MANAGING PRESSURES IN AN ACUTE SETTING

1. MANAGING PRESSURES IN AN ACUTE SETTING Grant Archibald Director Emergency Care & Medical Services 10TH JUNE 2011

2. A Short Introduction to Queuing Theory AndreasWillig July 21, 1999 The subject of queuing theory can be described as follows: consider a service centre and a population of customers, which at some times enter the service centre in order to obtain service. It is often the case that the service centre can only serve a limited number of customers. If a new customer arrives and the service is exhausted, he enters a waiting line and waits until the service facility becomes available. So we can identify three main elements of a service centre: a population of customers, the service facility and the waiting line.

5. Managing Pressures in an Acute Setting • Key Parameters • NHSGGC - 9 Acute Hospital Sites • 465,000 A&E attendences per year • 161,000 emergency admissions per year

6. Managing Pressures in an Acute Setting

7. Managing Pressures in an Acute Setting • UCC Performance • Chart shows a steady build up of performance figures as improvement work begins to take effect in the departments : • April 2006 – 81% compliance • December 2007 – 98% compliance achieved for the first time • 98% achieved in 18 of the following 22 months as • improvements are embedded and sustained • Numbers of attenders and admissions increasing in A&E • across NGSGGC • However, it also shows a recent period of decline and then partial recovery – what has changed?

8. Managing Pressures in an Acute Setting System pressure builds through 2010/11 (1): • Pressures re Delayed Discharges • Patients moving more slowly through the system • ASR - Re-design of Services • Winter Pressures • Extreme snow fall/freezing icy conditions • Increased number of H1N1/Flu like/Respiratory illnesses

9. Managing Pressures in an Acute Setting System pressure builds through 2010/11 (2): • Significant increase in emergency activity and admissions • A&E attenders • 24th December to 7th January 2011: 5% increase on previous year • Emergency Admissions • 25th December to 7th January 2011 : 9% increase on previous year • 1st to 3rd January : 17% increase on previous year • 3 days when emergency admissions exceeded 500 patients • 3 days when emergency medical admissions exceeded 300 patients • Continued attender and admission pressures through most of January 2011

10. Managing Pressures in an Acute Setting

11. Managing Pressures in an Acute Setting • Response to managing key pressures in system (1) • Immediate : • Implemented Escalation Policy • Opened additional capacity • Increased Home Visiting by GPs/Primary Care services • Longer Term :Understand Changes in Demand profiles • Continuing to progress planned improvements in length of stay and bed usage • Ongoing management of delayed discharges • Reviewing plans to deal with any exceptional peaks in emergency activity • EDD • Reviewing Outcomes of A&E Patient Audit and Inequalities Audit • A Review of all out of hospital measures – HEAT 10 Work Programme

12. Managing Pressures in an Acute Setting • Response to managing key pressures in system (2) • System wide Improvement Action Plan for Unscheduled Care (ATOS) • March 2011 – Flow Mapping • Local team engagement to identify patient processes • May 2011 – Stakeholder Engagement Event – whole system • Presentation of data analysis • Identified key priority issues to be addressed • 17th June 2011 – Stakeholder Event to agree future workplan

13. Issue Tree 46% of admissions < 2 days ALoS Beds = 39% ALoS in Wards 4.7 days 27% of Surgical processed in last 30 mins & getting worse 40% of A&E admissions are Surgical 12% of Surgical admissions breach 8% of Medical admissions breach 20% of Medical processed in last 30 mins & getting better Waiting A&E = 16% Reasons for breach Capacity vs Demand mismatch (1st Dr Assessment is 14%) Surgical = 3% Waiting Specialist = 12% People & Process? Ortho = 2.8% Footprint & routings (layout) Medical = 3% Other = 2% Support Services = 15% Transport = 9% Bloods = 3.6% Diagnostics = 1.3% Clinical Exception = 14% Radiology = 3.6%

14. Managing Pressures in an Acute Setting

15. Managing Pressures in an Acute Setting Key Issues identified at Stakeholder Engagement Event CAPACITY MANAGEMENT • Improve accuracy and use of predictive tools • Match staffing and services to demand profile • Set capacity parameters for all service flows

16. Managing Pressures in an Acute Setting Key Issues identified at Stakeholder Engagement Event WHOLE SYSTEMS APPROACH • Joined up performance targets for Acute services, Primary Care, SAS and NHS 24 • Re-emphasis on unscheduled care being a whole service target • Review arrangements for chronic disease management / repeat admissions to reduce emergency hospitalisation

17. Managing Pressures in an Acute Setting WAY FORWARD • Essential to recognise this is not just a product of extreme winter • A new paradigm in demand and capacity • Using structured analysis and tools to devise specific, hard edged solutions • Develop a programme of sustained improvement • Achieve a new steady system-wide steady state, which is also capable of managing demand variations