Tag Archives: Efficiency

Hot Topic: Patient Flow

A Word version of this briefing aimed at health care professionals is available for LKS staff to share in their own organisations. Please feel free to reproduce it (with acknowledgement) for your own purposes.

Impact on library policy/practice:

  • Skilled librarians can locate the evidence for different approaches to patient flow. The evidence may not always be accessible through bibliographic databases, but librarians have the skill to locate other sources of evidence such as case studies or reports
  • Library staff can support the publication and sharing of patient flow initiatives, either as published documents or as poster presentations
  • Library services can provide point of care information tools that can speed up the diagnosis and treatment of patients, and that can support junior medical staff to make decisions when there are fewer senior staff available

What does ‘patient flow’ mean?

Patient flow is about the avoidance of delays in transfers of care, from for instance hospital to home or from A&E to a ward. It can also encompass admission avoidance, but this will be looked at in a separate Hot Topic.

One definition is ‘the right care, in the right place, at the right time’.

Why has patient flow become a hot topic?

The majority of delayed transfers are still due to NHS delays (such as awaiting further non-acute NHS care) but the proportion due to social care (such as awaiting a care package in own home) has risen steeply since 2014. In October 2017 there were 170,100 total delayed bed days (3)

An audit by NHS Benchmarking showed that while only 5 per cent of people aged over 65 who are admitted to hospital stay for more than 21 days, that 5 per cent accounts for more than 40 per cent of all bed days (1). Longer stays in hospital are associated with increased risk of infection, low mood and reduced motivation, which can affect a patient’s health after they’ve been discharged and increase their chances of readmission to hospital (3).

When bed occupancy is higher than recommended, it can lead to difficulties finding beds for new admissions, with knock-on effects in other departments such as A&E. (4)

There is also an argument that due to the way the figures for delayed transfers are defined, there are many more cases of patients that could be cared for in other settings, such as forms of intermediate care. (4)

What are the consequences of poor patient flow?

Some of the consequences (2) are:

  • A&E departments become crowded, stressful and unsafe
  • Patients are admitted as ‘outliers’ to wards that are not best suited to manage their care, which may mean they have worse clinical outcomes
  • Ambulatory care services, clinical decision units, even catheter labs and endoscopy units may fill with patients waiting for ward admission
  • Inpatients are shuffled between wards to make room for newcomers
  • Clinical outcomes are measurably worse, particularly for frail older people, who suffer more harm events and may lose muscle tone due to extended periods in hospital beds

What is being done to improve patient flow?

Three approaches for improving flow are: shape or reduce demand, match capacity and demand, and redesign the system.

There are lots of potential ways to improve patients flow that follow one of more of three aproaches, with one of the ideas being tried that of Accountable Care Organisations which bring health and social care providers together to take responsibility for the care for a defined population.

Other suggestions for improving flow in hospitals include (2),(6):

  • Deploying ambulance managers (sometimes termed ‘HALOs’) to help manage the hospital–ambulance interface and release ambulances quicker
  • Co-location of primary care facilities in A&E department to stream patients
  • Using Clinical Decision Units outside of A&E for patients who can be discharged following a short period of observation, investigation or treatment
  • Assessing patients for frailty when they present at A&E so they can begin to receive specialist care and get the right level of support when they are ready to be discharged.
  • Using the SAFER patient flow bundle and ‘Red2Green days’ tools
  • Using lean or Six Sigma approaches to quality improvement 

Further reading and references

  1. NHS Benchmarking, 2017, Older People’s Care in Acute Settings: National Report
  2. NHS Improvement, 2017, Good practice guide: Focus on improving patient flow
  3. King’s Fund, 2018, Delayed transfers of care: a quick guide
  4. Nuffield Trust, 2017, What’s behind delayed transfers of care?
  5. BMJ Quality and Safety, Six ways not to improve patient flow: a qualitative study
  6. The Health Foundation, 2013, Unblocking a Hospital in Gridlock South Warwickshire NHS Foundation Trust’s experience of the Flow Cost Quality improvement programme

Primary audience: LKS staff and their wider organisations

Date last updated: May 2018

Due for review: May 2019

Group member responsible: JC

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Operational productivity and performance in English NHS Acute Hospitals: Unwarranted variations

Title of driver: Operational productivity and performance in English NHS Acute Hospitals: Unwarranted variations

Alternative Titles: Productivity in NHS hospitals Carter Review

Source: Lord Carter of Coles (Independent report commissioned by the Department of Health)

Link to main document https://www.gov.uk/government/publications/productivity-in-nhs-hospitals

Publication format: PDF

Date of publication: February 2016

Summary of driver:

Report sets out the findings of Lord Carter’s review of how non-specialist acute hospital trusts can reduce unwarranted variation in productivity and efficiency to save the NHS £5 billion each year by 2020 to 2021.

15 recommendations are made to reduce this variation, including proposing a set of metrics be developed for a ‘model hospital’ for trusts to be benchmarked against.

Key features of driver:

Various sources of unwarranted variation in productivity, costs and efficiency in acute hospitals were identified.

The review looked at clinical staffing, pharmacy and medicines, diagnostics and imaging, procurement, back-office functions, estates and facilities; and at the quality and efficiency of clinical specialties.

