document 8a health improvement partnership programme part 1

Health Improvement Partnership

“Where to from here?”

1yr Review ReportApril 2007

V4.

Sharon HendryService Improvement Manager

Contents Page

1.0 Introduction 3

2.0 Project Management 3

2.1 Work streams 4

3.0 Objectives of HIP 4

3.1 Integrated Approach 4-5

4.0 Process of Review 6

4.1 Review of HIP Programme at Year 1 7-9

5.0 Key Achievements & Benefits at Year 1 10

5.1 Culture Benefits 10

5.2 Clinical Benefits 10-12

6.0 Risks 13

6.1 Risk Log 13-14

7.0 Co-ordination of Work streams 15-16

8.0 Work Plan 17-18

8.1 Targets to Achieve 18-19

9.0 Summary and Conclusions 19

10.0 Recommendations 19-20

Appendix 1 21

Appendix 2 22

Appendix 3 23

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1.0 Introduction

The Health Improvement Partnership (HIP) programme commenced in October 2005.The programme is a joint venture, led by the Trust working in collaboration with local partner organisations in the health community. The goal of the programme is to provide ‘better care without delay’ throughout the patient’s healthcare journey.

The focus is therefore on both improving quality of care as well as reducing unnecessary delays for patients. This will be achieved by:

• Helping to develop a ‘whole systems’ approach by building on existing improvement work, in partnership with the local stakeholders.

• Focusing on improving clinical systems by reducing the variation in demand and capacity, ensuring a commitment to high-quality patient focused care.

• Assessing and improving the Trust’s organisational and leadership development culture to ensure that improvement is a core activity, aligned to business planning processes and delivered in a sustainable way.

2.0 Project Management

The HIP programme is lead by the Medical Director and Associate Director for Clinical Quality, and is operationally managed by the Service Improvement Manager.

On launch of the programme, an agreement document was completed which set out the aims of the programme (May 2005). The programme commenced in October 2006 and resulted in four main streams of work:

Cardiology

Surgery

Cancer

Organisational Development

The project work streams are managed through 90day action plans. These are formulated with the project leads.

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2.1 Work streams

The following project working groups were developed within the four main work streams:

Cardiology Surgery Cancer Organisational Development

Increase Daycase procedures

Waiting List Management

Rapid Access Lung Cancer Service

Sickness Management

Reduce Length of Stay

Increase pre-assessment

Length of Stay

Intensive Care Discharge

Thoracic Referral Processes

Culture of organisational health

Catheter Lab Team working

Long Term Stay (in ITU) and Case Mix

Administration Support Roles

Team working/development

Outpatient follow-up rates

Thoracic Development

Role Redesign and Competency

Nurse Sickness Management

3.0 Objectives of HIP

The HIP has an overall key performance indicator; to achieve the 18week referral to treatment pathway for all appropriate patients referred into the Trust by December 2008.

In order to achieve this objective the HIP programme has supported and pushed to the fore service improvement and re-design of our services.

This has been achieved through leadership, engagement and communication.

3.1 Integrated Approach

The HIP programme has been undertaken with an integrated approach. The 10 High Impact Changes for Service Improvement and Delivery was utilised as a major driver and starting point to the project. The 4 High Impact Changes for Cancer Services was also reviewed and utilised. The Integrated Service Improvement Programme (ISIP) Roadmap for Transformation Change has also been used for reference and project planning.

The Institute for Innovation and Improvement has been a source of reference and support. As well as a myriad of other service improvement web-sites, virtual communities and internal/external meetings.

In its integrated business plan (IBP), the Trust has defined 10 core values which support the achievement of 5 strategic objectives over the next five years. Four core values and two strategic objectives are directly relevant to quality improvement and are sited in the Clinical Quality Strategy.

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Core Values:1. Treating patients quickly and appropriately2. Treating patients with kindness, compassion, dignity and respect3. Empowering patients and carers to ensure meaningful involvement in the

planning and delivery of services, together with improving their own health4. Offering safe, modern, efficient and effective services

Strategic Objectives:1. To work with partner organisations to design and deliver patient services

around patients needs and expectations, providing integrated and seamless care across primary, secondary and tertiary sectors

2. To improve the health of patients through the development of cardiothoracic services in line with new technologies, treatments and lifestyle advice, backed by research and development, ensuring clinical excellence

Objectives are represented as below with Clinical Quality Dimensions as the foundation to achieve the strategic objectives.

The Clinical Quality Dimensions will be integrated into Improvement Reports, of which the HIP Programme will utilise to report progress of quality projects. This will enable the Trust to demonstrate, share and celebrate successes (see Appendix 3 for Improvement Report Template).

