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The term ‘patient flow’ is one of the most common healthcare management phrases used over the last decade. Overcrowding and waiting lists occur when the path of patients through the hospital system is blocked. These blockages are generally the result of capacity and process issues within hospitals. While additional funding is obviously needed to increase capacity in problem hospitals, healthcare leaders believe that process improvement can also make a difference. At times of financial stringency, this improvement not only becomes desirable, but necessary.
There is also a growing recognition that if one part of the hospital is not operating effectively, it tends to affect other parts. Improving patient flow is essentially about trying to make the patient’s journey through the hospital system and then back into the community as seamless as possible.
In Ireland, there have been many attempts to do this, but few have been met with lasting success. Various reports and strategies have been published in recent years on emergency department (ED) overcrowding, with little impact on the number of patients waiting on trolleys. The creation of the Special Delivery Unit (SDU) in 2011 was intended to transform the manner in which hospitals tackled overcrowding and waiting lists, but the initial gains made by the Unit failed to be built upon. The loss of key staff members and funding control, as well the transfer of the Unit from the Department of Health to the HSE, have drastically impacted the ability of the SDU to be the force for change that was once envisaged.
One reform project that the SDU is currently involved with is the Irish Hospital Redesign Programme (IHRP). Perhaps aware that other well-publicised HSE initiatives failed to meet their objectives the Programme was launched in 2014 with little fanfare. It was based on a performance improvement programme that the then HSE Director of Acute Hospitals Dr Tony O’Connell had previously implemented during his time as Director General of Queensland public health services. The IHRP was intended to support local change and innovation with external support and expertise provided by the SDU and the HSE’s Clinical Care Programmes. It would use – in its own terms – “design and improvement methodologies, such as Lean, Six Sigma, theory of constraint, and business process re-engineering”.
A small amount of funding (€1.6 million for 2015) was made available for the project, but it was intended to deliver improvements within existing resources. The IHRP’s main aims were to improve the management of demand through the consistent application of national clinical pathways; streamline patient journeys and providing alternative pathways; and remove the disconnection between services that cause blockages and delays.
The Programme was to be piloted on one site in 2014, with the initial intention being to roll it to other sites the following year.
However, there were recognised challenges to overcome. In an application form for the Health Managers Ireland Leaders Award, Ms Anne-Marie Keown of the HSE’s Acute Hospital Division, said that the healthcare system was under significant stress and there was a risk of ‘change fatigue’, with many existing reform initiatives in the past failing to deliver improvements. She also noted that there was “significant local scepticism” that the IHRP would work. But overall, Ms Keown argued that the Programme had considerable potential, stating it would tap into the experience of frontline staff and facilitate collaboration to develop new ways of tackling capacity problems.
Tallaght Hospital, Dublin, was chosen to be the initial site to trial the IHRP because of the perceived benefits the Programme could bring in terms of reductions in its overcrowding and waiting list problems.
A working group was established involving hospital leadership, key Clinical Programmes, the SDU and the outpatient programme, which met every fortnight to oversee development and implementation of the approach in Tallaght.
Some of the initiatives established included: An acute surgical assessment unit, ED advanced nurse practitioner review clinics, an early warning score (EWS) in the ED as well as a number of patient care pathways focused on admission avoidance and/or reducing the average length of stay in hospital.
These were not new ideas, and many, such as the EWS, existed already within the Clinical Programmes. The IHRP aimed to act rather as a catalyst for change, providing renewed energy towards their implementation, along with providing a forum for ideas from frontline staff. It aimed to bring together previously stand-alone national Clinical Programmes to coordinate work on integrated care pathways.
The initial results were promising. For instance, sharing theatre lists with the day ward led to an immediate improvement in start times. Opening the surgical assessment unit quickly impacted on patient experience times and reduced pressure on the ED. A surgical ward introduced a nurse-enabled discharge of patients following agreed blood results and was working to extend the criteria further to reduce the median time of discharge, to improve patient flow on the ward, and to reduce the need to bring surgeons out of the theatre to allow patients to leave the hospital. The change allowed on average one patient every two days to be discharged by 11am, which was a five- to six-hour improvement on the previous arrangement.
