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Understanding Patient Demand:
A Better Way to Make Healthcare Systems Work
Hamish Dibley | 17 November 2016
Contents
1. Current Cognitive Conventions
2. (A Bit of) Theory and Methodology
3. How to Understand Healthcare Systems
4. ...
Perspectives…
Improvement is all about adopting
the right perspective.
The way we currently perceive the
problems in healt...
Cognitive Conventions
Conventional Beliefs
1. Ageing and growing
elderly populations
1. Rising public expectations
on healthcare services
1. Ris...
Activity & Cost Conventions
ED Performance – Activity Analysis ED Performance – Activity Benchmarking
“Activity Obsession ...
Conventional Improvement
5
Logic and Methodology
Thinking Perspectives
6
Understanding Demand
Before managing demand... Let’s understand demand...
7
Patient Demand
8
Intelligent Analysis
Observation & Work Shadowing
Quantitative
Research
Qualitative
Research
Ethnographic
Research
Case St...
Understanding Healthcare
Hospital Patient Demand
Secondary Care User Type 2014/15 2015/16
Users 34% 34%
Non-users 66% 66%
Measure 2014/15 2015/16
S...
Helicopter View
All Settings
Pat / Pop Activity Cost
162,552 599,573 161M
34.2% 100% 100%
All ED
Pat / Pop Activity Cost
6...
Patient Cohorts
Profiling people according to their use of secondary care allows the segmentation of
patients into distinc...
Venn, Pyramid & The Vital Few
Financial Year Total Patients Elective Patients Emergency Patients Both % Both
2014/15 39,73...
ED Attendances & Admissions
15.6% of the top cohort’s
attendances end ten
minutes before the target
For all other patients...
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
%...
ED Breaches and Patient Flow
Patients in the
top cohorts are
twice as likely to
breachThe top 5
cohorts account
for around...
Patient Flow & Financial Deficits
Very few patient groups are
‘profitable’ particularly the
‘vital few’. They are flowing
...
Improving Healthcare
Contrasting Approaches
BetterCurrent Approach
Analyse
Activity
PMO
Standardise
Pathways
STUDY
PLAN
ACT
Understand
Patients...
Intelligent Improvement
The problem is demand amplification of ‘vital few’ patients caused by poor system
and service desi...
Changing the Process: A&E
Triage Dr Review Tests Dr Review Treatment DischargeClerk
Nurse
Assessment
Ambulance
Consultant
...
Changing the Process: A&E
Walk-in
Dr Review Treatment Discharge
Assessment
Team
Nurse
Assessment
Ambulance
Consultant
CDU
...
Case Study: Ms. Vulnerable
Old System Response
• Personality disorder, emotionally unstable
• Complex physical health needs… cellulitis
and UTIs are ...
New System Response
• Professional meeting with the person,
worked with the person not did to…
• Patient asked ‘what matte...
‘Ms. Vulnerable’: Cheaper to do the right thing
 Think Person Not Pathways




Think Needs
Think Systematically
Not ...
Conclusions and Opportunities
Healthcare
Performance
Issues
Conclusions
25
 Patient-centred analysis shows relatively consistent and stable demand for ...
Contact Details
hamish@hamishdibley.com
O778 6980 863
https://uk.linkedin.com/in/hamishdibley
https://twitter.com/hamishdi...
Health UX - Hamish Dibley - Understanding Patient Demand: a better way to make healthcare systems work
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Health UX - Hamish Dibley - Understanding Patient Demand: a better way to make healthcare systems work

A new and refreshing approach to understanding and improving healthcare systems. Hamish outlines his alternative approach to realising better healthcare services at less cost. It begins with looking at healthcare not from a conventional activity perspective but from a person-centred one.

