Operational Productivity Sub Programme CIP GuidancePathology………………………………………………………………………………………………………………..12
Imaging……………………………………………………………………………………………………….............15
Ambulance Services………………………………………………………………………………………..........21
Estates & Facilities………………………………………………………………………………………………....25
Introduction
This document has been prepared by the specialist teams in NHS Improvement’s Operational Productivity Directorate to help identify recurrent CIP opportunities for you to develop and deliver effective, robust and comprehensive 2019/20 CIP plans. In each of the 11 programmes included, you will find:
• Recent trends including pointers to where the most significant efficiencies have been secured by trusts over the past 18 months. You can use the case studies throughout the guidance which demonstrate the approach to identification and delivery;
• Key success factors and barriers, with examples of how to harness and overcome these respectively; and
• Links to existing guidance materials and tools in each programme.
Please don’t hesitate to contact your Regional Productivity Teams if you wish to discuss any information included in this guide. Contact details are as follows:
North Region: nhsi.northproductivityteam@nhs.net Midlands and East Region: nhsi.midlandsandeastopprod@nhs.net London Region: nhsi.londonproductivity@nhs.net South Region: nhsi.southproductivity@nhs.net
4 |4 |
Recent Trends
• The current year (grey line in chart) is already more costly than the previous years (red
and blue) and the trend is that it will continue in this manner. Year to date (YTD) position
is driven by an overspend of trainee grades pay of £99m and consultants pay of £62m
through WLI’s (Waiting List Initiatives) and utilisation of temporary staffing.
• YTD medical overspend is understated due to the phasing of the medical pay award in
18/19.
• Medical workforce CIPs have been poorly recorded over the last few years and Trusts
are beginning to recognise and own this. This is in part to trusts not having a handle over
their demand and capacity and therefore unable to identify the required establishment
needed to meet demand. Job planning is the direction that trusts need to be moving and
are moving to in order to get to grips with this.
Medical Workforce
Establishment setting tools
• An establishment setting tool should be utilised by trusts, to enable them to identify “what good looks like”.
• Tier systems that have been demonstrated in trusts should be available in conjunction with the optimisation of e-rostering functionality for different professional groups to be co-rostered together.
• Trusts need to consider a workforce model which would describe the capabilities of both doctors and newer roles such as PAs, ACP, ENP, ANP etc.
• Trusts should be utilising a suite of metrics that enables unwarranted variation in productivity and efficiency to be identified
Optimisation of e-job planning and e-rostering
• Trusts should use e-rostering to deliver team e-job plans. Be able to measure that against the Meaningful Use Standards and Levels of Attainment framework.
• Team job planning should reflect the workforce requirements.
• There needs to be a clear link between productivity metrics, workforce planning and quality outcomes identified in facilitating good quality care.
• Trusts should use the establishment tools to convert clinical demand to workforce requirements.
5 |5 |
Medical Workforce
Data cleansing of ESR data
• Working with trusts and the Model Hospital team to firstly understand how the data is entered onto ESR and to be able to reduce
the amount of options available on ESR, this therefore steers the trust to be more disciplined in the choices that they make. This
work has already commenced and the charts below highlights how important good quality data is. The data is submitted to NHSI
via the medical workforce template and this is then compared against the data included on ESR.
• Trusts focusing on improving the quality of data on ESR not only reduces the burden on trusts from the task of endlessly
completing spreadsheets, which is an exhausting task, but by using ESR data will provide them with a true reflection of how the
trust is performing.
• A self-assessment framework (SAF) toolkit has been successful in identifying /
confirming the areas of intervention that trusts need to focus on.
• For a copy of the SAF please email nhsi.clinicalworkforce@nhs.net
• Establishment Setting
Job Planning
• All consultant and permanent non-consultant grade (NCG) doctors have a current signed-off job plan aligned with the Trust’s strategic objectives and designed to ensure the delivery of a high quality, 7-day clinical service which is consistent across all trust sites:
• Planned activity is captured broken down to Direct Clinical Care (DCC) & Supporting Professional Activity (SPA).
• Establish percentage of consultants with an active, signed-off job plan.
- Maintain, or increase, to the 90% benchmark that NHS Improvement has set.
- Annual job planning review in place. - Job Planning Consistency Committee meet on a monthly
basis.
In year Consideration Medium / Longer Term
• Annualised team job planning review in place. • Job plan is aligned to GIRFT (Getting It Right First Time).
E-rostering
• All medical rotas (Non-consultant grade and Consultants) are managed using an e-rostering system to ensure visibility of workforce deployment and rota gaps.
• Ensure effective rostering is in place and demonstrate that its use can ensure the right team/personnel with the correct skill are available to patients when and where they are needed i.e. a rota is provided timely and job plan is in place for NCG doctors.
Productivity
• Review medical staffing efficiencies using Model Hospital metrics such as WAU/DCC, DCC/FTE and Cost/WAU.
• Investigate negative variation to determine if it is warranted which may present an potential opportunity for efficiency gains.
Extra Duty Payments
• Review level of payment offered for extra-contractual sessions, and align with other trusts in your STP.
• Ensure no EDP payments are made unless additional hours are worked i.e. no EDP payments for undertaking clinical activity during timetabled SPA sessions.
• Establish appropriate governance for approval of EDP payments (likely to be >£100 p.h.).
• A robust plan in place to reduce Extra Duty Payments across the Trust for both consultants and NCG.
Appraisal System
• Robust appraisal system is in place to ensure all the workforce have achieved the goals for the year, and allow goal setting for the next year, including expected levels of clinical activity (e.g. OPAs, Theatre cases etc) for each DCC session.
Leave Management
System
• Job planning, e-rostering and Leave management systems should be integrated to allow maximum transparency of where gaps are appearing due to leave and sickness.
• Enforce 6 week minimum notice for annual leave to avoid unnecessary cancellation of clinical activity.
• Ensure leave reporting is feeding into hospital capacity plans regularly.
• Trust to utilises 4 week rotas, published at least 6 weeks in advance, to ensure timely sign off to reduce the use of agency and better accommodate staff requests for flexibility.
Establishment Setting
• Medical CIPs plan are identified and signed off by medical director. Monthly validation of CIP delivery against plan and ensure Medical CIPs are categorised correctly.
• Medical rotas are reviewed regularly and identify areas for focus by the highest use of temporary staff.
• Job Planning Committee in place to facilitate delivery of metrics e.g. clinical sessions per FTE, and consistency in allocation of SPA. Introduce SPA “tariff” to ensure transparency.
• Align training needs (for doctors in training) with service provision.
• Robust system in place to audit rota and job plans to help align plans to patient and service need.
Agency & Bank
• Planned activities (DCC and SPA) are reported to ensure the clinical services are met with no or minimum use of Locum and agency staff.
• Review recruitment processes, establish and promote internal banks. Improve fill rate of vacant shifts through in-house medical bank.
• Review pay rates for bank shifts to ensure they adequately incentivise bank over agency.
• Ensure board accountability for temporary staffs spend is clearly defined and adequate management resources are allocated.
8 |8 |
Recent Trends
The national picture over the last 12 months shows continued overspend on nursing pay, in the region of £280m above plan. There is a
need to ensure the permanent workforce is deployed productively to maximise availability and ensure additional spend on temporary staff
is reduced. Over the last 12 months this has continued to rise with a circa £104m increase from previous year. It is widely recognised that
the overspend is caused by high vacancy rates, with over 40,000 nursing roles being vacant, as well as the impact of the 18/19 Agenda
for Change pay award. Therefore focus on retention of existing staff and optimum use of e-rostering and e-job Planning is crucial. The use
of evidenced based safe staffing establishment settings and the metric of Care Hours Per Patient Day (CHPPD) should be used to
regulate and manage deployment.
Optimal use of E- Rostering and E-Job Planning Tools
• Ensuring 4-week rotas are approved and published 6-8 weeks
in advance, with aim to extend to 12 weeks, KPIs and e-
rostering metrics should be reviewed monthly and reported at
Board Level.
• Net Hours - Ensure systems and processes are in place to
regularly track and monitor the contracted hours worked over or
not worked, with transparent process and policy for follows-on
actions e.g. recovery, restriction on bank shifts or overtime
payments where hours are owed.
• Monitoring the unavailability of staff in relation to additional
spend on temporary staff to fill gaps and in addition flexible
patterns to support work life balance. This should also be
reviewed at 6 monthly intervals.
