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The Whole System of Unscheduled Care: causal mapping, flows and improvement

The Whole System of Unscheduled Care: causal mapping, flows and improvement. Steve Kendrick steve.kendrick@scotland.gsi.gov.uk Emergency Access Delivery Team Networking Event Beardmore Hotel. Dec 18 th , 2008. I. A&E attendances: outcomes and the whole system. Outcomes: the target.

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The Whole System of Unscheduled Care: causal mapping, flows and improvement

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  1. The Whole System of Unscheduled Care: causal mapping, flows and improvement Steve Kendrick steve.kendrick@scotland.gsi.gov.uk Emergency Access Delivery Team Networking Event Beardmore Hotel. Dec 18th, 2008

  2. I. A&E attendances: outcomes and the whole system

  3. Outcomes: the target Reduce A&E attendances or more precisely Reduce ‘better treated elsewhere’ A&E attendances or more generally Everyone treated in the appropriate place in the system at the appropriate level of the system

  4. Whole system/outcomes • (BTE) A&E attendances as outcome of how whole system of unscheduled care is working: to reduce them you need to make the whole system work better. • (BTE) A&E attendances as an indicator of how well the system is working: reflect degree of balance in system

  5. Useful ways of looking at the whole system of unscheduled care Patient perspective Organisational system Data system Real system But today want to focus on • A system of causes and effects • As a system of patient flows

  6. II. Unscheduled care as a system of causes and effects

  7. What do you need to do to achieve an outcome? a) Identify the various causal influences which combine to produce the outcome b) Identify the opportunities to intervene to improve the outcome. Leads to driver diagram.

  8. Drivers Changes Outcome e.g Prevention Social Marketing Improved access to alternatives Improved algorithms/training Sharing of data e.g. Morbidity Patient knowledge/ behaviour Accessibility of different services Triage methods Integration of system Fewer ‘better treated elsewhere’ A&E attendances Unscheduled care. Driver Diagram. Illustrative Only!

  9. III. Unscheduled care as a system of patient flows

  10. Flows into A&E. Orders of magnitude! Ambulance 250 40 “999” 220 NHS24 70 800 A&E 600 Self-referral Public 600 30 OOH 1000 attendances 80 In hours primary care

  11. IV. Relating flows to causes/drivers to improvement.

  12. How do we relate ‘flows’ to ‘causes/drivers’ • Each of the flows is a result of decisions made by particular agents at particular points in system • Many of the changes we need to make are improvements in decision-making. Making sure patients are in the right flows. • Plus services to support those improved decisions.

  13. The potential for improvement • To a large extent defined by the number of patients who are in the wrong flows • End up being treated at too intensive a level of the system • e.g. treated A&E when could have been ‘better treated elsewhere’

  14. How do we assess this potential for improvement? (e.g. potential for reducing A&E attendances) • Need a much more detailed picture of patient characteristics in each of the flows • Which are the groups of patients with the greatest potential for diverting to a more appropriate flow/treatment point?

  15. V. Immediate priority: better understanding of who is attending A&E

  16. Immediate priority • Better understanding of the patients attending A&E • Can we characterise A&E attenders in terms of meaningful groups which e.g. • help us assess potential for alternative care? • given current set-up • given better alternatives • help us assess potential for prevention • help us assess the potential for improved services

  17. Examples of the kind of patient groups it would be useful to identify and quantify • Elderly falls • Minor illnesses who don’t need to be at A&E • Behavioural/psychological ‘chaotic lifestyle’ • Alcohol related • Admissions from care homes • Frail elderly in general • Exacerbations of LTCs e.g. COPD • ????

  18. Options for getting a better picture • Existing electronic data: EDIS, Manchester Triage data • Digging into ‘the cards’. Get information from A&E paper records. • Detailed survey of A&E attenders

  19. Taking this forward • Each method will give us a different and useful perspective • Each NHS Board has different strengths Timing. • January. Each Board to develop a picture using existing data: electronic, paper records /cards • Next couple of months: develop and do more detailed survey of A&E attenders

  20. Unscheduled Care Information Network • Mutual support and sharing of expertise • So far involves NHS Boards, NHS24, SAS, SG, ISD. • Need lead information person from each Board • Aiming for meeting late January

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