The Special Delivery Unit – Performance Improvement

Those working in the health service needed to stop externalising the problem, this was a personal leadership challenge for each and every one of us,  Ms. Lis Nixon, Director of Performance Improvement in Unscheduled Care with the Department of Health Special Delivery Unit (SDU) told the HMI Dublin/Mid Leinster Regional meeting in the Dublin Dental Hospital last evening. Maureen Browne reports.

Those working in the health service needed to stop externalising the problem, this was a personal leadership challenge for each and every one of us and we needed to accept challenges as they were, not as we might wish them to be, Ms. Lis Nixon, Director of Performance Improvement in Unscheduled Care with the Department of Health Special Delivery Unit (SDU) told the HMI Dublin/Mid Leinster Regional meeting in the Dublin Dental Hospital last evening.

Lis Nixon and Pat O'Boyle
Ms. Lis Nixon with Ms. Pat O'Boyle, Chair, HMI Dublin/North Leinster Regional Committee

“We need to be willing to recognise that even though the problems are endemic, chronic and long standing they are also amenable to solutions. We need to build the alliances that will enable us to get back on track, we must embrace a logical empirically driven approach to finding solutions, we need to develop unity of purpose about the things that matter, we need to think smart and work smart and not just be  busy for its own sake and last and first must be patients,” she said.

Ms. Nixon said that a current issue in the system, as seen from the SDU point of view, at the moment was lack of ownership. This was common, but so universal that it was at all levels for issues and problems and looking in from the outside it seemed that delays, waits and cancellations etc., were seen as normal or impossible to change. “When you are deeply embedded and working every single day, people find it difficult to see what they can do in their role to make a difference and they feel very isolated.”

She said that significant improvements had been made in some places.

The SDU had a number of objectives and tasks.  It had to:

  • Create an environment through which cultural and behavioural change in the delivery of unscheduled and scheduled care was implemented.
  • Create and embed the tools and techniques required to deliver sustainable hospital access targets in both unscheduled and scheduled care.
  • Ensure that improvement actions were financially viable and clinically sustainable.
  • Support the development and implementation of the Performance Management Framework, which could be used to monitor delivery of unscheduled and scheduled care access targets.
  • Support the transition from the current model of care to the new model.
  • Make sure risks to existing service delivery were minimised
  • Ensure that the future system had the capacity and capability to deliver safe and sustainable clinical care.

The SDU, which had been established in September 2011, had been asked to concentrate initially on Emergency Departments, inpatient waiting times, outpatient waiting times and maybe in the second half of next year, access to diagnostics.

“We need to be professionally led – sometimes managerial and clinical leaders do not work so well together, we need to be a team – a strong team is a nurse lead, a medical lead and a managerial lead.”

The key access targets were that no one  should be waiting longer than nine hours in an ED, with 95 per cent waiting no longer than six hours, that adults should have to wait no longer than nine months for an elective inpatient/day case procedure, (and this would be moving to eight months in 2013) that children should have to wait no longer than 20 weeks for an elective inpatient/day case procedure, that no patient should have to wait more than 13 weeks for a routine GI endoscopy and that no patient should have to wait more than 52 weeks for an outpatient appointment.

The SDU wanted to achieve safety, flow, reliability and sustainability. It wanted to improve outcomes, see there were no avoidable deaths, no harm, no unnecessary pain, no delays, no feelings of helplessness and no inequality. “We are trying to get across to people that it is not about hitting the target, but missing the point.”

She said that contrary to popular opinion, there was a body of opinion that felt that one of the main problems in providing a uniformly excellent health care was not lack of money, but lack of knowledge.

The values for healthcare transformation were that it had to be patient-centred, accountable, information rich, professionally led and quality based.

“We need to be professionally led – sometimes managerial and clinical leaders do not work so well together, we need to be a team – a strong team is a nurse lead, a medical lead and a managerial lead.”

Ms. Nixon said that the information rich objective was fairly difficult as some areas of the health service were data poor but the SDU was starting to get better systems in.

We needed to identify who was accountable – at every point of the patient pathway it had to be clear who was accountable for their care.

There would be intensive support in key improvement areas for struggling hospitals or intensive support in key operational issues. That might include teams going in to provide intensive support.

Some of the key success factors for sustainable change were a focus on patient clinical champions and visible senior executive support.

There also had to be regular communication, clear goals from the start, multiple learning methods and simultaneous improvement in other areas.

“You can never communicate enough with patients. In a strange environment, patients don’t always hear what is said and you should have your goal or endpoint in mind from the start and try not to get distracted and deflected into other things.

“We have to have a consistently high quality of service. We must have senior and timely decisions made and really good communications. We are struggling a bit at the moment to get senior timely decision making 24/7.”  When you are trying to make improvement in one area, remember it is one pathway and an improvement in one area will probably have an impact elsewhere, so try and improve that also.

She said the current situation had a particular impact on patients in EDs and it was a key priority to move patients through EDs.

“We need zero tolerance of delays in assessment in EDs and admissions from ED. People are anxious about how to make changes and every stakeholder has a key role to play.  This is about a whole national health system, a system where we want to be proud of what we all do.”

She said earlier in the year there was a small patient survey to see what patients thought of the health service.

One young woman said that she had waited over seven hours to get five stitches in her hand.  A second frail elderly patient said she had spent the previous 28 hours or more on a trolley in A & E. She said the staff were excellent although they worked in terrible conditions trying to fit around trolleys to do their work. Another said that after three hours waiting she had asked the staff nurse in charge what was happening and been told that they were very busy and she would just have to wait her turn.

The problem with trolley waits was that ED overcrowding had been shown to reduce effective diagnosis of often critical conditions, patient experience was poor at best, and at worst it directly affected their likelihood of a positive outcome, diagnosis and treatment were difficult to perform resulting in potential “near miss” events, and delays in timely intervention and senior clinical decision making resulted in poor outcomes.

She said that there had been some progress to date. Last year there were high numbers of trolley waits and this year there had been a significant improvement of approximately 25 per cent reduction in people waiting on trolleys in EDs across the country. The problem was that it was not uniform across the country and sometimes depended on the hospital’s position, the type of hospital, demographics, numbers of staff etc.   In the first nine months of this year the biggest problems were in the Dublin hospitals. However, some sites were making remarkable progress. Beaumont Hospital in Dublin had made some very sustainable changes in the way they worked and in the bed management system they had implemented and brought their trolley waits down significantly. Others were still struggling with the challenge of trying to reduce their trolley waits for lots of different reasons.

Ms. Nixon said the next steps were to develop key data sets for hospital, regional and national measurement and monitoring, then move towards national reporting in real time and patient experience time measurements. They also wanted to develop guidance documentation, checklists and material to support the key improvement changes required to deliver best practice in emergency care pathways.

They would also be identifying innovation sites, then working with them to develop and share their learning.

There would be intensive support in key improvement areas for struggling hospitals or intensive support in key operational issues. That might include teams going in to provide intensive support.