5

4.0 Process of Review

This 1year review has been undertaken to show the work that has been achieved thus far and to outline the work in progress.

The report, where possible, documents progress through the patient’s journey for cardiology, surgery, cancer and organisational development improvements. As organisational development (OD) is a core activity, all OD improvement work is contained within each speciality section.

6

4.1 Review of HIP Programme at Year 1

Cardiology Cardiac Surgery Thoracic Surgery Cancer

Referral Management

Process mapping of referral management undertaken, to be included in 18wk workshop programme for re-design of revascularisation pathway (March 07)

Process mapping of referral management undertaken to be included in 18wk workshop programme for re-design of revascularisation pathway (March 07)

Referral forms developed for Cancer information to assist with robust data collection and timely notification of patients’ transfer of care to CTC.

Administration mapping for Cancer Tracker role development.

Development of MDT alerts between DGH Trusts and CTC to enable early warning of patients being transferred for care between organisations.

Outpatient Services (including diagnostics)

Capacity Review underway of OPD capacity to ensure full utilisation.

Decrease ratio of new to follow-up appointments. Audit established results to be published March 07.

DNA rates and costs assessed. Changes to patient information and DNA policy.




Utilisation of Blackberry units for immediate access to diary for scheduling inpatient dates.


Pathology process mapping and PDSA cycles established to improve turnaround tissue to result times for bronchoscopy washings and OPD bloods. To be followed up during May 07 with second event and implement changes.

Review of 4 High Impact Changes for Cancer, assessment of nurse led follow-up services undertaken but not appropriate for lung tumour service.

Pre-Assessment

Increased capacity of pre-assessment October 06.

Pre-admission service integrated with consultant clinics.

Audit commenced Jan 07 to assess utilisation.

Increased utilisation of pre-assessment service.

Reduction in number of short notice patients.

Pre-assessment service established in November 06.

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Waiting List Management

Established process for all routine cardiology procedures to be booked as daycases (unless clinical exceptions).

Increased usage of “open” waiting lists for cardiac surgery from DGH partners.

Development of Euroscore Risk Tool/referral form utilised by all cardiologists.

Development of MDT for “high risk” patients to be implemented.

Balanced case mix established for thoracic/cardiac sessions.

Development of “open” referrals to inpatient waiting list established November 06.

Pilot scheme for 2week turnaround of referral to minor investigation result in association with Cancer Network.

Thoracic theatre sessions daily.

Admission

Increase of patients admitted on the day for PCI.

List scheduling in labs/theatres improved due to “block leave” project which enables labs to close during planned periods of absence.

Rapid Improvement Event Jan 07 to assess admission processes, recommendations to be taken forward. Reduce steps in process/increase efficiency and patient information.

Established 5day wards

Length of Stay

Increased daycase rates for cardiology procedures:

Radial PCI – June 06

Routine Pacing – May 06

Pacing efficiency study completed – delays with portering established and reduced.

Reduction in overall LOS for CABG patients (pilot for two surgeons). To be rolled out to all surgeons within 2007.

Reduction in critical care to discharge times.

Transfer policy established to reduce LOS.

Programme established to reduce LOS for major thoracic surgery procedures: lobectomy, pneumonectomy, wedge resection.

Programme established to increase daycase rates of minor procedures.

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Critical Care

Theatre start times defaulted to 8.00am.

POCCU discharge for 11am.

Decreased length of intubation.

Theatre start times defaulted to 8.00am

High Dependancy unit established for thoracic level 2 patients.

Discharge Planning

Discharge policy reviewed and re-designed.

Discharge plans for all patients established.

Nurse led discharge pilot scheme established for routine pacemaker patients.

Discharge policy reviewed and re-designed.

Discharge plans for all patients established.

Nurse led discharge pilot scheme established for routine CABG patients (two surgeons).

Organisational Development

Role redesign for catheter lab support staff. Multi-skilled role developed. Programme to be implemented April 2007.

Catheter Lab Team working project undertaken. Recommendations to be evaluated.

Sickness trend analysis report produced for Surgical Directorate. To be analysed.

Development of MDT role and Cancer Tracker roles to support management of Cancer Pathway.

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5.0 Key Achievements & Benefits at Year 1

Appendix 1 tables the key quality indicators for the HIP Programme and shows progress from January 2006.

5.1 Culture Benefits

Recognition that improving our services is required and crucial in delivering high quality patient centred care.

Increased communication between multi-disciplinary teams. Team working developed through project groups.

Clinical leadership established through Medical Director and Clinical Directors.

Partnership working developed with external organisations (DGHs, Networks, DoH)

HIP Programme central to Foundation Trust Application, and service improvement recognised as a “corner stone” to development of services.

