‘Breaking the Cycle’ or ‘perfect weeks’:

social movements improving emergency

flow & patient safety in acute hospitals

Nye Harries & Diane Fuller

Emergency Care Intensive Support Team (ECIST)

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Building a social movement

Social movements

start with:

• A compelling story

• A commitment

• A structure

• A strategy

• A set of measured actions

& outcomes

Social movements – 6 features:

A compelling story #1

• 48% of people over 85 die within one year of hospital admission Imminence of death among hospital inpatients: Prevalent cohort study

David Clark, Matthew Armstrong, Ananda Allan, Fiona Graham, Andrew Carnon and Christopher Isles, published online 17 March 2014 Palliat Med

• 10 days in a hospital bed (acute or community) leads to the equivalent of 10 years ageing in the muscles of people

over 80

Gill et al (2004). studied the association between bed rest and functional decline over 18 months. They found a relationship between the amount of time spent in bed rest and the magnitude of functional decline in instrumental activities of daily l iving, mobility, physical activity, and social activity.

Kortebein P, Symons TB, Ferrando A, et al. Functional impact of 10 days of bed rest in healthy older adults. J Gerontol A Biol Sci Med Sci. 2008;63:1076–1081.

If you had 1000 days left to live how many would you chose to

spend in hospital?

A compelling story #2

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Example commitments from ‘Breaking the cycle’ weeks

• Cancelling all non urgent meetings & reducing email traffic

• Consultants standing down non-clinical SPAs

• Two senior medical reviews a day on every ward, every day

• Increased visibility of senior staff • Deploying Liaison Officers to wards • Introducing Internal Professional Standards • Move to a ‘go and see’ approach (rather

than office based) • Permission from executives for front line

staff to get on and do things that prevent patient delays (no matter how small)

The Patient Flow Bundle - SAFER

S - Senior Review: all patients will have a consultant review before midday.

A - All patients will have an Expected Discharge Date (that patients are made aware of) based on the medically fit for discharge status agreed by clinical teams.

F - Flow of patients will commence at the earlier opportunity (by 10am) from assessment units to inpatient wards. Wards (that routinely have patients transferred from assessment units) are expected to ‘pull’ the first (and correct) patient to their ward before 10am.

E – Early discharge: a third of our patients will be discharged from base inpatient wards before midday. TTOs (medication to take home) for planned discharges should be prescribed and with pharmacy by 3pm the day prior to discharge wherever possible to do so.

R – Review: a weekly, systematic review of patients with extended lengths of stay (e.g. > 14 days) to identify the issues and actions required to facilitate discharge. This will be led by clinical leaders supported by operational managers who will help remove constraints that lead to unnecessary patient delays.

Breaking Free for Our Patients: A Perfect Week (July 2015) It’s all about ‘the Buzzzzzz’

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UHCW: impact of ‘Breaking the Cycle’ week

• 120 more patients were discharged during the BtC week compared to a poor

performing week

• 20 more patients were discharged before 12 noon each day compared to a

poor performing week

• 313 patients with LoS >14 days are in our hospitals now compared to 430

before

• 60 patients waited more than four hours in ED over this week compared to

584 six weeks ago

• We now have 16 medical outliers. On a bad week, we had 160.

What led to our performance improvement?

• Created a ‘Buzz’

• Which resulted in much better Engagement –

there’s a sense of ‘being in it together’

• Care bundle promotes the correct actions which

were delivered.

• Pride became important again and we’ve

recovered a sense of ‘we can do it’.

Tuesday 14th April 2015

System’s Flow Event

Summary & Feedback

Headline numbers

Results: 4 hours Week ending Sun 15 performance 88.79%

Week ending Sun 22 performance 96.23%

Drop in number of expected patients diverting to ED due to better

bed availability in GP Unit

Reduction in Medical outlier numbers (23 at end of April vs. average

of 40 - 60 through Jan/ Feb)

Feedback - Was Onwards Together worthwhile?

Yes! Overwhelmingly positive response.

“Very valuable exercise, we need to re-run it”

“My suggestion would be that onwards together

become a regular programme and we find ways to

engage every member of staff into the ideas &

philosophy of improving flow.”

“It would be great if the model for Onwards together

becomes business as usual. We need to maintain the

pace and responsiveness.”

So what next for a ‘social movement’…

..for NHS emergency care ? …in the rest of the NHS ?