Also, defining new pathways for cellulitis patients linked to use of outpatient antibiotic therapy (OPAT) helped avoid several admissions.
One medical ward also introduced a communication board to form a focal point to highlight the predicted date of discharge, the length of stay, the EWS, as well as required actions to progress care and plan for discharge. Through the board, the ward initiated a daily multidisciplinary team meeting involving nurses, medics, and physios to review and progress plans for every patient.
“The IHRP has succeeded for the first time in harnessing the collective expertise and efforts of the acute hospital division, the national Clinical Programmes and hospital staff on the ground, to work collaboratively to support performance in a single site,” said Ms Keown.
Difficulties, however, were experienced from the beginning. The initial ‘diagnostic phase’ of the Programme, where staff and managers developed a list of problems to be solved through the IHRP took longer than the intended four weeks. This was explained as part of the inevitable delays experienced with pilot projects. There were also resource issues. According to an IHRP Steering Paper from January 2015, the Tallaght project had been a “significant commitment” in terms of time and resources. A document on the organisation and resourcing of the project from February 2015 stated that “significant difficulties” were experienced with the resourcing of the Programme, which was done on an ad-hoc basis. These included key roles being performed on a “double-hatted basis” and “a lack of capacity to address some of the strategic aspects of the programme”.
It was agreed that further work was required to learn from the experience of Tallaght regarding the roll-out of the Programme to other sites.
The plan for the IHRP was that each hospital would spend around seven months from preparation through to the review of the initial project implementation. Different options were considered that would allow between four and even eight hospitals to be engaged in the Programme in 2015. The Emergency Department Taskforce report, which was published in April 2015, stated that the plan was to have four or five hospitals running the IHRP by the end of the year.
However, this expansion never materialised. Tallaght remained the only hospital to be engaged in the IHRP in 2015, with University Hospital Limerick identified as the sole succeeding site for implementation. The Programme’s roll-out in Limerick is contained in the Acute Hospital Division Operational Plan for 2016, as well as the Operational Plan for the University of Limerick Hospital Group. When contacted by the Medical Independent (MI), a spokesperson for the hospital said that, almost four months into the year, the Programme had not yet begun.
“As of yet, we have not commenced any work on the IHRP and we are awaiting details of next steps on this programme from our colleagues at a national level,” according to the spokesperson.
At the time of going to press, the HSE had not responded to MI about the reasons for the delay in implementing the IHRP in University Hospital Limerick, or, more generally, the decision to curtail the roll-out of the Programme nationwide.
What is apparent is that establishing the programme in Tallaght took longer than anticipated. Specific initiatives in the hospital such as an outpatient patient central office for referral management and triage, a review prioritisation of diagnostics, and the creation of a frail elderly ward were not able to be fully realised within the original timescale.
One problem identified in an IHRP Steering Paper, written by Ms Keown from June 2015, concerned the development of proposals for shared learning networks and a performance academy.
Ms Keown wrote that the experience of the Programme to date was that while a hospital may nominally have many people who have some training in improvement methodologies, it has proved difficult to harness this capability.
“It is also apparent that many people in central advisory roles do not have sufficient practical application grounding in performance improvement to fill that gap,” she stated.
Ms Keown also maintained that to date there has been a heavy reliance on “wisdom” coming from the National Clinical Programmes, but that over time “there may be more hands-on experience that can be brought to bear in spreading good practices”.
Given that one of the aims of the IHRP was to utilise frontline knowledge in devising solutions, this reliance on the Clinical Programmes could be seen as a serious shortcoming of the pilot project. The resignation of Dr O’Connell from the HSE last year was another blow to the Programme, with the loss of his experience likely to have affected the early progression of the IHRP.
The IHRP is still part of official healthcare policy. Although progression has been slower than planned, it is still intended for University Hospital Limerick to be the next site of implementation, while it is still being run in Tallaght Hospital. The IHRP is also planned to be merged with the new integrated care programme for patient flow this year. Trying to solve the capacity problems in the hospital system is a continual process and one that continues to prove very challenging for healthcare managers and staff.