‘Unblocking flow constraints’ within a medical directorate at a large acute NHS trust

Chris Whale; Liz Ryalls; Neil Radford; Jenny Sidle; Rachel Jerram; Sally Denman; Andrew Mott

doi:10.7861/clinmedicine.15-3-s32

Aims

We aimed to create better flow within the acute medical bed base at a large acute NHS trust by increasing the volume of discharges, reducing occupancy levels, reducing length of stay and helping improve performance in the emergency department (ED).

Methods

Following a challenging winter 2012/13, a core team of clinicians (from primary and secondary care), managerial/transformation and nursing staff worked across boundaries over 12 months from April 2013 to facilitate a transition from the standard twice-weekly ward round model to job plans with thrice-weekly consultant ward rounds in all medical specialties, with the additional standard of a structured daily consultant-led multidisciplinary team early-morning ‘board round’ on other days. In parallel, we advocated internal professional standards to ensure that all patients were reviewed by their consultant on a Monday, and sharpened the focus on ‘expected discharge date’ and early discharge planning.

Results

Over the 6 months of peak winter (Oct–Mar), we had a 34% rise in discharges from medical beds comparing 2012/13 with 2013/14 (2,512 vs 1,872). Average occupancy fell from 94% to 90%. We had a fall in the number of days spent in red/black escalation (39/9 days vs 3/0 days). We saw a reduction in length of stay within acute medical beds, and the trust had a significant improvement in ED performance, achieving the 4-hour target for the year 2013/14.

Conclusions

Optimal ED performance requires a whole-system approach, incorporating strong leadership, a network of effective clinical decision-makers, decisive operational management structures and appropriate escalation policies. This project team facilitated an increase in the frequency of consultant-led ward rounds and MDT board rounds on medical wards, which increased the volume of discharges and helped to improve flow. The consequences were reduced bed occupancy, improved length of stay and better ED performance. Our findings affirm the importance of ensuring that appropriate time is allocated to the care of inpatients within physician job plans.