The benefits of patient flow in bed management
Sherwood Forest NHS Foundation Trust
Delivering patient flow by looking at the end to end patient pathway increases capacity and many other benefits: shorter waiting times and length of stay, better patient experience and improved care and lower costs.
Sherwood Forest Hospitals NHS Foundation Trust is the main provider of acute hospital care for Central Nottinghamshire, operating two district general hospitals, King’s Mill Hospital in Sutton-in-Ashfield and Newark Hospital.
The challenge for us was to help address long waiting times in King’s Mill’s Emergency Care Centre (ECC), which includes an Accident & Emergency Department (A&E) and a 56-bed Emergency Assessment Unit (EAU). ECC were looking to achieve patient flow through best practice in bed management.
The centre’s unpredictable demand, particularly during the peak winter months when staff were forced to shift their focus from patient care to simply finding them a bed, was causing widespread problems right across the hospital, impacting impacting staff morale, key quality and performance targets and the Trust’s financial position.
Our experience, in our own company, has shown that a high level of employee engagement is central to ensuring that any new way of working is sustained.
Using our Lean approach, we began by engaging people from all areas and at all levels of the Trust to help identify issues affecting patient flow as well as examples of best practice. The existing bed management meetings, which coordinated usage of the hospital’s 22 wards, were also evaluated.
A hospital wide initiative
Any improvement initiative would need to take place simultaneously in all areas and would only succeed if clinical personnel were fully engaged in putting the patient at the heart of the solution.
It was found that, due to poor processes and information systems, people were working in silos, making decisions in isolation – such as protecting empty capacity on their ward – without considering or understanding the consequences to the other parts of the Trust.
Together with a lack of accountability and audit trails, a blame culture had developed that discouraged individuals from being open or taking responsibility for their actions.
As a result of this insight, the objectives of the programme were widened to help the Trust more effectively manage patient flow and capacity throughout the entire care pathway.
Creating a workable solution
We then worked with staff from all specialties and all levels of the Trust, including porters, ambulance services and community care. The aim was to nurture openness and collaboration, and to enable them to take a Lean approach to devising, implementing and improving their own solution.
Six inter-related areas for strategic improvement emerged and addressing these would require the right people to be in the right place at the right time.
Ensuring accurate information
New processes were defined that ensured data was accurate, individual roles and responsibilities were clear, and that all issues, decisions and outcomes were communicated and logged for future reference.
New information provided by external support services, for instance, allowed demand trends and potential service issues to be identified and dealt with, using proven methods laid out in easily-accessible Standard Operating Procedures. A single point of access scheme was also set up to ensure that patients not needing acute care were not admitted but redirected to a more appropriate care facility.
A patient flow and capacity control room
A patient flow and capacity control room was created as the hub of the solution, where daily, standardised meetings are supported by visual management. This provides the team with a clear, real-time view of the entire pathway’s performance. It also allows them to rapidly pinpoint, own and address any new issues arising using a Lean problem solving model to get to their root causes.
We also supported the behavioural perspective, enabling the meetings to be conducted in a structured, constructive and blame-free environment where all present are comfortable to make a proactive contribution to achieving the common goal.
By the end of our implementation, the following benefits had been achieved:
- 57% reduction in A&E treatment times
- 56% reduction in patients exceeding 48 hours in EAU
- 22% decrease in average length of stay in EAU for medical speciality patients
- 72% cost reduction compared to the same period in the previous year
- At the end of the winter peak period and 7 months after our departure, the Trust reported the following benefits:
- Senior nurses spending less time managing capacity
- 23% reduction in operations cancelled due to bed availability
- No same sex accommodation breaches
- A&E 4 hour wait target achieved despite activity 21% above plan
- Ambulance turnaround times reduced by16% and morning discharges increased by 13%
- More than £2m increased contribution with a £430k reduction in winter expenditure
- 31% of GP admissions were avoided enabling commissioners to re-invest more than £1m
The dramatic benefits delivered through the Trust’s peak winter months prove not only the robustness of the solution but of the overall Lean strategy, now championed by senior management, of enabling employees to take control, to collaborate and to use their unique insight to solve problems at their own level. As a result, senior nursing time spent managing flow and capacity has dramatically reduced, enabling them to restore their focus on the quality of patient care and boosting their morale.
The skills and knowledge transferred by us have equipped the team to constantly improve their processes, giving them the vital flexibility needed to cope with massive swings in demand. The control room’s knowledge management system, now available via the Trust’s intranet, continues to grow as new and improved process guidance is added and interest in Lean spreads across the Trust.