approaching neat targets from a policy & research perspective
DESCRIPTION
Andrew Gosbell, Director of Policy and Research & Deputy CEO, from the Australasian College for Emergency Medicine delivered this presentation at the 5th annual Emergency Department Management conference. For more information on the annual conference, please visit: www.healthcareconferences.com.au/edmanagementconferenceTRANSCRIPT
Approaching NEAT targets from a policy and research perspective
Andrew Gosbell, ACEM Director of Policy and Research & Deputy CEO
Can overcrowded EDs be totally eliminated from the modern public hospital system?
ED stress points
• Increasing demand for ED services – increasing at rate greater than population growth and with increases in admissions from ED
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presentations % admissions from ED
Data sources: Australian Institute of Health and Welfare. Australian hospital statistics 2011–12:
Australian Bureau of Statistics. Australian Demographic Statistics
ED stress points • Constrained in-patient bed stock
• Broader health budget limitations
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Data sources: Australian Institute of Health and Welfare. Australian hospital statistics 2011–12:
Australian Bureau of Statistics. Australian Demographic Statistics
ED stress points
• Ageing population
• Increased prevalence of chronic disease (from National Health Survey
data)
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Australian Health Survey: Health Service Usage and Health Related Actions, 2011–12
Admitted to hospital as inpatient
Visited emergency/casualty
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2011
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2051
Data sources: Australian Bureau of Statistics. Australian Social Trends & Australian Health Survey
ED stress points
• Evolving roles for EDs – Growth in hospital admissions from ED
– Impact on patient care (12% population attend ED but EPs represent only ~4% specialist workforce1)
– Complexity of diagnostic work-ups
– Preventive care
• ED workforce changes – Increasing intern & trainee numbers over next 5-10 years
– HWA EM supply & demand projections unclear
1. AIHW Medical Labour Force Survey 2009
Solving ED overcrowding
Harvard Business School and Harvard Medical School 2012 Forum on Healthcare Innovation:
• identified “process improvements in care delivery” as the number one opportunity for both improving quality and controlling the cost of health care over the next 5 years
http://projects.iq.harvard.edu/forum-on-healthcare-innovation/
From problem to potential solution – National Emergency Access Target
COAG Expert Panel stated the primary aim of NEAT was to 'improve patient safety and quality of care by removing obstacles to patient flow that contribute to emergency department overcrowding‘
So to improve patient access NEAT is not as an end in itself, but ‘a tool to drive clinical service redesign and whole-of-system change, ensuring all obstacles to effective patient flow within a hospital are removed’ with ‘sustainable improvements over the longer term’
Expert Panel Review of Elective Surgery and Emergency Access Targets under the National Partnership Agreement on Improving Public Hospital Services, Report to the Council of Australian Governments , 30 June 2011. http://www.yourhealth.gov.au/internet/yourhealth/publishing.nsf/Content/Expert-Panel-Report/$File/Expert%20Panel%20Report-D0490.pdf
ACEM support for time-based targets
ACEM STATEMENT ON NATIONAL TIME BASED EMERGENCY ACCESS TARGETS IN AUSTRALIA AND NEW ZEALAND (S60)
• Time based targets are not an end in themselves
• Clinically appropriate patient care is paramount
• Targets must drive change throughout hospitals and into the community, and not just in the ED
• Additional resources necessary to achieve improvements
• Increased physical capacity and access to beds required
• Transparent, rigorous and independent monitoring expected
http://www.acem.org.au/media/policies_and_guidelines/S60_Time_Based_Access_Targets.pdf
Schedule C – National Partnership Agreement on Improving Public Hospital Services
C1. The objective and output of this Schedule will be achieved through a four hour NEAT where 90 per cent of all patients presenting to a public hospital ED will either physically leave the ED for admission to hospital, be referred to another hospital for treatment, or be discharged within four hours.
C10. The parties agree that whole-of-hospital engagement in achieving the NEAT will be essential, ensuring that all obstacles to effective patient flow are removed.
http://archive.coag.gov.au/docs/nap_improving_public_hospital_services.pdf
NEAT: why 4 hour 90% target?