5.2 Clinical Benefits

Increased daycase rates in cardiology for elective routine procedures.

% of All Cardiology Elective Procedures completed as Daycase 2006/07

33%

64%65%

54%

57%

56%

49%

44%

48%49%

35%

CL 47%

25%

35%

45%

55%

65%

75%

Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07

Data Points

UCL

+2 Sigma

+1 Sigma

Average

-1 Sigma

-2 Sigma

LCL

% Daycase

Increased pre-admission utilisation in all specialties. Reduced cancellation rates, increased patient care/advice.

Cardiac Surgery - Monthly Pre-Assessment % including All ProceduresSummary 2006/07

82%

93%

85%

95%

88%

87%84%87% 88%

91%

85%

99%UCL

CL 88%

LCL 76%

70%

75%

80%

85%

90%

95%

100%


All ProceduresUCL+2 Sigma+1 SigmaAverage-1 Sigma-2 SigmaLCL

%Pre-Assessment for Cardiology Procedures - ALL PROCEDURES2006/07

40.0%

45.3%48.3% 49.4%

38.3%

44.9%43.3%

52.5%54.3%

72.0%

60.8%

CL 44.2%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Data PointsUCL+2 Sigma+1 SigmaAverage-1 Sigma-2 SigmaLCL

% pre-assessed

10

Development of pre-admission service for thoracic surgery patients in January 2007.

Reduction in length of stay for routine elective CABG procedures.

Cardiac Surgery - CABG Length of Stay (Admission to Discharge)2006/07

10.8

12.1

9.9

10.510.7

9.910.1

10.8

8.2

10.6

UCL 13.0

10.4CL

7.8LCL

7

8

9

10

11

12

13

14

Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07

Average(Days)


n=655 cases

Pilot commenced

Christmas Period

Discharge plans implementedNurse Led Discharge

early mobilisation

Introduction of discharge planning from date of admission. New discharge plans introduced in January 2007.

Introduction of “open referral” systems in cardiology, cardiac surgery and thoracic surgery. Provides access and equity.

% of Surgical Referrals that are Booked Through the Open Referral Route

CL 16.2%

0%

5%

10%

15%

20%

25%

30%

Sep-05

Oct-05

Nov-05

Dec-05

Jan-06

Feb-06

Mar-06

Apr-06

May-06

Jun-06

Jul-06 Aug-06

Sep-06

Oct-06

Nov-06

Dec-06

Jan-07

%

PUCL+2 Sigma+1 SigmaAverage-1 Sigma-2 SigmaLCL

Comms to DGH for utilisation

Introduction of “risk scoring system” for cardiac surgery referrals (Euroscore). Enables improved scheduling and case mix of patients.

Established standard discharge times from Post Operative Care Unit; greater efficient with patient flow.

% of POCCU Discharges by 11am (adjusted for Clinical Conditions)

2006-2007 Summary

45.8%

51.9%48.9%

55.9% 54.8% 55.9% 56.6%

31.7%

45.22%CL

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07

% D

isch

arge

d


11

High Dependency ward established for thoracic level 2 patients. Increased occupancy in CCA area and captured additional revenue.

Increase skills and competencies of nursing staff to enable nurse-led discharge and extubation of critical care patients. Increases communication between medical and nursing staff. Reduces length of stay.

Average Length of Intubation in CCA - 2006/2007

10.7

8.3

11.2

8.2

9.4 9.59.2 9.2

11.1

9.3

7.98.1

8.5

CL

9.6

6.0

7.0

8.0

9.0

10.0

11.0

12.0

13.0

14.0

Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07

Hours

Data Points

UCL

+2 Sigma

+1 Sigma

Average

-1 Sigma

-2 Sigma

LCL

Jr AnaestheticExtubation Proactive

Extubation Protocol

Development of administration support for Cancer Pathway. Reduces breaches, increases communication between organisations.

% of Patients Meeting the 31 Day Target - All Referrals exc. IOM

CL 95.9%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jul-

04

Au

g-0

4

Se

p-0

4

Oct

-04

No

v-0

4

De

c-0

4

Jan

-05

Fe

b-0

5

Ma

r-0

5

Ap

r-0

5

Ma

y-0

5

Jun

-05

Jul-

05

Au

g-0

5

Se

p-0

5

Oct

-05

No

v-0

5

De

c-0

5

Jan

-06

Fe

b-0

6

Ma

r-0

6

Ap

r-0

6

Ma

y-0

6

Jun

-06

Jul-

06

Au

g-0

6

Se

p-0

6

Oct

-06

No

v-0

6

De

c-0

6

Jan

-07

Fe

b-0

7

%


PET scan ITU move

▪ 2 no ITU beds▪ 1 Surgeon on leave ▪ 1 Cancellation due to Emergency Admission

▪ 1 patient - no ITU bed

▪ 1 patient - Cancelled due to Emergency

▪ 1 patient - Admin error. Removed from WL and coded as Treatment Complete, should have been Treatment Incomplete

