Our work

Together with the client’s clinical and operational teams, we then identified a list of root-causes of under-performance based on the quantitative and qualitative evaluations, and developed a set of potential solutions to address the bottlenecks.

Key issues facing our client

The NHS Trust in the East Midlands had delivered the 4 hour A&E target for two consecutive quarters, however in the most recent quarter its performance had deteriorated below target and vs. its local peers. The Trust engaged us to undertake detailed diagnostic with the objectives to develop an accurate picture on the root causes of poor performance in Emergency Care across the entire local health system, and to highlight the main areas of focus and outline what the system needs to put in place to achieve the desired quality, safety, and patient experience.

What we did

We conducted granular data analysis so to identify and quantify bottlenecks at each stage of the Emergency pathway. In parallel to the analysis, our team conducted hospital walkthroughs and spent time on the ground with managers and clinical leaders to get a real sense of how the challenges manifest in day to day operations. This accurate “on the ground” picture helped guide and focus the analysis on the most important areas, interpret the insights of the analysis, and avoid “misguided” insights that could arise when the analysis is performed in isolation from the real options and from the people who deliver the care.

The combined quantitative and qualitative evaluations detailed performance trends and identified underlying issues along the pathway:

  • Higher than peer-average inflow of >60 year patients with “standard” triage, and a high variation in ED attendance rate across GP practices
  • A high proportion of weekly ED breaches happen on Sunday and Monday, and most of patients are seen by junior and middle grades who have higher conversion rates than consultants
  • Higher than peer-average conversion rate partly due to a higher proportion of elderly population, and partly due to inappropriate admissions
  • Referrals to specialty overall represent 1/3 of total attendances, however they represent 85% of total breaches
  • Only ~15% of patients leave the assessment wards before middays, and discharges are lower at the weekend than during the weekdays
  • The rising number of “simple” short stay admissions combined with a decline in NEL ALOS indicating that the pathway is more “congested”
  • 60+ hospital beds are occupied by patients who are “medically fit” and who are waiting for a supported discharge

Using the diagnostic insights, our team worked with senior leaders from the Trust and the broader local health system to generate and prioritise the most critical areas of focus and initiatives that have the potential to transform the pathway.

Outcomes

3 priority areas underpinned by initiatives were agreed by the local health system leaders to be taken forward for implementation:

  • Enhance senior medical input at the front: ensure consistent daily acute medicine input and presence in ED, and restructure ED / MAU interface
  • Expediate simple discharge: put in place actionable daily ward and board rounds, develop daily discharge targets by ward, reinforce bed meetings
  • Expediate complex discharge and release blocked hospital capacity: improve in-hospital operational processes, build robust information system, and introduce regular performance management meetings; introduce new process for the transfer of care of patients from hospital to out of hospital, and establish regular system-wide performance management forums

Together with the client’s clinical and operational teams, we then identified a list of root-causes of under-performance based on the quantitative and qualitative evaluations, and developed a set of potential solutions to address the bottlenecks.

Key issues facing our client

The NHS Trust in South East London was facing increasing inflows and blocked outflows along its in-hospital emergency pathway. The Trust’s deteriorating A&E performance was behind its 4-hour trajectory. The Chief Exec engaged us to undertake a Trust-wide effort aimed at transforming the in-hospital Emergency Pathway clinical operations so to push the efficiency frontier of the hospital to the next level. We were also asked to help shift the culture and mindset of the organisation and re-energise the hospital teams to move them into action.

What we did

We had previously conducted detailed diagnostic and generated a set of initiatives for the whole local health system. Starting with this list, and based on our experience in helping other hospitals with similar challenges, we agreed with the hospital senior leaders to focus our implementation support on 4 key initiatives:

1. Upgrading the daily operational model of the hospital – this required synchronous coordinated actions by 100+ hospital staff

  • We facilitated discussions with medical leaders to set parameters for good discharge performance, and cascaded parameters to all wards
  • We established full MDT board rounds on all base wards every morning, and we redesigned and rolled-out best practice board round processes including appropriate attendances, ward whiteboard structure, and robust action monitoring
  • We advocated and supported the increase usage of discharge lounge

2. Introducing “real time management” and improving the effectiveness of the site operational and leadership teams – this is especially important when the hospital was working at 100% capacity utilisation whiles activity continued to rise

  • We revamped daily bed meeting structure and attendance to up the operational rhythm and the “real time” site management – we attended these meetings daily and helped ran them at the start of the programme
  • We worked with the hospital’s data team to better use data and analytical tools to create an accurate picture in “real time”, and ensured effective flow of accurate information across teams
  • We supported the executives to accurately interpret the information and to take appropriate proactive actions in real time
  • We redefined the model of working for the site management team during the day and at night, and reduced variability across teams