• CNS e-job planning should demonstrate efficiencies across
services and pathways and complement other professional
groups e-rostering or e-job plans. Job planning related CIPs are
more likely to be as a result of improved tariff remuneration and
increased clinical capacity as opposed to any pay reducing
activity.
Levels of Attainment framework.
Use of Model Hospital and Productivity Metrics Cost per WAU
and CHPPD
Hospital compared to national averages as well at ward level
with selected comparable units. Unexplained negative variation
will need investigation to determine if this is warranted. If found
to be unwarranted, this may present a potential opportunity for
efficiency gains.
• Consider Model Hospital CHPPD data at ward level and capture
the CHPPD available on the roster against budgeted CHPPD
(per establishment) and also required CHPPD (using evidence-
based patient acuity / dependency models) on a daily and basis
as a transparent basis for levelling and redeploying staff across
wards in response to safety and quality of care.
Management of Enhanced Care Additional Staffing
• Ensure systems and processes such as enhanced care needs
assessments are in place to ensure evidence-based
assessment of clinical need and workforce deployment required.
• Robust early approvals process for additional staffing and to
optimise deployment opportunities.
staffing required to inform establishment reviews and local
workforce deployment arrangements.
• Evidence based establishment setting (safe staffing) is paramount to ensure e-rostering templates ultimately reflect the patient acuity
and dependency, ESR and the financial resource required to ensure staffing is available to meet clinical demand, to ensure CHPPD
can be used effectively as a metric to support workforce deployment.
• E-rostering KPIs need to be understood and embedded from ward to board to maximise the efficiency of the clinical workforce.
• Converting the use of temporary staffing from agency to bank offers significant improvement to patient safety, staff wellbeing and
workforce retention, whilst reducing excessive financial spend.
• CHHPD needs to be understood and embedded particularly at ward level to provide assurance at board level of variation between
wards, clinical specialties and peer trusts.
• CHPPD should be used alongside clinical quality and safety outcomes measures.
Nursing Productivity Opportunities for 2019/20
• Reduction in bank and agency spend through
effective workforce deployment created by optimal
use of e-rostering and e-job planning tools.
• Alignment of non-ward-based roles to better
understand how roles such as Advanced Nurse
Practitioner, ACPs, APs, CNSs fit into care
pathways, how they provide value and explore
how job planning can optimise these roles.
Long Term Plan
NHS Improvement’s Retention Collaborative has already delivered substantial measurable improvements through targeted support for
trusts with high turnover. We will extend this support to all NHS employers, and NHS Improvement is committed to improving staff
retention by at least 2% by 2025, the equivalent of 12,400 additional nurses.
Over the next two years we will focus on ten priority areas as part of a strengthened efficiency and productivity programme by improving
the availability and deployment of the clinical workforce to ensure the right clinicians are available to patients at all times and further
reducing bank and agency costs. By 2021, all clinical staff working in the NHS will be deployed using an e-roster or e-job plan. By 2023,
all providers will be able to use evidence-based approaches to determine how many staff they need on wards and in other care settings.
This will provide staff with opportunities for flexible working while helping reduce unwarranted variation and improve safety.
10 |10 |
Nursing Workforce
Presentation title
• CHPPD
https://improvement.nhs.uk/resources/care-hours-patient-day-guides/
• E-rostering
https://improvement.nhs.uk/resources/rostering-good-practice/
• Trusts should consider their AHP CIPs in the context of
workforce redesign rather than cutting workforce (e.g. not filling
vacancies). There are examples of successful ‘gainshare’ CIPs
where AHP services have been invested in to reduce overall
length of stay, or to substitute consultant / doctor time.
• Trusts should be looking at reviewing capacity and demand for
diagnostic image reporting and using Radiographers and
Sonographers to supplement Radiologist reporting where they
have suitably trained staff. This may enable a cash-releasing
saving through reduction in requirements to outsource excess
demand or reducing medical agency or premium cost WLI
spend.
Practitioners to support the acquisition of diagnostic images,
releasing registered Radiographers to work at the top of their
licence.
• All AHPs services should implement job planning to their AHP
services. Early examples of trusts that have done this shows
that efficiencies have been found which increased clinical
capacity (and therefore has potential to reduce (AHP) unmet
need and reduce LoS)
• Integrating acute Physio and OT services should be a priority
for trusts that have not yet done this.
• Caution must be exercised when identifying opportunities from
the Model Hospital AHP data – reasons for high AHP spend
could be:
clinics,
2) the trust hosts AHP services on behalf of another trust
(often this is the case for Speech & Language therapists
that incidentally are more expensive than other AHP
professions as they did well out of AfC review / banding).
3) trusts have already ‘invested’ in AHPs to create gain share
CIPs across divisions. E.g. creating front of house AHP
teams to prevent unnecessary admissions.
12 |12 |
Recent Trends
The cost of delivering pathology in trusts that have not networked services continues to be higher than what can be expected from a fully
consolidated network service. Networks that have fully consolidated services have seen the overall cost per test drop considerably as the
benefits of consolidation are realised. There continues to be pressure upon the workforce leading to activity being outsourced to other
providers, normally at a higher rate. Nationally, agency spend is high and Trust bank is under-utilised in this area, with an estimated £20m
savings possible by removing agency spend and converting staff onto an internal staff bank. Trusts are making progress:
• The first tranche of networks are in operation.
• Almost half of the proposed networks have delivered to NHS Improvement Strategic Outline Cases and over a third are working up
Outline Business Cases as they progress towards forming pathology networks.
• Networks that are in the process of conducting joint procurement activities are anticipating significant recurrent savings delivered to
each partner, together with other efficiencies driven through use of the same equipment across the network that will be delivered
through common SOPs and training pathways for staff. In one example we have seen circa £350,000 savings per annum with an
overall saving of £25m over the life of the contract
Pathology
Networking
Networking is a multiyear programme however there are a number
of areas that trusts can concentrate on that do not detract from
networking and proactively drive forward this strategic direction
(see Productivity Opportunities for 2019/20 – Grip and Control).
• Reviewing staff skill mix, including looking at advanced and
extended roles.
vendors to buy at scale.
• Review services provided against long term strategy to
understand investment versus efficiency opportunities.
Key success factors and barriers
The main success criteria for ensuring pathology services deliver
the long term strategic and the short term efficiency is executive
engagement.
• The most important factor for trusts to remember is that cost
improvements can be realised in year as services progress
toward consolidated networked services, however, these need
to be aligned to the networking agenda and not focus on short-
term plans that will ultimately elongate the timeline for delivering
a network. It is important that trusts work collaboratively with
network partners.
• Approximately 40% of acute trusts in England do not report
pathology CIPs. Regional leads report that all the Acute
pathology services have CIPs based on visits to laboratories.
This is a classification issue that needs rectifying and trusts to
report all their pathology CIPs for FY 2019/ 2020.
Pathology – Efficiency Actions (Jan ‘19)
Rapid actions
Governance & comms
Non- recurrent
• Consolidate referral activity to a single diagnostic provider. • Review service contracts – Level of cover versus clinical
requirement. • Review logistics - operational delivery and contracting
arrangements. • Business cases and Capex review. • Demand management of testing – RCPath/IBMS/ACB guidance.
• Ensure all R&D activities are funded and appropriately priced. • Sale of old equipment. • Asset review. Consolidation on technology type across disciplines.
• Reduce reliance on agency / locums. • Review Out of hours arrangements where the are outside of AfC. • Review sample delivery time to reduce out of hour staffing
requirements. • Review Consultant Job plans. • Increase staff availability – remote and flexible working. • Improve staff retention –Training & Development.
• Governance and cash management – PO or approved testing request route only.
• Capital and assets opportunities.
• Clear delivery plan on and around consolidation. • Engage staff and key stakeholders, particularly Clinical users. • Clinical need rather than clinical want.
In year consideration Networking / Collaborative Opportunities
Inventory Management
• Adoption of just in time stock management. • Introduction of automated stock management systems to meet
accreditation requirements and reduce staff time. • Removal of ad-hoc deliveries via improved stock management.
Non-pay / all cost actions
• Ensure all R&D activities are funded and appropriately priced. • Consolidate referral activity to a single diagnostic provider. • Demand management of testing – RCPath guidance.