▪ 2 patients - Admin errors▪ 1 patient - Elective capacity inadaquate▪ 1 patient - Elective cancellation, surgeon study leave

% of Patients Meeting the 62 Day Target - All Referrals exc. IOM

55.8%CL

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jul-

04

Au

g-0

4

Se

p-0

4

Oct

-04

No

v-0

4

De

c-0

4

Jan

-05

Fe

b-0

5

Ma

r-0

5

Ap

r-0

5

Ma

y-0

5

Jun

-05

Jul-

05

Au

g-0

5

Se

p-0

5

Oct

-05

No

v-0

5

De

c-0

5

Jan

-06

Fe

b-0

6

Ma

r-0

6

Ap

r-0

6

Ma

y-0

6

Jun

-06

Jul-

06

Au

g-0

6

Se

p-0

6

Oct

-06

No

v-0

6

De

c-0

6

Jan

-07

Fe

b-0

7

%


▪ 1 breach due to genuine clinical uncertainty, Clinician elected to observe

▪ 1 breach due to genuine clinical uncertainty

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6.0 Risks

In order for Service Improvement to become a main stream activity that is inbuilt into the fabric of the Trust’s processes, risks have been identified and graded by impact and probability. The future work plan can then incorporate necessary actions to overcome barriers where possible.

6.1 RISK LOG

IMPACT (where 5 is high impact and 1 is little impact)PROBABILITY (where 5 is highly likely and 1 is highly unlikely)

These scores should then be multiplied to give the risk factor. The higher the risk factor the more serious the risk poses to the Trust/HIP Programme.

Risk Imp

act

Pro

ba

bility

Ris

k F

acto

r

Action

Lack of identity for future of programme; is HIP a project? Or is it to become mainstream? If staff do not think it is main stream there is no sustainability factor and motivation decreased.

5 4 20 Need decision on funding of HIP for future. Need to re-brand HIP into Quality Improvement, which becomes part of the way we work.

Increase co-ordination and communication between work streams to ensure full integration of projects.

3 3 9 Shared folder on SDrive for all leads to review work plans for all work streams. Regular review and update meetings with HIP Manager to be scheduled.

Lack of communication and marketing concerning awareness of quality improvement programmes to front line staff.

3 2 6 Develop communication and marketing plan aimed at front line staff. Develop programme of short presentations on current work and progress.

Reporting mechanism not regular. Currently through Management Board.

5 3 15 Improvement Reports to Clinical Quality Committee on a regular basis.

Lack of wider audience/stakeholder engagement within work streams from internal environment. Same faces around the tables!

5 3 10 The need to engage with all grades of staff appropriate to project work. Thereby developing a wider culture of quality improvement, views and interest.

Failure to develop partnership working with external stakeholders and show tangible benefits for not concentrating on internal processes only.

3 3 9 Develop at least 3 partnership projects per year with small but relevant project objectives, where outcomes are show real tangible benefits.

Lack of patient and public involvement in improvement work.

4 2 8 Develop separate PPI work plan for Quality Improvement Work. One for each project work stream.

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Risk Imp

act

Pro

ba

bility

Ris

k F

acto

r

Action

Lack of presentation, reporting and sharing successes.

3 3 9 Develop Improvement Report Template to publish and share within Trust. Improves communication and shares progress.

Loss of funding for Manager and Analyst

4 5 20 Secure funding for posts to continue to build a Quality Improvement Team in order to maintain quality improvement as a main stream activity.

Insufficient administration support 2 2 4 Review administration requirements and support. Develop case of need if required.

Improve spread of clinical engagement into improvement work

5 2 10 Review current clinical engagement within work streams. Discuss capacity and motivations with Clinical Directors to recruit and increase clinical interest.

Lack of knowing where you want to get to – objectives need to be SMART

3 2 6 Need to impress on SMART objectives, can be achieved through Improvement Report Template.

Failure to understand and integrate affects on workforce; capacity, roles, motivation

4 4 16 Ensure workforce and organisational development components are integrated into all future work and evaluated at start/mid/end of project work.

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7.0 Co-ordination of Work streams

At present each work stream is working toward set objectives, mainly in isolation of other work streams. It is essential that each Lead is informed of objective, progress, constraints and outcomes of other related work streams. It is the role of the HIP Programme Manager to communicate and co-ordinate all programmes of work.

The diagrams below outline the relationships of work streams within each project area and their dependency on each other.

