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John Thornbury
Director of IT
Worcestershire Acute Hospitals NHS Trust, Worcester, UK
This is a story about how our Trust addressed the issue of bed management within our acute and general wards and how we helped to specify and develop new technology to help us manage our beds and patient admissions and discharges even better.
Worcestershire Acute Hospitals is a busy NHS trust right in the middle of England. We provide hospital-based services from three sites in the county. We provide a wide range of services to a population of over half a million people from Worcestershire and surrounding areas.
We have over 850 general and acute beds and we care for an impressive number of patients: more than 500,000 outpatient appointments were completed and over 95,000 planned and emergency operations were carried out last year. And although our bed utilisation record was better than the national average for the NHS, we were determined to do even better.
Beds are of critical importance to every hospital. It is a simple way of comparing the size of the operation. Combined with time, it becomes a unit costing measurement and, without available beds, patients will not be admitted from A&E – and operations can be postponed. Ineffective management of beds can lengthen patient stays and unnecessarily reduce the overall capacity of the hospital with an adverse effect on patients, those who care for them and the finances of the trust. But despite their traditional importance, we have fewer beds than we used to in England.
Doing more with less
An NHS Confederation study in 2006 found that patients were receiving better treatment despite hospital bed numbers falling by more than a third over the previous 20 years. Between 1984 and 2004 the number of beds in England fell by 31%, while the number of treated inpatients increased by 57%.
Home treatment and better management of chronic conditions such as diabetes have both resulted in fewer people being admitted to hospital for long periods of time. And that trend continues. Earlier this year, the Department of Health (DoH) announced that the NHS was to provide more care at home, including home dialysis for up to 7,000 patients and guidance on chemotherapy in the community.
Add to this the concern over hospital-acquired infections, which encourage earlier discharge, coupled with big increases in day surgery and you might imagine that beds and bed-day savings were becoming less important and strategic.
On the contrary, beds remain a critical enabling asset and their availability ensures implementation of trust policy, faster response to patients and revenue for the trust. With a reduced estate, we just have to get better at managing them. This, in effect, was the conclusion drawn by the National Beds Inquiry chaired by the Chief Economic Adviser to the DoH, Clive Smee, in 2000.
Worcester ready for the challenge
So how do you set about improving the management and utilisation of a scarce resource in the best interests of patients and those who care for them? And what is the appropriate role for changes in people, processes and technology?
The first task is to collect the appropriate data. These metrics not only helped us to decide what changes we needed to make, but using them consistently helps us now to monitor patient inflow, outflow and flow within the system. This information enabled us to identify current and potential bottlenecks in the system and helped us to shape required improvements.
We then examined elective and emergency arrival and admission profiles by day and time and identified patterns. We still monitor unexpected variances from this pattern every day.
Processes
Traditionally, it has been assumed that it is emergency admissions that could skew the bed capacity profile and have an adverse effect on planned admissions – stealing the allocated bed, as it were. But numerous studies have now demonstrated that the real variation and unpredictability comes from elective admissions and, to an even greater extent, the number and timing of discharges.
Taking on board the advice from the NHS Modernisation Agency and their publication called 10 high impact changes for service improvement and delivery, our efforts to smooth out variation in our processes concentrated on the discharge and not the admission process. Admissions represent demand for the resource, and discharges – simple ones at least – create the supply. Balancing these two is the definition of the challenge we bed-
owners share.
People
Getting better at bed management requires, most of all, timely communications and co-ordination between the professionals in clinical departments, nursing, patient placement, environmental services and patient transport. This is a real team game. But however well-integrated the team, accurate, up-to-date information about the bed status now and planned admissions and transfers is vital. This is what led us to start work on the definition of a technological solution that would add real value to the process and staff changes we were putting in place.
Technology
Worcestershire Acute Hospitals and our technology partner Oasis Medical Solutions put our joint skill and imagination together to develop a real-time bed management system – Oasis WhiteBoard. Now it has been successfully trialled and is currently being deployed across all wards. What it does, in a nutshell, is to enable our ward staff to make changes to the bed profile in real time, even at night and over the weekend, with no additional workload.
A whiteboard for the 21st century
All hospital staff are familiar with the traditional whiteboard as an efficient and popular way of managing beds and placing patients. The Oasis WhiteBoard (a large, heavy-duty touch-screen computer) gives the flexibility of a traditional board but with all the benefits of connection to the central patient database, which is updated automatically when the patient name and location is selected by fingertip on the touch-screen and moved to a new location in a drag-and-drop movement. No keyboard entries are required and the patient database is updated.
It displays bed and patient-pending status to the whole team accurately and automatically in real time.
It was designed and developed to be independent of any single patient administration system (PAS) and offers bidirectional messaging. This independence and flexibility enables hospitals within the same trust but with different core IT systems to use the system in combination – giving flexibility across the whole trust. And it makes it possible for trusts, within a single health economy, to share information on bed availability and to process transactions.
In addition, the screen and the constantly updated information behind it can also:
- Monitor the bed-cleaning process
- Communicate real-time information on patient discharges and transfers
- Alert doctors and nurses when tests are to be carried out or when results are ready.
The information feeding the real-time Whiteboard can only be captured at ward level. The system is designed to reduce and not increase the workload of staff at the front line, thus encouraging take-up and consistent real-time use of its features.
Capacity dashboard
Optionally, our system has the additional capability of providing a hospital-wide dashboard to enable clinicians and managers to access and view critical information about:
- Admissions
- Discharges
- Outliers
- Compliance with single-sex wards policy
- Escalation processes.
How does it work technically?
Using current Java technologies, the interactive whiteboard is easy to deploy, with the only requirement being a compatible web browser on the end user’s machine/citrix server.
The interactive whiteboard is based on a Java SOA web services architecture that has been designed from the outset to allow the whiteboard to be deployed with alternative PAS systems. The interactive whiteboard is implemented using cost-effective and proven open-source apache web-server software. The system has minimal server requirements.
It has been built from the bottom up to allow us to address everything that was required. It is important that the whiteboard is easier and less time-consuming for our staff, otherwise they would be no point developing it.
Benefits
What are the benefits we have obtained through our focus on processes and people and our joint work with Oasis on creating a technological framework?
We have listed the advantages as:
- We are managing better a key asset – the overall capacity of the hospital and bed availability at ward and department level
- We have streamlined the whole process of bed management
- A complete administrative process has been removed
- The current system is less time-consuming for busy staff and reduces opportunity for costly mistakes
- Accuracy of real-time bed state is assured – even overnight and at weekends
- Fewer empty beds
- It is highly configurable and was developed with the input of clinicians at every level
- It is an incremental application that required no changes to underlying systems.
But the real winners from this focus on bed management are the patients, whose experience of their hospital stay will have been improved.