Procurement
• Review service contracts – Level of cover versus clinical requirement.
• Review provision of complex testing against savings of retiring equipment and outsourcing.
• Consolidation of consumables providers within trust and across aspirant network.
• Consolidate referral activity to a single diagnostic provider.
Networking
• Consolidating pathology services allows for the most consistent, clinically appropriate turnaround times, ensuring the right test is available at the right time. It also makes better use of our highly skilled workforce to deliver improved, earlier diagnostic services supporting better patient outcomes.
• Taking a hub and spoke approach to this consolidation can ensure an appropriate critical mass to support specialist diagnostics, so that patients have equal access to key tests and services are sustainable.
14 |14 |
Pathology
Supporting resources provided by NHSI / E The NHS Improvement Pathology programme have produced a number of resources that can support trusts and networks in
understanding where opportunities can be derived.
• Pathology programme Detailed Guidance
• National & Regional Teams
Regional and National pathology teams are on hand to support trusts in reviewing plans to ensure they are appropriate which will
increase chance of successful delivery.
15 |15 |
Recent Trends
Delivering imaging services in trusts continues to rely on an increasing spend on ‘outsourcing’ (Independent sector providers) and
‘insourcing’ (use of extra sessional payments), to meet the capacity shortfall. This increasing spend is not sustainable in the longer-term
due to increasing costs, with vacancy rates remaining high (12.5% Consultant Radiologists, 15% radiographers).
• Some imaging departments are beginning to organise themselves into Imaging Networks, setting up programme structures and
rudimentary governance structures to begin working as a network and gain benefits. Most networks have come together to gain
benefits from a joint procurement, to replace their existing PACS systems and have started to recognise and look for wider benefits of
working together across a number of areas (Workforce, Capital Equipment, Training opportunities, ISAS accreditation). Some
networks have been successful in gaining funding for an IT platform that will allow image sharing and offer them the opportunity of
joint backlog reporting or shared reporting gains. Most of this funding has been secured through either Cancer Transformation Funds
or STP Transformation Funds, however, this funding is not universal and large parts of England do not have funds to procure a
technical solution. Those with funding have encountered quite a challenging procurement landscape and have not yet secured a
technical solution. Where technical solutions have been acquired, there have been some benefits of joint backlog reporting securing
savings over outsourcing solutions.
• NHS Digital are developing a Toolkit to support networks through the technical procurement process to ensure an optimum image
sharing solution, based on the experience of networks to date. This is due for completion in Spring 2019.
• There continues to be significant workforce challenges, with high vacancy rates, however skill mix remains variable with the
percentage of plain x-rays being reported by advanced practice radiographers varying from 80% to 0%. Backfill to replace
radiographers undertaking advanced roles remains a challenge and Assistant Practitioner roles remain low. Challenges accessing
appropriate training for this staff group, and access to funding for training remain an issue. The apprenticeship levy may offer some
opportunity.
• Radiography academies / multidisciplinary radiology academies have offered opportunities to increase skill mix by training cohorts of
staff to develop reporting skills as Advanced Practitioners. Innovation in new pathways for suspected lung cancer have had success in
some trusts and are starting to be adopted in others.
• Some networks have started to work together on shared reporting networks for on call, to increase the availability of radiologists
available during the day and to increase training opportunities.
Imaging
Networking is a long-term, multiyear programme however there are
a number of areas that trusts can concentrate on that do not
detract from networking and proactively drive forward this strategic
direction (see Productivity Opportunities for 2019/20)
• Reviewing staff skill mix, including looking at advanced and
extended roles.
protocols (and reduce duplication / repeats).
• Rreviewing capital replacement requirements and understand
where ‘economies of scale’ can be leveraged (utilising Category
Tower 7 – NHS Supply Chain).
• Negotiating ‘outsourcing’ contracts at scale, by agreeing
multisite deals and planning for known capacity shortfalls.
Key success factors and barriers
The main success criteria for ensuring imaging services deliver the
long term strategic direction of imaging networks and the short-
term efficiency gains is executive engagement. The Strategic Plan
for Imaging is yet to be published, however, there is a commitment
to Imaging Networks by 2023 in the NHS Long-Term Plan.
• Trusts will be able to deliver cost improvements in year as
services progress towards imaging networks, with ‘economies of
scale’ being offered by collaborative working, procurement and
training. Any local CIPs will need to be aligned to the networking
agenda and not short-term plans that could cause challenges for
delivering a network. It is important that trusts work
collaboratively with network partners, particularly when
considering PACS / RIS and image sharing solutions for the
next 10 years.
• Classification of CIPs for Imaging are not yet clear with
pathology and imaging opportunities only being identified
separately this year. Work needs to be done in identifying where
imaging spend is accounted for in ‘outsourcing’ and ‘insourcing’
budgets, so that these can be transparent.
• Information submitted for national data collections such as the
DID (Diagnostic Imaging Dataset) and the DM01 through
information departments should be ratified with imaging
departments to improve data accuracy.
Imaging - CIP opportunities (Jan ‘19)
Pay Cost
Coding & Classification
of CIP
Protocols & Pathway
Capital Equipment
• Understand where sourcing / outsourcing spend is accounted in your budget and track alongside demand (overtime, locum, WLI).
• Implement an annual leave policy (monitor compliance). • Review “on call” or out of hours arrangements (could shift
systems offer improved cover). • Review staff availability and flexible working arrangements
(e.g. 3 long days, reporting from home). • Use “retire and return” to retain skilled staff at the end of
their career. • Review job plans for Consultant Radiologists and advance
practice radiographers to ensure any shortfall in reporting capacity is understood and planned for.
• Re-negotiate outsourcing contracts in a planned / effective way. Utilise economies of scale across sites.
• Review use of advanced practice radiographers to ensure appropriate utilisation of their skill set and attendance at appropriate MDT, audit etc.
• Encourage multidisciplinary working to ensure advance practice skills are developed and maintained while appropriate review and supervision is undertaken.
• Agree referral protocols for defined care pathways and use clinical decision support to improve the appropriateness of referrals.
• Monitor inappropriate referrals and provide feedback. • Agree standardised scanning protocols for the same type of scans
both within the organisation and for tertiary transfers e.g. Neuro, cancer.
• Offer patients a choice of appointments (not next available slot) by partial booking.
• Offer pre-assessment or telephone triage/ support for more complex procedures (IR) or complex conditions.
• Consider having x-ray booking clerks in high volume clinics (to agree appointments before the patient leaves clinic and minimise DNA rates).
• Consider dedicated lists for patients with high DNA rates or incomplete studies (anxiety to MRI).
• Ensure the age of capital assets (asset register) is understood by the trust board and any risks of using older equipment are documented.
• Have a capital replacement plan agreed and contingency plans for sudden outage.
• Ensure that savings on consumables and contrast agents are attributed to Imaging departments.
• Ensure staff groups such as “sonographers”, “mammographers” are appropriately coded to imaging where they are not obviously radiographic posts.
• Ensure staff are accurately coded within ESR to ensure financial and workforce planning is informed by accurate workforce data including support staff.
• Work with commissioners to review opportunities to deliver system wide efficiencies.
Cash releasing / In year
consideration Longer Term Considerations
Networking / Collaborative Opportunities
• Consider tasks and opportunities for assistant practitioners to release radiographers for advanced practice roles (some plain x- ray or theatre). Scope of practice and supervision must be clear.
• Access the apprenticeship levy to support the development of assistant practitioners and new support roles.
• Work with information departments to agree and sign off DID and DM01 returns. Be clear on how activity data is counted .
• Agree network wide protocols to enable easier shared reporting and reduced repeats, reduce risk.
• Use intelligent reminder services (txt, appropriate calls, artificial intelligence for those most likely to DNA).
• Use appropriately trained staff to protocol and vet requests (justification must follow IR/(ME)R guidance.
• Review opportunities for cost effective replacement through NHS Supply Chain to gain economies of scale or cheaper financing options.
• Optimise capital replacement opportunities across multiple trusts in an imaging network (incl PACS / RIS).