ReferralManagement

EPS Ser vice

Pacing Ser vice

Length ofStay

Cath Lab(angio/PCI)

Generic ReferralForms

Open ReferralSys tem

Pre-admission Admission/Daycase Discharge Planning NLD*

Daycase Ser vice NLD*

Efficiency Team Worki ng*

Efficiency Multi-Skilled Role* Team Worki ng*

Efficiency

Daycase Ser vice

Cardiology Dependency Network

* Organisational Dev elopment Projects

Cardiac Surgery Dependancy Network

Waiting listManagement

CardiacLength of Stay

Case Mix/Long Term Stay

Critical CareDischarge

Thoracic Development

Open referral system

Euroscoreutilisation

Pre-assessment

Admission Inpatient LOSDischarg ePlanning

MDT Development

Reduction inLTS

Reduce DelayedDischarge

Nurse extubation

NLD

NLD

Step DownFacility

ITU LOS

Task Dependancy:

Euroscore U tilisation - feeds – MDT Development – feeds – Length of Stay

MDT Development has not commenced

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ReferralManagement

Admi nistrationSupport

Thoracic Surgery

RALC

Support Services

Generic ReferralProformas

2ww Rul e“One Stop” Ser vice

New PatientsFollow-up Service

DGH Service 3 Trust Pathway

Cancer Tracker MDT Co-ordinator

Pathology

Open ReferralSys tem

Radiology

Cancer Dependency Network

Choose & Book

Secretaries Databases

Pallati ve C are

Upper GI Ser vice

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8.0 Work Plan

The table below puts forward the suggested work plan for the next 12months, which includes on-going actions from current work plans.

Work Plan Benefits

Redesign patient information process for cardiology – DGH to give out information.

Patient satisfaction and increased knowledge of services/waiting times.

Increased communication

Develop a referral criteria list for referrers (i.e. same as Directory of Service in CaB)

Correct investigations carried out before patient referred. Decreases number of inappropriate referrals.

Centralise referral management and appointment systems. Generic administration systems, greater efficiency and cover for absences. One point of contact for patients.

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Eliminate and reduce breaches by increasing usage of open referrals and pooled waiting list systems.

Eliminate and reduce breaches of waiting times. Increased access for patients.

Co-ordinated waiting list management and scheduling Waiting lists co-ordinated and scheduled by co-ordinators in order to avoid breaches and track 18wk pathway.

Review capacity and utilisation of Outpatient Services Organise capacity requirements to increase new outpatient capacity and decrease follow-up rates.

Ensure capacity is utilised efficiently.

Reduce un-necessary follow-up appointments Create additional new activity capacity.

Appropriate follow-up settings for patients (i.e. primary care or secondary care)

Decrease DNA rates in outpatient and inpatient setting. Increase capacity, reduce costs

Clear guidance for patients on policy.

Re-design pre-assessment clinics and consultant clinic flow.

Greater efficiency in system – reduce number of steps. Fewer appointments for patients.

Commence admission on the day for cardiac surgery. Reduce length of stay.

Eliminate un-necessary tests e.g. Echos Reduce costs. Reduce anxiety/waiting for patients.

Roll-out decreased Length of Stay programme. Assess all inpatient stay procedures.

Greater efficiency. Reduce patient stay, increase capacity, and reduce costs.

Implement new pre-admission processes. Patient centred process, ensure all procedures are carried out in one visit.

Roll-out discharge plans and increase nurse led discharges for appropriate procedures.

Reduced length of stay. Up skill and increase motivation of nursing staff. Free up clinician time.

Establish MDT for high risk cardiac surgery cases. Reduce long term stay patients.

Knowledge of high risk patients known. Case mix complexity can be assessed for theatre scheduling.

Evaluate operating room availability and efficiency Increase efficiency in theatres. Examine tasks involved in room turnover and patient preparation.

Increase availability and volume of cases.

Reduce total cost per case.

Improve outcomes for patients (shorter pump times)

Achieve 6hr extubation in Critical Care. Evaluate re-intubation rate.

Define parameters for re-intubation times and measures to see if increase in rate due to decreased extubation times.

Reduced LOS in critical care and overall LOS.

Reduce patient anxiety. Earlier mobilisation and ambulation. Increase satisfaction and comfort.

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Reduce clinician time.

In connection with 6hr extubation work, critically evaluate reasons for delayed discharges from POCCU, aim to achieve 70% of discharges by 11.00am

Reduced LOS in critical care and overall LOS.

Improve patient flow in system.

Evaluate possibility of “same day to ward” for critical care patients

Reduce LOS. Set out parameters for transfer to ward (e.g. 5%).

Lower ICU costs.

Improve patient and family satisfaction/emotions.

