When South Warwickshire NHS Foundation Trust Chief Executive Glen Burley received a letter from Gerard, a retired management consultant and former patient, he thought ‘we can do better’. Gerard said that though he was treated well when he was admitted to the hospital, he was concerned that his care hadn’t been organised efficiently.
The letter came at a time when the trust was beginning to work with the Health Foundation to identify problems with the flow of patients through its emergency care pathway, part of the Flow Cost Quality programme. ‘Gerard’s letter was a powerful force in getting clinicians to see the impact on an individual patient,’ says Glen.
The trust invited Gerard to meet the project team and together they mapped his journey through the emergency care system. They worked out that only 18% of the eight days Gerard spent in hospital had added value to his treatment and care. Gerard’s story was one of the biggest drivers in getting staff on board. ‘We had staff around the table saying, “I want to change things”’, says Jayne Blackley, Director of Service Improvement.
Fundamentally, the department wasn’t achieving the national target to see, treat, admit or discharge patients in under four hours – and there were other problems too. ‘Our length of stay was increasing, mortality was increasing and patients were undergoing multiple bed moves,’ says Jyothi Nippani, Associate Medical Director for Emergency Care. ‘There was gridlock in the hospital.’
Key to unlocking this gridlock was getting staff to work together to understand where the problems were coming from. Dr Kate Silvester, who provided improvement expertise as part of the programme, put together a circuit diagram of the whole emergency pathway and plotted how poor flow of patients through the system was leading to wasted resources and poorer outcomes for patients.
Data analysis showed that there wasn’t enough capacity to meet demand for emergency care in the evening and at weekends, when senior decision-making staff weren’t available. There was a four-hour delay before patients were passed on from A&E and those needing specialist care were often on the wrong ward.
Improving patient care
The solution was for senior clinicians to assess patients on the day they arrived and introduce extended and weekend working for consultants. Seeing the benefits of getting patients on to their wards quicker, cardiologists chose to try out working in the emergency medical assessment unit (MAU). ‘It gave them greater ownership and empowered them to discharge patients who didn’t need to be there and pull in cardiology patients from MAU,’ says Jayne.
Glen (the Chief Executive), clinical directors, communications staff, as well as consultants and nurses, conveyed the need for change to other staff through meetings, workshops, newsletters and a blog. This helped convince them that although changing their working patterns might be inconvenient, it would benefit patients. Soon other departments came up with solutions to patient flow problems.
For example, a patient complaint showed that clinical decisions were being made on out-of-date blood tests. As a result, the blood sciences department organised a team meeting which revealed that phlebotomist and doctor ward rounds were out of sync. Porters suggested that they change the way they worked to shuttle between the phlebotomist and the laboratory. Same-day blood test results have now increased from less than 15% to more than 80% – consultants can make quicker and safer clinical decisions for patients.
Other solutions included having a ‘consultant of the week’ on wards and daily consultant-led ward or ’board rounds’, where clinical teams met in front of a board highlighting key patient information, including their expected discharge date.
Creating an impact
The changes put in place have brought a range of benefits. Despite dealing with an 11.5% growth in emergency admissions over the past year, the trust has managed to maintain performance and reduce the average length of stay and bed occupancy. Patients are now assessed faster and have quicker access to specialist input or admission.
Importantly, the mortality rate for emergency patients admitted from June 2008, as measured by the trust, has reduced, and for the first time in two years, the trust is ahead of its four hour A&E target.
Staff satisfaction has also improved. ‘Figures from the 2012 NHS Staff Survey show that the trust now has some of the best scores in the country for staff engagement’, says Glen. Over a third (35%) of staff believe strongly that they are able to do their job well, an increase from 11%.
‘I met Gerard at our public governors’ meeting recently and he was surprised by how we’ve responded,’ says Glen. ’Now he wants to be a governor.’
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