18 |18 |
Supporting resources provided by NHSI / E
The NHS Improvement Imaging programme will be publishing the proposed Strategy for Imaging (including Imaging Networks) in Spring
2019. The resources to support its adoption will be:
• A Toolkit for procuring an Image Sharing Solution (In development with NHS Digital)
• A resource plan for Imaging Networks (to support set-up and infrastructure)
• A proposed programme of supportive workshops to share best practice and identify ‘barriers to change’ – A National Development
Programme
• A Leadership Development Programme (for identified network leads)
• Regional and National imaging teams are on hand to support trusts in reviewing plans to ensure they are appropriate and will increase
their chance of successful delivery
• Case studies can be found below.
Case Study 1 – East Midlands Radiology (EMRAD) Shared Backlog Reporting
Improving Efficiency through Collaboration, Technology and a
Shared Vision.
The Problem The EMRAD consortium supports eight NHS Trusts, thirteen Hospitals and a 6.0 million population. There
simply aren’t enough Radiologists or reporting capacity to cover the ever-increasing demand.
Fig1. Summary of the current landscape.
- Systems were installed in 2004 with multiple PACS and RIS in the region.
- There was some very local workload sharing but no routine regional image sharing.
- There was Case-by-case distribution using IEP with some regional clinical pathways developed.
- The technology struggled to keep pace.
The Solution It was envisaged that radiologists reporting
images remotely would result in lower costs to
the Trust than the outsourced model and that
the model would also be financially and
logistically attractive to the radiologist. It was
predicted that cross-trust reporting would
deliver efficiencies that would assist in
reducing Trust backlog. Radiologists for a pilot
project were selected, specifically to review
and report neuroradiology images from the
Trust.
The challenges and lessons learned - The deployment of the cross-Trust
reporting product was difficult at first as
the software didn’t quite work as expected
and there were issues with networks and
adoption of change.
hardest aspect, as there was an
established governance procedure and a
number of policies that, due to their
rigidity, were not set up to support this
model.
the current state of backlogs in Trusts,
current Trust outsourcing spend and the
method for bridging the gap should not be
underestimated.
Overview
To cope with increasing demand across the region, the EMRAD consortium developed a pilot program of
cross-Trust reporting to assist in reducing Trusts’ backlogs and reduce the spend on outsourcing. The pilot,
which was run by neuro-radiologists, was successful and has been expanded beyond neuroradiology and now
includes radiographers too. Backlogs in the region have been reduced as has outsourcing spend. The EMRAD
consortium is now looking at further innovations for cross-Trust reporting.
Simon Harris. EMRAD Project Manager
simon.harris@nuh.nhs.uk
Email:
• 5% increase in the total number of studies
reported during the 3 month pilot period.
• 240% increase in waiting list initiative
reporting activity.
generated the equivalent of 1.0 WTE
Radiologist.
was significantly higher than national
guidance.
reporters in the pilot and variation in the
amount of waiting list initiative
attributable to each Trust, there was an
overall significant increase in productivity.
The pilot study encouraged the expansion of
cross-Trust reporting beyond the three-
month trial, wider than neuroradiology and to
include radiographers. EMRAD colleagues are
leading the process of multiple Trusts
reporting on behalf of others in their
consortium, outside their NHS contracted
hours, which is assisting in meeting the
capacity gap.
expanded cross-Trust reporting has successfully
delivered:
- Insourced 38,826 Reports - Insourced 4,164 CT reports - Insourced 9,627 MRI Reports - Insourced 25,035 Plain Film Reports - 2017/18 financial year saving was £119,832.60 - Reduced the cost of outsourcing by 30.84% for
the Trusts involved in the insourcing initiative
Fig 2. Job Planned, WLI and pilot reporting activity before and
during pilot.
Future Opportunities For future successes:
- Reviewing of CT imaging is required prior to decision for thrombolysis.
- Stroke prognosis dramatically improves with more rapid diagnosis and timely treatment.
- Inability for remote image review/slow system start up can slow time to treatment decision.
- Remote image review with portable tablet devices can speed up decision making process.
“Cross-Trust reporting has afforded the opportunity to compile a wealth of data allowing high level analysis of reporting volumes and associated metrics and also the productivity of participating radiologists in terms of both reporting throughput and report quality.” - Simon Harris, EMRAD Project Manager.
0
500
1000
1500
2000
2500
3000
3500
WLI work only
Pilot work only
Developing a networked approach for sustaining your ‘on-call’
Overview The demand for overnight radiologist reporting was stretching radiologist capacity across the south
west to an unsustainable level. Several models were evaluated which lead to the creation of Peninsula
Radiology On Call [PROC]. PROC is a collaborative venture to provide overnight radiology on call
services for four of the acute NHS Trusts in the south west peninsula from a single location. It has
overcome many of the sustainability challenges faced by the region and has delivered cost saving
benefits to the member Trusts as well.
The problem • There was an increasing demand for emergency CT
overnight across the region that was stretching the
radiologist reporting capacity
an adverse impact on training for the Specialist
Trainee Radiologists across the region as a result of
compensatory days off during routine working hours
in order to comply with the European Working Time
Directive (EWTD) and The New Deal.
• These factors lead to the overnight service reaching
an unsustainable level.
the entire region.
would employ the registrars.
• Administration.
overnight imaging has increased
interrupt reporting.
o Occasional PACS network failures which is
a challenge not unique to PROC.
o Images unavailable for viewing on the
consultant’s virtual private network
[VPN].
on call consultant
• To overcome the resistance to change a range
of tailored stakeholder engagement sessions
were held with the following groups;
o Service managers
o Consultant radiologists
o Radiology registrars
communication and stakeholder engagement
selected.
addressed the HR, governance and
administration challenges.
of Radiology is responsible for management
and governance of PROC.
emergency CT and MRI studies conducted
between 21:00-09:00, 365 days a year.
• All specialty registrars providing reporting services
for PROC are employed by Plymouth Hospitals NHS
Trust and have honorary contracts with their base
hospital. Trainees providing reporting services for
PROC will be covered by the terms of the honorary
contracts and the SLA. At the end of each shift the
on-call consultant reviews all scans acquired from
their locality
timely consultant review and regular audit. On call
radiologists are responsible for providing feedback
to reporting registrars on discrepancies.
• There has been a reduction in staffing costs.
Tom Sulkin
Email: tom.sulkin@nhs.net
• An existing model for cross site working which
encourages collaboration and operational
• Registrar attendance during normal service hours
have been increased which creates a better learning
environment and more positive interaction with
imaging and hospital colleagues.
that is well supervised.
Case study 3 – Working Together ACS – A pilot Radiography Academy
Working Together Programme
• Reporting radiographers training was accessed piecemeal across Trusts; no consistent approach to either training or the scope of professional competence and practice.
• A clearly identified need to provide effective clinical education for trainee reporting radiographers from disparate hospital sites was agreed and articulated across the South Yorkshire region.
• Recognising workforce pressures in radiology in terms of both image acquisition and interpretation, the priority became to increase reporting capacity to stabilise and provide sustainable services and reduce financially crippling reliance on outsourcing to the independent sector.
• Analysis of data across the patch showed activity rises of approx. 7% and it is estimated that in 2-3 years’ time, the reporting capacity gap would be approx. 750,000 images per annum.
The challenges and lessons learned
The WTP principles are to pool collective expertise and
knowledge to support staff development. The challenges
are to expand the number of advanced practitioners and
recruit and retain radiologists:
• To provide effective clinical education for trainee reporting radiographers across a number of hospital sites a number of objectives needed to be agreed: o To establish governance processes to
enable cross organisational working o To establish a standardised educational
programme o To accelerate the learning period o To share resources and efficiency gains
o To explore the challenges in delivering a collaborative programme
o To robustly evaluate the initiative
o To identify opportunities for future
collaboration
equipment. Hosting arrangements was
number of barriers required overcoming:
o Student access to PACS
o Data transfer and sharing to allow
trainees access to the same images
o Information governance agreements
organisations
ensure the programme could be
shortened
WTP radiography clinical lead and a
part time clinical educator.
agreed to support the pilot with
funding for the university course
fees and backfill for training.
o Each Trust was asked to support the
academy with in-reach sessions and
a named mentor for the sign off of
the report competency portfolio.
The solution and future
established collaboration of 7 NHS Trusts with the aim of
collectively strengthening the ability to deliver safe,
sustainable local services.
Overview
With a national shortage of radiologists impacting on both the ability to make timely reports for patient diagnosis, management and
surveillance and afford time to train staff within each of the separate Trusts, A solution was proposed and taken through pilot study to see if a
Reporting Radiographer Academy jointly supported by hospital Trusts in Sheffield, Rotherham, Barnsley, Doncaster, Bassetlaw and
Chesterfield would offer radiographic staff the opportunity to up-skill and provide the eventual plug to the reporting capacity gap.