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Health UX - Hamish Dibley - Understanding Patient Demand: a better way to make healthcare systems work

  1. 1. Understanding Patient Demand: A Better Way to Make Healthcare Systems Work Hamish Dibley | 17 November 2016
  2. 2. Contents 1. Current Cognitive Conventions 2. (A Bit of) Theory and Methodology 3. How to Understand Healthcare Systems 4. How to Improve Healthcare Systems 5. Case Study: ‘Ms. Vulnerable’ 6. Conclusions and Opportunities 1
  3. 3. Perspectives… Improvement is all about adopting the right perspective. The way we currently perceive the problems in healthcare systems… …is the problem. 2
  4. 4. Cognitive Conventions
  5. 5. Conventional Beliefs 1. Ageing and growing elderly populations 1. Rising public expectations on healthcare services 1. Rising public demand for healthcare services 3
  6. 6. Activity & Cost Conventions ED Performance – Activity Analysis ED Performance – Activity Benchmarking “Activity Obsession Disorder” 4
  7. 7. Conventional Improvement 5
  8. 8. Logic and Methodology
  9. 9. Thinking Perspectives 6
  10. 10. Understanding Demand Before managing demand... Let’s understand demand... 7
  11. 11. Patient Demand 8
  12. 12. Intelligent Analysis Observation & Work Shadowing Quantitative Research Qualitative Research Ethnographic Research Case Study Analysis Demand Analysis Workflow Analysis Process Maps Economic Flow Costing 9
  13. 13. Understanding Healthcare
  14. 14. Hospital Patient Demand Secondary Care User Type 2014/15 2015/16 Users 34% 34% Non-users 66% 66% Measure 2014/15 2015/16 Secondary 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. 10
  15. 15. Helicopter View All Settings Pat / Pop Activity Cost 162,552 599,573 161M 34.2% 100% 100% All ED Pat / Pop Activity Cost 63,181 92,175 12M 13.3% 15.4% 7.5% All Inpatients Pat / Pop Activity Cost 52,366 123,307 114M 11.0% 20.6%% 70.2% All Outpatients Pat / Pop Activity Cost 124,114 384,091 36M 26.1% 64.1% 22.5% ED Not Admitted Pat / Pop Activity Cost 49,329 65,195 8M 10.4% 11% 4.7% ED Admitted Pat / Pop Activity Cost 19,641 26,980 5M 4.1% 5% 2.9% Elective Inpatients Pat / Pop Activity Cost 24,567 38,805 41M 5.2% 6% 25.5% Emergency Inpatients Pat / Pop Activity Cost 21,712 31,116 59M 4.6% 5% 36.2% First Outpatients Pat / Pop Activity Cost 92,409 143,486 17M 19.4% 24% 10.7% Follow Up Outpatients Pat / Pop Activity Cost 85,794 240,605 19M 18.0% 40% 11.7% 11
  16. 16. Patient Cohorts Profiling 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. 12
  17. 17. Venn, Pyramid & The Vital Few Financial 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% Text 10% Cross-Over Elective 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. 13
  18. 18. 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
  19. 19. 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 15
  20. 20. ED Breaches and Patient Flow Patients in the top cohorts are twice as likely to breachThe 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 16
  21. 21. Patient Flow & Financial Deficits Very 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 17
  22. 22. Improving Healthcare
  23. 23. Contrasting Approaches BetterCurrent Approach Analyse Activity PMO Standardise Pathways STUDY PLAN ACT Understand Patients Prototype Customise Care 18
  24. 24. Intelligent Improvement The 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 19
  25. 25. Changing the Process: A&E Triage Dr Review Tests Dr Review Treatment DischargeClerk Nurse Assessment Ambulance Consultant Triage 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 20
  26. 26. Changing the Process: A&E Walk-in Dr Review Treatment Discharge Assessment Team Nurse Assessment Ambulance Consultant CDU AMU AAA T a r g e t 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’ 21
  27. 27. Case Study: Ms. Vulnerable
  28. 28. 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 22
  29. 29. 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 23
  30. 30. ‘Ms. Vulnerable’: Cheaper to do the right thing  Think Person Not Pathways     Think Needs Think Systematically Not Eligibility Criteria Not Service Silos 24
  31. 31. Conclusions and Opportunities
  32. 32. Healthcare Performance Issues Conclusions 25  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
  33. 33. Contact Details hamish@hamishdibley.com O778 6980 863 https://uk.linkedin.com/in/hamishdibley https://twitter.com/hamishdibley 26

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