Improving patient flow and discharge
Whilst working in an acute hospital, during a meeting discussing patient flow I suggested to the chief executive, director of nursing, medical director and chief operating officer that they and I should all put on a patient gown and lie on a trolley in an emergency department for 24 hours. I thought this would allow us all to get an idea what it would be like to be a patient. I was asked to leave the meeting, they called me bonkers and I wasn’t promoted for several years. This may seem extreme to some people but at the time I thought and still do that we don’t really make enough effort to think like patients when we are looking to reduce length of stay and improve patient flow.
I worked within the NHS for 36 years in a variety of roles including nursing, management and improvement. More latterly I was the head of the national Emergency Care Improvement Support Team (ECIST) which gave me the privilege to visit and see multiple health systems across England trying to help teams improve patient flow. I’ve also visited several healthcare organisations in other countries and it’s no surprise that the problems people face are more similar than not.
One of the biggest problem patients experience is long periods of waiting. In the media A&E/emergency departments (EDs) always make the headlines for long waits, the most recent headlines being ‘More than 150k patients wait at least 24 hours for bed after arrival at A&E, data shows’. With this amount of waiting there is quantifiable increased risk of mortality, ‘for every 82 admitted patients whose time to inpatient bed transfer is delayed beyond 6 to 8 hours from time of arrival at ED, there is one extra death’. However, it’s much less common that we hear as much about the significant patient waiting elsewhere in health systems particularly for hospital inpatients which happens for a multitude of reasons.
All too often national, regional and local improvement efforts, mandates and investments to improve patient flow are focused upon the emergency department as that’s where national emergency performance (i.e. A&E performance) has been historically measured and judged. In my experience the root cause of the poor patient flow rarely sits within emergency departments. Yes, ambulances are queuing outside, and patients spend countless hours waiting (the symptom of the problem not the root cause) but more tinkering within emergency departments rarely makes a notable difference in my humble opinion.
There’s plenty of advice describing what people should do to improve emergency patient flow but even with all the available advice, hospital crowding continues. Of course, it’s complex and multi-factorial with politics at play and a lack of investment in the right places etc but one thing I think is scarce is leaders really trying to think like patients, what adds value for them and what is of no value.
Over the past 6 months since I left the NHS I have been caring for my mum (86 years old) and my dad (92 years old) who have had multiple interactions with primary and secondary care (including hospital admissions) all with me by their side. Additionally, one of my sons (22 years old) who has complex special needs is currently facing significant challenges within my local system which neither health nor social care seem to be able to resolve, just lots of waiting and uncertainty. During this time whilst experiencing waiting as a carer within various health settings, I have watched and listened and it’s amazing how much you see. Some of the poor and unclear processes seem to be designed to create extra patient waiting, poor flow and delayed discharges particular for older people and those with special needs i.e. my parents and son. It’s important to point out that whenever we saw the right healthcare or social care professional, everything was usually excellent, it’s the waiting and poor processes that drive you bonkers.
On Saturday 30th March 2024 I was reading the Times newspaper magazine and saw an article by Adam Luck (a writer) about his 82-year-old mother titled ‘How long have I been in hospital? I’ll go gaga if I’m trapped any longer’. The article grabbed my attention (see below) as a real and clear example of exactly what I was thinking. The author describes his mother’s timeline from admission with a suspected stroke to discharge (January 9th – March 1st 2024).
The story won’t be a surprise to many and unfortunately is not unique. In summary, his mother was expected to be in hospital for about 10 days but ended up being an inpatient for 53 days, many of those additional days wasted with unnecessary waiting and anguish. His mother had a delayed MRI scan, they were told there was pressure on beds (i.e. a crowded emergency department), yet she continued to wait for weeks, she moved wards a number of times, referrals took too long, there was lack of clarity who was leading i.e. the NHS integrated discharge team or social care, the family complained, there was a lot of buck passing and finally the patient was discharged to a nursing home that the family was previously told she had been declined from.
Anyone who has read the article will surely think:
How much wasted time did this patient experience?
What a terrible experience for the patient and her family.
The hospital was crowded with ambulances queuing outside. I imagine there was lots of front door firefighting happening and the poor emergency department and acute assessment units were at their wits end. Reducing the length of her unnecessarily long stay could only help the problems of a crowded hospital.
Many of these unnecessary delays were due to hospital and system processes which seemed to work against the patient and could definitely be improved. My guess is the medical teams declared the patient medically suitable for discharge a long time before she was discharged from the hospital.
Now, imagine we were brave and said let’s start thinking like a patient, maybe the patient in this article with the aim of reducing the amount of preventable waiting which in turn would help (not completely solve) reduce crowding in the emergency department and improve patient flow. Let’s get everyone involved with the patients’ journey together, not just senior folk who don’t experience the poor processes every day. The people who do the work always know the answers and are best placed to make the improvements with support from leaders, as long as there’s a psychologically safe environment to do so. Let’s hear from the patient and hear how bad her experience was and what would make it better. Let’s do it in a way that everyone feels safe to give ideas, test them out, have the ability to fail without judgment.
Imagine:
Imagine we said what would it take to reduce this lady’s length of stay by a third. We’d probably say this is possible and if we can reduce the length of stay for similar patients there’d be a positive effect upon patient flow.
Imagine if we banned phrases such as ‘yes but we’ve always done it this way’ or ‘yes but the rules say we must do stuff that make patients wait unnecessarily’?
Imagine if we agreed that silos and territorial teams passing the buck don’t benefit patients and agreed that this causes harm? More importantly let’s agree to do something about it.
Imagine if we said, ‘let’s be brave and break the rules that make no sense’.
Imagine an environment where everyone felt psychologically safe to make and implement improvement suggestions? The evidence that psychologically safe environments are hugely beneficial is compelling with positive outcomes including improved performance, innovation and improvement.
Imagine if we tracked this lady’s journey and length of stay as an inpatient as well as we track the length of stay of emergency department patients and with the same amount of focus?
Imagine if the patient and her family had a clear plan and realistic expected date of discharge that we stuck to and if we go past it, we escalate so action can be taken without delay rather than the usual ‘escalitis’ which rarely results in notable action?
Imagine if the system really bought into and implemented a model of discharge to recover and assess (or discharge to assess) preferably to their normal place of residence that worked smoothly and clearly from the time or just before a patient is deemed medically suitable for discharge or transfer.
Imagine if there was one simple process for ward and unit staff to refer to a transfer of care hub simply describing the patient and then the transfer of care hub arranged the patient’s ongoing care (preferably at home if possible) with minimal delay.
Imagine if it was your mum, would you be happy?
Imagine if you were the patient, what improvements would you suggest?
If you were being honest, how many improvable processes can you think of that are rubbish and cause patients to wait and frustrate clinical teams.
The author of the article writes ‘we do not blame individuals, but rather the system, and that someone in authority needs to take ownership of the situation’ and that’s 100 percent correct. It’s rarely individuals, it’s usually the system and processes which leaders are employed to improve.
Of course, there’s no magic bullet to any of this but one thing is for sure, we could do better. Some of the initial steps for leaders include encouraging everyone to really think like a patient, really understanding and doing something to improve processes that don’t work for patients and patient facing teams across the system, creating a psychologically safe environment for teams to suggest and implement ideas (to reduce unnecessary waiting and improve patient flow) even if it causes healthy friction that leads to positive outcomes.
Maybe it’s time for us to spend that 24 hours on an emergency department trolley?