Title: How can frontline expertise and new models of care best contribute to safely reducing avoidable acute admissions?
Funder: Department of Health (England)

Abstract: The design comprises a case-study design of four acute admission sites using primarily qualitative and additional quantitative methods in two periods of data collection with a mid project stakeholders conference and learning sets between these phases. The study incorporates: - Ethnographic qualitative methods (observation interview and documentation analysis)- Up to 6 mini case studies of patient journeys in each of the four case sites - Quantitative analysis of key processes of care using an adapted Value Stream Mapping (VSM) approach.- An embedded study of cost.- A parallel learning set to encourage exchange of ideas and learning across sitesThe mixed methods design incorporates a sequential process. Qualitative research will map out the issues. Then quantitative methods will assess the extent to which key processes occur and how costs compare. In addition data will be summarised into predictor outcome matrices to identify key mechanisms for reducing avoidable admissions. Table one (in detailed project description) relates data type to research question. The research is underpinned by two complementary theory driven frameworks. Realistic Evaluation (Pawson and Tilley 1997; Anderson 2008) will be used to determine key processes of change within a system how these relate to outcomes resource use cost and context. ‘Theories of Change’ (Weiss et al 1996) will be used to develop theories about how interventions achieve their aims Our approach uses ethnographic methods within a subtle realist framework (Hammersley 2002). Following piloting data collection will take place as follows:1. System-level cases Setting and sample: The organisational case study design comprises a comparative analysis of four South West acute admission sites three with innovative ways of providing experienced clinician input early in the pathway and one traditional model. Systematic comparison of sites is shown in Table 2Data collection: To describe decision making roles and input and to identify ways in which organisational pathways spaces and resources affect decision making:1) Formal Interviews (6-8 per organisation) with key informants (RQ 13 & 4); Interviews will explore experience of acute care settings and decision making processes. 2) Participant observation of organisational processes team make up and function (RQ134). 3) Documentary analysis of financial and business planning governance and implementation of process change (RQ134)4) Data on costs and admissions; staffing costs (RQ3).Phase two data collection will follow a similar pattern but focus on testing the provisional theories developed in phase one.2. Mini case studies - the patient journeySetting and sample: Detailed study of 6-10 patient journeys per site will permit comparison of decision making patient level clinical and patient pathway variation. Individual patient cases will be selected from ED and AA settings on the basis of being potentially avoidable (Table 3).Data collection in phase one:1) Participant observation of acute admissions location (RQ1 RQ2).2) Individual interviews with up to10 patients practitioners and family members at key points (RQ1 RQ3). 3) Analysis of medical and nursing records.4) Quality of admissions decisions will be analysed using peer-review and consensus by external/internal clinicians modeled on the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) methodology.3. Measuring key processes of care: Value stream mapping To quantify differences in acute admissions processes between the four participating NHS trusts and estimate the extent these occur across the NHS we will map patient pathways for predetermined core common tracer symptoms studied in 2 above using value stream mapping - structured diagrams documenting the steps and activities in the care process a lean management method for improving patient flow and pathway efficiency across departmental boundaries (Graban 2009 Ng et al 2009). For each site a minimum of 30 patients’ movements will be mapped recording timing place type length and seniority of professional contacts. 4. An embedded health economic study Comparison of resource use and cost implications between the four sites for the core conditions and pathways will be defined mainly through the Value Stream Maps of the sampled patient journeys using data on staffing costs and resource allocation to patients with potentially avoidable admissions and the feasibility of estimating the opportunity cost of these resources. Resource implications of the hypothesised key mechanisms driving the outcomes of the different models of care will be explored and a generic modelling framework developed (RQ4).5. A parallel learning set to encourage exchange of ideas across sites and learning from clinicians and managers will be set up at each site. Interaction and systems changes will be encouraged between sessions. The learning sets will be based on action learning methodology to promote self-awareness critical enquiry ideas generation active reflection and solution finding.


Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE