Advancements in Emergency & Acute Medicine Programs 2012

1. Welcome on behalf of SDU and Clinical Programmes Tony O’Brien

2. Speakers • Mr. Tony O’Brien, Chief Operating Officer, SDU • Dr Garry Courtney, Clinical Lead, Acute Medicine Programme • Dr Una Geary, Clinical Lead, Emergency Medicine Programme • Dr Martin Connor, Senior Advisor, SDU

3. National Emergency Medicine Programme March 2012Dr Una Geary Consultant in Emergency MedicineEmergency Medicine Programme Lead

4. Emergency Medicine Programme 2012 Aim: to improve safety, quality, access and value in Emergency Medicine and reduce waiting times for patients. An implementable plan developed by ED nurses, doctors and other healthcare workers in consultation with patients. Supported by the Medical Training Bodies, HSE Directorate of Nursing and Midwifery, Therapy Professions Committee, HSE Patient Advocacy Unit, the HSE and the Department of Health.

5. Emergency Medicine Programme – update 2012 Analysis & Recommendations Implementation Sustaining Improvement National levelimplementation High quality, high value National Emergency Care System Hospital level implementation Emergency Medicine Programme

6. Patient Safety and Quality of Care • A National System of Emergency Care based on hospital networks • Explain what is necessary to provide safe, high quality emergency care • Clear governance, quality standards and accountability • More senior clinicians delivering patient care • National clinical guidelines in all EDs • Data-driven continuous quality improvement; ICT, data definitions etc. • Work with the SDU and other clinical programmes to reduce and eliminate ED overcrowding

7. Patient Access & Experience Access standard: 95% of all ED patients admitted or discharged within 6 hours and 100% admitted or discharged within 9 hours of ED arrival. Other access key performance indicators: • Ambulance Handover • Patients leaving before completion of treatment • Admission to ED Clinical Decision Units < 24 hours Improve ED efficiency and effectiveness: • Process improvement methods from industry • Patient streaming • Expanded nursing roles & reallocation of tasks • Reduce non-value added time

8. Value in Emergency Care Patient outcomes value in healthcare cost e.g. the number of patients recovering from cardiac arrest, or receiving stroke treatment to reduce paralysis, or better than expected recovery following major trauma • Measurement systems – ICT, outcome measures, cost measures • Is there waste in our system? e.g. duplication of effort or tests • What is the most effective and efficient use of our staff? • Success is defined from the patient’s perspective

9. Benefits of the Clinical Programmes • Clinicians setting standards and designing solutions • Patient input to service development • Clinicians collaborating with the Department of Health and HSE • “Joined-up thinking” across programmes, specialties and services • Working with hospital management teams for better patient outcomes • Focus on appropriate resource utilisation and value • A new culture of continuous systems learning and improvement • Building shared understanding and commitment • Sustaining motivation, staff and patient participation • Planning, measurement and a long-term view

10. Emergency Medicine Programme Patient participation People Process Technology Strategy & Structure Education & professional development Physical infrastructure NetworkModels EmergencyCare Governance Workforce models Staff skill mix Senior clinicians Patient pathway KPIs & measures Quality guidelines Information management Digital infrastructure Electronic records Links with other specialties & services FundingModels

11. National Emergency Medicine Programme Thank-you

12. National Acute Medicine Programme Professor Garry Courtney March 8th 2012

13. Acute Medicine Programme objectives • Key objectives: • Quality: Reduce the admission rate of medical patients by 10% per year for 3 years post full implementation without increasing 28 day readmission, thus enhancing the global patient experience. • Access: Every medical patient presenting to the AMU/AMAU/MAU* will be seen by a senior medical doctor within one hour and will be discharged/admitted within 6 hours. • Cost: Achieve a national medical patient mean ALOS of 5.8 days, generating total bed day savings over 3 years of 500,000 (1,300 beds). • Elimination of trolley waits. • (* Acute Medical Unit/Acute Medical Assessment Unit/Medical Assessment Unit) 13 13

14. AMP key features Streaming of acute medical patients to defined locus of care (AMU) Early opinion from Senior Medical Doctor Early diagnostics (“investigate to discharge” NOT “admit to investigate”) Expedited Specialist Consultation Fast track OPD/procedures Disposition decision within 6 hours (admit or discharge) Daily ward/board rounds Week-end discharges 14

15. AMP Goals • Better patient care • Better patient/staff experience • Better clinical outcomes • Appropriate clinical environment • Reduced elective waiting times for admission/day cases, etc. • Less trolley waits • Improved efficiency • Better value for money 15