Assess re-admission rates for procedures targeted for reduced Length of Stay

Reduces costs if few re-admissions. Improved communication between organisations due to partnership working.

Evaluate EPS Pathway Identify bottlenecks, delays and constraints within system. Map out and action plan to reduce.

Evaluate ICD Pathway Identify bottlenecks, delays and constraints within system. Map out and action plan to reduce

Develop PPI work plan. Develop patient/relative diaries. Evaluate service from patient perspective. Powerful tool to improvement services that are truly patient centred.

Develop communication and marketing plan for future of improvement service.

Create an identity and understanding of service improvement within the Trust.

8.1 Targets to Achieve

At the end of 2006, KQI measures were evaluated and targets set out for 2007/2008. These are detailed in Appendix 2. The table sets out the measure and uses a traffic light system to indicate progress toward the target; this has been taken from February 2007 performance.

A positive start has been demonstrated in the achievement of the 2007/2008 targets with 21 measures set; 2 have already been achieved, 6 measures are at amber status thereby steadily working toward the set target, and 8 have not yet been achieved. 5 of the measures have not been established as these KQIs have only just been set out, are new to the HIP Programme of work.

9.0 Summary and Conclusions

As the HIP programme moves into the 2nd year, what is very clear is that there is still much more that could be achieved. The changes and benefits that have occurred during the past 12months have been a credit to the staff involved in the projects and the organisation as a whole for accepting change is necessary and needs to be part of the way we work.

Unfortunately what has not occurred yet within the organisation is “transformational change”, although the organisation is well on it’s way in a long journey. Our beliefs and culture are still quite traditional; we need to increase innovation and creativity in the way we provide services to our patients.

Service improvement needs to be seen as the “norm” and not as a “project”. The organisation will have to embrace continuous change, because without this, improvements will stall and may not be sustained. Performance only improves when people do things differently.

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The Trust has developed a new Clinical Quality Strategy, at the core of the strategy is improvement; be it in clinical practice, administration processes or patient care. Therefore it is imperative that “improvement” is imbedded into the organisation for this strategy to be successful.

The HIP programme has achieved many goals in the past year, but we need to be aiming higher with what may seem unrealistic goals; if we don’t strive for the best we will not even get to average. Continuous improvement is the cornerstone of the HIP programme, but in order to achieve this, the correct environment and resource need to be in place in order to sustain any achievements.

10.0 Recommendations

In order to continue to have service improvement as part of the way we work, we need to ensure that it is part of all employees KSF outline and objectives. Managers need to enforce and have a clear vision roles and expectations.

Managers at every level need to understand how “we do business” on the ground. Part of the problem is lack of understanding of everyday processes. The use of the Trading Places scheme is recommended to gain a knowledge of staff roles.

Develop a change management and service improvement training programme in conjunction with the Human Resources Training & Development Team.

Review of Business Plan, IBP Roadmap and Directorate Action plans to ensure HIP 2nd

year programme is aligned with overall business strategies.

Review work plan with Directorate General Managers and Associate Director for Clinical Quality to ensure direction and steer is appropriate.

Formulate bi-monthly 1:1 meetings with leads to support and assist with development of work plan.

Formulate quarterly KQI review schedule with all leads to ensure appropriateness of measures and data quality.

Evaluate target aims for 2007/2008, ensure we are “stretching” ourselves and not just ensuring we will achieve.

Detail performance using “traffic light system” against target aims in KQI reporting table each month.

Align Trust Board Length of Stay information with what is being produced through HIP programme to ensure synergy of knowledge and information.

Evaluate resources required to sustain service improvement as part of everyday business.

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APPENDIX 1

Key Quality Indicator Table

Health Improvement Partnership

Key Quality Indicators

Inclusion: All elective NHS patients

Area KQI Measure Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07

Cardiac Surgery Avg Post-Op LOS for CABG (days) 10.5 11.5 10.3 9.3 9.3 9.6 10.0 10.8 9.3 7.6 9.5Cardiac Surgery Avg Post-Op LOS for VALVE (days) 15.9 11.2 8.4 11.4 10.5 8.8 13.5 9.2 12.8 10.4 10.0Cardiac Surgery Avg Post-Op LOS for CABG&VALVE (days)

12.8 12.7 15.3 10.7 17.4 22.1 13.7 13.4 21.9 11.3 13.0Cardiac Surgery Postop >6days CABG 9% 10% 15% 35%Cardiac Surgery Postop >6days VALVE 10% 12% 14% 15%Cardiac Surgery Postop >6days CABG&VALVE 2% 5% 2% 0%Cardiac Surgery % of pre-assessments completed by procedure