• Consensus view that 4 hour timeframe = reasonable time to deal with the majority of ED patients and is aligned with patient expectations on timeliness of care
• 90% target allows for clinical appropriate LOS>4hrs in some patients
‘Four hours … it is meant to be tight – a stretch target’1
‘the final target of 90% is hard, but doable and safe’2
1. Four Hour Rule Program Progress and Issues Review. December 2011. Perth: Department of Health WA. http://www.health.wa.gov.au/publications/documents/FourHourRule_Review_Stokes.pdf
2. National Emergency Access Target Q&A with Mark Monaghan http://www.ecinsw.com.au/mark-monaghan
NEAT: as a stretch target? Pros:
• an important tool to drive process and system improvements in health care delivery
• focus attention on identified priority areas & promote excellence and innovation
Cons:
• Target fixation = improving outcome metrics rather than the process
• Stretch goals demotivating when seem overwhelming and unattainable
NEAT as public policy • Schedule C of NPA implicitly ends the debate on the serious
consequences of access block and provides a policy imperative to address this issue across the healthcare system
• Ongoing monitoring by NHPA, COAG Reform Council & AIHW is holding hospitals and jurisdictions to account and keeping this healthcare reform issue on the political/public policy agenda
Initial (period 1) NEAT performance
Data sources:
• National Health Reform Agreement - National Partnership Agreement on Improving Public Hospital Services, July
2011, Schedule C34
• Australian Institute of Health and Welfare 2012. Australian hospital statistics 2011–12: emergency department
care. Health services series no. 45. Cat. no. HSE 126. Canberra: AIHW
Initial impressions on level of support for NEAT
Data source: Australasian College for Emergency Medicine (May – 2013). Hospital Data and Accreditation Part 1:
Report of Findings. http://www.acem.org.au/media/publications/Hosp_Data__Accreditation-_Part_1_Report.pdf
DEM perceptions on the overall levels of support for NEAT from:
0%
20%
40%
60%
80%
FACEMs Registrars JuniorDoctors/CMOs
ED Nursing staff Clinical staff inother
departments
Clinicalleadership atyour hospital
Seniormanagement at
your hospital
No-minority support Equally divided support Majority-Unanimous support
Initial system reforms following implementation of NEAT
Data source: Australasian College for Emergency Medicine (May – 2013). Hospital Data and Accreditation Part 1:
Report of Findings. http://www.acem.org.au/media/publications/Hosp_Data__Accreditation-_Part_1_Report.pdf
0%
20%
40%
60%
80%
100%
ED Redesign Additional staffemployed
Hospital redesign Additional acuteinpatient beds
Improved access toradiology
Improved access topathology
Yes No NA
Initial impressions on effect of NEAT
Data source: Australasian College for Emergency Medicine (May – 2013). Hospital Data and Accreditation Part 1:
Report of Findings. http://www.acem.org.au/media/publications/Hosp_Data__Accreditation-_Part_1_Report.pdf
DEM perceptions on the effects of implementation of NEAT
0%
10%
20%
30%
40%
50%
60%
70%
Disagree-strongly disagree Neutral Agree-strongly agree
Initial impressions on barriers
Top 5 barriers to achieving NEAT, from DEM responses:
• In-patient: Lack of engagement with/ slow review process
(46%)
• Lack of beds/poor bed management practices (40%)
• Lack of staff/VMO (on-call) model (33%)
• Lack of executive/wider hospital support (23%)
• Lack of direct access pathway (21%)
Initial impressions on enablers
Top 5 enabling factors to achieving NEAT, from DEM responses:
• Efficient patient flow processes, e.g. SSU/fast track (26%)
• Senior staff as leaders (21%)
• Global hospital support (19%)
• Proactive/supportive ED staff (19%)
• Specific staff for decision making/medical assessment units
(19%)
Important indicators
Top 5 indicators to be measured to assess safety & effectiveness of NEAT, from DEM responses:
• Representation rates – planned vs unplanned (42%)
• MET call rates (31%)
• Patient satisfaction/complaints (29%)
• Morbidity/mortality (27%)
• Critical incident/error reporting (17%)
Where to next with NEAT…
• NEAT metrics show that to meet target improved performance required in ED and especially the broader hospital
