Pioneering work in Hungary

Posted on: January 28th, 2019 by matthew_bacon

The Conclude Consultancy Limited has recently completed the first phase of a clinical reorganisation project for the 1st Department of Medicine at the Szeged University Hospital in southern Hungary.  This appointment is the first time that a UK health planning consultancy has been appointed to work in Hungary within its health system. TCC was appointed because of their unique methods for the analysis of health systems and health planning known as ‘Occupancy Analytics’ (TM). The appointment was awarded to TCC after extensive research by the the Hungarian Ministry of Health to identify internationally recognised health planning consultants who offered true innovation, rather than traditional methods of analysis, based on ‘this is the way we have always done it’ approaches. They required new ways of thinking and methods proven to deliver significant benefits.

Szeged University Hospital

The hospital is recognised as the leading institution of its kind in Hungary and has a very strong international reputation. It is currently collaborating in research with a number of UK universities such as University of Liverpool and Newcastle.  Dr Bacon, founding director of TCC leads the specialised team who are working directly with the Executive leadership team and the 1st Department of Medicine.

Why the need for the reorganisation?

Hungary has some of the worst health indicators in Europe, yet it has some of the brightest minds working in the health system. Reports from The World Health Organisation and the European Commission have both identified significant latent capacity in the health system. Simply put, the need for the reorganisation is to achieve a much needed re-alignment between clinical needs of Hungary’s citizens and the effective and efficient delivery of clinical services. The 1st Department of Medicine was selected to be the candidate department for the reorganisation, and is the sponsor of the work.

A challenge for Europe not only Hungary

Hungarian healthcare needs are, to an extent, no different to the needs of other more developed health systems elsewhere in the European Union. For example, within the next 20 years around 35% of European populations will be over the age of 75. By this age well over half of this age group will have two or more morbidities.  These pressing demands are causing significant strains in all acute care hospitals across Europe. TCC believes that in recent years these strains have become a significant concern to many health leaders because acute care facilities are ill-equipped to care for the rising numbers of patients presenting complex needs. Most notable in this respect is a primary focus on delivering healthcare through specialities, but with patients presenting comorbidity, the need is for ‘generalist specialists’ or multi-speciality services that consider the holistic needs of the patient.

TCC: Integrated Clinical Pathways

Harnessing multi-speciality skills requires carefully designed processes (Integrated Clinical Pathways) and specific skills such as co-ordination of specialist inputs and effective clinical information management along the patient care pathway. It also requires structured care plans that are designed for the specific needs of the patient, and provide the reference point for the management of the Integrated Clinical Pathway. It is in this work that the 1st Department of Internal Medicine led by TCC has been developing the major operational policies that will provide the foundation for the reorganisation and the development of the Integrated Clinical Pathways.

Ensuring that the patient receives the right care in the right place, first time is a key objective of the reorganisation and thus aligning the care system to serve the specific needs of the patient, is the primary objective. The development of an Acute Medical Assessment Unit will be one part of the clinical reorganisation. Within this multi-speciality environment the Integrated Clinical Pathways will be planned for specific patient types. Experimental pathway models using the sophisticated ‘Occupancy Analytics‘ (TM) simulations are to be developed, so that patient flows can be evaluated. It will be from this analysis that the resource needs for each pathway will be established.

Operational trial: learning from experience

A common observation of implementations of Integrated Clinical Pathways in Western Europe has been a lack of empirical evidence to substantiate the effectiveness of them. The reasons for this can only be speculated. Yet without measurement against key success criteria the benefits to both patients and staff cannot be appreciated, and the drivers for change lose impetus. To evidence the benefits of the Integrated Clinical Pathways, and to understand the operational challenges that they present to the hospital, TCC will be leading an Operational Trial for the experimental pathways using their sophisticated simulation capability to support the work. By this means it is hoped to achieve the required state of readiness for the proposed Acute Medical Assessment Unit, along with the policies and practices on which the trial will be based. Patient outcomes measures, clinical effectiveness and operational efficiency measures are all to be evaluated in the trial.