The report makes recommendations in 15 areas to reduce this variation, improve quality and productivity, make cost savings, use resources in a cost effective manner and increase efficiency.

The report calls for action by NHS Improvement, NHS England, the Department of Health and hospital trusts with recommendations for the below areas:

  • Developing and implementing a national people strategy – simplifying system structures, raising people management capacity, building greater engagement and improving leadership capability.
  • Ensuring hospital pharmacies and pathology and imaging departments achieve their benchmarks – resulting in pharmacists spending more time on clinical activities, and a consistent approach to the quality and cost of diagnostic services
  • Procurement – trusts should report procurement information monthly to NHS Improvement; collaborate with other trusts and the NHS Supply Chain; and commit to the NHS Procurement Transformation Programme – resulting in increasing transparency and at least 10% reduction in non-pay costs across the NHS.
  • Estates and facilities management – trusts should meet or operate above NHS Improvement’s benchmarks. Including not exceeding a maximum of 35% of floor space for non-clinical functions and 2.5 % of space unoccupied/underused.
  • Trust corporate and administration functions – should be rationalised so that costs don’t exceed 7% of their income by April 2018 and 6% of income by 2020, or have plans for shared service consolidation or outsourcing to other providers.
  • NHS Improvement and NHS England should establish joint clinical governance to set standards of best practice for all specialties.
  • Key digital information systems – should be in place in all trusts.
  • The Department of Health, NHS England and NHS Improvement should work with local government to provide a strategy for trusts focusing patient care on recovery and how patients can leave acute hospital beds as their clinical needs allow.
  • Quality and efficiency opportunities for better collaboration and coordination of clinical services across local health economies – NHS England and NHS Improvement should work with trust boards to identify these.
  • NHS Improvement should develop the Model Hospital and underlying metrics so there is one source of data, benchmarks and practice.
  • Metrics and reporting – NHS Improvement should develop an integrated performance framework to ensure there is one set of metrics and approach to reporting; reducing the reporting burden for trusts.
  • Various deadlines are suggested- all trusts should work towards these and national bodies should develop timetables for efficiency and productivity improvements.

Primary audience: Department of Health, NHS Improvement, NHS England, Acute Trust Boards

Impact on library policy/practice:

Libraries are not specifically mentioned but:

  • The focus on efficiency, quality and benchmarking may lead to increased interest in resources for business decision making, and clinical/service auditing.
  • Consortia purchasing of library resources could contribute towards cost reduction.
  • Libraries can supply resources on leadership and people management to support the staffing changes proposed.
  • Library staff could partake in any leadership training and development made available by their trusts – for CPD and to improve the structure and leadership of the library service.
  • Library services can highlight that by having trust computers available in their setting – they are supporting staff to have access to the digital information systems the report calls for.
  • Working in collaboration with other libraries to deliver projects and services e.g. inter-library loans could support the initiative of collaboration and cost reduction.

However with the stipulation for the maximum percentage of hospital floor space for non-clinical functions – if trusts feel they need to reduce non-clinical floor space, libraries may be one of the areas that faces challenges to their use of space. Library managers will need to highlight the value of the library service to counter this pressure.

Date last updated: November 2016

Due for review: November 2017

Group member responsible: FG

Providing Evidence for Supplies Group University Hospitals of Morecambe Bay NHS FT

Title of project: Providing Evidence for Supplies Group

Project team: Head of Procurement and Supplies; Productive Ward lead/Senior Nurse;
Clinical Librarian; Nurse Practitioner; Accountant; Practice Educators; Ward Managers; Departmental representatives

Resources required: Clinical Librarian time, literature searching, Supplies account for document supply.

Intranet: Supplies Group rep will manage the Intranet content.

Intranet publishing: CL needs Cutepdf installing on computer – liaise with IT

Timeframe: Ongoing: 2010-2011 initially

Description of product/service: The University Hospitals of Morecambe Bay NHS Trust is committed to providing high quality research based care within the resources available. The purpose of the Trust Supplies Group is to consider the research around the clinical efficacy and safety of clinical items available for use and make recommendations based on clinical and cost effectiveness.

A Clinical Librarian will attend the Trust Supplies Group meetings and will provide a literature searching service to support decision-making around procurement. The CL will summarise the search results and recommendations in an evidence based summary which will be published on the Intranet.

Alignment to local, regional and national drivers:

Trust Business Plan 2010-11: “To provide excellent value for money for tax payers and provide sustained long term financial viability”

National: Productive Ward; QIPP; Operating Framework 2010-2011

McKinsey Report page 37

Intended outcome for customer / organisation / library: Support evidence based practice in purchasing; Raise the library profile; Demonstrate contribution to organisational objectives. The aim of the Trust Supplies Group is to save money and streamline ordering for 2010-2011. The Library contribution promotes evidence based decision-making and demonstrates a contribution to achieving the Trusts savings.

Next steps: CL continued attendance at Trust Supplies Group Monthly meetings; CL present highlight report/update at each full team meeting

Milestones:

  • Deliver evidence summaries when requested
  • Create ‘Supplies’ account for document supply
  • Manage content/update Intranet site
  • Manage status of proposals on Intranet

Update: This project won the Sally Hernando Ward 2011 for Product Innovation and was presented at a Procurement Conference in 2013

Read the case study which has been added to the Toolkit