Improving Patient Flow by Chris Isles

Dave Pedley gave an excellent talk two Wednesdays ago on Tackling Crowding in Emergency Departments, triggered no doubt by the number of times recently we have been running at 100% bed occupancy with patients sitting in chairs in the Emergency Department because there were no free cubicles.

The nightmare scenario for us all as the clock ticks inexorably towards December 2017 is that the same thing happens when our fabulous new hospital opens and the TV cameras, newspapers and journalists begin to salivate at the prospect that something goes wrong (there will be no story to report if the transition to the new hospital goes smoothly and there are no corridor patients).

The chances that something could go wrong are actually quite high and the problem is almost entirely medical by which I mean the large number of frail older people living precariously in the community who fall, become immobile, incontinent or delirious and require at least some form of assessment but often admission to hospital.

The omens are not good.  Dumfries and Galloway has the second highest proportion of people in Scotland who are aged 75+ and living alone.  Our Health Intelligence Unit have shown that despite numerous initiatives and new ways of doing things the Medical Unit would be sailing perilously close to 100% bed occupancy if we moved into the new hospital today. (See me previous blog on the new hospital here)

During his talk Dr Pedley showed a powerful 5 minute video by Musgrove Park Hospital in Somerset entitled Tackling Exit Block ie their hospital’s inability to move patients through ED because of numerous interrelated system failures.  (https://youtube/WX1YwKIkWzA).  Musgrove Park ‘s Top Ten Reasons Why People Cant Leave Hospital were as follows:

  1. Discharge delayed so patient can have lunch
  2. Carer/relative can’t pick them up till after work
  3. Nurses too busy looking after other patients to arrange discharge
  4. Waiting for transport or refusing to leave without free transport
  5. Waiting for pharmacy
  6. Waiting for ward round
  7. Waiting for blood or scan results
  8. Waiting for discharge letters
  9. Packages of care planned for late afternoon/early evening
  10. Patient doesn’t want to go to the assigned bed in community hospital

During discussion a number of solutions to our own recurrent difficulties with patient flow were proposed.  These included tackling all of the above in addition to attempting to educate the public about when and when not to attend ED.  My own view is that this might be as fruitless as King Canute sitting in his throne on the beach and attempting to stop the incoming tide on the grounds that any patient who comes up to ED and is prepared to wait up to 4 hours and possibly more to see a doctor or a nurse must feel they have a very good reason to be there (one often quoted reason being that they could not get an appointment to see their GP).

There were some illuminating moments.  We asked Patsy Pattie whether Dynamic Daily Discharge was still as effective as it had been when it was first rolled out.  She replied that some wards needed support on embedding the process.  Dr Pedley praised staff for their firefighting skills on those occasions when patients were unable to access cubicles in ED which prompted Philip Jones, our chairman, to say that a corporate rather than firefighting response was needed.  Many heads nodded in agreement.

A corporate response might mean fixing lots of little things in order to make patients flow through the system more speedily.  Dynamic Daily Discharge could then become an established part of ward routine rather than an optional extra; the paperwork in the medical assessment area might need to be simplified to allow nurses to move patients into the body of the ward more quickly; a nurse on each ward might be designated to carry the ward phone rather than allow it to ring endlessly in the hope that someone else will pick it up; clinical teams would actively consider how patients might get home;  consider community detox for alcohol withdrawal; patients earmarked for discharge might move to the dayroom unless physically unable to do so; hospital taxis might take people home if relatives or patient transport cannot do so; patients could be issued with a prescription to take to their local pharmacy if new medications are required or go home with immediate discharge letter to follow if not.

To these solutions I would add fully funded Ambulatory Emergency Care and Comprehensive Geriatric Assessment services together with more and better social care and a commitment to fill the hospital with more staff on public holidays (of which there will be four within one month of the new hospital opening).

The Chief Executive of Musgrove Hospital finished her contribution to the Exit Block video by saying ‘we need every single member of staff to understand their responsibility in ensuring patients flow through our hospital so that we can discharge them home as quickly and as safely as possible’.  Who could disagree?