Professor Beverly Snaith, Clinical Professor of Radiography
Bev.snaith@midyorks.nhs.uk
Be
This has been achieved by:
• Clinical Academy for Radiographer Reporting (CARR) - in 4 months CARR was ready to run the initial pilot and accept the first cohort of radiographers.
• A successful pilot has seen the training of 8
reporting radiographers within this first cohort.
• This first pilot has run for nine months.
Delivered over 3 phases the structure of the
programme meets the needs and expectations
of professional bodies:
Phase 1: Sep-Dec
scenarios, peer review and practical reporting
experience.
and transition into the clinical environment at their own
base hospital.
practice, working alongside radiographers and
radiologists. They attend the academy 1 day per month
for ongoing peer support.
(minimum) case reports with an accuracy of at least
95%.
organisational boundaries – a first in addressing
reporting radiographer workforce issues across
an entire region.
delivered a cohort of radiographers who are
ready to work as advanced practitioners and
support clinical services with a single standard
across organisations.
facilitated peer support “One of the key
benefits for me is that we are all learning lots
from each other, not just the tutor.”
• Duplication of effort has been reduced by
sharing the training in a single setting. This has
not only facilitated the sharing of resources
(including educators) but has allowed
intensive, timely clinical support to take place.
One educator has been able to provide the
support to 8 trainees which is far more efficient
than the input of a single trainer in each
organisation.
specialist input from external trainers – an
opportunity which would not have been easy to
access over multiple sites.
Advanced Practitioners are delivering
• The intensive nature of the programme has
allowed the trainees to complete their course 4
months earlier than normal but with no
reduction in quality or skill set.
• The reporting capacity generated by these
individuals will be key to delivering clinical and
cost-effective efficiencies across organisations.
boundary working as governance, evidenced
based outcomes and standards are agreed.
• Importantly, the cohort will be able to
challenge each other’s practice, provide peer
support and expert opinion to the benefit of
patients and their care and management
teams.
Interest from around the UK has been high with regions
across Scotland, East Midlands, East Anglia and
Manchester already developing plans to replicate the
model.
reporting radiographer numbers.
A second cohort has been planned with the prospect of
extending the anatomical scope of practice. There is no
doubt: this model, its structure and delivery programme
provides unparalleled opportunities for advancing
radiographic reporting practice
is now part of the South Yorkshire & Bassetlaw Shadow
Integrated Health and Care System (sICS).
approach to ISAS Accreditation
Background
The Acute Care Collaboration Vanguard in Dorset has a mission to create One NHS in Dorset and one
of their work streams is radiology. The collaboration consists of The Royal Bournemouth and
Christchurch Hospitals NHS Foundation Trust, Poole Hospital NHS Foundation Trust, Dorset County
Hospital NHS Foundation Trust and Dorset Healthcare University NHS Foundation Trust.
The Aims of The Radiology Work stream
One of the key aims of the radiology work stream is to achieve ISAS accreditation. The group has
identified this accreditation as a tool to support the integration of radiology staff from the four
trusts involved. Achieving ISAS accreditation for all the radiology services in Dorset demonstrates to
patients, staff and commissioners that services are safe, of high quality and well managed.
The Experience & Outcomes
As the group works towards ISAS accreditation, with the assistance of an appointed project
manager, clinical leads have worked with their colleagues across all four Trusts to share ideas and
agree pan-Dorset policies and protocols, based on best practice and guidelines. The positivity of the
experience is highlighted by Poole Hospital Radiology Manager, Mandy Tanner:
Overview
The Radiology Work stream of the One Dorset Acute Care Collaboration Vanguard is working towards obtaining
ISAS accreditation across the region. This process has brought the Trusts closer together and fostered positive
close working collaborations. A shining example of this is the Pan-Dorset Lumbar Spine X-Ray Referral Guidelines
which have reduced unnecessary X-Rays by up to 37%. Not only is this great for patients as there is less
unnecessary exposure to radiation, but it highlights the positive results that working together, standardising
services and reducing variation can have.
Mandy Tanner: Radiology Manager, Poole Hospital NHS FT
Email: mandy.tanner@poole.nhs.uk
“Previously, any joint working within Trusts has largely been at a higher management level. With
ISAS, teams are really starting to work openly together with colleagues in other Trusts for the first
time. Staff are enjoying collaborating and are proud of the improved experience for patients taking
place across the sites as a result of their work. The work for ISAS offers us a unique opportunity to
define common standards across the sites and to explore the potential for sharing staff expertise.
This will help us as we strive to improve the quality of service we provide to our patients throughout
Dorset.”
The Lumbar Spine Example
A prime example of how the ISAS accreditation process is having a positive effect on the service is
the standardisation and implementation of the Pan-Dorset Lumbar Spine X-Ray Referral Guidelines.
The guidance was adapted from existing guidance by the lead clinicians from all 3 acute Trusts and
reflects current best practice.
Dr Robert Ward, Clinical Lead for the radiology vanguard work stream explains:
“The typical effective dose for a lumbar spine plain film x-ray is particularly high at 1.0 mSv,
equivalent to the radiation dose from 50 chest x-rays or five months of background radiation -
therefore it is particularly important that these investigations should only be undertaken when
needed to inform patient care. Unfortunately in many common scenarios these x-rays provide only
very limited value and so these guidelines will hopefully help to ensure that only patients who will
gain some benefit undergo this examination.”
The guidance has had an immediate effect on demand management and curbed unnecessary
referrals by up to 37%.
“Working collaboratively as part of the vanguard has enabled us to provide uniform advice for GPs,
share best practice and make positive changes for patients in Dorset.” - Mandy Tanner
The problem
• Despite a long-standing record of 100%
recruitment to clinical radiology training
posts, approx. 1 in 10 consultant posts
remains vacant
to meet demand for imaging services
• Potential to increase clinical radiology
training numbers is limited by resources
including capacity to teach and
supervise and by difficulty accessing
training time and equipment in busy
departments
professional learning environment
• Collaborative academy-style learning
direct consultant supervision in
comparison to traditional training
clinical departments improve training
experience because they:
activities
technology-enhanced learning
(e.g. simulation)
formal assessment of knowledge
peer and academic support
Observations
accelerates the development of
• Networked off-site training environments
be supported at any one time
• Academies provide safe and supported
teaching, supervising and assessing
trainees and for advanced and consultant
practitioner radiographers and
support clinical radiology training
Overview
In 2005 the Department of Health and the Royal College of Radiologists collaborated to set up
three Radiology Academies - Leeds & West Yorkshire, Norwich and Peninsula (Plymouth) – with
each academy co-ordinating training across a network of individual NHS Trusts.
Since their set up the academies have boosted Clinical Radiology trainee numbers in their local
geographies and offered a high standard of speciality training alongside the more widespread
traditional hospital-based training schemes.
Following a national review in 2018, access to the academies and development of further
academy-style learning environments is being extended to the wider multiprofessional
healthcare team involved in delivering imaging services.
Case study 5 – The ‘academy’ approach to training in Clinical Imaging
Multiprofessional Clinical Imaging Training Academies
Paul.Deeley-Brewer
19 |19 |
Recent Trends
The significant volume of CIP delivery is routinely from medicines management, with the data tracked in the Model Hospital via the Top 10
Medicines metrics. However, several additional CIP initiatives are delivered by provider trusts (see CIP Opportunities slide below) these
can be split into cash releasing, longer term and workforce related initiatives.
Hospital Pharmacy & Medicines Optimisation
• Trusts achieve best success through detailed and tracked ‘CIP
Pipeline’ work.
scrutiny and accountability. Assessment of use of both e-
rostering and e-job Planning should be measured against the
Meaningful Use Standards and Levels of Attainment framework.
Productivity Opportunities for 2019/20
• The slide below sets out the CIP initiatives we believe are
prudent for 2019/20 these are categorised into the following
areas:
• Cash Management
Supporting Resources
• A template has been developed for trusts to adapt and track
each suggested CIP initiative. We have seen this work well in a
number of trusts, providing a RAG status for each initiative and
highlighting opportunities for CIP pipeline work, the template
can be found below.