BMJ: Leaders in Healthcare 2018

Posted on: October 26th, 2018 by matthew_bacon

The British Medical Journal, and the Faculty of Leadership and Management have invited Dr Matthew Bacon, to lead a workshop at this event.  Dr Bacon will be inviting delegates to consider the impact of an ageing population on how clinical services are provided to this cohort.  With the next 10 years well over 30% of the UK population will be over the age of 75 and associated with this will be a corresponding rise in multi-morbidity.  This raises the need to challenge conventional practice built around clinical specialities, and suggests also the need for holistic diagnostics in the treatment of patient health.   Delegates will explore what this could mean for clinical service redesign.

In the workshop, Dr Bacon supported by his colleague Professor Oren Lieberman, will introduce the notion of ‘Situated Health Ecology’. This is a method of considering the context in which patients receive their care.  It helps us to understand how and why patients respond differently to health care services. We already understand the need for the special consideration of vulnerable patient groups in paediatric and adolescent care for example, but there is limited special-case provision in geriatric care.  Yet it is clear from contemporary research that the self-perceived physical and mental wellbeing of this patient cohort is critical to successful health outcomes, reduced demand both for hospital readmission and further follow-up demand on Primary Care services.

https://www.leadersinhealthcare.com/news/matt-hancock-secretary-state-health-and-social-care-confirmed-speak

UK Guardian article commenting on our work

Posted on: May 25th, 2018 by matthew_bacon

The Guardian has published an article about our work here:

https://www.theguardian.com/sustainable-business/best-practice-exchange/the-conclude-consultancy-science-energy

Since 2017 The Conclude Consultancy has been a strategic partner of Schneider Electric. The reason?  Because uniquely we discovered a way to create new business intelligence from clinical information system metadata and to model it with physical space and other resources used in hospital planning and engineering. In doing so we have been able to create new knowledge to inform building engineering science, in the pursuit of high performance buildings.

It is a win-win. Hospital managers learn how to improve space efficiency through improved patient flow, and in doing so the demand for new space is reduced. This leads to both lower capital and operational costs. Reduced energy consumption and lower carbon emissions  are further significant added value benefits.

Please use our contact page to find out more.

Case Study: Optimisation Day Surgery Services

Posted on: November 6th, 2017 by matthew_bacon

Earlier this summer The Conclude Consultancy (TCC) completed an analysis of Day Surgery facilities in the northern region of Gothenburg, Sweden. This is now published as a Case Study. This project was typical of many that we work on, where the client wished to understand how clinical service delivery could be optimised to improve both the patient experience as well as improving the efficiency of patient flow through the surgery facilities.

In an ideal world day surgery should be a predictable and systematic process, but it must also recognise that patients come to day surgery with significantly varying needs – both from clinical wellbeing as well as emotional wellbeing perspectives. Whilst this means that the process must accommodate many variables it does not follow that it cannot be effectively managed.

On this project, TCC used their unique patient pathway method, which is one that recognises that different patients can be categorised as ‘patient types’, and as such their specific resource needs can be identified and planned for. An elderly patient with specific emotional wellbeing needs for example, should be managed differently to a younger adult patient who’s clinical and emotional needs maybe quite different. The clinical leadership team originally argued that the process was wholly unpredictable, but in analysis of the patient pathway data, TCC found that patient types could be allocated to procedure time bands, and within these time bands there was substantial predictability.

However, TCC identified that there were still significant outliers in the process where, for example,  patients displaying multiple morbidities necessitated greater complexity that often resulted in significantly longer duration in theatre, which could result in hours of delays.   Contrasting with a typical time band for the same procedure type this might only require around 90 minutes for example.  Working with the clinical leadership team we identified that these outliers could potentially be reduced by instigating an improved pre-operative assessment process, and that through this process patients displaying multiple morbidity, or other complicating factors would be treated on an inpatient pathway for surgery and not a day surgery pathway.  By this means it was determined that the incidence of significant outliers should be substantially reduce. Operational trials would seek to quantify this potential benefit.

