A/Prof Harvey Newnham, Clinical Program Director Emergency & Acute Medicine, Director of General Medicine, Alfred He

1. NEAT within the hospitalCulture, strategy and how to embed timely quality careorDon’t mention the war!ACI/NSW Health/ECI Seminar, Sydney, 13th December 2013 A/Prof Harvey Newnham, Clinical Program Director Emergency & Acute Medicine, Director of General Medicine, Alfred Health, Melbourne

2. How are we doing? No idea Improved Much the same Worsened 1. Quality of patient care in your sphere of influence in 2013 compared with 2011 is ……………..? 2. In what way do you feel the 4h NEAT approach to date has contributed to quality of care?

3. Survey of Directors of Victorian General Medical UnitsSeptember 2013

4. Certainly has led to increased focus on patient through put and we have implemented some practice change to improve this Focus on KPI's to the detriment because we are treating a performance measure as an objective The 4 h NEAT target has been a catalyst for some positive changes although there are balancing negative effects Have noticed very little difference in reality It has helped focus on what was previously very poor and unpatient centred performance.

5. Pressure on JMS to discharge patients and to transfer patients to ward regardless of clinical management requirements It has been challenging to maintain the high standard of patient care but feel we have achieved this. Shorter ED length of stay and earlier contact with the treating team has lead to benefits overall

6. There have been stress points with ED at times and some tensions that we have had to resolve Pressure leads to deterioration in behaviours General medicine is looking closer at internal structure and perhaps not filling gaps in other services as it was previously We have been better accepted by ED people

7. The registrars feel more stressed and there has been some pressure put on them by ED staff which they have found difficult to manage Resources allocated to assist with achieving targets We have had to operate within existing budget It has helped focus on gaps in rostering

8. Consistent practice, excellent senior staff input, wonderful nurses and junior medical staff with great nursing leadership Very happy with care once they get in.

9. It’s not about what happens. • It’s about what you do with what happens. The Zen of Healthcare Modified from Aldous Huxley

10. The people: • Smart, • Experienced, • Committed, • Ultimately want to do the best job they can for our patients • Very substantialResource • High degree of public, political and administrativeEngagement Working in healthcare:What’s not to like? We can't fail

11. Context of NEAT:Essential problems in delivery of care For many patients we don’t know what to do. When evidence exists it is often not applied. Fidelity of execution. Our health system is tweaking an historical model of care rather than designing its own future Solution: Design and create a comprehensive system for delivering health care. Richard Bohmer “Designing Care” 2009

12. Don’t mention the war

13. All just too hard

14. It’s not about 4 hours – pebble in a pond Don’t mention the war(However will we win?)

15. It’s not about working harder

17. Which department would you prefer to work in? E &TC cubicle occupancy May to August 2011, 2012, 2013 2011 2009 2012 2013

18. Timely Quality Care (TQC) Itis about excellence in patient care Transforms the way we treat our patients to ensure they all receive timely, quality care consistent with their clinical needs Is a whole of health service change that involves everyone (clinicians, managers and support staff) Changes how we assess and treat our patients from the moment they arrive to the time they are discharged

20. ‘It is no longer tenable that a good practitioner can provide the best care other than as part of an effective team within a well organised health care delivery system.’ • Translated into medicalese: • We can enjoy what we do, use our skills to provide effective care, have a manageable workload and maintain reasonable remuneration, if we learn how to be part of an effective team. • Management speak: • We want everyone to work at the mid-upper level of their competency. • We all need to • work differently or • be paid less or • get off the bus. It is a new paradigm

21. The best innovations happen within the tightest constraints The Good News Paraphrased from Clayton Christensen, in ‘the Innovator’s Prescription’

22. Our Timely Quality Care Journey

23. Alfred Health • 3 hospitals: The Alfred; Caulfield Hospital & Sandringham Hospital • Around 900 beds; 90,000 ED presentations, 92,000 inpatient events; 170,000 outpatient attendances. • Approximately 5000 equivalent-full-time staff made up by around 7000 people • State-wide services for trauma, burns, heart & lung transplants, HIV / AIDS, hyperbaric service, cystic fibrosis, haemophilia, Melbourne Sexual Health Centre • $900 million per annum • Strong General Medicine • Highest bed-day user

24. The Journey starts: In August and September 2010, four of us (H H N, P De V S, M J K, A M S) undertook an investigative tour of 13 emergency hospitals in the United States and the United Kingdom to observe innovative approaches to patient flow pathways from the emergency department (ED) to inpatient wards and consider their potential for use at Alfred Health Harvey H Newnham, Pieter De Villiers Smit, Martin J Keogh, Andrew M Stripp, Peter Cameron MJA 2012 p101

