Health care that flows

It was previously thought that the only way to improve healthcare was by adding more resources. However, as many have observed, increased NHS funding over recent decades hasn’t always delivered proportionate improvements in access to, or quality of, care.

The current period of austerity has led to new questions: Can access and patient outcomes continue to improve with less resource? If the timeliness and quality of care is improved, what happens to cost? Our Flow Cost Quality improvement programme was developed to explore these questions. Jane Jones, Assistant Director at the Health Foundation, tells us more about the thinking behind the programme and what it has achieved.

About Flow Cost Quality

The Flow Cost Quality programme ran in two trusts: South Warwickshire NHS Foundation Trust and Sheffield Teaching Hospitals NHS Foundation Trust. The programme explored the relationship between patient flow, costs and outcomes. In particular we wanted to examine patient flow through the emergency care pathway, and develop ways to better match capacity to demand.

The term ‘flow’ is used here to denote the flow of patients between staff, departments and organisations along a pathway of care. Flow is not about the what of clinical care decisions, but about the who, how, where and when of care provision. How services are accessed, when and where assessment and treatment is available, and who it is provided by, can have as significant an impact on the quality of care as the actual clinical care received.

Our approach

The programme’s improvement approach was based on the methodologies of lean and clinical systems improvement, as well as the theory of constraints.

The ‘lean’ improvement approach was originally developed by Toyota. It focuses on getting the right things to the right place, at the right time, in the right quantities, while minimising waste and being flexible and open to change.

Kate Silvester, clinical systems improvement coach for our Flow Cost Quality programme, explains the benefits of using this learning from the manufacturing industry within healthcare:

‘Factories and their supply chains are managed as value-streams that serve particular customers with particular needs. This principle of lean thinking has the advantage of bringing staff from different functions together to focus on the one thing that matters to them all: the patients in their care.’

Thinking differently

The two trusts systematically examined patient flow through emergency care pathways, while collecting feedback about patient experience. They wanted to challenge the way services are traditionally planned and organised, which can inadvertently create delays in the patient pathway.

‘It’s about looking at it from the patient’s perspective – how do we remove the barriers and for the patient make it seem integrated? Because that’s where the quality and efficiency gains lie.’ Tom Downes, Clinical Director for Quality Improvement, Sheffield Teaching Hospitals NHS Foundation Trust

The issues the programme wanted to solve included:

• capacity not being available when demand presents (eg not being able to request diagnostic tests out of hours)
• senior decision makers not being available at the time patients are admitted (leading to junior doctors admitting patients)
• results not being available in a timely fashion to enable decision making
• patients having to fit around the organisation rather than the organisation fitting around them (eg waiting to be discharged even though they are medically fit).

The trusts then implemented changes designed to help better match capacity with demand. This involved introducing a single multi-disciplinary assessment process, and speeding up patient flow by improving the turnaround time of core support processes. They also focused on improving the flow around discharge from hospital.

You can read in more detail about the changes implemented by one of the trusts in this month’s case study article.

Learning from the programme

Both trusts discovered a strong relationship between poor patient flow and poor quality care. They found that a key problem was a persistent mismatch between the predictable variations in emergency demand and the availability of workforce capacity. This raises interesting conclusions about the impact of our traditional five-day working week on patient safety.

By taking steps to improve flow, both trusts have managed to improve performance during difficult financial times and, in some instances, remove problems with capacity or reduce length of stay. By tackling the root cause of problems, they are starting to see results they can feel confident are based on a solid foundation.

These trusts are by no means unique in applying the techniques used in the Flow Cost Quality programme. However, what is particularly interesting is the systematic approach taken, the application of the techniques across whole organisations and the sustained duration of the improvement effort, all of which have begun to change the core service model, culture and approach of the organisations. Robust data analysis has also given the teams the insight to quickly understand where to intervene when they face further performance challenges.

The work makes it clear that, in order to realise the more radical benefits offered by prioritising flow, how change is approached and the organisational context in which it happens are just as critical as finding the right service design.