Optimisation of Day Surgery thus analysed the whole process and sought to develop strategies with the clinical leadership team that would ensure improved predictability of it.  Simulation of alternative strategies enables the leadership team to understand ’cause and effect’ and in doing so develop new strategies focused on improving patient flow. Ultimately, it is the clinical leadership team to decide which strategies provide the best overall patient experience – TCC simply provides the data and analysis to support informed decision-making. The Case Study examines these issues.

Regional analysis of healthcare demand

Posted on: April 24th, 2017 by matthew_bacon

The Conclude Consultancy has just been appointed to carry out a strategic analysis in Northern Gothenburg for five regional surgery centres.  The planning of a new service in Uddevalla also forms a key part of the work. This appointment is endemic of a larger need for healthcare infrastructure owners, which is to establish much more realistic forecasts of patient demand than has hitherto been possible. With the advent of geo-located data, and powerful mapping systems, these enable Conclude to analyse the causal factors of demand and to investigate the impact of them on the location and sizing of new infrastructure. The influx data that is generated from this analysis becomes the critical data that Conclude utilises in their Occupancy Analytics (TM) methodology for the planning and analysis of specific facilities.

In emerging economies investors in health infrastructure need reassurance that forecast patient demand (and therefore capacity planning) is based on sound evidence. In-built and untested assumptions in conventional planning models often lead to  over-sized health facilities that are uneconomic and provide a poor return on investment. In a changing context such as this, the failings of established current practice are readily exposed.

Our latest project therefore has importance well between the borders of Sweden. It will not only inform emerging best practice, but provides a valuable case study that leverages established technologies in a new form of analysis.

New Masters Degree Module in Architecture and Wellbeing

Posted on: November 8th, 2016 by matthew_bacon

Dr Matthew Bacon has been working with the Schools of the Built Environment, School of Nursing, Midwifery, Social Work & Social Sciences, and Health Sciences at the University of Salford to develop a unique Masters degree module in Architecture and Wellbeing.  Bacon has long held the view that a rich ground for innovation can often arise at the interface between very different professional disciplines. This has been the foundation of much of the work in The Conclude Consultancy (TCC).

In their drive for low energy hospital performance, TCC has identified the compelling need to develop the skills required to translate the needs of clinical professionals into requirements for hospital planning and engineering design. However, this is not a ‘one-way’ process, because planning and engineering teams can add much value in a challenging process and so the need is to translate opportunities into the impact on clinical space, environmental strategies and of course clinical delivery processes. Innovation works both ways.

However, it is a sad reality that few professionals are either equipped with the knowledge and expertise needed to facilitate such a dialogue. Few are equipped to understand decision-making processes in either domain (architecture) or health (wellbeing) and how one potentially impacts the other. As we drive for challenging targets in low energy performance  in the built environment it is obvious that buildings of the near future will have to be very different from those of today – but at what cost to the user and user wellbeing?

This programme is designed to answer questions such as these. It is designed to educate a new generation of post-graduate architects, engineers and health professionals in the practices necessary to create an integrated process where they learn the skills necessary for effective communication, decision-making and requirements management. The programme will bring together clinicians and health professionals from the Nursing leadership management programme with the Architecture and Wellbeing programme into a collaborative environment where both set of students work together to solve classic issues of contemporary hospital planning and design.

Please do contact us through our contact page or alternatively, Prof. Oren Lieberman at the University of Salford (o.r.lieberman@salford.ac.uk), should you wish to find out more about this exciting offer.

