The NHS spends millions of pounds every month paying for people to occupy beds in hospitals who could either be at home or in different, more suitable and often cheaper settings. Simple things can transform the length of stay and reduce costs significantly.
Substantial amounts of managerial and clinical time are spent balancing the need for beds with ensuring that discharges occur safely. This can be complicated by unplanned admissions and delays in the transfer of care. High pressure need for additional beds increases stress levels and lowers productivity, raising the risk of mistakes occurring. Rising to these challenges is not easy.
Sue Stanley, Director of Service Improvement at Northampton General Hospital (NGH), says: “Success in reducing Length of Stay is achieved when we understand the pathway from the patient perspective and then remove all the delays and duplication that occurs.”
In addressing these issues, NGH have developed the ‘Think Home First’ programme using Regional Innovation Funding. The programme brings together acute and community care clinicians with a ‘task force’ including transport, reablement and social care to effect faster discharges. It has reduced the time from referral to assessment to around 24 hours in most cases and has already saved over 800 bed days, as well as winning two ‘Health & Social Care Awards’ for partnership working and the ‘Winner of Winners’ award.
The focus hasn’t stopped there. Work done by Sue’s team in dispensary has reduced the time to dispense medications by 57%, itself leading to an average 0.25 day reduction in LoS.
Other examples of a proactive approach to improving patient care and reducing LoS can be seen at UCLH (University College London Hospital). It launched its Quality, Efficiency and Productivity Programme in 2010. To improve ward efficiency, the programme brought together various strands of activity including enhanced recovery, increasing morning discharges and Lean methodology to improve patient pathways. The work was commended by HSJ judges when UCLH was shortlisted for Acute Hospital of the Year.
Lisa Hollins, Deputy Director of Service Transformation for UCLH, says: “In 2009 our patients described delays in discharge as one of their key concerns for NHS services and we have worked hard to improve our systems and processes and build new services with local partners.”
This work has involved redesigning pathways so patients are seen by experienced clinicians as soon as possible and providing specialist COPD and elderly care input in A&E and on admission.
The results at UCLH have been impressive. LoS reduced in elderly care and neurology by 2,307 beds and 1,112 bed days respectively comparing 2009 and 2010. Smaller gains in high volume areas such as maternity have reduced average LoS by 0.2 days, which has reduced bed days by 2,933, a large impact due to the high volume of admissions.
Overall, LoS reductions across all specialities have released 10,360 bed days, enabling the Trust to place a hyper-acute stroke centre on the site. The reductions in LoS have also helped to reduce the impact of winter pressures with fewer delays in pathways and continuing to ensure that over 98% of patients are treated within the 4-hour A&E timescale.
Lisa added: “The work we have done has improved our patient feedback scores and we are delighted that changes to our processes are being felt by patients. At a local level clinical teams have worked together to deliver fantastic improvements and every week we showcase our ‘Ward of the Week’, an initiative that has helped with staff engagement and created a competition for improvement.”
Coupled with this work, both NGH and UCLH have taken steps to tackle indirect activities that also increase stay length. For example, NGH have run a highly successful Lean programme in pathology that has reduced turnaround times by as much as 93% and increased productivity by 20% whilst UCLH has focused on a ‘pre-11am’ peak for discharges that has tripled the number of patients discharged pre-lunchtime and brought the availability of beds much more in line with demand.
Effective team working across multiple organisations is often the key. As Judith Kay, Adult Services Manager at Hounslow & Richmond Community Healthcare (HRCH) says: “Proactive support from community and social care teams is often the conduit to reducing excess bed days.”
Using CQUIN (Commissioning for Quality & Innovation) funding, HRCH provides a 7 day per week in-reach service to their two local Acute Trusts. This involves on-site input into discharge planning activities and active support from community respiratory and stroke teams working in the acute setting to shorten referral times and create community capacity. This service has removed almost all patients with greater than 80 day excess bed days and reduced significantly those with greater than 20 days. It is also increasing community bed utilisation and providing acute care teams with faster access to a variety of ‘out of hospital’ solutions to patient needs.
Such examples of good practice are balanced by that the knowledge that reducing LoS is not all plain sailing. There are instances of community commissioners using a 24/7 in-reach service to work with organisations that only discharged patients Monday-Friday and a healthcare economy that resisted establishing a geriatrician-led community team to speed up discharge for elderly patients because they couldn’t agree on how the service would be funded. Leaving these aside, the examples of best practice in this article do demonstrate that reducing LoS can be achieved through a practical ‘service improvement’ mentality by:
- Treating every step from admission to discharge as key steps in the process of reducing LoS and not just discharge activities themselves;
- Getting to grips with the difficult, controversial and non-value adding activities that increase the workload for staff and delay discharge by redesigning pathways, minimising delays between steps and ensuring greater levels of consistency in the way discharges are managed within and between departments; and
- Increasing multi-disciplinary working and breaking down ‘funding barriers’ that effectively prevent the effective transfer of care.
Obviously, other strategies such as starting the discharge planning process as early as possible and keeping a twin focus on both areas with exceptionally long stays and those with high volume, short duration stays are also required.
Reflecting on the NGH experience, Sue Stanley says: “Without the commitment to working on the difficult issues surrounding Length of Stay and to refining what we did until we got it right we could not have achieved what we have.”