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Delivering non-acute, hospital-based care

Alex Knight - Sunday, July 30, 2017

Non-acute, bed-based care has two important roles: to improve the quality, safety, timeliness and affordability of care for those patients under its supervision; equally importantly, it has a role in improving the productivity of the entire health system through the positive, indirect impact it can have on the acute care sector. Indeed, in healthcare there is a growing realisation that an increase in the provision of non-acute-based care can affect the overall productivity of the whole healthcare system.

Diagram 1 is an example of the all-important dependent links in the health and social care chain. Disruption and delay in patient flow through any part of the downstream activities can hold up patient flow and cause queues and backlogs in patient care all the way upstream. With improved patient flow through the whole system, higher quality, safe, more timely and affordable care for more patients can be achieved: those in the system and those waiting to receive care.

Diagram 1: example health Diagram 1: example health and social care chain of activities

In my recent blog about delivering healthcare in the community I claim that community-based care is divided into two very different types of patient flow: through the bed-base and through the provision of services in the community not requiring a bed. In this blog I focus on patient flow through the non-acute bed-based hospitals.

Non-acute bed-based care 

The most commonly described currency of capacity in a non-acute or acute hospital setting is beds. This is because beds are a resource whose availability directly influences access to care, patient flow and improvement opportunities. It is often the case that when a surge in demand upstream occurs the loudest cry is for more beds and when bed availability is a problem one immediately sees queues forming and a rapid deterioration in the quality and timeliness of care. Management attention within each part of the system and across the system is then diverted to manage the multitude of negative effects that result and it is not uncommon for relationships between the parts of the system to deteriorate. Management in all parts become under pressure to open and resource more beds while also feeling the ever-present pressure to close beds to keep the finances under control.

An analysis of any non-acute hospital will quickly reveal there is a very wide spread in the length of stay. A deeper review reveals that this variation is not simply down to the severity of the clinical needs of the patient or the individual patient’s recovery time. Many patients experience delay in waiting for care, during their passage of care and often towards the end of a particular stage of their care.

For each patient who has been admitted into a hospital they will experience a period of time before they are clinically fit for discharge. During this period there are a number of tasks which need to be carried out. Some of these are clinically related and some are more related to ensuring there is a safe and successful discharge of the patient from the hospital to their home or to their next place of care. For an individual resource, the key question is to know:

“Of all the patients I could attend to next, which one should I attend to?”

Synchronisation will help coordinate activities for each patient and will have a positive impact on the patient’s care and a significant impact on their length of stay. However, in order to provide high quality, safe, timely and affordable care for all patients – those in the non-acute hospital and those waiting to be transferred into it – we need to know which resource/task combination most often causes the most disruption and delay to the most patients, so that we have the answer to the question:

“Of all the areas we could improve, which will have the greatest impact
on the performance of the whole system?”

From this we can uncover the local policies and practices in this area that are disrupting and delaying patient flow within the non-acute hospital and consequently the whole system. Identifying and addressing this hospital-wide underlying cause of disruption and delay will increase flow within the non-acute hospital, significantly reduce length of stay and release much-needed protective capacity; something that is vital if we are to ensure the hospital does not suffer the devastating downward spiral in performance that occurs when protective capacity is cut and wandering bottlenecks emerge. It will also – as importantly – enable patients to flow more quickly from the acute into the community setting, and by doing so increase the quality, safety, timeliness and affordability of patient care.

Removing the unnecessary disruption and delay in this part of the system is not just key to improving productivity of the non-acute bed base but also for improving the overall flow through the whole health system. Typically, the average length of stay will be between five and ten times the average length of stay in the acute sector, and so an improvement in this area can have a major impact on bed availability and patient flow across the whole system.

Summary: A Theory of Constraints (TOC) approach for bed-based patient care

The guiding principles are:

  • A patient-centred, clinically led approach is an essential element of the way forward.
  • Improving patient flow through all pathways simultaneously is the primary objective.
  • A focused process of ongoing improvement to balance patient flow is vital.
  • Removing local performance measures is essential when improving any chain of activities. It becomes non-negotiable when improving multiple interacting chains of activities.
Outlined below are the practical steps to deliver this approach.

For each patient create a clinically-based expectation for the timeliness of their care need. In the non-acute, bed-based setting this is a simple planned discharge date.

Use the proven TOC-based time-buffer management principles to:

  • rapidly identify and remove the causes of disruption and delay
  • rapidly identify and remove the causes of disruption and delay between the acute and non-acute sector
  • transfer these gains in ‘free capacity’ into higher quality and more timely care by removing backlogs and freeing up front-line staff to treat patients rather than managing queues
  • identify and exploit those opportunities where an integration of resources would create the fastest improvement in performance for the system as a whole. In non-acute, bed-based services this should be driven by reducing the total length of a patient’s stay across both the acute and non-acute bed base. 

Provide the basis of a throughput-based measurement system that will enable management to understand the performance of both the bed-based and service-based parts of the system and the system as a whole; in particular, to be able to answer the following key questions:

  • 'How well is the system performing and what opportunities remain to improve the performance of the system?'
  • 'Of all the things that could be changed, what should be changed?' (Identifying those few key areas that will have the biggest impact in the shortest timescale.)
  • 'What are the necessary and sufficient changes that should be implemented and how do we avoid any unintended negative outcomes both within the non-acute setting and across the whole system?'
  • 'How do we gain commitment and agreement to the above?'

Educate and coach clinicians to take the leadership role in the delivery of the above changes. This is a vital ingredient in ensuring the approach remains patient-centred and sustainable.