Acute Medicine: The Scottish perspective Essential actions, flow - PDF document

10/5/2018 Acute Medicine: The Scottish perspective Essential actions, flow and a touch of realism @djbeckett 1

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10/5/2018 Why SAM Scotland? 4

10/5/2018 “The Scottish Patient Safety Programme marks Scotland as leader, second to no nation on earth, in its commitment to reducing harm to patients d ramatically and continually” Donald M Berwick, MPP Former President and CEO Institute for Healthcare Improvement Fill rates Acute (Internal) Medicine fill rates, Fill rates, A(I)M, 2015 Scotland 100% 100% 80% 80% 60% 60% Unfilled 40% 40% Filled 20% 20% 0% Scotland England 0% 2013 2014 2015 5

10/5/2018 SAM Scotland • Hosted by RCPE • Route of entry through SAM UK, initially with no additional cost (regional representation) • Annual conference (next is December 14 th 2018 at FVRH … ) @weeSAMScotland Acute (Internal) Medicine fill rates, Scotland 100% 90% 80% 70% 60% Unfilled 50% Filled 40% 30% 20% 10% 0% 2013 2014 2015 2016 2017 2018 6

10/5/2018 Scottish Government ‘ Acute Physicians play a key role in the Unscheduled • Care process and we are keen to see a vibrant and representative SAM Scotland work with us and the other key partners to improve patient and staff experience which are inextricably linked’ Alan Hunter, Director of Performance, 7

10/5/2018 Emergency Access Standard • The Emergency Department cannot deliver this target alone • It requires a whole system response to ensure capacity meets demand - by hour of the day and day of the week • Whole system barometer Charles Goodhart 8

10/5/2018 Crowding There is an association between ED crowding and: • Mortality • Increased length of stay both in ED and I/P • Reduced quality of care • Poor patient experience • Staff burnout • Difficulty recruiting and retaining staff 9

10/5/2018 Scotland: weekly, self-reported acute inpatient boarding rates, Nov 2009 to Oct 2014 Proportion of estimated staffed acute inpatient beds reported occupied by boarded patients, % Sources: (i) SG weekly monitoring submissions; (ii) hospital-level ISD(S)1-derived ISD IR2012-00483 and hospital bed statistics publications Notes: (i) interpretation of inpatient boarding definition may vary between Health Boards, hence caution should be taken when interpreting trends; (ii) reported measure changed from Mon census in 2009/10 to bed day usage from 2010/11; (iii) data imputed where required, except for Highland Health Board, for which no consistent data are available; (iv) results are intended for management information only 15% 2009/10: 2010/11 onwards: Nov 2012 onwards: 14% boarder census total boarded continuous collection of at Mon 23.59 bed days weekly monitoring submissions 13% 12% 11% 10% 9% Health Board variation 8% 7% 6.1% 6% 5.4% 5.1% 5% 4.6% 4% 3.6% 3% 3.0% 2% 2.0% 1.3% 1% 0% 08/11/2009 22/11/2009 06/12/2009 20/12/2009 03/01/2010 17/01/2010 31/01/2010 14/02/2010 28/02/2010 14/03/2010 07/11/2010 21/11/2010 05/12/2010 19/12/2010 02/01/2011 16/01/2011 30/01/2011 13/02/2011 27/02/2011 13/03/2011 06/11/2011 20/11/2011 04/12/2011 18/12/2011 01/01/2012 15/01/2012 29/01/2012 12/02/2012 26/02/2012 11/03/2012 11/11/2012 25/11/2012 09/12/2012 23/12/2012 06/01/2013 20/01/2013 03/02/2013 17/02/2013 03/03/2013 17/03/2013 31/03/2013 14/04/2013 28/04/2013 12/05/2013 26/05/2013 09/06/2013 23/06/2013 07/07/2013 21/07/2013 04/08/2013 18/08/2013 01/09/2013 15/09/2013 29/09/2013 13/10/2013 27/10/2013 10/11/2013 24/11/2013 08/12/2013 22/12/2013 05/01/2014 19/01/2014 02/02/2014 16/02/2014 02/03/2014 16/03/2014 30/03/2014 13/04/2014 27/04/2014 11/05/2014 25/05/2014 08/06/2014 22/06/2014 06/07/2014 20/07/2014 03/08/2014 17/08/2014 31/08/2014 14/09/2014 28/09/2014 12/10/2014 26/10/2014 Standardised results Summary Multilevel model standardisation Expected values: Crude rates: Non- Non- Non- Boarded, Non- Boarded, boarded, boarded, boarded, site- boarded, site- site- site- no specialty no specialty Total specialty specialty sitespec boarding sitespec boarding boarding boarding boarding present boarding present present present 31.6% 59.2% 9.2% 981,798 1,836,546 285,688 3,104,032 Spells 3.2 4.3 5.3 1.7 4.5 9.4 4.1 days, n Spell LoS: 3.1 4.2 5.0 99% CI lower 3.4 4.4 5.6 99% CI upper 3.7% 4.5% 5.2% 3.3% 4.8% 4.9% 4.3% 7 days, % Emergency 99% CI 3.6% 4.5% 5.0% lower readmission 99% CI 3.8% 4.5% 5.3% upper within, of 7.9% 9.5% 10.7% 6.4% 10.3% 11.5% 9.2% 30 days, % discharge: 99% CI 7.8% 9.4% 10.5% lower 99% CI 8.0% 9.5% 10.8% upper 2.1% 2.4% 2.6% 1.0% 2.8% 3.7% 2.3% 7 days, % 2.0% 2.4% 2.5% 99% CI lower Death within, 2.1% 2.4% 2.7% 99% CI upper of discharge: 3.0% 3.4% 3.8% 1.5% 4.1% 5.6% 3.4% 30 days, % 99% CI 3.0% 3.4% 3.7% lower 99% CI 3.1% 3.5% 3.8% upper 10

