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Understanding Patient Demand:A Better Way to Make Healthcare Systems Work

Hamish Dibley | 17 November 2016

Contents

1. Current Cognitive Conventions2. (A Bit of) Theory and Methodology3. How to Understand Healthcare Systems4. How to Improve Healthcare Systems5. Case Study: ‘Ms. Vulnerable’6. Conclusions and Opportunities

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Perspectives…

Improvement is all about adopting the right perspective.

The way we currently perceive the problems in healthcare systems…

…is the problem.

2

Cognitive Conventions

Conventional Beliefs

1. Ageing and growing elderly populations

2. Rising public expectations on healthcare services

3. Rising public demand for healthcare services

3

Activity & Cost Conventions

ED Performance – Activity Analysis ED Performance – Activity Benchmarking

“Activity Obsession Disorder”

4

Conventional Improvement

5

Logic and Methodology

Thinking Perspectives

6

Understanding Demand

Before managing demand... Let’s understand demand...

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Patient Demand

8

P A C

Intelligent Analysis

Observation & Work Shadowing

QuantitativeResearch

QualitativeResearch

EthnographicResearch

Case Study Analysis

Demand Analysis

Workflow AnalysisProcess Maps

Economic Flow Costing

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Understanding Healthcare

Hospital Patient Demand

Secondary Care User Type 2014/15 2015/16Users 34% 34%

Non-users 66% 66%

Measure 2014/15 2015/16Secondary Care Users 161,951 162,552

Change on previous year +0.4%

Relative Demand for Secondary Care

Absolute Demand for Secondary Care

In discussing the nature of demand for acute healthcare services it is important to differentiate between two types: actual and relative demand. Actual demand signifies the total population of a locality that uses secondary care. Relative demand represents the proportionate percentage of that population that access secondary care.

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Helicopter View

All SettingsPat / Pop Activity Cost162,552 599,573 161M34.2% 100% 100%

All EDPat / Pop Activity Cost

63,181 92,175 12M

13.3% 15.4% 7.5%

All InpatientsPat / Pop Activity Cost

52,366 123,307 114M11.0% 20.6%% 70.2%

All OutpatientsPat / Pop Activity Cost124,114 384,091 36M26.1% 64.1% 22.5%

ED Not Admitted

Pat / Pop Activity Cost49,329 65,195 8M10.4% 11% 4.7%

ED Admitted


Elective Inpatients


Emergency Inpatients


First Outpatients

Pat / Pop Activity Cost92,409 143,486 17M

19.4% 24% 10.7%

Follow Up Outpatients

Pat / Pop Activity Cost85,794 240,605 19M18.0% 40% 11.7% 11

Patient CohortsProfiling people according to their use of secondary care allows the segmentation of patients into distinct and real patient cohorts or typologies. For the purposes of understanding the case-mix of patients using hospital services, the work has grouped patients according to their highest consumption in each of Urgent and Planned Care.

Zero Urgent = total of no A&E attendances or emergency admissions

Low Urgent = total of 1 A&E attendance or emergency admission

High Urgent = total of 2-3 A&E attendances or emergency admissions

Very High Urgent = total of 4+ A&E attendances or emergency admissions

Zero Planned = total of no outpatient attendances or elective admissions

Low Planned = total of 1 outpatient attendance or 1 elective admission

High Planned = total of 2-6 Outpatient attendances or elective admissions

Very High Planned = total of 7+ outpatient attendances or elective admissions

Number Overall Classification 1516

Number of Patients

Average Number of Encounters

Average Bed Days

Cumulative SUS Tariff

Cumulative % SUS Tariff

1 Very High Urgent - Very High Planned 1390 19 15 £13,036,765 8.7%2 Very High Urgent - High Planned 2326 9 13 £27,205,894 18.3%3 High Urgent - Very High Planned 2374 13 4 £37,934,118 25.5%4 Very High Urgent - Low Planned 832 7 10 £41,617,949 27.9%5 Very High Urgent - Zero Planned 1584 5 9 £47,413,398 31.8%6 High Urgent - High Planned 6544 6 3 £62,301,277 41.8%7 High Urgent - Low Planned 3292 3 3 £67,584,078 45.4%8 High Urgent - Zero Planned 9053 2 2 £77,884,041 52.3%9 Low Urgent - Very High Planned 2257 12 1 £84,410,963 56.7%

10 Low Urgent - High Planned 8472 4 0 £92,067,903 61.8%11 Low Urgent - Low Planned 5183 2 0 £94,098,186 63.2%12 Low Urgent - Zero Planned 22522 1 0 £97,952,626 65.7%13 Zero Urgent - Very High Planned 9044 10 0 £116,138,237 77.9%14 Zero Urgent - High Planned 49467 3 0 £143,556,457 96.3%15 Zero Urgent - Low Planned 34860 1 0 £148,408,132 99.6%16 Zero Urgent - Zero Planned 3377 0 0 £148,408,132 99.6%17 Unclassified - Unattributable 0 2239 274 £149,000,034 100.0%18 Non User 313,077 0 0 £149,000,034 100.0%

The top 5 patient cohorts (8,500 patients in red border) account for 32% (£48m) of all costs. These same ‘vital few’ patients equate to 70% of the hospital’s net deficit.

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Venn, Pyramid & The Vital FewFinancial Year Total Patients Elective Patients Emergency Patients Both % Both

2014/15 39,739 24,760 18,895 3,916 9.85%

2015/16 42,018 24,567 21,712 4,261 10.14%

Text10%

Cross-OverElective Admissions

Emergency Admissions

► Top 1% of patients ► This is 1,391 people ► They cost £13.6M per annum or 9.1% of total costs► They use on an average of 14.8 bed days per annum

Top 5%

Top 3%

Top 1%

► Top 3% of patients ►6,091 people ► They cost £31.5 per annum or 21.1% of costs

► Top 5% of patients ► 8,507 people ► They cost £48M per annum or 32.2%

From 16 patient cohorts it’s possible to further refine the analysis and breakdown the classifications. The 3 sub-groups are as illustrated via the ‘pyramid of consumption’ diagram.