Assessment Framework (below) has been developed to help
NHS trusts review their approach to medicines optimisation.
• A number of webinars / workshops are being planned during
the CIP planning process, hosted by the NHSE-I Regional
Pharmacists, further details to follow.
Hospital Pharmacy and Medicines
Gap Analysis
Assurance Patient Access Scheme price arrangements in place - reimbursement sought for any overpayment
Yes/No/Partial
2
Yes/No/Partial
3
Yes/No/Partial
4
Yes/No/Partial
2
Engage pharmacy & organisation staff and key stakeholders (e.g. STP leadership)
Yes/No/Partial
3
Yes/No/Partial
Yes/No/Partial
3
Yes/No/Partial
4
Yes/No/Partial
5
Yes/No/Partial
6
Full engagement with Local Workforce Advisory Board on funding for apprenticeships
Yes/No/Partial
1
Ensure all R&D including clinical trials are appropriately priced and fully funded (including non-commercial trials)
Yes/No/Partial
2
Purchasing agreements in place for best value consumables including dispensing & aseptics
Yes/No/Partial
1
Review service contracts in all areas to provide assurance of VFM including supply & educational input
Yes/No/Partial
2
Ensure charging structure in all SLAs covers full costs of service not just salaries
Yes/No/Partial
3
Local purchasing agreements for all medicines not on regional/national contracts
Yes/No/Partial
4
Yes/No/Partial
5
Acceleration of progress to full electronic ordering and invoicing for medicines
Yes/No/Partial
Medicines
1
Process in place to plan for patent expiries and immediate uptake of new contract waves
Yes/No/Partial
2
Yes/No/Partial
3
Check pharmacy stock levels are appropriate and cannot be reduced
Yes/No/Partial
4
Yes/No/Partial
5
Yes/No/Partial
1
Clear formulary and process for shared care in place including funding arrangements
Yes/No/Partial
2
Yes/No/Partial
3
Yes/No/Partial
4
Yes/No/Partial
Governance and cash management - PO or approved use route only
Yes/No/Partial
2
Yes/No/Partial
3
Yes/No/Partial
4
Capital and assets opportunities including review of asset registers & capital charging
Yes/No/Partial
Key information/enablers:
1) Finance and pharmacy work together to create clear, open view of medicines spend with Joint governance processes e.g. joint monthly medicines budget control meeting
2) Proactive use of Rx-Info Define benchmarking to generate Cost Improvement Plan pipeline
3) Link to efficiency and productivity of clinically facing pharmacy work e.g. ward rounds etc.
4) CIP opportunities that require clinical engagement present an additional challenge
5) Barriers to change within trust from some clinical areas
&P/&N
Trust:
Acute services
Other
Adapted and prepared by Richard Seal, Chief Pharmacist, NHS Trust Development Authority, June 2013. Updated March 2014
Introduction
INTRODUCTION TO THE FRAMEWORK
1.
SUMMARY
The purpose of this hospital pharmacy and medicines optimisation assessment framework is primarily to help NHS trusts to review their approach to medicines optimisation (MO) and pharmaceutical services. In addition, the outcome will be used by NHS Improvement to provide an assessment of the extent and quality of services provided by NHS trusts as a focus for developmental support.
The framework is based on an approach developed by the NHS Trust Development Authority.
This framework can help you understand where you are now and where you might need to be to develop. It should used as a guide rather than a blueprint for service delivery.
The core domains and criteria used in the framework draw on a wide variety of sources for inspiration. These include standards and guidance published by the Department of Health, National Patient Safety Agency (now part of NHS Improvement), Care Quality Commission, NHS Litigation Authority, Audit Commission and the Royal Pharmaceutical Society.
The framework content has been devised in consultation with NHS trust Chief Pharmacists, as well as peers and other clinical colleagues. It is intended to meet the specific needs of NHS Improvement. However, it may be of interest to other healthcare providers.
2.
ABOUT THE FRAMEWORK
The purpose of the framework is threefold. Namely to enable trusts to:
l
l
Identify areas of existing good practice but also areas for development
l
Provide assurance on medicines optimisation and pharmaceutical services
The framework should ideally be completed by the senior management team with responsibility for hospital pharmacy services and medicines optimisation (usually the Chief Pharmacist, Director of Nursing and Medical Director). It provides an opportunity for both clinical leaders and managers to reflect on the trust's overall approach to medicines optimisation and to consider how systems and processes contribute to delivering the organisation’s wider clinical strategy and assurance on the provision of safe, effective and patient-centred services within the trust.
Following completion of the framework, the outcome should be considered as part of strategic planning and organisational development to ensure that high quality, sustainable services are provided.
The outcome of the assessment should also help organisations identify areas for future development and improvement.
3.
APPROACH
The framework builds on earlier work published by a number of national bodies and professional organisations. It takes into account the requirement to adhere to the principles described in the NHS Constitution and to deliver the NHS outcomes framework.
4.
The framework is divided into the following 7 core domains:
l
Use of resources
Each of the 7 core domains is made up of the following:
l
l
Each criterion is further divided into four levels against which trusts assess their level of attainment
In addition, there are two additional worksheets where you can identify areas for development and examples of good practice for sharing.
5.
HOW TO EVALUATE THE OUTCOME OF THE ASSESSMENT
Most trusts should expect to identify areas of both good practice and areas for further development. It would be unusual for any trust to achieve the maximum score across all of the core domains in the framework. However, you may anticipate that:
l
Most trusts will perform well within the core domains of safe use of medicines and effective choice of medicines and mixed scores within the other domains.
l
There is no right or wrong outcome. This will be influenced by a number of factors including the type of services provided, the patient demographic and previous investment in medicines use and pharmacy services within the trust.
l
Some of the benefit from completing the framework will arise from comparing the outcome for your organisation with those of organisations similar to your own. There will be some areas for development which are common to a number of organisations and these will be used as the focus for development support from NHS Improvement.
Guidance
GUIDANCE ON COMPLETING THE ASSESSMENT
Getting started
Providing information about the organisation
The assessment framework is based on a number of Excel spreadsheets. Individual domains can be accessed by clicking on the appropriate domain title tabs at the bottom of the workbook page.
Access the first page by clicking on 'TITLE_PAGE' tab.
The title page provides space for the following details:
l
l
l
The date of the completion of the assessment
Save your own copy of the workbook as "(Name of your trust) self assessment framework"
Saving your assessment
You can stop work on the assessment at any point although you must make sure you press the 'Save' icon to save the work that you have done.
2.
Information about the self assessment framework and instructions.
You can access further information about the framework by clicking on the "Introduction" tab at the bottom of the page. This section provides an overview of the self-assessment framework and advice about interpretation of the results.
3.
The individual domains.
The framework has 7 domains. These are: Strategy, Risk and Governance; Safe use of medicines; Effective choice of medicines; The Patient Experience, Environment for medicines optimisation, Workforce for medicines optimisation and Use of Resources. For each domain there are 6 criteria. Work through the core criteria for each domain one at a time. Each criterion provides four statements. You should make your assessment by clicking on the button in the box that is most closely matches you trust's position. The statement may not fully reflect your local circumstances in which case, choose the statement that is closest. Remember to press the save button as you progress through the domains.
Note: You should complete all of the criteria in each of the 6 domains in the assessment. The default level for each criterion is level 1.
4.
The charts and dashboard.
As you make an assessment of your trust's level for each criterion, the relevant chart for that domain will automatically be updated to reflect your choice. In addition the overall summary chart will also change to reflect your choices.
Upon completion of the entire assessment, the data will be visually available as:
l
l
l
A summary dashboard. The darker the colour, the higher your level of assessment.
5.
Saving and printing.
You can keep a hard copy of the assessment by clicking on 'File' then 'Print'. Make sure you select 'Entire workbook' from the 'Print' options.
&G
DOMAIN 1 - STRATEGY, RISK & GOVERNANCE
Medicines optimisation is integrated into the trust's strategy, systems, working practices and culture at all levels. The roles of managerial and clinical leaders are aligned and unambiguous. There are clear lines of accountablity for medicines optimisation from the board to operational delivery units. Risks are identified and mitigated.
