Real time flow in A&E – there’s an app for that!

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We know that Sir Bruce Keogh is very keen on ‘wearable apps’ – little apps you can download onto your smartphone to improve your health. NHS England seem enthusiastic about getting senior staff in the NHS to dream up apps to improve patient care. Part of this, presumably, is wishing to make the NHS profitable like Apple; but part of it is genuinely driven by a wish for technology at low or no cost to improve vastly someone’s quality of life.

Apple in their recent launch proudly showed off a new app which could act as a mini research lab, taking samples of your speed of finger tapping for example. It boasted that you could contribute to a giant ‘research lab’, and the multinational corporation showcased people from prestigious American hospitals with impressive titles.

The philosophy behind ‘targets’ in the NHS, latterly being rebranded as ‘ambitions’ in the innocent hope of diffusing their toxicity, was to ensure a minimum level of performance. It is a quick fix way for a politician or hospital manager to say that something is being done. Of course, to total embarrassment of everyone is when targets are regularly missed.

In terms of ‘performance management’, it is hard to see how repeated missing of a target can be good for staff morale. One would think it at first is bad for morale, but, then as repeated missing of the target becomes the new baseline, it can theoretically implant a culture of ‘it cannot get any worse’. This is of course is bad for the organisational culture of any institute, let alone which is supposed to be driven by patient safety. It is this culture, together with a sense of ‘too something to fail’, which presumably kept Mid Staffs and Morecambe Bay in their bad times.

You would not typically dream of rating your experience of a meal in a restaurant by how fast it took you to get your food, unless it was a very protracted way, rather than the quality of the actual meal. You should not wish your food to be rushed to your plate if half of it was blatantly undercooked, and not fit for consumption. You should not be particularly inspired if the restaurant were clearly understaffed, relative to the demand of customers, such that it took you a long time to get a waiter’s attention.

Managers refer to this as the ‘visibility’ of ‘operational management’. A restaurant is a good example, compared to a NHS A&E department, not because of the similarity of the service it provides; but because it is a high visibility service. In other words, it is pretty clear to the ‘end user’ when the organisation of the operation is more chaotic than competent.

In judging how long it takes for an Ambulance crew to arrive at a medical scene, there are clearly unsafe time windows, particularly for acute medical emergencies such as chest pain or anaphylactic shock. But there is a danger if something is then misdiagnosed, sending a patient on completely the wrong care pathway.

What happens at 3 hrs 45 mins of the ‘four hour wait’ target is similarly interesting. A four-hour target in emergency departments was introduced by the Department of Health for National Health Service acute hospitals in England. Setting a target that, by 2004, at least 98% of patients attending an A&E department must be seen, treated, admitted or discharged in under four hours. The target was revised by the Department of Health to 95% in June 2010.

If an A&E team have a few missing results from investigations they’ve ordered in assessing a patient, say a blood test has not even been ordered or the result has not come back from the lab, a clinician (or even potentially a non-clinical flow manager) might take a decision to admit the patient to hospital, or to discharge, to avoid breaking the four hour wait. This decision can therefore be primarily managerial.

A disparity of information between patient and doctor, “information asymmetry”, can mean that it will be clear to the doctor when this 3 hr 45 mins time has been reached (but not clear to the patient). Anyone who has ever been a a patient in A&E, or even worked there, will testify what a stressful working environment it is, taking on a timeless feeling to it.

But a smartapp on your smartphone would be able to tell you this information as you ‘count down’ your experience in A&E. You see, more helpful to you as a patient, and ultimately the NHS, is whether your experience in A&E has been a good one from the perspectives of patient safety and patient experience.

A simple checklist on a questionnaire would be triggered at four hours so that you could ‘rate’ which staff you had seen, whether you had been seen by a senior clinician, whether your investigations had been ordered, whether your test results had arrived, at the four hour mark. If so many people are repeatedly missing the four hour target, there would be plenty of respondents to the survey. You could of course be asked to suggest what you think your working diagnosis might be.

This information could then be downloaded by your GP, the hospital and NHS England, so that they get a feel for your experience in A&E in a way that would be beneficial for rating patient safety and patient experience. Such raw data would be likely to be much more helpful than filling a questionnaire for the ‘Friends and Family Test’ weeks after an event. Such information could be available in real time such that hospitals could be aware if their services in reality were understaffed compared to demand.

The smartphone app might cost the NHS a minimum amount, if it could be downloaded by the NHS patient for 99p. You would not need the NHS to pay vast amounts of money to the types of IT companies you see at Olympia every year at these NHS ‘Expos’.

Such an innovation is clearly disruptive. Disruptive innovation, a term introduced by Prof Clayton Christensen at Harvard, describes “a process by which a product or service takes root initially in simple applications at the bottom of a market and then relentlessly moves up market, eventually displacing established competitors.”