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Two Valuable Lessons for Redesigning Geriatric Care

By Tom Downes | Tuesday, March 8, 2016

Redesigning Elder Care

What is the most effective way to avoid falling in the hospital? I’m not being facetious when I say the best way is to not be in the hospital in the first place.

Of course, avoiding a stay in the hospital isn’t an option for many geriatric patients. That’s where the work of redesigning care comes in — and where these two lessons our team has learned can be helpful.

First, though, a bit of context: The Health Foundation’s recent report, Continuous Improvement of Patient Safety: The Case for Change in the NHS, includes a case study of the Sheffield Teaching Hospitals’ work to improve the flow of older patients’ care. As a result of our improved care design, we have observed a reduction of inpatient falls on the pilot ward. Also, last year in Sheffield, more than 8,000 older patients who had completed acute hospital treatment were able to transfer to care in their own home in an average of 1.1 days compared with 5.5 days just three years ago. In other words, the patient experience was better, more efficient, and safer.

To redesign our complex geriatric care system at Sheffield, we needed to address the human dimensions of the system. We have learned much on our five-year journey, which has been a rollercoaster of discovery and emotion. In reflecting on our work, two lessons stand out:

Lesson 1: Fill Your “Big Room” with the Right People

When we set our aim to reduce hospitalization of older patients, the complexity and technology of modern health care initially overwhelmed us. But the recent National Patient Safety Foundation report, Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human, calls for an ”overarching shift from reactive, piecemeal interventions to a total systems approach to safety.”

To meet that challenge, we chose a method developed in the highly complex motor industry, an industry in which systems thinking is now the norm. Specifically, we looked to Toyota.

In 2001, Toyota developed the Obeya (Japanese for “large room”) methodology to prototype, design, and launch the hugely successful 2003 Corolla. We translated their process – without Japanese words or talk about cars – of sharing information, bringing together key staff, and meeting regularly to iteratively design our processes to improve patient flow.

We referred to these meetings as our “Big Room.” And while on the face of it, the Big Room may look like a technical meeting, the drivers of our success have been human – starting each meeting with a patient story, flattening the hierarchy, and learning together. We believe these human elements have allowed us to achieve transformative rather than transactional improvement.

Lesson 2: Plan-Do-Study-Act not “Do, Do, Do”

Julie Reed and Alan Card’s recent article, “The problem with Plan-Do-Study-Act cycles,” helped me understand why we are achieving success. They assert that PDSA cycle implementation in health care is limited by “failure to invest in rigorous and tailored application.”

In our patient flow work at Sheffield, we have been disciplined. Using PDSA cycles, starting with a one-patient test, our health and social care staff (including nurses, physical or occupational therapists, and other specialists, when appropriate) have flipped the traditional process of “assessing to discharge” into the novel “discharge to assess.” The discharge to assess process allows us to identify the support needs of frail older patients as they return home so we can meet those needs in real-time.

We took the time to learn from one cycle and apply it to the next one — rather than charging ahead without discipline.


Professor Tom Downes (follow him on Twitter @sheffielddoc) is Consultant Geriatrician and Clinical Lead for Quality Improvement, Sheffield Teaching Hospitals. He was also an IHI/Health Foundation Quality Improvement Fellow. Tom’s perspective on improvement: "It was 21 years after entering medical school that I was first introduced to the concepts of quality improvement. With every year that passes, I increasingly learn to appreciate its importance."

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