Low energy – low carbon hospitals in Sweden

Posted on: November 12th, 2015 by matthew_bacon

It is perhaps ironic that hospitals as caring institutions, are one of the most energy intensive building types, yet have the greatest potential to do harm to the environment. It is lamentable too, that the overall hospital energy performance of hospitals has hardly changed in two decades. This is why fundamental change to hospital planning and engineering design is required. The Conclude Consultancy are operating at the forefront of that change and in this regard we can announce that we are to be working in Sweden with the Gothenburg regional administration on a pilot project for a new 30,000m2 women’s hospital – focused on achieving a new benchmark in In-use energy consumption.

The administration recognises that control of In-use energy consumption is a major challenge in driving for Near to Zero Energy Buildings (NZEB’s). This is a definition under the European Building Performance Directive that requires all new public buildings to achieve near to zero energy consumption from 2018 onwards.  The challenge is made all the more difficult because a European Union (EU) study carried out in 2012/13 identified that the growth of In-use energy in buildings has effectively nullified all gains made through improved thermal and engineering systems performance. This was referred to as the ‘activity effect‘.  In other words it is the growth in electrical energy consumption caused by the building occupants activities that has largely led to this situation.

In Sweden, which has one of the most advanced NZEB strategies in the EU, they have progressively reduced thermal energy consumption to amongst the best in the EU.  They now recognise the need to focus on In-use electrical energy consumption and to make a substantial impact on the ‘activity effect‘. This is why the Gothenburg administration has decided to engage with Conclude, who will guide them to achieving Near to Zero Energy Hospitals performance.  Conclude will be using their unique OCCUPANCY ANALYTICS ™ and Whole Facility Energy Modelling methods to inform the optimised planning and design of engineering systems. Working with the clinical leadership team, Conclude will be identifying the major causes of energy consumption associated with each clinical pathway for the different types of patient using the services of the hospital. Our unique methods provide detailed insights as to the operational practices that can be streamlined to drive down In-use energy consumption.

Readers of this article might ask the obvious question – “well doesn’t it stand to reason that there has been a growth in hospital energy consumption – after all with all the additional equipment and people is it not inevitable?’  Of course this is a reasonable point – that is until one discovers just how much energy is wasted and that clinicans have very poor understanding of why and when this situation arises.  This is the work of Conclude: To analyse, to inform, and then support better decision making in the pursuit of optimised energy performance.  The opportunity is to reduce In-use energy consumption between 30- 50% and yet improve hospital capacity by making it more efficient AND improve the patient experience at the same time!  These are the possible win – wins of hospital operations today – drive down the cost of operation and drive up service performance.

Please do contact us through the contact form should you wish to learn more.

Latest work: Operational risk management in energy performance contracts

Posted on: December 29th, 2014 by matthew_bacon

Earlier this summer The Conclude Consultancy was appointed by Brighton & Sussex University Hospitals NHS Trust (BSUH) to carry out an analysis of In-use operational policies and working practices that impact energy consumption and carbon emissions across their health care estate.  Conclude were appointed by the Trust because of the unique methods that they developed, known as OCCUPANCY ANALYTICS ™ and Whole Facility Energy Modelling. It is through these methods that the energy and carbon impacts of operational policies and working practices are analysed.

BSUH Assistant Director of Estates and Facilities, Mr Des Weeden said: “We are currently engaged in the planning of an Energy Performance Contract with one of the UK’s largest ESCO’s, and in that work we have identified that operational risks have the potential to negatively impact the contract. We believe that the highly innovative methods developed by Conclude will enable the Trust to effectively manage those risks.  The consultancy has developed a means of holistically modelling the whole hospital operations and to directly corrleate these to the energy and carbon impacts of those operations.”

Dr Bacon adds: “The usual concern of the ESCO is that operational practices can undermine any M&E plant infrastructure improvement programme, such that the forecast benefits may not materialise.  Currently ESCO’s often manage these risks through what can amount to substantial financial contingencies.   However, research from Europe finds that without addressing the underlying operational causes of energy consumption, then these risks are likely to be endemic in many energy performance contracts within the health care sector. Thus the objective of our analyisis is to expose those underlying causes, and so enable the associated risks to be managed through clinical service optimisation or redesign.”