25. E&TC and Acute/GenMed in same program Site visits US & UK 2010 In house conversations Individual unit developments – AMU model of care etc, E&TC modifications Formation of Whole of Hospital TQC Steering Group Data, and more data Site visits to Perth Hospitals Importance of engaging HMOs Draft principles established for whole of hospital approach Stakeholder input into principles Sign off by HOUs of principles Travelling roadshow by COO E&TC Design sessions Launch of daytime TQC Nov 2012 Formation of Hospital at Night steering committee late 2012 Conversations about hospital at night Draft principles established Stakeholder input Promulgation of hospital at night plan Launch of hospital at night (ie 24h TQC) Feb 2013 Ongoing monitoring by steering group The Journey towards Timely Quality Care

26. TQC – Craft group specific approaches to implementation

27. Leadership Workshop

28. Concerns must be voiced and taken seriously

29. GENERAL MEDICINE DESIGN WORKSHOP

30. Key Whole of Hospital Changes • Trust • The Emergency physicians’ decision to admit • The inpatient team to promptly provide appropriate care • The investigative/interventional services to deliver in 24 hours (treat in turn) • Management to apply resources according to system design/priorities based on accurate data • Adjust rosters/work patterns to ensure staff are available when required • Match bed capacity to the time of highest demand and ensure patient goes to the correct bed first time • admission beds, SAAU’s, MAAU's & Flex beds • Develop safe after hours/overnight teams

31. Triage has become Streaming • 3 minute assessment maximum • ATS allocated (? is it still relevant) • Patients streamed to either: • Resus & Trauma: • RITZ: • Prioritise Cat 2 & AV to front of queue • Everyone else treat-in-turn • Fast Track: • Treat-in-turn

32. Upfront Senior Decision making for all patients…. RITZ (Rapid Intervention & Treatment Zone) • Consultant led assessment team • Determine interim management and disposition plan • “Treat in turn” principle instead of “triage & wait”

33. Safety is OK

34. Dr Foster global health comparator Alfred Health

35. Bypass: Our Doors are Always Open The Alfred

36. The Alfred Target 75% NHPA website Sept 2013

37. Patient Access as per NEAT

38. Acute General Medicine Patient Pathway *Lead Consultant Streaming nurse Streaming APT Ward 4AMU Ward 4GMU Team C Team D Team A Team B DIRECT ADMIT from community, clinic or other hospital via call to *lead consultant HOME or CH, SH, HITH, private hospital AAU 4 Identical teams A-D Consultant (8-12/1600*pm) APT (8-1700) BPT (8-2130) 2 x Interns (8-4 & 11-1930/2130) Daily consultant ward round *Via call to streaming APT registrar & nurse. With interim orders ESSU Cubicles RITZ E & TC As at 2nd December 2013 Patient

39. TQC GenMed % E&TC Admitted <4hJune-November 2013

40. Staff Experience – 12 months on…….

41. What NEAT is showing us Before NEAT Good Doctor + Experience + Resources = Best Care Doctor: custodian of knowledge, skills and application of these to the individual patient Organisation: provider of resources After NEAT Health care delivery organisation manages…. Practitioners - typically in multidisciplinary teams Knowledge base - decision support and practice-basedevidence Processes of care – reduced variation and delays, outcome orientated to provide best healthcare outcomes at affordable cost Adapted from Richard Bohmer “Designing Care” 2009

42. 10 Big IdeasFuture Hospital Commission 2013: “the most important statement about the future of British medicine for a generation” “Hospitals must offer “seven-day care, delivered where patients need it”. It's time to build a new movement for generalism, not specialism—”generalists are the undervalued champions of …acute hospital service”.

43. Major Gaps Practice-based evidence is in its infancy in our system Can’t implement change unless monitoring systems are good enough to learn from mistakes and measure failure Integration is essential The divide between hospital and community care leaves us impotent regarding demand management

44. Where next? PM’s & weekends Treat-in-Turn expansion Cardiology Gastroenterology Patient discharge pathway Matching staff with workload (volume and time) New ward governance models Standardisation of ward rounding How many admitting units do we need?

45. Conclusions • Don’t mention the war – it’s not about the 4 hour KPI! • It’s not about working harder - • It is about leadership, teamwork, design, and reducing variation • Hospitals are full of smart people, we need to create the environment/culture that allows them to achieve their potential • It is about quality and excellence in care – quality saves time and money • It is a journey that your staff have to travel with you • Let’s get the job done and move on to address the bigger issues

46. Acknowledgements • Martin Keogh – Services Director, Emergency and Acute Medicine • Andrew Stripp – Chief Operating Officer • De Villiers Smit – Director Emergency Services • Peter Hunter – Program Director of Aged Care and Rehabilitation • Andrew Way – CEO • Bill Johnson – Program Director Surgical Services • Amy McKimm – Redesign manager • Many, many others

49. A A A A A A B B B B B B C C C C C C D D D D D D GenMed Team Staffing Dec 2013+ WEEKDAYS WEEKENDS CON INTERN CON APT BPT INTERN BPT 8am A 12pm 1pm 5pm 7.30pm 9.30pm

50. “Culture Eats Strategy for Breakfast”