Thursday, 11 March 2010

What problem are we really trying to solve here

As we work with more and more healthcare organisations in the UK it becomes more and more apparent that their biggest problems (the ones that keep their Chief Exec awake at night) are:
  • Financial performance
  • Hospital Acquired Infections
  • The 18 week Access target
  • The A&E/ED 4 hour and 8 hour targets
  • Length of Stay (LoS)
It becomes even more evident that LoS (for medical patients in particular) is the deepest cause for concern.

Extended Medical Los is a massive drain on finances, necessitating the opening up unfunded beds which require un-budgeted bank and agency usage (it is unrealistic, however, to close beds without firstly reducing LoS). The longer a patient remains in hospital the greater their chances of acquiring an infection (which extends LoS even further). Extended medical LoS also results in the practice of out lying medical patients onto surgical wards (which prevents the admission of revenue generating elective patients), and leads to a lack of available beds for A&E patients requiring admission (resulting in excessive breaches).

We have yet to work with any organisation (to date) that do not insist that extended medical LoS is indeed their biggest problem. However they still typically have a portfolio of (on average) 500 ongoing projects (trust wide) attempting to address ALL of the Trust’s problems. This huge portfolio, perversely, prevents staff from working full time on reducing LoS, their biggest problem, and making it part of the day job.

Understandably finance in today’s environment seems to rule the roost resulting in many ‘turnaround’ initiatives. As a result, for example, Pathology or MAU are asked what can they contribute to financial savings but will their proposals also help reduce LoS? This applies to all the divisional and departmental silos.

Can you imagine if we all acknowledged that a reduction in LoS would be the greatest contributor to achieving all of our other targets and just worked on that. Then we would be asking all the divisions, departments and services “what can you contribute to a reduction in LoS”.

Every division, every department and every service would then be perfectly aligned to work on one goal, to reduced LoS. True North as we call it. Imagine how the project portfolio would look then.


  1. Dr Steven Allder12 March 2010 at 12:31

    Dear Ian,

    An Email from Dan arrived in my intray which lead to your blog.

    I have been analysing and change emergency flow in our hospital for the past 4 years. It is excatly as you describe. However, I have now had some notable success by focussing on the end to end pathway for patients with stroke.

    This has been posible because of several key issues:

    1. A new management structure that is accountable for the end to end pathway.
    2. A genuine sytems analysis of the end to end pathway - which reveal some expected findings about which patient subtypes were most tricky to manage.
    3. A focus on aligning all the providers to the same goal - improve the end to end flow
    4. Ensuring the accountable operational managers in each of the providers was identified, given clear priorties and accurate data to act on.

    With this we have achieved the following within 12 months!

    Demand has been very stable throughout
    Time to ASU from admission – 5 days to 0.2 days
    100% of patients to ASU
    All patients achieveing 100% compliance with CQC targets while on unit
    LOS 30 days to 7.6 days
    Daily mean Occupancy from 33 beds to 19 beds
    Proportion of patients going to RSU increased by 50%
    Time to RSU from request for bed 10 days to 3 days
    LOS on RSU 45 – 35 days
    Occupancy on RSU from 23 to 19
    And we haven’t really changed much yet! There is much more analysis and change emerging which is very exciting

    This has improved care for patients, improved life for staff considerably and significantly reduced costs. Lets see if we can evolve and sustain it!

  2. Hi Steven

    It sounds like you've been doing some fantastic stuff. As you know, we are always looking for exemplar organisations and to showcase their good work.

    As a result it would be great if you could you kindly e-mail me on to enable us to discuss further.

  3. Advanced anaesthetic techniques have a key role to play in reducing length of stay. The hospital management is yet to recognize its potential.

  4. I can, absolutely, see how processes like regional anaesthesia (please forgive my lack of clinical knowledge here) would reduce LoS.

    When you say minimal support from your trust. Is it downright opposition (a cost or quality debate). or is it apathy.

    Are the senior clinicians with you? On the clip that you posted Malloy Roy appears to be a supporter.

    Do you have a robust business case that the 'bean counters' cannot contest?

    We have found that if you can provide a bullet proof, factual, business case that clearly demonstrates improvements in patient safety/experience and, especially in today's environment, shows a cost benefit - then you are likely to gain support.

    I guess that I need to, better, understand the problems that you are encountering before suggesting a new approach.

    I'd be really interested in hearing more from you around this.