Frailsafe: from conception to national breakthrough collaborative.

The number of people aged over 60 years worldwide is projected to rise from 605 million in 2000 to almost 2 billion by 2050, while those over 80 years will quadruple to 395 million. Two-thirds of UK acute hospital admissions are over 65, the highest consultation rate in general practice is in those aged 85-89 and the average age of elective surgical patients is increasing. Adjusting medical systems to meet the demographic imperative has been recognised by the World Health Organisation to be the next global healthcare priority and is a key feature of discussions on policy, health services structures, workforce reconfiguration and frontline care delivery.

Timely care for frail older people referred to hospital improves efficiency and reduces mortality without the need for extra resources.

BACKGROUND: hospitals are under pressure to reduce waiting times and costs. One strategy that may be effective focuses on optimising the flow of emergency patients. OBJECTIVE: we undertook a patient flow analysis of older emergency patients to identify and address delays in ensuring timely care, without additional resources. DESIGN: prospective systems redesign study over 2 years. SETTING: the Geriatric Medicine Directorate in an acute hospital (Sheffield Teaching Hospitals NHS Foundation Trust) with 1920 beds. SUBJECTS: older patients admitted as emergencies. METHODS: diagnostic patient flow analysis followed by a series of Plan Do Study Act cycles to test and implement changes by a multidisciplinary team using time series run charts. RESULTS: 60% of patients aged 75+ years arrived in the Emergency Department during office hours, but two-thirds of the admissions to GM wards were outside office hours highlighting a major delay. Three changes were undertaken to address this, Discharge to Assess, Seven Day Working and the establishment of a Frailty Unit. Average bed occupancy fell by 20.4 beds (95% confidence interval (CI) -39.6 to -1.2, P = 0.037) for similar demand. The risk of hospital mortality also fell by 2.25% (before 11.4% (95% CI 10.4-12.4%), after 9.15% (95% CI 7.6-10.7%) which equates to a number needed to treat of 45 and a 19.7% reduction in relative risk of mortality. The risk of re-admission remained unchanged. CONCLUSION: redesigning the system of care for older emergency patients led to reductions in bed occupancy and mortality without affecting re-admission rates or requiring additional resources.

Does process flow make a difference to mortality and cost? An observational study.

PURPOSE: The purpose of the paper is to investigate the potential relationships between emergency-care flow, patient mortality and healthcare costs using a patient-flow model. DESIGN/METHODOLOGY/APPROACH: The researchers used performance data from one UK NHS trust collected over three years to identify periods where patient flow was compromised. The delays' root causes in the entire emergency care system were investigated. Event time-lines that disrupted patient flow and patient mortality statistics were compared. FINDINGS: Data showed that patient mortality increases at times when accident and emergency (A&E) department staff were struggling to admit patients. Four delays influenced mortality: first, volume increase and mixed admissions; second, process delays; third, unplanned hospital capacity adjustments and finally, long-term capacity restructuring downstream. RESEARCH LIMITATIONS/IMPLICATIONS: This is an observational study that uses process control data to find times when mortality increases coincide with other events. It captures contextual background to whole system issues that affect patient mortality. PRACTICAL IMPLICATIONS: Managers must consider cost-decisions and flow in the whole system. Localised, cost-focused decisions can have a detrimental effect on patient care. Attention must also be paid to mortality reports as existing data-presentation methods do not allow correlation analysis. ORIGINALITY/VALUE: Previous studies correlate A&E overcrowding and mortality. This method allows the whole system to be studied and increased mortality root causes to be understood.

Discharge to assess: transforming the discharge process of frail older patients.

The 2012 Royal College of Physicians report Hospitals on the edge is clear that 'decisions about service redesign must be clinically led and clinicians must be prepared to challenge the way services - including their own service - are organised'. This paper describes a service redesign in which we have gained learning and experience in two areas. Firstly, a description of measured improvement by the innovation of redesigning the traditional hospital-based assessment of frail older patients' home support needs (assess to discharge) into their own home and meeting those needs in real time (discharge to assess). In combination with the formation of a collaborative health and social care community team to deliver this new process, there has been a reduction in the length of stay from completion of acute hospital care to getting home (from 5.5 days to 1.2 days for those patients that require support at home). Secondly, the methodology through which this has been achieved. We describe our translation of a Toyota methodology used for the design of complex cars to use for engaging staff and patients in the design of a healthcare process.

Introducing quality improvement as an intrinsic part of healthcare.

Healthcare systems worldwide face the challenge of recognising and improving safety, timeliness, quality and productivity. The authors describe how the COM-B model, developed by Michie et al in 2011 to explain and change criminal behaviour, is useful in identifying what skills and capabilities healthcare providers require to improve their systems. These skills include the intellectual capability to understand, design and improve healthcare processes; the opportunity to do this in their daily work; the motivation to do this - in particular recognising the reasons not to change; and finally unlearning the behaviours based on historical system beliefs that are now invalid. Individual self-awareness and organisational leadership are required to give staff the time and resources to reflect, experiment and learn.