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ED Attendances & Admissions

15.6% of the top cohort’s

attendances end ten minutes before the target

For all other patients it’s 8.5%

Patients tend to wait a long time to leave ED – breaches are just a symptom of this 14

Emergency Bed Capacity

1% 3% 5%218

15.3%

21,031

£4.2 million

652

31.2%

42,927

£9 million

1,086

41.8%

57,635

£13 million

% Patients

No of Patients

% Bed Days

No of Bed Days

Costs

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ED Breaches and Patient Flow

Patients in the top cohorts are

twice as likely to breach The top 5 cohorts

account for around 50% of all breaches The top 5 cohorts

account for around 50% of all admissions to assessment units

Increased emergency activity is associated with Assessment Units

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Patient Flow & Financial DeficitsVery few patient groups are ‘profitable’ particularly the ‘vital few’. They are flowing patients they shouldn’t be flowing! Hospitals cannot grow themselves out of

deficit

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Improving Healthcare

Contrasting Approaches

BetterCurrent ApproachAnalyse Activity

PMO

Standardise Pathways

STUDY

PLAN

ACT

Understand Patients

Prototype

Customise Care

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Intelligent ImprovementThe problem is demand amplification of ‘vital few’ patients caused by poor system and service design. Improvement means redesigning services and systems to work for patient cohorts according to geographies, service functions, specialities and/or conditions in order to ‘learn to improve and improve to learn’.

Clarity of Purpose• What matters?• What needs to be

solved?• What needs to be

better managed?

Performance Metrics• End-to-end time• First-time resolution• Representing

demand• PAC profiling

Paper Prototype• Develop design• Develop

processes• Anticipate

economies• Roles & resources

Working Protoype• Initiate with small

cohorts• Control groups• Extend scope• Extend volume

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Changing the Process: A&E

Triage Dr Review Tests Dr Review Treatment DischargeClerk

NurseAssessment

Ambulance

ConsultantTriage nurse job is to decide how long you should wait How long is the waiting between each phase

of the process? Rework with the consultant?

Current system is designed to make you wait! Two routes in – walk-in or arrive by ambulance Patients receive two different types of process Potential for inexperienced staff to order unnecessary tests

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Changing the Process: A&E

Walk-inDr Review Treatment DischargeAssessment

Team

NurseAssessment

Ambulance

Consultant

CDU

AMU

AAA

Target

4-Hour

The future utility? ED system designed for predictable patient demand Same route in – walk-in or arrive by ambulance Specialists with juniors placed at the front-end of the process Treat the 4-hr target as a constraint, don’t drive performance by it!

‘Assessment Units’

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Case Study: Ms. Vulnerable

Old System Response

• Personality disorder, emotionally unstable• Complex physical health needs… cellulitis

and UTIs are just two of them• In receipt of social security benefits• Immobile and house-bound• Principal career mum died in 2011 – ‘trigger’• Neighbours jeer when ambulance is called

– repeat medical prescription debacle…• Patient cannot care for herself

• Social care support doesn’t meet needs• Most expensive ambulance user• Regular ED attender and admitter – 30

visits (Jan-Sept 2016) for self-harm; falls; collapses; shortness of breath

• GP and community nurse not commissioned to customise care

• Person didn’t meet eligibility criteria for further care and support

44 year old female leaving in a ground floor social housing flat Morbidly obese – 45 stone or 286 kilograms Socially isolated with a sister who is not supportive A ‘top 20’ high consumer of healthcare services over many years

Issues Activity

Annual System Cost for this Person?

£224,000

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New System Response

• Professional meeting with the person, worked with the person not did to…

• Patient asked ‘what matters’: she ‘wanted a normal life’ but ‘did not want to live on her own’ – the goal/aim/purpose!

• Busted the myth she was going to die within the next year or two

• Person holistically understood Professionals sought a perfect package of care around the person – do the right thing

• Care customised and patient-centred plan enacted – new processes, roles, budgets not limited by service and financial barriers

• Care team built around the person’s needs • Senior person responsible for the care support

and care comes to the patient• Plan is working – no further ED attendances

and care can be ‘flexed’ according to changing needs

• Plan to work on the causes of obesity

44 year old female leaving in a ground floor social housing flat Morbidly obese – 45 stone or 286 kilograms Socially isolated with a sister who is not supportive A ‘top 20’ high consumer of healthcare services over many years

Activity Outputs

Annual System Cost for this Person now?

£57,200

That’s a 75% cost reduction

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‘Ms. Vulnerable’: Cheaper to do the right thing

Think Person Not Pathways

Think Needs

Think Systematically

Not Eligibility Criteria

Not Service Silos

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Conclusions and Opportunities

Healthcare Performance

Issues

Conclusions

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Patient-centred analysis shows relatively consistent and stable demand for acute care services

Patient demand is concentrated within ‘vital few’ numbers of the local population who consume disproportionate levels of activity and cost - ‘demand amplification’ is the greater problem not rising demand

Attempts at improvement do not work as they rest on simplistic reductionist thinking: too reactive and based on activity and cost assumptions

Transformation starts with studying the ‘who, why, how, what, where, when’ of patient demand and intelligent system and service redesign around patients, not pathways

Focus improvement on small patient numbers to see big system benefits

The Vital Few

Contact Details

[email protected]

O778 6980 863

https://uk.linkedin.com/in/hamishdibley

https://twitter.com/hamishdibley

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