How reduced internal delays can save money, and thousands of bed days

The need to reduce delays in providing care to inpatients is a challenge faced by all hospitals but particularly affects large acute trusts like Nottingham University Hospitals Trust.

Long waits for internally provided services and processes create logjams in the system. These lead to blockages in patient pathways and can restrict the ability of busy emergency departments to admit patients efficiently or lead to the cancellation of operations.

No hospital can claim to run a healthy and efficient service for its patients without reducing its internal waiting times. But any solution to the problem has to take a whole-hospital approach. Patients, wards and departments must be viewed as part of a dynamic and fluctuating acute hospital, and cannot be analysed in isolation.

Getting better

At Nottingham University Hospitals, we treat more than one million patients a year and have one of the busiest emergency departments in the country. We have been using our trustwide improvement programme, Better for You, to drive improvements and increase efficiency in the two hospital campuses within our trust, which cover the Queen’s Medical Centre and Nottingham City Hospital.

Better for You is designed to ensure our patients receive safe, consistent and efficient services, and improve the experience of patients and staff while delivering financial savings. Part of this scheme focused on reducing internal waits – the aim was to cut the time patients on our adult medical and surgical wards spent waiting for any service we delivered.

We wanted to reduce the level of internal waits from a total of 750 bed days per week by at least 50 per cent, but with a stretch target of 80 per cent. The result would be a reduction in unnecessary waiting, thereby improving safety and enhancing the patient experience.

The programme also supported directorate cost improvement plans by enabling a reduction in bed numbers and their associated cost.

There were four key parts to the project:

Assessing the starting position: The initial discovery phase was carried out in summer 2010. It  included manually collecting information detailing the internal and external waits on all of our adult wards over eight weeks as well as the subsequent analysis of the main themes and top waits, and identification of the reasons or services causing them.

We asked the wards to capture data for any patients who had been waiting for more than 24 hours for a service or process that we are responsible for delivering. When we started, the top four waits were for imaging, cardiology, waiting for specialty beds and ward processes.

At the end of the discovery phase we were able to estimate the size of the potential improvement and, given the considerable size of this opportunity, decided to roll out and embed the initiative across the trust.

Developing a toolkit of actions for the wards This was supported by a training programme to facilitate implementation. With a multidisciplinary working group, we designed a toolkit of actions that would enable us to identify and reduce internal waits across the trust every day (see triangular image, attached right).

We used evidence of best practice in other trusts to construct the toolkit. At the heart of that and the new ways of working was a daily board round on every ward led by a senior decision maker and attended by key members of the multidisciplinary team for each ward.

Other parts of the toolkit include:

• a formalised escalation process, involving the matrons liaising with wards on a daily basis and helping to resolve any outstanding waits;
• training to help the wards with problem solving, together with practical information from services to help wards resolve their own waits;
• a standardised way of displaying ward information whiteboards to provide an easy visualisation of patients’ current status and any outstanding waits of more than 24 hours.

The toolkit was rolled out by a team of trainers in a structured training programme. Every ward had a named trainer for a five week period: one week of preparation, two weeks of daily training at board rounds, and a two week support period to embed the new ways of working. The named trainer remained as a “buddy” for their wards to provide longer term support. The training programme of 60 wards took us more than four months to complete.

Implementing a “knowing how we are doing” process: Every ward provides a weekly datasheet that captures information about any waits they experienced in the previous week, as well as providing details of the implementation of any of the toolkit’s elements, particularly those concerning the board rounds (such as how often they ran, the presence of a senior decision maker, weekend performance).

This information was analysed by the Better for You team and presented to, and reviewed by, a weekly steering group that was chaired by one of our executive directors. Every week we review the top causes of waits and the performance of individual wards and services. Every ward is provided with a dashboard showing its performance over the past 15 weeks and departments are given an overview of waits for their services.

Designing and implementing a fast, effective escalation process: Matrons have been central to helping embed the process and assisting the wards in tackling their internal waits. Every day matrons visit their wards after board rounds, check progress with the nurse coordinator, and then help to resolve any outstanding waits.

During the rollout period, a daily meeting was held to review waits that were long or hard to resolve; this was chaired by a clinical lead from one of the key directorates. The main services involved in the projects – predominantly imaging and cardiology – were active steering group members and ran their own Better for You improvement projects. Through this combined effort, improved working between wards and services has developed, including formalising the escalation routes between the two.

Reaping the benefits

As the toolkit training programme was rolled out we began to see the full picture of unnecessary patient waiting across our wards. The total reported number initially rose as the data collection was rolled out across an increasing number of wards. At the point of full rollout in February 2011 there were 545 bed days of waiting per week.

This already constituted a large reduction from the initial baseline data of 750 beds days of waiting per week, but we continued a rigorous focus on identifying the causes of delays, understanding the reasons and improving our ways of working.

By mid-June 2011 we had reduced waits to 238 per week – a reduction of 68 per cent from the baseline audit of July 2010 (see first graph image, attached right).

There have been several benefits of this work including:

• reduced length of stay;
• reduced bed occupancy, leading to improved patient safety, patient experience and improvements in patient flow;
• fewer outliers; and
• lower costs.

We have seen the greatest improvements in the highest wait categories, where we were able to link into other improvement work. For example:

• The imaging team has worked with staff to reduce internal waits in a number of ways, including: weekend working; longer working hours on Mondays; and implementing their own internal escalation process which enables the team to keep on top of, and resolve, waits.
• The cardiology team has redesigned the way it works, including reducing waits for echocardiograms (vast majority are now completed within 24 hours of request) and implementing a three day admission and treatment pathway target for patients requiring angioplasty.

The outcome is that we have reduced our bed base by 96, which equates to three fewer wards. We have been able to do this not because we are seeing fewer patients, but because patients are spending less time in our hospitals.

By working together differently, we have seen improvements across all categories of waits so that many of our patients no longer have unnecessary waits for hospital services.

Reducing internal waits and the length of stay for patients is within our control and we have acted on that. This has saved us approximately £4m while improving patient care and patient experience.