Quality Improvement in Patient Care at Cork University Hospital May 10, 2018 -
J. A. McNamara
The Irish hospital system has, in the first quarter of this year, experienced possibly the most challenging circumstances in recent times, with a combination of flu viruses and adverse weather conditions adding to the increased demands that are a feature of hospitals at this time every year. An indication of the impact of the flu virus on hospitals is that this year there were 4,100 presentations with flu-like symptoms nationally, which is three times more than for the same period in 2017.
The convergence of these circumstances has made the provision of high quality patient care ever more difficult yet there are many examples of hospitals continuing to implement substantial quality improvement programmes and this is the story of one of those initiatives based in Cork University Hospital.
The hospital is continuously seeking to implement improvements to its’ services and in the first quarter of 2018 has implemented improvements in the areas of;
- Emergency Patient Flow
- Day Surgery Services
- Orthopaedic Trauma Services
- Intensive Care Services
Emergency Patient Flow
Remarkably, patterns of activity in Emergency Departments (ED) remain very predictable over time and in the three-month period to March 2018, 17,000 patients presented in the Department compared with 16,000 in 2017 an increase of over 7%. What does differ between both years is that Cork University Hospital is now over 9 months in to the implementation of a quality improvement programme called Project Flow ’17, for emergency care, that resulted in a 50% reduction in trolley numbers by year end since its commencement in mid-2017.
This change programme incorporates multiple new processes to improve patient flow but especially it reflects a commitment by leadership at all levels to improve the experience of patients attending ED. The changes implemented in recent months bring to almost 250, the number of changes that have been implemented to improve patient flow over the past four years. Importantly these changes have contributed to a significantly improved performance in the flow of patients through the ED and in quarter 1 of 2018, there were 270 trolleys less than in the comparable period in 2017 a reduction of over 12% notwithstanding the increase in attendances during that period.
Day Surgery Services
Increasingly hospitals are delivering planned surgical services on a day case basis to improve the experience for patients and to increase efficiency. In early January, a Day Surgery Unit opened in CUH, adjacent to the theatre complex that is an independent, autonomous elective facility that will not be compromised by demands on emergency care. This Unit opened on January 8th in tandem with a commitment from hospital leadership that except in extremis, there will be no cancellation of elective surgical admissions to the Hospital.
Two benchmarks may serve to represent what actually happened in the first quarter of 2018 relative to the same period in 2017 in respect of elective planned activity, (i) the relative level of day case activity and (ii) the relative level of cancellation of planned surgical admissions in both periods.
In respect of the levels of activity in both periods, the evidence demonstrates that there were more surgical day patients admitted to the hospital in the period to March 2018 relative to 2017.
In 2017, the hospital experienced great difficulty in managing to continue to provide elective, planned surgical services because of demands on the Emergency Department and an unacceptable level of elective admissions were cancelled, leading to patient dissatisfaction and to concern about the alignment of emergency and elective care. The opening of the Day Surgery Unit this year has meant that less than 40 surgical admissions have been cancelled (as a direct result of recent adverse weather) and the policy of non-cancellation of admissions is being implemented satisfactorily. This represents a material improvement in the quality of care for patients.
Orthopaedic Trauma Patient Flow
Every year, 2000 patients present to the Emergency Department in CUH requiring Orthopaedic care for fractures and many other conditions. Recognizing the need for improvements to be made in the flow of care for those patients, the hospital has implemented a programme of improvements in the past six months that has included consolidation of all trauma patients on a single floor, streamlining of the pathway for admission of fractured hips and shorter wait time for patients to go to theatre.
The impact of these changes, which represent the first phase of this quality improvement programme are encouraging and are represented in Table 1:
Performance Data for Orthopaedic Trauma Patients November 2017 - March 2018
Key Performance Indicator
% Patients to Ward < 4 hours (age 60+)
% Patients to Theatre < 48 hours (age 60+)
Prevalence of Pressure Ulcer (age 60+)
Patient Seen by Geriatrician (age 60+)
Received Bone Health Assessment (age 60+)
Received Falls Assessment (age 60+)
The combined impact of these changes is a demonstrable improvement in the performance of the Orthopaedic service and most importantly a better quality of service for patients.
Intensive Care Capacity
There is an accepted need for an incremental increase in the number of General Intensive Care beds in CUH from a base of nine beds (there are an additional six Cardiac ICU beds) and this requires the recruitment of 7 nurses for each of those beds.
The hospital has been fortunate to have obtained support from HSE leadership and the National Intensive Care Programme to secure funding for the opening of three additional beds as part of the expansion of this critical infrastructure and following a concentrated recruitment programme the necessary specialist nursing staff have been recruited to support this key development. It is intended that this expansion programme will continue in support of CUH being the only named Trauma Centre, as was set out in the recently published government paper on trauma care.
Future Patient Care Improvement Initiatives
The pursuit of quality care must be continuous and leadership at all levels must demonstrate a capacity to innovate and implement change to improve services at all times. The constant tension between planned and emergency care in a hospital that is functioning at full capacity is a particular challenge but one that we must accept as a reality. In response leadership must look at creative solutions that will deliver sustainable value for the investment that the state is making in our health service.
In this regard, the application of Lean Management principles to achieve at a minimum, a 3% increased level of efficiency has the capacity to release resources worth the equivalent of €10m each year. The establishment of a Lean Innovation Centre in CUH now provides the focus for multiple projects that will in the short and medium term deliver quantifiable improvements in patient care. In the coming months the Innovation Centre will be focusing on identifying opportunities for improvements in the delivery of cancer care, cardio-thoracic surgery pathways and endoscopy services.
We owe it to the public to continue to focus our energies on implementing quality improvement processes and they deserve no less.
Chief Executive Officer