• Based on 2011-12 national average data for admission rates and access time performance:
• 90% = %admitted x %admitted<4hr + (1-%admitted) x %discharged<4hr
target
current
to meet target
discharge
admit
> 4hrs
Discharges perform at 95% or better
Admits perform at 75% or better
10%
90%
64%
Discharges at 78% Admits at 29%
Data source: Australian Institute of Health and Welfare 2012. Australian hospital statistics 2011–12: emergency
department care. Health services series no. 45. Cat. no. HSE 126. Canberra: AIHW
NEAT solutions
• Based on data/evidence and implemented with broad clinician buy-in
• Areas for consideration include:
– Emergency Department activities
– Hospital systems:
• Bed management
• Admission processes
• Discharge planning & processes
– Community actions
• Primary & secondary care options
• Preventive medicine
ED solutions & ACEM support
• Demand management – Review of Guidelines for Constructing an Emergency Medicine Medical Workforce (G23)
• Workforce numbers and roles – Workforce baseline data studies
– ‘ED Top of Scope of Practice’ Project
• Quality & safety of patient care – Quality standards project
– Patient safety project
– ACEM Quality Framework for Emergency Departments (P28)
– EMER (Emergency Medicine Events Register) Project
• ED design – Review of Guidelines for Emergency Department Design (G15)
Workforce baseline data studies
• Analysis of current staffing levels and rostering at all reporting
EDs in Australia to ascertain existing resource management
strategies.
• Includes all ED medical staff : FACEMs, non-specialist
medical staff, trainees and ED nurse practitioners.
• Aims to evaluate staffing levels in relation to demand for
service within Australian EDs in order to:
• establish the best practice for effective utilisation of ED
resources
• inform forecasting for future workforce needs
‘Emergency Department: Top of Scope of Practice’ Project
• To inform optimum use of the Emergency Department (ED) team so as to:
• better meet current and future ED demand in Australia
• facilitate the achievement of NEAT and other performance indicators
• improve the patient experience of the ED
• inform planning for the future ED workforce.
• By identifying and articulating:
• the specialised skills and knowledge that Emergency Physicians (of
different levels) have
• how Emergency Physicians are currently using these skills and
knowledge
• whether Emergency Physicians are working at the top of their scope of
practice, and if not, how this can be facilitated in the ED
• whether other ED staff are enabled to work at the top of their scope of
practice
Quality Standards and Patient Safety Projects
• Quality standards:
• within the context of the ACEM Quality Framework, to
develop detailed quality standards which include
objectives and criteria that can be audited and clinical
indicators that can be monitored, for implementation in all
EDs across Australia
• Patient safety:
• to establish a group of patient safety and diagnostic error
experts amongst the fellowship and promote the
reduction of clinical error in the context of emergency
medicine
Emergency Medicine Events Register (EMER)
• ED-specific near miss and adverse event reporting system. being piloted across a
number of EDs
• Key elements of EMER are:
• it is quick, intuitive, easy to use, and specially designed for EDs,
• it is anonymous, data protected by Qualified Privilege.
• the system can identify problem areas & patient safety deficiencies in EDs
that can be used to support arguments for better equipment, improved
staffing, system changes
• pilot sites receive aggregated data identifying key features of collected data
• ‘burst reporting’ capabilities (NEAT issues included in pilot)
• CPD points for reporting: 1 point per 2 incidents, up to a total of 50 points per
year,
• dedicated time and expertise at the back-end (once data is collected) to
analyse data, feedback results to the profession, and publish findings, and
help drive future improvements in patient safety and preventative strategies in
Australasian EDs
www.emer.org.au
NEAT & whole of system…
• Initial performance results (period 1) indicate that admitted patients is where most gains are to be made so focus should be on whole of hospital
• Access block causes lie outside the ED, and….
