At Northern Devon Healthcare NHS Trust, we have historically performed well against A&E emergency care standards, but during the winter of 2014/15 it became apparent that this was slipping. We were struggling to offer high-quality and safe care for patients presenting to our emergency department and this was adversely affecting patient experience.
As a way of resolving this, we wanted to improve the flow of patients through our hospital – for example, by reducing the number of people who were staying for longer than 14 days. We also wanted to educate staff about how important the four-hour A&E target is for determining how well patients flow through our hospitals, from when they are admitted to when they are discharged. Failing to meet the four-hour target was leading to other problems, such as overcrowding in the emergency department, and cancelled operations.
We also had a growing reliance on agency staff, were having to firefight daily and had concerns about how this was impacting on the safety of our patients and staff. And it became clear that, going into the next winter period, we would not have the same level of inpatient beds available as both staffing and funding had become a problem.
After winter 2014/15, as a result of local consultation and other changes, we reduced the number of beds in the local system, investing the money instead in providing better care closer to home. Many people were concerned that we would be unable to cope, particularly during the winter, and that there would be knock-on effects across the system.
However, since then, our length of stay has reduced, and our emergency department was named as a top national performer by the end of 2015/16.
So how did we do it?
Breaking the cycle
We made a series of changes as part of our ‘Breaking the Cycle’ initiative, based on the Emergency Care Improvement Programme’s Perfect Week methodology, which has grown into something unique. The methodology involves having one week of intense improvement activity to improve the flow of patients, resulting in higher-quality care that can then be sustained. We enhanced the methodology to suit the particular challenges we were facing around getting people back out of hospital once they had been admitted, which was often resulting in longer emergency waiting times. The initiative is now in place right across the organisation.
As we entered winter 2015/16, we developed the Perfect Initiative, which aimed to make a cultural change to ensure we would be able to improve patient flow.
Three previous Perfect Week initiatives had all resulted in positive patient flow for up to three weeks post-intervention, but we wanted to embed this into day-to-day work. To do so, we:
Held twice-daily tactical meetings, led by senior operational management, supported by the executive director, and with senior health and social care and clinical commissioning group representatives. This reduced duplication of questions, allowing for efficient information sharing
Piloted components of an enhanced acute frailty pathway for supporting patients at home and preventing admissions to hospital
Provided more medical, pharmacy, therapy and radiography support in the medical assessment unit and emergency department.
What were the outcomes?
We spent more days on green or amber escalation status (where the trust is able to free up enough beds to meet demand) in the last quarter of 2015/16, with quicker recovery, while maintaining a reduced acute bed base of 20 fewer beds and 25 fewer community beds compared to the 2015 period. We sustained our referral-to-treatment performance across the same period, and reduced the number of occurrences where patients were not treated in the appropriate setting.
Our performance improved by three per cent in January and February compared to last year, with the trust being in the top 10 best-performing trusts in England for compliance against the A&E four-hour standard.
We saw a reduction in the number of patients with over 10-day and 14-day length of stay at the acute hospital.
We increased the proportion of morning discharges, with up to 25 per cent of patients being discharged during the morning (a 10 per cent improvement) and a reduction in the proportion of patients discharged during the evening/night.
Containing the number of beds required for winter meant we were able to substantially reduce the prevalence of temporary agency nursing staff: we have now reduced agency shifts from 350 per week to as low as 75 per week.
What have we learned?
The initial Perfect Week initiatives built momentum for change, but embedding the approach into day-to-day operational functions has started to change the culture and improve ownership of the flow agenda in clinical teams. Our trust's community services have also been key in achieving an improved position by providing support to people in their own homes or residential settings. This often prevents unnecessary admissions to hospital and means we are able to get people out of hospital quicker in cases where they would be better off being looked after at home.
We have concluded that improving flow needs senior leadership and focus, and that system partners such as the clinical commissioning group, the mental health trust and local government have helped us to tackle the issues we are encountering. In turn, working in partnership with other local players supports joint commissioning plans to address these issues in the long term. However, the greatest opportunity for efficiency remains within the internal acute system in tackling variation.
Please note that all views expressed in guest blogs on our website are the authors' own and do not necessarily reflect the views of the Nuffield Trust.
Sainsbury R (2016) 'Making patient flow everybody’s business'. Nuffield Trust comment, 26 Octber 2016. https://www.nuffieldtrust.org.uk/news-item/making-patient-flow-everybody-s-business