Improving Patient Flow in Cork University Hospital Feb 2, 2018 -
In order to understand the patient flow difficulties that manifest themselves in our Emergency Departments, it is necessary to appreciate that the contributory factors reside in our processes both in our acute hospitals and in community services. Accordingly the resolution of these patient flow challenges requires a focus on multiple factors such as collective leadership in our hospitals and community services, the creation of a shared passion that we will resolve impediments to patient flow and a commitment to a change management programme that will incrementally exploit opportunities for improvement.
There is no quick fix solution to this, perhaps the most complex of problems in our health service and this is the story of what we are doing to address the challenge of patient flow in Cork University Hospital (CUH) where to date over 200 different change initiatives have been implemented with evidence of success over the past six months.
The implementation of these change initiatives began over four years ago with an acknowledgement that the internal processes in the Hospital were not fit for purpose and were in need of urgent attention. In response, hospital leadership undertook a week-long study of the flow of c. 1,400 patients (there are c. 65,000 patients per year attending our Emergency Department). The application of science and analysis to understanding the impediments to patient flow coupled with the use of Lean Management techniques, resulted in a body of work that was focused on addressing inefficiencies in patient flow.
These individual change initiatives were largely implemented by redirecting existing resources in the Hospital to improve, for example, the flow of patients to assessment units for a decision to be made on admission or discharge, to the implementation of new processes to reduce pre-Cardiac Surgery inpatient numbers to a minimum with considerable savings in bed days. Where necessary additional resources were invested in establishing new services such as an Ortho-Geriatrician service that streamlines the flow of Orthopaedic trauma patients out of CUH to the South Infirmary University Hospital, where the rehabilitation service is located or to another community setting. The full range of initiatives can be viewed at www.cuh.hse.ie.
In 2017, leadership in CUH decided that priority would be given to a series of initiatives that are embodied in Project Flow ’17 (PF’17) that set specific targets to reduce trolley numbers in the Emergency Department but also critically to improve the patient experience time for patients attending the ED. One of the most important aspects of PF’17 is that it focuses on the contribution that every member of staff in the Hospital has to play in optimizing patient flow.
However the resolution of the difficulties in the flow of emergency patients cannot be dealt with by changing processes in the Hospital alone and must incorporate a programme of work with our community partners. In April 2017 a weekly systematic review of every patient in the Hospital who was over 14 days as an in-patient commenced (the average length of stay in CUH is 6 days which is considerably shorter than any comparable similar sized hospital in Ireland) and this has effectively created c. 10 beds by reducing the number of such patients.
These meetings have highlighted many of the challenges that the health system faces in working to place patients appropriately in alternative community settings such as Community Hospitals, Nursing Homes and in the home setting with homecare packages. The development of a shared leadership commitment to improving the system of discharges from acute hospitals to community settings is possibly the greatest challenge that the HSE faces and given that 3% of patients in CUH occupy 30% of bed days, there is a compelling argument that additional beds are needed in community settings rather than in acute hospitals. In any event, a range of different types of beds ranging from Intensive Care to community placements are required and the forthcoming Bed Capacity Report is critically important in this debate.
What then has been the change in patient flow as measured by the number of patients on trolleys in the Emergency Department in CUH at 8am since the implementation of PF ’17 and the other many individual change initiatives? The target set in the Plan was for an ambitious 50% reduction in the number of patients on trolleys each day in ED and the following Figure 1 demonstrates that this has been achieved on a consistent basis over the past six months.
Trolley Numbers in Emergency Department in CUH 2016 – 2017
The number of patients on trolleys in ED in CUH remains at an unacceptable level but the progress made in the implementation of PF’17 in the second half of 2017 and the implementation of 200 individual change initiatives provides encouragement that this most intractable of problems can be managed to a level that provides the public and the exchequer with assurance that it is getting value for the very substantial additional investment that has been made in additional staff, promotional opportunities and increased resources. Of note the trolley count for the second half of 2017 averaged 12 per morning which represents a 50% performance improvement over the first half of that year. Our plan for a continued, sustained improvement programme that will be embodied in Project Flow ’18 is now being finalized that will set ever more challenging targets for our performance in 2018.
The experience in CUH suggests that additional resources of themselves will not resolve the challenge of optimizing patient flow for emergency patients. Additional resources must be invested commensurate with change in process in our individual hospitals and community settings.
The public has invested significant additional resources in our hospital and community services since Minister Harney declared in 2006 the Emergency Department problem a “National Emergency”. They deserve our collective leadership commitment to demonstrate that this seemingly intractable problem can in fact be resolved not by more of everything but by a commitment to continuous change.
Chief Executive Officer