‘It takes time to break from historical methods of doing things (in the ED and the hospital as a whole) especially when we are tackling deeply ingrained cultures of practice within the hospital at large. Emergency medicine has a history of being flexible and rapidly adaptive to new requirements and creating novel solutions to problems; however specialty units and the hospital as a whole needs time. This is clearly seen in most facilities whereby discharge rate compliance with NEAT is the first to improve and admission rate compliance with NEAT lags behind.’1
• But….
‘Emergency Department workforce engaged and believe in targets - drivers of change’1
1. Australasian College for Emergency Medicine (May – 2013). Hospital Data and Accreditation Part 1: Report of Findings.
http://www.acem.org.au/media/publications/Hosp_Data__Accreditation-_Part_1_Report.pdf
NEAT where to next…
• Need to further promote “whole-of-hospital ownership” of NEAT = it is a hospital performance metric, not an ED target
• Engagement of senior clinical leaders to champion NEAT within hospital and, in particular, improve buy-in from clinical staff within hospital in-patient departments
http://youtu.be/MNLNDsIN_TM
NEAT – need for research & evidence to inform implementation
• Over 100 strategies1 identified in terms of leading practices to address the patient experience in the Emergency Department and beyond
• What are best-practice improvements for rapid and safe patient flow while ensuring high quality care?
• How can these models be generalised and promulgated to other settings?
1. Leading Practices in Emergency Department. Patient Experience. Prepared for the Ontario Hospital Association by InfoFinders
http://www.oha.com/KnowledgeCentre/Library/Documents/Leading%20Practices%20in%20Emergency%20Department%20Patient%20Experience.pdf
Whole-of-System resources
• NSW Health Whole of Hospital Program http://www.health.nsw.gov.au/wohp/Pages/default.aspx
• NZ Health Improvement and Innovation Resource Centre http://www.hiirc.org.nz/section/9088/shorter-stays-in-ed/
• Emergency Care Institute NSW National Emergency Access Target Resources http://www.ecinsw.com.au/neat
NEAT politics
• Political drivers vs evidence
• Buy-in and understanding
• A national target that is implemented by state governments
• Increasing health care costs vs budget constraints
NEAT: research questions?
• Is the target improving patient outcomes?
• Is the target effectively driving whole-of-system reform?
• Is a uniform target appropriate for all hospital settings?
• Is the balance right? Can 4hrs/90% give sustainable improvements in patient flow and quality of patient care?
For NEAT to meet its primary goal:
• Whole-of-system reform involves cultural change that is a fundamental requirement for success = transformational change is challenging and must have top-down support and commitment to ensure it is sustainable
• Leadership from all levels is essential
– Ministers and Health Depts. must remain engaged and fully supportive of process and outcomes
– Local Hospital Network executives and Hospital CEOs need to facilitate change management processes in partnership with clinicians
• Clinical engagement required to ensure ownership of changes and implementation of best-practice solutions
• Innovation encouraged to address local needs
• Trustworthy communication, including performance feedback
ACEM & NEAT:
• Continue to support target, informed by developing evidence base, as a means to an end
• Advocate for political engagement and policy commitment, from across the entire health care community, to enable and ensure sustained whole-of-system reforms
• Promote best practice outcomes both within ED and across healthcare system
• Promote the use broad range of performance indicators that measure quality and safety of patient outcomes (not just time!)
• Advocate for ongoing resourcing of initiatives that enable improved flow and quality patient outcomes
NEAT – the ends are worth it….
‘Somebody on the Orient Express gets killed and the question is, who killed him? The answer is, everybody on the train killed him.
And the answer about who killed healthcare is: the status quo.’1
1. Regina E. Herzlinger – Nancy R. McPherson Professor of Business Administration at Harvard Business School at Harvard Business School and Harvard Medical School 2012 Forum on Healthcare Innovation
Questions / discussion