ALL PROCEDURES 81.9% 87.1% 87.9% 90.8% 92.6% 84.0% 85.0% 95.2% 86.5% 88.0% 85.0%Cardiac Surgery % of pre-assessments completed for CABG

82.9% 91.8% 89.8% 92.9% 92.2% 84.0% 91.1% 97.1% 87.9% 91.9% 86.2% Cardiac Surgery % of pre-assessments completed for

CABG&VALVE 82.4%Cardiac Surgery % of pre-assessments completed for Valve

90.5% 87.0% 81.0% 90.9% 94.4% 90.0% 72.0% 96.9% 92.3% 88.9% 88.2%Cardiac Surgery % of pre-assessments completed for Other

Cardiac 50.0% 20.0% 85.7% 33.3% 0.0% 56.0% 33.3% 0.0% 25.0% 0.0% 50.0%Cardiac Surgery % of Open Referrals 19.0% 16.7% 11.6% 9.7% 8.9% 15.2% 15.6% 19.3% 15.5% 20.9% SH/MS

Cardiac Surgery Average Length of Intubation in CCA (hrs)

8.2 9.4 9.5 9.2 9.2 11.1 9.3 7.9 8.1 8.5 MSCardiac Surgery POCCU % Delay Discharges (by 11.00am)

0.0% 0.0% 31.7% 45.8% 51.9% 54.8% 58.9% 62.2% 55.9% 56.6% 65.2%

Cardiac Surgery No. of Long Term Stayers in ICU (>10days)7/129 4/123 4/152 5/123 5/132 5/128 5/120 5/121 8/109 2/129 n/a

Cardiology % of All procedures as daycase

35.0% 33.5% 48.8% 48.1% 44.3% 49.4% 55.6% 57.4% 53.8% 64.8% 63.5%Cardiology % of PM as daycase

5.9% 7.4% 3.2% 14.8% 0.0% 4.5% 17.4% 16.1% 15.0% 41.2% 20.8%Cardiology % of PCI as daycase

26.0% 34.1% 36.7% 32.4% 38.7% 48.2% 44.0% 56.7% 60.7%Cardiology % of EPS as daycase

81.0% 66.7% 70.8% 75.9% 60.7% 53.8% 68.2% 68.6% 50.0% 74.3% 60.0%Cardiology % of Angios as daycase

80.3% 78.5% 80.2% 69.8% 88.9% 79.1% 81.0% 78.9% 84.5% 77.3% 83.6%

Cardiology % of pre-assessments completedALL PROCEDURES 39.7% 45.3% 48.0% 49.4% 38.3% 44.9% 43.3% 52.5% 54.3% 72.0% 60.8%

Cardiology % of pre-assessments completedPCI 65.4% 62.1% 68.4% 68.9% 62.2% 60.2% 66.7% 72.2% 74.7% 76.3% 73.2%

Cardiology % of pre-assessments completedPacing 2.9% 3.6% 12.9% 10.7% 3.1% 12.5% 16.7% 25.8% 26.3% 47.1% 33.3%

Cardiology % of pre-assessments completed EPS 0.0% 0.0% 12.5% 6.9% 14.8% 16.0% 6.8% 11.4% 7.1% 67.6% 40.0%

Cardiology Follow-up Ratio 2:1 (exc pacemakers)2.2 : 1 2.3 : 1 2.2 : 1 2.1 : 1 2.8 : 1 2.4 : 1 2 : 1 2.1:1 2.3:1 2.4:1 SH/MS

Cardiology% Open Referrals for PCI SH

CardiologyAvg LOS fos ICDs only 2.4 4.5 4.1 3.8 2.3 3.5 1.9 3.4 3.1 1.7 1.9

Thoracic Surgery % of pre-assessments completed Major procedures 17.3% 38.1% 29.3% 18.2%

Thoracic Surgery % of thoracic cases as daycaseMinor procedures 66.7% 72.2% 53.8% 66.6% 76.2%

Thoracic Surgery POLOS Elective Lobectomy

9.0 9.9 7.3 6.6 8.7Thoracic Surgery POLOS Pneumonectomy

5.5 nil nil 11 15Thoracic Surgery POLOS Wedge Resection

6.3 4.9 8.7 4.5 6.2

Cancer31day wait from DTT to first treatment of cancer (%) 100% 100% 100% 93.0% 100% 82.6% 100% 100% 100% MS MS

Cancer

62day wait from urgent GP refrral to first treatment (%) 80.0% 87.5% 95.8% 94.0% 92.9% 92.9% 81.3% 82.8% 100% MS MS

Quarter 4

Service Under Development - data on PAS from mid Oct06

Quarter 1 Quarter 2 Quarter 3

under development/negotiation

under development/negotiation

21

Appendix 2

Service Improvement Target Measures for 2007/2008

Area KQI Measure Aim 07/08Cardiology % of routine pacemaker insertions (single/dual) as daycase 25%