Professor Chris Isles is Sub-dean for Medical Education and is a Locum Acute Physician.

Topping Out by Phil Jones

Reflections on the Topping Out Ceremony (held at the site of the new hospital on the 14th September 2016)

In June last year, just 15 months ago, I stood spade in hand alongside Cabinet Secretary, Shona Robison, in a big green field and said:

‘Today marks the start of one of the most significant periods in the history of public services in Dumfries and Galloway.’

We were marking a significant milestone, ‘breaking the ground’ for the start of construction of the new District General Hospital (ground works to prepare the site for construction had started in March, just days after Financial Close). I went on to say that we expected it to be delivered on time, on budget and built to the highest standards.

Decent progress on that front I think.

The decision to invest in a new hospital was taken well before that date, indeed before my time as Chairman, and a huge amount of work was put in examining different business and financial options before a final business case was approved in partnership with the Scottish Government in June 2013.

Our corporate team, under the leadership of Jeff Ace the Chief Executive, had complex overlapping work streams to manage, that I could simply categorise under technical, financial, legal and commercial, to get us up to and beyond financial close.

There was however nothing simple about it. I know from my own experience how professionally challenging all of this is.

I take this opportunity to say to Jeff that the leadership demonstrated in delivering on this vision through clear direction, the creation and motivation of a top team, and importantly the confidence to let them get on and do what they are best left to do is outstanding.

phil-jones-1topping-out-2

Turning now to that top team, Chief Operating Officer, Julie White who is the Project Executive and Katy Lewis our Finance Director  have taken this project forward at the same time as doing their day jobs, and also in tandem with Executive roles on our newly established Health and Social Care Integrated Joint Board.  Both are held in the highest regard locally and nationally and we are rightly proud of them. 

It is also right I think to acknowledge the contributions made by the previous Board under the Chairmanship of my predecessor, Andrew Johnston, who I was delighted could join us at the Topping Out Ceremony.

We see so many examples, in all walks of life, of the negative effects of short termism, and it is really uplifting to see that in Dumfries and Galloway once again we can, and do make strategic decisions for the longer term benefit of the people of our region in the knowledge that these projects will probably be completed after our individual terms of office.

There were many important decisions to make and history will clearly show the foresight and resolve of the Board in providing this region with a health care service to be proud of, and one that stands comparison with best of the rest.

This 344 bed acute facility, which includes;  a combined assessment unit, theatres complex, critical care unit and out patients department has been designed, in collaboration with clinicians and patients, adopting new models of care and utilising cutting edge technologies.

All directed towards providing patients with the highest standards of care, and providing our staff with the highest quality working environment.

We required additional community benefits to be delivered through the project, and High Wood Health, in conjunction with construction partner Laing O’Rourke, have more than delivered on their commitment to provide opportunities for local people and businesses. They have exceeded targets set to employ local people, provide apprenticeships, graduate placements and opportunities for small and medium enterprises to tender for contracts.

I was an ex apprentice myself and really value that route through to a lifetimes work.

This project will deliver not only a first class health facility but also a lasting legacy through jobs creation and skills development.

It is also important that I acknowledge the small army of our own staff who, in addition to the day job, are working in 16 or more specialisms and in dynamic teams under the Change Programme that is being skilfully led by John Knox, which I must say impresses me greatly.

John and his team are working to ensure the high quality services delivered at DGRI migrate as seamlessly as possible to our new District General Hospital later in 2017, incorporating amongst other things the most modern technology solutions.

I understand that Graham Gault and his IT team have digitised some 50 million patient records, which if that was the only project we were taking forward would be a huge undertaking in itself.

We have grasped with both hands, the once in a generation opportunity, to examine every aspect of the way we organise our acute workload and our new approaches are being designed very much around our model of Health and Social Care Integration.

Our new hospital may be located in Dumfries but it is central to the decentralised and localised model of care that we are developing across the region.

So in closing, I am absolutely confident that by December 2017 we will have not only the finest District General Hospital imaginable but also a huge number of staff whose work experience has been enriched by their involvement in this project.

Philip N Jones is Chairman of the Board at NHS Dumfries and Galloway 

September 2016