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Addressing our A&E problem - volumes is not the true cause

Helen Gibb - Tuesday, January 31, 2017

January 2015 and our A&E departments across the country are struggling to deliver high-quality and timely care. In this blog are pages 201-203 from Pride and Joy that explain what to do to reverse the spiraling downward trend in performance. It will make a difference. It's common sense, but just not common practice. 

We walk into the A&E department and through the waiting room where less than a third of all of the chairs are occupied. This in itself is a big difference for us and I wonder whether Kieran will notice. The first person we meet is Mo and, with his usual warm smile, he comes straight up to both of us and I introduce him:

“You’ve met Mo before at your office.”

“Hello, Kieran,” says Mo, shaking hands. “Thanks for coming to have a look around.”

Kieran has been looking at the A&E numbers and seen the impressive inroads Mo has made towards achieving the ninety-five per cent access target.

“It seems there are now only a few days in a month that you are missing it. Can you tell me how you have done it?”

“I’ll be delighted,” says Mo. “Let me walk you through and I will explain as we go.”

Firstly, he takes Kieran to the reception area where he can see that, rather than just taking the patient details, we have a doctor-led assessment process working. Mo explains to Kieran that if the patient is an inappropriate attendance we refer them immediately to either their GP or the local treatment centres in town.

“So has this been the major part of your solution?” asks Kieran.

“Not really,” says Mo, “but it has definitely helped. Before we started this process these patients would have spent a couple of hours in the department before eventually being referred back, but actually this is not the major change.”

He goes on to describe how in the past, once a patient had been registered, the majority either completed their treatment just before or after the four-hour target. Kieran knows this full well. Quite often two or three hours passed before any diagnosis happened and patients were queuing everywhere. Kieran nods at Mo to continue.

“So we’ve instigated a pretty simple approach. Rather than throwing more resources at the problem we worked out that we needed a better system of prioritising and synchronising all our individual efforts but, more importantly, we needed to identify what the underlying cause of the delay was across all patients.”

Mo then explains how his version of the time buffer management system works.

“We have split the four hours into three time zones of eighty minutes each, and as the patient passes through the department we identify at eighty minutes, one hundred and sixty minutes and two hundred and forty minutes the task and resource that was disrupting or delaying the patient’s journey.” 

Kieran interrupts: 

“But surely there were hundreds of causes.” 

“Surprisingly not,” answers Mo. “There are actually relatively few tasks and resources that are causing most of the delays.” 

He then takes us into the office and shows us, on the wall, graphs of the last eight weeks of causes of delay. Kieran scans the graphs as Mo explains that there were two types of delay: the first caused by resources within our own department and the second caused by resources outside the department. 

“I explained to our staff that there was no way we would ever get the external sources of disruption resolved until we could prove to the rest of the hospital we were squeaky clean ourselves. We had to get our own house in order.” 

Kieran likes that so Mo continues, saying that he uncovered some behaviours where we were shooting ourselves in the foot, the first being the A&E doctors’ propensity for cherry-picking once true emergencies have been treated. We were not treating patients according to a common prioritisation. In too many cases patients were first seen by a junior doctor and finally escalated through to the consultant. So we have moved to a truly consultant-delivered service with all staff now working to this common list. This also resolves the bad multitasking, which was inevitable in this environment. Mo explains that when each resource is working on patients in a different order, and when a number of different resources are required to complete the diagnosis, invariably there were one or two different outstanding tasks for each patient. He says: 

“Every hour we review the green, amber and red status and escalate to the various internal resources accordingly. Everyone knows if they are the cause of a delay to a particular patient, and we also monitor throughout the day if one of our own internal resources is causing multiple delays across multiple patients. Then we can do something about it. 

Mo explains the previous approach of analysing the cause of the final breach is really missing the true underlying cause. 

“It is more valuable to explore what is happening in the amber and red zones. Now, every shift change we review the performance, the causes of delay and what we need to do differently, and discuss with the next shift. Then every week we sit down for an hour to review the data and identify what we need to improve.”

“It’s a pretty simple process,” says Kieran looking at me.

“And that is its strength,” I reply.

Kieran wanders up and down, looking carefully at the graphs before homing in on one of the bar charts for the last week. He points out that for one of the delaying resources the amber bar is much higher than the red bar, which is higher than the small black bar, and yet for another resource the amber is small, the red grows and then the black is the largest.

“What is this telling you?” he asks Mo.

“Well, in the first case something which was a large cause of delay early in the process has actually diminished as the journey unfolded, and yet frustratingly there are still some patients where this early disruption resulted in a later breach. Looking at the resource that was responsible as the patient went through the black zone is not really the issue. We have to tackle the problem that is occurring much earlier in the process in the amber. If we can reduce the ambers we can reduce the reds and eliminate the corresponding breaches at four hours.”
Mo explains that the second case is an example of a resource outside the department.

“This is where we were waiting for an external specialist to review the patient. It did not really matter whether they were called when the patient was in the amber zone or the red zone; whatever time they were called, by the time they arrived and the rest of the diagnosis was completed almost all such patients end up breaching the target.”

In reality, if we’d looked at the graphs eight weeks ago the problem was significantly worse, but colleagues in the rest of the hospital have helped Mo to resolve his issues. I speak up...

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