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The complicated journey in improving patient flow

Last year, the HSE decided to disband the Irish Hospital Redesign Programme (IHRP) and establish another patient flow initiative in its place. The decision was criticised by those behind the IHRP, which was initially planned to be rolled-out nationally, yet was never implemented anywhere apart from the pilot site at Tallaght Hospital, Dublin, despite achieving positive outcomes in terms of waiting times and patient flow management. In its final report, the IHRP said the new initiative, titled the National Patient Flow Improvement Programme (NPFIP), was guilty of unnecessary duplication and wasting resources.

However, speaking to the Medical Independent (MI), the HSE’s National Director for Clinical Strategy and Programmes Dr Áine Carroll offered a defence of the approach adopted by the HSE in establishing the initiative. Dr Carroll argued the NPFIP, which is currently operating in University Hospital Limerick and Galway University Hospital, offers a new perspective on how to navigate patients through the hospital system.

“I don’t think that there is one solution to these issues,” Dr Carroll said.

“What I find really interesting and exciting is having the opportunity to look at different methodologies that can be applied to achieve the same outcome, which is to get patients seen at the right place, at the right time, by the right team, whether that’s in the hospital or the community. I think it’s important that part of the work that we do is to test different methodology so we can see what works and what doesn’t work. Horizon scanning is really important.”

Learning

She said the new project was thus not “instead of” the IHRP, but was part of “a programme of change to test different methodologies and identify what works well”.

“There was really valuable learning from IHRP in terms of…the governance arrangements that need to be in place around projects like this, what is the need for clear national support, the need for the local team to have back-fill and time to put to the change programme. That was all immensely useful learning that we have applied to the next phase. I am quite sure we have a lot of learning from Galway and Limerick that we will apply to the next phase. The whole point of the flow programme is that we develop that capability within our own staff so that we get to the point where we have our own ‘train the trainers’ and that we can spread that knowledge.”

An initiative underway in Galway as part of the new programme (Medical Patient Flow Kaizen Project) aims to reorganise wards to have a certain number of medical specialities rather than the current system, improve streaming of patients from the emergency department and acute medical unit, and create an acute medical inpatient ward where patients remain for up to 48 hours and are then either discharged or streamed to appropriate specialty wards in an effort to improve length of stay.

There is also an Emergency Surgical Kaizen Project, which involves improving emergency surgical flow through creating an acute surgical assessment unit and also the development of a second emergency theatre.

The new three-year programme has been designed as a ‘proof of concept’ exercise to test and assess the application of operations management science to healthcare, initially across the two sites over an 18-month timeline, with subsequent planned roll-out over a further 18-month period to other sites.

MI has previously revealed how G Healthcare has been hired as a “technical partner” for the initiative. The budget for the contract has a maximum annual value of €650,000, exclusive of VAT. Additional funding of approximately €580,000 per annum has been provided for establishment of NPFIP teams in the two sites, which brings the total maximum annual budget of the programme to €1.23 million.

Political will

In its final report, the IHRP suggested a withdrawal of political support had harmed its prospects of being rolled-out in other hospitals.

“At the outset the [then] Minister for Health Mr Leo Varadkar openly supported and was kept appraised of progress in Tallaght, but this support waned in the face of the trade-off between the necessary methodical pace that quality improvement required and the political imperative for quick solutions,” according to the document.

The report outlined how the IHRP led to an increase in the capacity of the emergency department in Tallaght, a decrease in the use of overflow areas, and an improvement in overall processing outcomes.

IHRP-led projects in Tallaght have also realised a reduction in average PET scan times by 72 minutes, a freeing-up of the equivalent of 12 beds to reduce trolley waits and bed day savings in excess of €3.7 million per year.

In addition, it was estimated that the specialist care of the elderly ward in Tallaght would free-up 4.4 beds, to give a further saving of €1.3 million.

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