16. AMP Model of Care Stroke Unit Respiratory Unit Gastro- Intestinal Unit GP Acute Rehabilitation Unit Acute Bed Pool 2 nights Decision to admit ED Metabolic Unit Critical care Cardiac Unit

18. AMP Summary • Improves the quality and the safety of care • Reduces in-hospital length of stay • Increases same day discharge rates • Improves efficient use of hospital resources • Greater patient, GP and staff satisfaction

19. Conclusion 19

20. TD Briefing Martin Connor SDU 8th March 2012

21. The strategy cannot be about marginal adjustment – it has to be about system transformation

22. Introduction • SDU and its values • Practical elements of the approach

23. The SDU and its values

24. Brief introduction to the SDU • Established as management team at start September, now formally a branch of DH • Delivery through ‘associated partners’: • Clinical Programmes • ISD • CPCP • Quality and Patient Safety • NTPF • Ministerial remit to resolve problems • Supporting HSE performance management through existing processes: ISD and RDOs • Will be a constant presence as structural reform takes place

26. What we have done so far

27. Practical elements of the approach • ‘From day one’ partnership with clinical programmes • Established the performance priority: overcrowding, long waits for surgery, long waits for outpatients, long waits for diagnostics • Introduced SPC • New process for managing December/January • Discharge/ bed management collaboratives established • Resource re-allocations to support main risk sites • Sponsored ED IT upgrades • Created web-based patient level monitoring • Weekly monitoring for at-risk sites • Developed new accountability framework • Capacity and demand modelling • Leveraging international networks

28. Introduced SPC

30. We are establishing a ‘web form’ process (the ‘SITREP’) to capture daily variation over key pressure measures from each site…

31. New process for managing December/ January

32. ISA-based capacity planning for Winter ED ICT prepares 2012 shift to total journey times Discharge/ bed mgt networks established Weekly planning meetings Local capacity plans signed off Daily pressure monitoring Escalation plans signed off Nov Dec Jan July Aug Sept Oct The Plan

33. Capacity & Risk Assessment

34. New discharge/ bed mgt collaboratives established

35. NEL Admitted Demand + Capacity Profile of admit arrivals and discharges over a 24 hour period (hourly blocks) - data from the last 8 weeks.

36. New discharge/ bed mgt collaboratives established • Every hospital in the country has a nominated senior nurse as part of the network • We have adopted a ‘learning set’ approach with independent facilitation • First cycle now completed with positive feedback – programme will run continuously • This form of staff empowerment an essential part of the development of the system

37. Resource re-allocations to support at-risk sites

38. Resource re-allocations • At-risk sites identified as having the worst overcrowding • €5m moved from NTPF – full year equivalent of c. €40m • Schemes developed from the bottom up • Support will be maintained through January and extra resource will need to be ‘worked out’ • Took this step to support service and patients despite real risks: • Moral hazard • A lot of this isn’t about capacity • Begins the challenging process of thinking through the broader opportunity cost of eliminating trolley waits

39. Sponsored ED IT upgrades

40. ED IT upgrade strategy • In two phases: • Phase one: establish real time monitoring of journeys • Phase two: implement ED EPR • Phase one rolling out successfully with some bumps in the road – aim to have >80% of patient journeys monitored daily by Q2 • Phase two approved by CMOD for procurement and roll out 2012 • Linked to development to implement upgrades to get real time monitoring data from MAU/AMU

41. Created web-based patient monitoring

42. Web-based patient monitoring and performance management • Designed and produced here in Ireland on an organic basis • Delivered on time and in budget • Local software house did programming – building skills and creating employment • Three products now delivered: • PTL monitor • Emergency Department patient journey time monitor • ‘Compstat’ system for hospital performance management • Potential to become world leading within 12 months

43. Web systems demo

44. Close monitoring of trolley waits

48. Weekly monitoring for at-risk sites • The risks of not getting strong enough early improvements, and not seeing a return on the capacity capital are very high • It’s desperately important for public confidence that all our collective efforts translate to a better December/January • SDU resource now 80% dedicated to trolley waits – and this will remain the case until we begin to get on top of it • Weekly process involves most senior leadership of hospital sites meeting with senior SDU liaison officer

49. Developed new accountability framework

50. We start here with simplified, clearer targets that better reflect the patient journey Numeric Objectives Escalation Monitoring: Frequency, Quality, Lag Intervention We establish systematic, comprehensive and high frequency weekly monitoring systems We clarify sanctions and incentives (an essential part of the leadership challenge) PERFORMANCE IMPROVEMENT WHEEL We hold leaders personally accountable for performance against KPIs