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A practical step to dramatically improve flow through A&E

Alex Knight - Tuesday, January 31, 2017
In my blog, ‘The assessment unit is at the heart of patient flow’, I explain how this part of the system can be used to leverage performance of the whole system and remove, in that example, the devastating effect on length of stay and capacity of outliers and unnecessary admissions. This was one example of how to leverage the link between the parts of the system to improve the performance of the whole system. This blog looks at one practical step that can be taken to increase the rate of flow of patients within a part of the system; the A&E department, and how it simultaneously releases capacity and increases flow in other parts of the system.

Since publishing Pride and Joy there has been one question I have been asked a few times which relates to some of the ideas presented in Chapters 14, 15 and 16.

In these chapters you will recall that Linda is sharing with her boss Kieran all of the improvements that have been made to the overall flow of patients through the system. One of these improvements is right at the beginning, in the emergency department. It involves Mo, the top doctor in the emergency department, explaining to Kieran how they have gone about improving the overall flow of patients by the senior doctors taking a much more proactive role in the first step of the process.

The question that has been raised is, ‘Would this result in there being less time to train the junior doctors?’ This is clearly something that we must not compromise.

Now, while the solution I propose does result in earlier use of key resources, what I want to demonstrate is how it results in less overall use of these resources and, just as importantly, less overall use of all the resources through the emergency pathway. As a result, this not only creates more time for the senior doctors to treat more patients, but more time for the senior doctors to train the junior doctors too. It also gives the junior doctors the opportunity to watch more carefully how these critical, early decisions are made.

At the very heart of Pride and Joy is the premise that it is possible to implement a focused process of ongoing improvement that will simultaneously increase the quality of care, the timeliness of care, the affordability of care and, as importantly, bring pride and joy to the overstretched key resources who deliver the quality of care in the first place.

It is the last part of this sentence that is so important: not only delivering all those benefits but also reducing the stress on these overstretched key resources, and this is achieved by making improving patient flow the primary objective, transferring this theory into a practical mechanism, implementing a process of ongoing improvement and eliminating inappropriate local measures.

In Pride and Joy, these second and third principles are achieved by having a patient-centred and clinically led approach that improves the synchronisation of resources and simultaneously helps us to identify the largest disruptions and delays to patient flow. It is through the resolution of these disruptions that flow across the whole system is improved and capacity is revealed.

Now, if you have not already played the manager’s dice game, which is Dice Game number 2 on the website, then I suggest you take a moment now to have some fun and play the game.

The game highlights the devastating impact that bad multi-tasking has on throughput (which is the number of patients treated) and lead time (which is the time they spend in the system).

When you play the game you also experience the devastating effect that bad multi-tasking has on capacity, particularly the impact on the resources that are closest to being capacity-constrained or who operate a number of tasks within a patient pathway or across a patient pathway. In the example in Chapter 14 this certainly fits the role of the senior clinicians.

Bad multi-tasking is the workplace equivalent of a circus performer trying to keep several plates simultaneously spinning on poles, moving from pole to pole in an attempt to keep all from crashing to the ground. Bad multi-tasking occurs where staff attempt to do the equivalent with multiple tasks. Work is started on a task and is progressed for a period of time. Before the task is completed the staff member moves to start or progress another task, leaving the first task waiting to be completed. Bad multi-tasking can lead to many tasks being simultaneously ‘open’ as the staff member moves from one to the other trying to make progress on all fronts.

In this environment what we have to do is to try and eliminate bad multi-tasking at source. This is very, very important because we are not talking about a machine that simply switches from one customer order to another. We are asking this professional resource to carry out a meaningful diagnosis of the patient and to be aware of inconsistencies in their diagnosis. Switching from one patient to another and then going back to the first will inevitably require them to retrace their steps to ensure that quality of care is not compromised. In many instances, switching from one patient to another also increases the set-up time or preparation of the key resources, directly pillaging the precious capacity of this resource.

So bad multi-tasking directly consumes capacity.

Let me give you a very simple example. Ask a doctor to carry out a diagnosis of five patients one after the other without interruption. Compare the time it takes when he or she is constantly interrupted or only carries out a partial analysis of each patient before jumping to the next patient and then the next and then the next and then back to the first, etc.

Eliminating bad multi-tasking is absolutely essential if we are going to improve patient flow.

I hope it is clear that bad multi-tasking directly increases the time actually spent working on a task and directly risks a deterioration in quality of care. When such a deterioration occurs it is not unusual for this to then require further additional resource and further time of the key resources.

Now, in the proposed solution I suggested this important senior clinical resource should be as early in the process as practical. Moving this key resource to the beginning of the process may appear slightly counterintuitive. But if we think about the impact of this on bad multi-tasking we can see two desirable outcomes.

Firstly, patients who do not require further treatment are more quickly identified. The senior clinicians are much more likely to be able to do a more effective early diagnosis, decide which patients require further treatment and decide where, for others, no further treatment is required. This stops the emergency floor being flooded with unnecessary work and reduces the ability for bad multi-tasking by others.

The second outcome is that having the key clinical resource at the first stage allows a better diagnosis to be made earlier in the process and means that those who do require further investigation are more likely to have the right diagnosis earlier, with fewer unnecessary tests and activities flooding the rest of the system, slowing down flow.

So, by putting the key resource at the beginning of the process we are able to reduce the total number of patients flowing through the system and we are able to reduce bad multi-tasking at source.

Both of these result in exposing significant amounts of ‘free’ capacity. This means the senior doctors have a greater opportunity to spend more time with patients and a greater opportunity to spend more time training junior doctors.

I hope this explanation is helpful. If you have any further questions please do not hesitate to drop me a note.

Comments
SDSA commented on 09-Feb-2015 09:44 AM
Thanks. Is there evidence that our NHS high-A&E-performance hospitals have similar working practices. Are they bench-marked?
Alex Knight commented on 09-Feb-2015 12:05 PM
In response to SDSA:
This is a great question. As a start we have to determine if the difference in performance between various hospitals is significant. In some instances there are hospitals failing by a very large margin but the difference between hitting and missing the targets is often very small. There are two main causes, one is related to disruptions and delay within the emergency department and often, equally important, is the disruption and delay in the rest of the hospital which culminates in not enough beds for patients waiting to be admitted from the emergency department. This is where the focus should be to improve patient flow.
Diana Smith commented on 09-Feb-2015 12:20 PM
That sounds like sense to me - but how has it worked out in practice? Do clinicians accept the idea?
Alex Knight commented on 09-Feb-2015 12:21 PM
In response to Diana Smith:
​I believe, i​mproving patient flow based on patient-centred and clinically based planned discharge dates is 'music to the ears' of clinicians. It makes huge sense to everyone I have explained it to. Once they also see it can become the basis of an evidence-based investigation into the most common causes of disruption and delay they can see how it can drive the improvement of quality and timeliness of the care they provide.
Simon Dodds commented on 09-Feb-2015 12:21 PM
Hi Alex ... I am 100% with you that improving flow to free up capacity is counter-intuitive. Looking forward to reading this
Alex Knight commented on 09-Feb-2015 12:22 PM
In response to Simon Dodds:
It is the disruptions and delays in patient flow that consume capacity. Many patients stay in a hospital longer than clinically required and almost all of this is due to disruption and delay. When we identify and eliminate the most common cause of delay across the most patients there is an immediate benefit of a release of capacity which can be used to deliver higher quality and more timely care.

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