10/5/2018 Standardised results Summary Multilevel model standardisation Expected values: Crude rates: Non- Non- Non- Boarded, Non- Boarded, boarded, boarded, boarded, site- boarded, site- site- site- no specialty no specialty Total specialty specialty sitespec boarding sitespec boarding boarding boarding boarding present boarding present present present 31.6% 59.2% 9.2% 981,798 1,836,546 285,688 3,104,032 Spells 3.2 4.3 5.3 1.7 4.5 9.4 4.1 days, n Spell LoS: 3.1 4.2 5.0 99% CI lower 3.4 4.4 5.6 99% CI upper 3.7% 4.5% 5.2% 3.3% 4.8% 4.9% 4.3% 7 days, % Emergency 99% CI 3.6% 4.5% 5.0% lower readmission 99% CI 3.8% 4.5% 5.3% upper within, of 7.9% 9.5% 10.7% 6.4% 10.3% 11.5% 9.2% 30 days, % discharge: 99% CI 7.8% 9.4% 10.5% lower 99% CI 8.0% 9.5% 10.8% upper 2.1% 2.4% 2.6% 1.0% 2.8% 3.7% 2.3% 7 days, % 2.0% 2.4% 2.5% 99% CI lower Death within, 2.1% 2.4% 2.7% 99% CI upper of discharge: 3.0% 3.4% 3.8% 1.5% 4.1% 5.6% 3.4% 30 days, % 3.0% 3.4% 3.7% 99% CI lower 3.1% 3.5% 3.8% 99% CI upper 11

10/5/2018 Six Essential Actions Improvement Approach  Launched in May 2015  Developed in partnership with the Academy of Royal Colleges, NHSScotland and Scottish Government  Aims to improve the patient and staff experience of Unscheduled Care  Delivery of 95% target for all patients to be admitted, discharged or transferred from the Emergency Department within 4 hours.  Aiming towards a standard of 98%  Ministerial objective 12

10/5/2018 Clinically Focussed Empowered Leadership Responsive Operational Management Whole System Escalation Determining and utilising Triumvirate Leadership Team Pathways to reduce appropriate information and trend - Site Director, attendance, avoid admission data for performance improvement - Chief Nurse, and if admission necessary to ensure correct resources are - Chief Doctor ensure home when ready applied to meet demand and Signposting and redirection to system need appropriate community services Basic Building Blocks Ensuring Patients Care for at Home Capacity and Patient Flow Realignment 7 Day Services Patient Rather Than Bed Management To reduce variation in access Daily Dynamic Discharge to all services across Shifting the discharge curve left Designed to weekend and out of hours. pull patients from ED Developing a coordinated, Includes clinical assessment, through assessment and multidisciplinary approach to diagnostics, and access to diagnostics process to be discharge planning encompassing Senior Decision Makers. Also seen at right time, by right person acute and community resources support services such as in right place porters, cleaning and Improve rate of early in Medical and Surgical Processes transport day and weekends Aligned for Optimal Care Discharges Admissions Scheduled and direct admissions with XRI AU LoS > 24 hr Emergency admissions with ED* LoS > 4 hr, % Hospital discharges 26 13