High quality safe acute services

1. High qualitysafe acute services Professor Derek Bell Director NIHR CLAHRC for NW London Imperial College London Chelsea and Westminster Hospital

3. Characteristics Safe Effective Patient Centred Quality Innovative Prevention Productive Value

4. Patient perception of quality by waiting time in acute care

5. 5

6. P < 0.0001 ED Door to medical team time30-day adjusted mortality

7. 7

8. QUARTERLY A&E WAITING TIMES (ENGLAND 2005-2010)Percentage less than 4hrs: Seasonally Adjusted

9. 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

10. 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

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

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

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

14. 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

15. Emergency care Minor injury and illness Short stay emergency admissions (<48hrs) 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 ? Patient flow groups- must be whole system !

16. Findings Systematic review of acute careScott 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 LoS of 1-2.5 days. Direct discharge rates(DDR): 3 hospitals increased their DDR (24, 48 and 72 hrs). One hospital increased DDR24 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