An important part of the method that Conclude has developed is a model of each ‘patient pathway.’ This is a view of the clincial pathway, but it is modelled in conjunction with the physical pathway through the functional spaces of the hospital.  A temporal dimension is added to this model so that the forecast energy impacts can be analysed. Conclude has found this a particularly effective means of developing a dialogue with clinicians, so that as these pathways are investigated, the underlying energy impacts are exposed.

Low energy – low carbon acute hospital design in the UK: An Analysis of In-Use

Posted on: August 15th, 2014 by matthew_bacon

The International Symposium of Energy Challenges and Mechanics is taking place in Aberdeen next week (21st-23rd August 2014). We will be attending, having been invited to submit a paper for it, following the publication of  OCCUPANCY ANALYTICS ™: a new basis for low-energy–low-carbon hospital design and operation in the UK. This was originally published by Taylor and Francis in a special edition of the Architectural Engineering and Design Management Journal: The Impact of the Building Occupant on Energy Consumption (http://www.tandfonline.com/eprint/RTGSmimUqH3cgMI9TaTs/full).

The Symposium objective is driven by the need to; ‘facilitate a rich exchange of knowledge between academia, industry, and research societies who seek solutions to address energy challenges worldwide’. The topics include both fossil fuels and many different forms of renewable energy. In addition, they will discuss issues related to energy efficiency, safety, environment and ecology.  Attendees include engineers, scientists, ecologists, regulators, administrators and policy advisors. The organisors promote the symposium as follows:

‘China’s rise as an international superpower and the global energy crisis are challenging the world. We are at a transitional age. We see technology advances in the exploration and development of oil and gas, a depleting resource; we see growth in handling aging and decommissioning. On the other hand, we see ideas and plans for the future’s new energy structure. This symposium is about energy challenges, the underlying energetic basis (mechanics) for society, involving multiple disciplines in technology, science, management and policy-making’.

Our paper introduces an innovative contribution to the low energy – low carbon design of acute hospitals in the UK. The need for innovation in acute hospital design arises from the consistently poor energy and carbon performance of the health care estate over a period of nearly three decades. This poor performance translates into a situation where overall consumption of energy in the healthcare estate has remained largely unchanged over that period, despite substantive improvements in the
asset specifications of these facilities. In terms of energy consumption and the associated carbon emissions, our research has discovered that the issues of poor In-Use performance and poor predictability of performance in acute hospitals are directly linked. The central causal factor that leads to both is a poor understanding of clinical user practices and the impact of those practices on the design and engineering of the hospital. The research identified that without such an understanding it means that
hospital designers and engineers are required to make substantial assumptions concerning In-Use during the design process, most notably concerning occupancy presence and the diversity of occupancy.
For a more in-depth look at the submission paper, please see  http://tinyurl.com/qbvtj9d. For more information, please contact www.conclude.org.uk/contact

Energy modelling of patient pathways

Posted on: March 21st, 2014 by matthew_bacon

The Conclude Consultancy has recently completed a fascinating study into the energy modelling of patient pathways. We believe that this work will make a significant contribution to understanding how energy is consumed in complex facilities such as acute hospitals. We believe that this will be the case because we have succeeded in directly correlating the energy impacts of use to each patient episode within any part of the hospital.

Why is this important?

It is important for a number of reasons. Firstly because current norms of energy consumption are usually based on building area and volume. So typical norms are: kWh/m² or GJ/100m³ . Many of the standards used in health care facility energy performance use these norms. Yet they can be both very misleading as well as potentially irrelevant to the needs of a clinician who might just be interested in how they personally or how their department could improve energy consumption. Such norms are misleading because they do not reflect intensity of use. For example for the energy conscious clinician when they see that despite the results of their efforts consumption actually goes up, would that not be a little deflating for them? Perhaps the reason for the increase in consumption is because the number of patients processed through the department has risen, and perhaps it is that increase which has caused the increase in consumption?  This is what we mean by intensity of use: more patients per hour, per day, per month for example.  Perhaps it is the difference of intensity of use between UK hospitals and those in Europe that explains why UK hospitals do not appear to perform as well from an energy consumption perspective?

