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

Tom Downes MB BS, MRCP, MBA, MPH (Harvard)

Clinical Lead for Quality ImprovementSheffield Teaching Hospitals

The Health Foundation / IHI Quality Improvement Fellow

28th November 2012

Healthcare inflation

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

UNSUSTAINABLERises in healthcare spending: where will it end?

Jon Appleby, BMJ 1st November 2012

‘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

Day 2127 as a consultant

A ‘system’ problem

A complex system problem

2003 Toyota Corolla

Toyota Oobeya Room

How do others design complex systems?

First find a room

The Room

Board 1: The Business objectives:

GSM weekly bed occupancy from April 07 with target lines

Board Level Business objectives for GSM

Board 2: What do these objectives mean for our patients?

A Future StatediagramOf the GSM Process as it evolved

Post-it note comments from stakeholders

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

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

Programme Plantime

April 01 2012

Each row presents the tasks (yellow post-its)tobe performed by each stakeholder group

Tests

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

PDSA tests of moving from ‘post take’ to ‘on take’

Challenge to UK geriatric medicine traditions:

Split of inpatient / outpatient care

Combined immediate delivery

of specialist MDT care

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

Twice weekly senior clinician ward rounds

Daily senior decision capability on every ward

MDT planning meetings

Assess needs at home once acute hospital environment no longer adding value

Porter’s Value Based Design

VALUE

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

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

Outcome measure: 34% increase in discharge within 1 day

Outcome measure: Bed occupancy reduced by over 60 beds

Was reduction in bed usage due to reduced admissions? No

Balance measure: Would it have happened regardless?

Balance measure: Decrease in readmissions

Balance measure: Decreased mortality

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

• Resources have started to move to the community

• Designing hospital@hospital and home@home

Not hospital @ home

‘Improvement in health care is 20% technical and 80% human’

Marjorie Godfrey

The Dartmouth Institute

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

Thank you

Tom.Downes@sth.nhs.uk@sheffielddoc