Cardiology % of PCI as daycase 40%

Cardiology % of EPS as daycase 20%

Cardiology % of Angiography as daycase 95%

Cardiology % of pre-assessments completed for PCI 75%

Cardiology % of pre-assessments completed for Pacing 50%

Cardiology % of pre-assessments completed for EPS 50%

Cardiology follow-up ratio of 2:1 (exclude pacemaker) 02:01

Cardiac Surgery % of open referrals 30%

Cardiac Surgery Avg Post-Op LOS for CABG (days) 6days

Cardiac Surgery Average Length of Intubation in CCA (hrs) 6hrs

Cardiac Surgery % of patients discharged by 11.00am from POCCU 75%

Cardiac Surgery No. of long term stayers on ICU (>10days) Not set

Cardiac Surgery % of pre-assessments completed for CABG 90%

Cardiac Surgery % of pre-assessments completed for Valve 90%

Cardiac Surgery % of pre-assessments completed for Other Cardiac 90%

Thoracic Surgery % of pre-assessments completed by procedure 90%

Thoracic Surgery % of thoracic cases as daycases Not set

Thoracic Surgery LOS Elective Lobectomy Not set

Thoracic Surgery LOS Pneumonectomy Not set

Thoracic Surgery LOS Wedge Resectomy Not set

22

Appendix 3

Improvement Report Template

Improvement Report

This is a simple one-page summary report for detailing “improvements” in service provision.

These one-page reports are a standard, easy-to-understand way of summarising the organisation’s

work.

Improvement Objective: What are we trying to accomplish? State the objective clearly, including numerical goals. All objectives should be “SMART”; specific, measurable, achievable, realistic and time bound.

How does this objective link into Quality Strategy?All objectives should have a link to an Clinical Quality. Please define what Clinical Quality Dimension has been identified by ticking the appropriate box on the template. A summary of the dimensions can be found at the end of this report.

Key Quality Indicator (KQI): How will we know that a change is an improvement? Define and track a few basic measures to help the team know if the changes are having the intended effect—that is, if the changes are helping to achieve the stated objective.

Sampling Plan: What are the criteria for data collection? State the population for whom data are being collected and the duration of data collection. Explain any definitions or exclusions.

Graphic Display of a Measure: Make sure graphs are directly related to the stated objective. Plot data over time. All graphs must include the following: •Title Brief but explanatory description of the measure •Annotations Indications of which changes were made and when •Sample size The size of the population being measured per time interval •Axis labels x axis (horizontal) = dates of data collection y axis (vertical) = measure and unit of measure

Changes: What changes can we make that will result in improvement? Describe changes concisely and key them to the annotations on the graph. Include enough description to explain each change. For example, saying “Standardised pain management” isn’t as informative as saying “ICU nurses began using smaller, more frequent doses of narcotics to avoid over-sedation.”

Results: What progress was made toward achieving the objective? State what numerical goals were achieved and within what period of time.

Improvement Objective

Decrease overall length of stay, from admission to discharge, to 7days for routine elective NHS CABG patients

Link into Clinical Quality Dimension:

Efficiency Effectiveness Access

Patient Centred Equity Safety

Key Quality Indicator:Mean average of overall LOS for routine elective CABG.

Sampling PlanData was collected monthly for routine CABG patients from April 06. Pilot for reduced LOS commenced May 06 with 2 cardiac surgeons. All routine, elective, NHS & Private patients are included in the data collection.

ChangesAll patients to have estimated day/time of discharge calculated on day of admission, recorded in new discharge plan. Implemented late Dec 06.

All patients are mobilised early, using a newly devised “hearts” programme – measured walking distances daily. Implemented September 06

Implement nurse led discharge to expedite patients quickly on day of discharge. Implemented January 2007.

Roll out reduced LOS plans to all cardiac surgeons. Implementation Summer 2007.

ResultsIn January 2007 the average LOS for routine CABG patients was 8.2 compared with 10.8 in April 2006. As a result of saving 2.5days on CABG LOS, and reducing total number of bed days, this has contributed toward reconfiguration of wards.

Cardiac Surgery - CABG Length of Stay (Admission to Discharge)2006/07

10.8

12.1

9.9

10.510.7

9.910.1

10.8

8.2

10.6

UCL 13.0

10.4CL

7.8LCL

7

8

9

10

11

12

13

14

Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07

Average

(Days)


n=655 cases

Pilot commenced

Christmas Period

Discharge plans implementedNurse Led Discharge

early mobilisation

23

document 8a health improvement partnership programme part 1

Documents