who reported much higher levels of stress. Multi-professional teams better