3. Improving management of the patient journey within the ED and reducing conversion rate

  • We worked to enhance patient flow within ED by firstly conducting on-the-ground observation of the existing flow co-ordination, problem solved with operational and nursing teams to agree roles and responsibilities of the newly created “flow co-ordinator” role, and communicated and managed teams against the agreed roles and responsibilities
  • We helped ensure the appropriate usage of CDU, including agreeing clinical pathways for CDU patients, determining the appropriate staffing for CDU, and educating ED teams on how to appropriately use CDU
  • We assisted in defining and agreeing the exact role of ED consultants, and facilitated performance discussions based on daily conversation rates by shift and by doctor at daily handover

4. Resetting the culture of the organisation – this is the major enabler as success of the transformation programme depends on shifting the narrative of a large number of hospital staff and on transforming the way they think and act

  • As soon as the objectives and the operational KPIs for the above initiatives were developed and agreed upon, we supported the medical leaders to communicate and cascade these across the hospital to provide each of the 100+ staff involved tangible targets and the explicit link between what they do on a daily basis and the desired outcome
  • We launched Trust-wide campaign on the importance of timely discharge so to ensure clear understanding amongst staff
  • We understand that delivering these targets consistently day in, day out is difficult to achieve as it requires changing ways of working that have been embedded in the organisation for years, as such our daily interactions, challenge, and support focused on helping the staff deliver this change

Throughout the transformation programme, we worked alongside the hospitals operational and clinical teams on a daily basis to ensure that in addition to making change happen, we also transferred skills and capabilities to ensure transformation can be sustained post our engagement. We supported 100+ hospital staff to develop skills in effective project planning, and the ability to prioritise and focus. We instilled delivery mindset with daily action list and review, operational discipline through daily tough points, and a sense of urgency to ensure an operational rhythm which delivers milestones in days, not weeks.

Impact delivered

The Trust improved its 4-hour performance as the result of quantifiable efficiency in a number of operational areas:

  • Average of 9% improvement vs. previous year’s 4-hour monthly performance, and an outperformance vs. South East London average 4-hour for 23 consecutive weeks
  • An increase in average daily discharges from 48 to 54, with decreases in average length of stay across medicine (-19%), CoE (-17%), and surgery (-13%)
  • An increase in average number of patients going through discharge lounge per day from 13 to 17 (+31%)
  • Faster ED process time with first seen to DTA time for admitted patients decreased by 62 minutes

Morale and staff satisfaction have also improved significantly, as evidenced by positive staff feedback on more effective communications between teams, higher job satisfaction, strong sense of team identify, having a sense of purpose, and a more positive working environment.
Impact delivered

The Trust improved its 4-hour performance as the result of quantifiable efficiency in a number of operational areas:

Together with the client’s clinical and operational teams, we then identified a list of root-causes of under-performance based on the quantitative and qualitative evaluations, and developed a set of potential solutions to address the bottlenecks.

Key issues facing our client

The local health system in South London was facing a growing number of Ready for Discharge patients in the hospitals and a continuing rise in the “delayed” bed days. Furthermore, these patients spent an increasing amount of time between stages of the transfer of care process. The health and social care commissioners engaged us to radically redefine the existing ‘architecture’ of the transfer of care process with the overarching objective to expediate these patients to the most appropriate setting and avoid the delays in acute beds.

What we did

During the initial intensive diagnostic phase, our team conducted quantitative evaluation together with qualitative assessment based on staff interviews, key stakeholder discussions, and on-the-ground walkthrough and observations to better understand the root causes of the poor performance. The diagnostic highlighted a long list of challenges, most notably around the complexity of the current discharge process, the silo-way of working in- and out of hospitals, inefficient and inaccurate operational information flow across the system, misaligned organisational priorities and incentives, and demoralised teams.

Through discussions with senior leaders across the health economy, the concept of a Transfer of Care Organisation (TOCO) emerged as the best approach to address these bottlenecks. During the design phase, our team firstly worked with system leaders to agree the mandate of TOCO, confirm the participating organisations, and decide on the governance and financing of TOCO. Together with clinical and health leaders, we facilitated in-depth discussions to define and agree the MSFT policy across the system. We then conducted working group discussions to develop the operational specifications of TOCO, define roles and responsibilities of the integrated teams, and identify improvement areas for the supported discharge pathways. In parallel, we helped create an information system to track supported discharges and worked with senior leaders to agree KPIs focusing on patient “stock”, patient “flow”, and “speed” at which they are moving.

Following the design phase, we worked side-by-side with participating organisations to put TOCO in place. Through the actual implementation, we reviewed, refined and finalised the new transfer of care process, and the detailed roles and responsibilities of TOCO teams. We also developed a detailed bottom-up model on the out-of-hospital capacity required to enable the smooth functioning of TOCO. To effectively manage performance, we held weekly review forums with senior leaders to discuss progress against the agreed KPIs, and address obstacles.

