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Redesigning Acute Care for Older People: The Start of Sheffield’s Journey

Redesigning Acute Care for Older People: The Start of Sheffield’s Journey. Tom Downes MB BS, MRCP, MBA, MPH (Harvard) Clinical Lead for Quality Improvement Sheffield Teaching Hospitals The Health Foundation / IHI Quality Improvement Fellow 28 th November 2012. Healthcare inflation.

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Redesigning Acute Care for Older People: The Start of Sheffield’s Journey

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  1. Redesigning Acute Care for Older People:The Start of Sheffield’s Journey Tom Downes MB BS, MRCP, MBA, MPH (Harvard) Clinical Lead for Quality Improvement Sheffield Teaching Hospitals The Health Foundation / IHI Quality Improvement Fellow 28th November 2012

  2. Healthcare inflation Rises in healthcare spending: where will it end? Jon Appleby, BMJ 1st November 2012 Rises in healthcare spending: where will it end? Jon Appleby, BMJ 1st November 2012 • 4.3% per year over the last 30 years • Driven by technology and expectation • Only 0.4% attributable to ageing • Need to deliver over 20% more care in 5 years’ time • Need to deliver over 50% more care in 10 years’ time UNSUSTAINABLE

  3. ‘We must redesign services. Decisions about service redesign must be clinically led and clinicians must be prepared to challenge the way services - including their own service – are organised.’ Hospitals on the Edge – The time for action Royal College of Physicians, 13th September 2012

  4. Day 2127 as a consultant

  5. A ‘system’ problem

  6. A complex system problem

  7. 2003 Toyota Corolla

  8. How do others design complex systems? Toyota Oobeya Room

  9. First find a room

  10. The Room

  11. Board 1: The Business objectives: Board Level Business objectives for GSM GSM weekly bed occupancy from April 07 with target lines

  12. Board 2: What do these objectives mean for our patients? A Future State diagram Of the GSM Process as it evolved Post-it note comments from stakeholders

  13. Board 3: How are we doing against the GSM business and patients objectives?

  14. Board 4: High Level GSM Process through the complex health and social care system & Board 5: Real time plan High Level: Current State Map of the GSM process April 01 2012 Each row presents the tasks (yellow post-its)to be performed by each stakeholder group Programme Plan time

  15. Tests

  16. PDSA tests of moving from ‘post take’ to ‘on take’ Let me introduce ‘George’ • 82 years old • Lives independently and wants to continue doing so • Widowed 5 years ago • Has mild dementia • Daughter lives locally • Losing weight and finding walking more difficult

  17. Challenge to UK geriatric medicine traditions: Split of inpatient / outpatient care Combined immediate delivery of specialist MDT care

  18. Batching patients for ‘Post-take ward round’ Real-time senior specialist review (7/7) Bedded medical assessment unit could be unnecessary for most geriatric medicine patients

  19. Twice weekly senior clinician ward rounds Daily senior decision capability on every ward

  20. MDT planning meetings Assess needs at home once acute hospital environment no longer adding value

  21. Porter’sValue Based Design VALUE What Is Value in Health Care? Michael E. Porter, Ph.D. N Engl J Med 2010; 363: 2477-2481December 23, 2010

  22. Implementation headlines: • April 2012 • New discharge process from assessment units • Consultant geriatricians ‘on take’ 7 days per week • May 2012 • Frailty Unit process initially virtually • Frailty Unit opens mid-May • July 2012 • Ambulatory care area for work formerly considered to be outpatient

  23. Outcome measure: 34% increase in discharge within 1 day

  24. Outcome measure: Bed occupancy reduced by over 60 beds

  25. Was reduction in bed usage due to reduced admissions? No

  26. Balance measure: Would it have happened regardless?

  27. Balance measure: Decrease in readmissions

  28. Balance measure: Decreased mortality

  29. Value Value = Outcome / Cost Return on investment = Saving – Investment / Investment = (£3,000,000 - £750,000) – 140,000 / £140,000 = 2,110,000 / 140,000 = 15

  30. Not hospital @ home • Resources have started to move to the community • Designing hospital@hospital and home@home

  31. ‘Improvement in health care is 20% technical and 80% human’ Marjorie Godfrey The Dartmouth Institute

  32. Conclusion • Modern health care is complex • Iterative testing and prototyping is required • Cooperation between and health and social care is essential • Our journey has only just started

  33. Thank youTom.Downes@sth.nhs.uk@sheffielddoc

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