Indicator
Level
Str 1.2
1
Criterion 2 - There is an executive level medicines policy group for overseeing medication safety and policy development
Str 1.3
1
Criterion 3 - The management of medicines is underpinned by an overarching medicines policy
Str 1.4
1
Criterion 4 - There is oversight and control of clinical risks and costs associated with medicines
Str 1.5
1
Criterion 5 - A Chief Pharmacist plays a leading role in medicines optimisation
Str 1.6
1
Criterion 6 - The Trust Board and senior management are actively involved in medicines optimisation
Total
6
The trust does not have a hospital pharmacy transformation plan
Level 1
The trust does not have a strategic oversight group for developing medicines policy, procedures and guidance and providing oversight of medication safety.
Level 2
There is a draft hospital pharmacy transformation plan but it has not been approved by the board or it has not been fully funded
Level 2
The trust has a strategic oversight group for developing medicines policy and procedures and overseeing medication safety.
Level 3
A fully-funded hospital pharmacy transformation plan has been approved by the Board. An implementation plan, with timescales, is in place.
Level 3
The trust has an oversight group for developing medicines policy & procedures and it is responsible for making decisions about medicines that are implemented across the trust
Level 4
As level 3 plus key performance indicators developed and mechanism in place to regularly review and report progress to the board
Level 4
The trust can provide evidence that implementation of policy, procedures and decisions about medicines applies across the whole trust. The oversight group produces regular board reports.
Level 1
No evidence that there is an overarching medicines policy that supports an integrated approach to medicines optimisation across the whole organisation.
Level 1
The trust does not have robust business and financial planning, management, monitoring and reporting systems to manage clinical risks costs associated with medicines.
Level 2
There is a comprehensive, overarching medicines policy that supports an integrated approach to medicines optimisation across the whole organisation.
Level 2
The trust has rudimentary business and financial planning, management, monitoring and reporting systems to manage clinical risks & costs associated with medicines.
Level 3
There is an overarching medicines policy in place and all clinical staff receive a copy or can access a copy as part of their induction.
Level 3
The trust has robust business and financial planning, management, monitoring and reporting systems to manage clinical risks & costs associated with medicines.
Level 4
The is a comprehensive, overarching medicines policy in place and a regular audit programme exists to assure compliance.
Level 4
The trust has robust business & financial planning, management, monitoring & reporting systems to manage clinical risks & costs associated with medicines. These are routinely shared and discussed with commissioners.
Level 1
The trust does not have a chief pharmacist (or equivalent).
Level 1
There is no named lead board level Director for medicines optimisation and medication error incident reporting and learning.
Level 2
The trust has a chief pharmacist (or equivalent) responsible for operational pharmacy management and service delivery.
Level 2
There is a named lead board level Director for medicines optimisation and medication error incident reporting and learning.
Level 3
The trust has a chief pharmacist who has trustwide responsibility and is held accountable for medicines optimisation and pharmaceutical services.
Level 3
There is a named lead board level Director for medicines optimisation and medication error incident reporting and learning and Board members are generally informed about medicines related issues
Level 4
As per level 3 and reports directly to a named Executive Board member eg. Medical Director, Director of Nursing.
Level 4
There is documentary evidence via Board minutes of active participation by the named lead Director and Board discussion of medicines optimisation & safety issues that impact on the trust's business and its service users.
© NHS Improvement 2017. All rights reserved.
3butts: These details must be entered on the 'Title_Page' worksheet.
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Page &P of &N
1.1
Safety Criterion 1 - Hospital pharmacy transformation planning Criterion 2 - There is an executive level medicines policy group for overseeing medication safety and policy development Criterion 3 - The management of medicines is underpinned by an overarching medicines policy Criterion 4 - There is oversight and control of clinical risks and costs associated with medicines Criterion 5 - A Chief Pharmacist plays a leadin g role in medicines optimisation Criterion 6 - The Trust Board and senior management are actively involved in medicines optimisation 1 1 1 1 1 1
1.4
1.3
1.6
1.5
1.2
DOMAIN 2 - SAFE USE OF MEDICINES
Systems, processes and work practices are designed to prevent or reduce the risk of harm to patients from medicines.
Indicator
Level
Saf 1.2
Saf 1.3
1
Criterion 3 - Medication errors and harm from medicines are measured & lessons learned are routinely embedded in policies and practice
Saf 1.4
1
Criterion 4 - The quality impact of cost reducing schemes involving medicines or pharmacy services is routinely assessed and monitored
Saf 1.5
1
Criterion 5 - Policies and procedures for the safe use of medicines are in place
Saf 1.6
Total
6
Level 1
No evidence of a system to routinely monitor and review the safe and secure handling of medicines to meet the clinical needs of patients and legal and Regulatory requirements.
Level 1
No evidence that there is a formal system for medicines reconciliation of medicines as recommended by national guidance.
Level 2
Evidence the trust has an effective system to routinely monitor and review the safe and secure use and handling of medicines to meet the clinical needs of patients and legal and Regulatory requirments.
Level 2
Evidence that there is a medicines reconciliation policy in place and medicines reconciliation takes place for some patients.
Level 3
The trust has an effective system to monitor & review safe & secure handling of medicines and a named pharmacist is responsible for safe & secure handling of medicines. Regular compliance audits undertaken.
Level 3
Evidence that there is a medicines reconciliation policy in place and medicines reconciliation takes place for the majority of patients within a specified time after admission.
Level 4
The Board receives regular audit reports on the the safe and secure handling of medicines and takes steps to address shortcomings. The Board is assured that it meets legal and Regulatory requirements.
Level 4
Medicines reconciliation takes place for more than 80% of patients within 24 hours of admission and actions are routinely followed up, documented and communicated.
Level 1
Medication incidents are not routinely monitored & reported across the trust. There is not a documented mechanism to enable learning from medication incidents to be shared. Medication safety officer not identified or not in post.
Level 1
No evidence that the impact on service quality of CIP, QIPP, CRES or other cost saving measures related to medicines use and pharmacy services are formally assessed.
Level 2
There is an effective system for identifying, monitoring, analysing and reporting medication incidents across the trust. Evidence that learning from medication incidents is routinely shared across the trust. Medication safety officer identified.
Level 2
Cost reduction schemes (as level 1) involving changes to medicines use or pharmacy services are devised and signed off by the Chief Pharmacist (or equivalent).
Level 3
There is a robust system, which includes performance measures, for routinely monitoring, reporting and embedding learning from medication errors across the trust. Medication safety officer identified and in post. Harm related to medicines is identified and reported to the Board.
Level 3
Cost reduction schemes (as level 1) involving changes to medicines use or pharmacy services are quality assessed and signed off by the Chief Pharmacist and another senior Trust manager.
Level 4
Action plans to reduce medication errors are devised, implemented and audited. Evidence that the Board is able to assure itself that the trust complies with national "best practice" guidance for medication safety through regular reports on learning arising from incidents. Medication safety officer identified and in post.
Level 4
Cost reduction schemes (as level 1) involving changes to medicines use or pharmacy services are quality assessed and signed off by the Trust Medical Director or Director of Nursing. Quality impact is monitored regularly and reported through governance arrangements
Level 1
No evidence that the trust has a set of comprehensive policies and standardised procedures to minimise the risk to patients from medicines.
Level 1
No evidence of a policy for the safe use of unlicensed, ''off label' or investgational medicinal products
Level 2
Evidence that the trust has comprehensive policies and standardised procedures to minimise the risk to patients from medicines. This includes policies for patient group directions and non-medical prescribing.
Level 2
Policy for the safe use of unlicensed, ''off label' or investgational medicinal products in development
Level 3
As level 2 and a clear description of the responibilities of all staff involved in medicines procurement, supply, prescribing and administration is available and included in staff appraisals. Process for regularly reviewing all patient group directions is in place.
Level 3
Policy for the safe use of unlicensed, ''off label' or investgational medicinal products implemented for all patients and regularly audited.
Level 4
As level 3 and evidence that compliance with medicines policies and procedures is monitored routinely and reported through the trusts integrated goverance system. All patient group directions are up-to-date.
Level 4
Policy for the use of unlicensed, ''off label' or investgational medicinal products. Evidence that all patients consent to the use of such products and this is routinely recorded in their clinical notes.
© NHS Improvement 2017. All rights reserved.
3butts: These details must be entered on the 'Title_Page' worksheet.