Impact delivered

As the result of our support, the system achieved significant improvement in discharge performance metrics, information flow, and staff morale:

  • Total ALOS of supported discharges has declined by ~8%
  • The bed days occupied by patients post-MSfT have declined by ~8%
  • 30-40% of a case manager’s time is saved by having 1 single shared system rather than having to use 3 different systems previously
  • Health and social care staff working on the interface managing supported discharges feel more productive and positive than their peers in other health economies

Together with the client’s clinical and operational teams, we then identified a list of root-causes of under-performance based on the quantitative and qualitative evaluations, and developed a set of potential solutions to address the bottlenecks.

Key issues facing our client

The NHS Trust in the North of England delivers Mental Health Acute Liaison Service across two hospital sites. The Trust has been awarded transformation funding to support the improvement of this service. In order to inform service redesign and future service provision, the Trust engaged us to conduct a detailed review to model current and future demand, assess current performance against access standards and other relevant KPIs, identify constraints and bottlenecks impacting performance, pin-point gaps in current service provision, and estimate the associated impact on the acute provider.

What we did

During the initial diagnostic phase of our engagement, we carried out granular analysis of the Mental Health and Acute Trust data sets, and complemented this quantitative evaluation with on-the-ground operational observations in the ED at different times of day, and in-depth discussions with the operational teams to understand what is really reflected in the analysis.

We then synthesised these quantitative and qualitative findings and insights into a comprehensive “one version of the truth” report, covering:

  • Activity baseline by agreed cohort of patients
  • Detailed mapping of patient journey through the ED with detailed timings between stages by cohort of patient
  • Highlighting bottlenecks
  • Individual patient case studies to better illustrate pain points

To ensure this “one version of the truth” has the buy-in of the whole health system, we conducted a half-day workshop to review the report in detail with the system leaders, agreed on how to incorporate the insights and the “so what” in the service redesign such as pathways and staffing model, and aligned on how the system can work together to take this forward.

Outcome

Using the “one version of the truth” as the basis for discussion, the half-day workshop aligned the system leaders on the urgency and the importance of:

  • Improving ED triage and assessment processes for mental health patients in order to speed up ED referral times
  • Improving Mental Health Acute Liaison team’s response time via e.g., safely reducing the time spent on “irrelevant” paperwork, reducing the duration of assessment for “simple” cases, ensuring sufficient information sharing
  • Improving response time of Rapid Response, and reducing community team referral waiting time
  • Improving doctor availability to form the Mental Health Acute Liaison team, and identifying safe location (other than ED) for patients waiting for assessment
  • Improving data quality to fully represent the journey of the patient, and putting in place appropriate KPIs and reporting

Together with the client’s clinical and operational teams, we then identified a list of root-causes of under-performance based on the quantitative and qualitative evaluations, and developed a set of potential solutions to address the bottlenecks.

Key Issues facing our client

TBD

What we did

The diagnostic consisted of a quantitative review focusing on assessing performance trends, timelines along the pathways, and activity levels, and a qualitative review centring around understanding current processes, forums, roles and responsibilities. Our team conducted detailed analysis of “Patient Tracking Lists” and patient level data with the objective to:

  • Quantify current activity levels in terms of patient inflows, stock, and outflows, broken down by specialty
  • Detail generic and granular pathway timelines to quantify delays at each stage of the cancer pathway from referral to starting treatment
  • Assess cancer service performance focusing on trends and relative performance vs. comparable Trusts on key measures such as 62 days, 31 days, and 2ww cancer performance
  • Individual patient case studies to better illustrate pain points

In parallel, in order to pinpoint root-causes of poor performance and identify any bottlenecks, our team conducted in-depth interviews, operational walkthroughs, and on-the-ground observations with the objective to:

  • Understand how central team (e.g., divisional cancer manager, operational manager, patient pathway co-ordinators, multidisciplinary co-ordinators) and site team (e.g., divisional directors, service managers, support managers, CNSs, consultants) currently work together
  • Understand how information is currently being captured in terms of data collection and processing methods, and how it is used to support operations, drive improvement, and produce reports and performance manage pathways

Together with the client’s clinical and operational teams, we then identified a list of root-causes of under-performance based on the quantitative and qualitative evaluations, and developed a set of potential solutions to address the bottlenecks.

Outcome

  • Detailed data analysis suggested that 62 day cancer performance is the main area of under-performance which has been deteriorating vs. historical performance and peers, driven by the increase in time patients spend along the pathways rather than the increase in activity
  • A long list of potential solutions were generated to help shorten the timelines, examples include:
    -   Process improvement: creating a “live view” of issues and outstanding actions for each patient
    -   Effectiveness of forums: better preparation by patient pathway co-ordinators on the detailed status of each patient for meetings, ensure presence of clinical team members (CNSs or consultants) during meetings, and introduce meeting structure
    -   Better use of information: introduce “RAG” rating to help teams identify which patients take priority for meeting discussions
    -   Clarity on roles and responsibilities: clarify and agree roles and responsibilities of patient pathway co-ordinators, multi-disciplinary co-ordinators, and central service managers