Figure 1. Intensity of use. [Source: http://www.hope.be]

In Figure 1 we can see (if you click on the image it will enlarge) that France and Finland for example have similar intensity of use, but the evidence is that their acute hospitals appear to perform  better than the UK from an energy performance perspective. In contrast Swedish hospitals appear to perform much better than the UK hospitals, but then they have much lower intensity of use. So if intensity of use might partially explain the difference in performance (all supposing we are comparing like for like) then what are the other factors that drive energy consumption and how might these be controlled?

This leads is to the second point as to why area or volume based norms are misleading. It is because of this – that unless the clinicians can be presented with concrete evidence to explain how their working practices impact energy consumption, then they are unlikely to appreciate the need for change. Consequently area or volume based norms mean little to them, because they are intangible measures unrelated to their work.  However, by correlating their working practices directly to patient centric energy consumption, then compelling evidence to support the need for change can be provided.  We mean by patient centric energy consumption that energy consumption is directly correlated to each patient episode for each patient type. It follows that the energy needs of different patient types will vary according to the demand for clinical services of that patient type.  Clearly a patient requiring a video fluoroscopy will consume more energy in their episode than an orthopaedic patient having a plaster cast removed. Furthermore, studies in the United States have demonstrated how different x-ray equipment can impact the working practices of the clinician and yet have very different energy consumption profiles. Both the studies that we have been involved in and the research that we have undertaken have demonstrated much potential for control of energy consumption through analysis of working practices and operational policies. This is the evidence that clinicians require to start to see the need for change.

How did we carry out our analysis?

We have developed two forms of analytics: OCCUPANCY ANALYTICS ™ and Whole Facility Energy Modelling. (Please refer to the Conclude Process at the bottom of our web page). By taking a whole systems perspective of organisational processes and energy modelling focused on patient demand, we have been able to understand the impact of working practices and the energy impacts of those practices from different perspectives within the organisation. For example we can study consumption from a whole hospital perspective, but we can also study it from a departmental, or specialist function perspective. Yet we can also study it from a patient perspective.  We have been able to achieve this because we understand the statistical probability of where each patient type will be in the hospital at any hour of the day. We also understand the energy consumption within each part of the hospital at each hour of the day, and thus by modelling these two datasets we can forecast the statistical probability of energy consumption for each patient type for each patient episode at any period of the day.

Figure 2. – Energy consumption probability profile for a Nuclear Medicine outpatient appointment

How does this help the clinician to understand how they could influence energy consumption?

Because we use the documented working practices and operational processes as the basis of our simulation (quantitative analysis) and so provide the evidence to explains the impact on energy consumption. We then work with the clinicians to consider ‘what-if’ scenarios where we consider the energy impacts of different working practices and operational policies.  We discuss the issues and the challenges and in doing so establish a clear context for improvement (qualitative) analysis.  It is through this process that clinicians are empowered through learning – learning about how to they can impact energy consumption – consumption focused on each patient pathway through the organisation.

It is through this learning that clinicians can also start to understand how the control of patient flow impacts energy consumption, because flow impacts the demand on the environmental systems that provide occupant comfort. As flow becomes interrupted it places larger demands on those systems – a demand which drives energy consumption.  In Conclude, we argue that if we can improve patient flow – we can also improve energy consumption. In fact we can also impact the sizing of the engineering systems, which drives down the capital cost of them. Effective management of patient flow impacts not just the patient experience (reduced waiting times for example) but improved energy performance.

It is for all of these reasons that modelling of patient pathways offers many benefits, and not just providing visibility to the factors that drive energy consumption. It also becomes a valuable means to bridge the divide between the coupling of hospital engineering design with In-use working practices, and that must be a good thing.