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2.1
Safety Criterion 1 - Medicines are handled safely and securely Criterion 2 - Medicines are reconciled routinely Criterion 3 - Medication errors and harm from medicines are measured & lessons learned are routinely embedded in policies and practice Criterion 4 - The quality impact of cost reducing schemes involving medicines or pharmacy services is routinely assessed and monitored Criterion 5 - Policies and procedures for the safe use of medicines are in place Criterion 6 - Unlicensed and 'off-label' use of medicines 1 1 1 1 1 1
Safety - Developmental
2.2
2.4
2.3
2.6
2.5
DOMAIN 3 - EFFECTIVE CHOICE OF MEDICINES AND PATIENT OUTCOMES
Systems and processes help to deliver good clinical outcomes through effective medicines optimisation supported by robust local decision-making.
Indicator
Level
Eff2.1
1
Criterion 1 - There is an effective local decision-making process for medicines use
Eff2.2
1
Criterion 2 - There are metrics for monitoring the cost and quantity of medicines used
Eff2.3
1
Eff2.4
1
Eff2.5
1
Eff2.6
1
Criterion 6 - The trust has a published formulary for medicines
Total
6
Level 1
No evidence that there is a clearly defined process for overseeing and deciding on the medicines that are used within the trust.
Level 1
No evidence that there is regular review of the types of medicines, quantity and cost of medicines used across the trust.
Level 2
Evidence that there is a drugs and therapeutics committee (DTC) or equivalent local decision-making body for overseeing effective use of medicines within the trust including new medicines.
Level 2
Evidence that the types of medicines, quantities and cost used by individual directorates, wards or teams are reviewed regularly.
Level 3
As level 2 plus the DTC has a formal business plan approved through the integrated goverance process. The introduction and use of new medicines is audited.
Level 3
Evidence that information on the types of medicines, quantities and cost used by individual directorates, wards and teams are reviewed regularly and sent to team managers.
Level 4
DTC monitors and regularly reviews implementation of its decisions and takes action to address non-compliance. Evidence of active engagement with commissioners
Level 4
Evidence that senior managers receive and act on information about the types of medicines, quantity and cost used by their wards and teams.
Level 1
There is no use of the Pharmacy and Medicines compartment of the Model Hospital
Level 1
No evidence of a policy to support the judicious use of antimicrobials and promote antimicrobial stewardship.
Level 2
Pharmacy and Medicines compartment of the Model Hospital accessed infrequently (<1 access per month)
Level 2
Evidence of a specific policy to support the judicious use of antimicrobials. Antimicrobial stewardship audit undertaken.
Level 3
Pharmacy and Medicines compartment of the Model Hospital accessed regularly (at least 1 access per month)
Level 3
Trust antimicrobial policy contains specific recommendations on the implementation of national "best practice" guidance (eg Start Smart then Focus) and a lead pharmacist for antimicrobials is in post. Evidence of active engagement across local health economy.
Level 4
Pharmacy and Medicines compartment of the Model Hospital accessed routinely (at least 5 accesses per month) and used to drive service improvements and choice of medicines
Level 4
As level 3 plus lead pharmacist has specific responsibility for monitoring and auditing antimicrobial usage and is a formal member of infection prevention and control committee (or equivalent). Evidence that audit results influence use of antimicrobials.
Level 1
No evidence of a formal process for implementing relevant NICE technology appraisal guidance.
Level 1
Level 2
Evidence of a process for implementing relevant NICE technology appraisal guidance within 90 days of publication.
Level 2
Level 3
Evidence of an effective mechanism for monitoring and reporting on the implementation of NICE technology appraisal guidance and taking action where poor compliance is identified
Level 3
Comprehensive formulary developed and published in a publically accessible format. Evidence that commisioners have been actively engaged in development of the formulary.
Level 4
Level 4
© NHS Improvement 2017. All rights reserved.
3butts: These details must be entered on the 'Title_Page' worksheet.
&"Arial,Bold"&16 Medicines Optimisation and Pharmaceutical Services Framework &G
Page &P of &N
3.1
Safety Criterion 1 - There is an effective local decision-making process for medicines use Criterion 2 - There are metrics for monitoring the cost and quantity of medicines used Criterion 3 - Use of Model Hospital Criterion 4 - The prinicples of antimicrobial stewardship are implemented Criterion 5 - NICE guidance is implemented effectively Criterion 6 - The trust has a published formular y for medicines 1 1 1 1 1 1
3.2
3.4
3.3
3.6
3.5
DOMAIN 4 - THE PATIENT EXPERIENCE
Patients (and carers) are involved in decisions made about their medicines and supported to take their medicines as intended
Indicator
Level
PE6.1
1
Criterion 1 - There is a policy and suitable facilities for the use of patient's own medicines
PE6.2
1
Criterion 2 - Patients who are competent to do so can self administer their medicines
PE6.3
1
Criterion 3 - Patients are supported to take their medicines as intended
PE6.4
1
Criterion 4 - A duty of candour is applied to harm from medicines
PE6.5
1
PE6.6
1
Criterion 6 - Transfers of care occur according to national 'best practice' guidance & pharmaceutical care plans
Total
6
Level 1
The trust does not have a policy for use of a patient's own medicines and there are no/limited facilities in patient areas for the safe storage and ready access to patient's own medicines
Level 1
The trust does not has a policy to enable patients to be assessed as competent to administer their own medicines.
Level 2
A policy for use of patient's own medicines is in development and there are facilities for the safe storage of patient's own medicines in some clinical areas.
Level 2
Level 3
A policy for use of patient's own medicines is in place and there are facilities for the safe storage of patient's own medicines in most clinical areas.
Level 3
Self administration policy and assessment scheme in place and some patients assessed as comptetent to do so are able to administer their own medicines
Level 4
A policy for use of patient's own medicines is in place and audited regularly and there are facilities for the safe storage of patient's own medicines in all clinical areas.
Level 4
Self administration policy and assessment scheme in place and all patients assessed as competent to do so are able to administer their own medicines
Level 1
No evidence that patients have access to and are helped to understand information about their medicines
Level 1
The trust does not have a mechanism for monitoring, reporting and informing patients (or their carers) when they have suffered harm as a result of a medicines-related issue eg. adverse reaction, medication error etc.
Level 2
Level 2
A policy to include a duty of candour with respect to medicines-related incidents is in development.
Level 3
Patients are provided with written and verbal information about their medicines.
Level 3
Duty of candour policy in place and staff are trained to ensure effective implementation. Duty of candour requirement included in staff job descriptions.
Level 4
Evidence that there is a mechanism to ensure that patients have understood the information that has been provided and know how to get help with their medicines should they need.
Level 4
Evidence that patients are routinely informed when they have suffered harm as a result of a medicines-related issue. Chief Pharmacist routinely involved in investigation of all incidents leading to harm.
Level 1
The trust does not routinely monitor omitted and delayed doses.
Level 1
The trust does not have a process that complies with NICE guidance [NG5] for ensuring that medicines information is communicated accurately and efficiently following a hospital episode
Level 2
Level 2
The trust has a manual process that complies with NICE guidance [NG5] for ensuring that medicines information is communicated accurately and efficiently following a hospital episode
Level 3
Mechanism for monitoring omitted and delayed doses implemented and audited. Results are reported to service managers.
Level 3
The trust has an electronic process that complies with NICE guidance [NG5] for ensuring that medicines information is communicated accurately and efficiently following a hospital episode
Level 4
Mechanism for monitoring omitted and delayed doses implemented and audited. Trust can provide evidence that it is actively taking steps to make improvements.
Level 4
As level 3 and implemented in all wards or departments and that this is regularly audited, including feedback from relevant stakeholders (eg GPs, care homes) plus ability to include the community pharmacy of the patient's choice when this is appropriate
© NHS Improvement 2017. All rights reserved.
3butts: These details must be entered on the 'Title_Page' worksheet.
&"Arial,Bold"&16Medicines Optimisation and Pharmaceutical Services Framework &G
Page &P of &N
4.1
Safety Criterion 1 - There is a policy and suitable facilities for the use of patient's own medicines Criterion 2 - Patients who are competent to do so can self administer their medicines Criterion 3 - Patients are supported to take their medicines as intended Criterion 4 - A duty of candour is applied to harm from medicines Criterion 5 - Patients receive the medicines that they need Criterion 6 - Transfers of care occur according to national 'best practice' guidance & pharmaceutical care plans 1 1 1 1 1 1
4.2
4.4
4.3
4.6
4.5
Environment