18 Weeks Whole Pathways Project - National Priority Projects 07/08 Summary Document

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18 Weeks Whole Pathways Project - National Priority Projects 07/08 Summary Document
This summary document include descriptions, supporting information and key learning from the project. Details of each project site are available in the summary document, and are linked to the priority project online resource – an interactive tool that shares the learning across all project areas (Published June 2008).

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18 Weeks Whole Pathways Project - National Priority Projects 07/08 Summary Document

  1. 1. NHS NHS ImprovementCANCERDIAGNOSTICS Heart ImprovementHEART 18 WeeksSTROKE Whole Pathways National Priority Project
  2. 2. Delivering 18 weeks in cardiology was always going to?be one of the most challenging areas in the 18 week pathwaybecause it is a many headed beast. You have a number ofinvestigations and diagnostics to perform as well as definitivetreatment so it’s always going to be difficult. If you can deliver it incardiology you can deliver it anywhere.Dr Guy Lloyd, ?Consultant Cardiologist, Eastbourne District General Hospital
  3. 3. 18 Weeks Whole Pathways 3ContentsIntroduction 4Key Findings 6Project Summaries 10Lancashire & South Cumbria Cardiac Network – Redesigning the 11Whole Patient Pathway for Cardiology PatientsTrent Cardiac Network – Angiography Rapid Redesign Project 12Leicestershire, Northamptonshire and Rutland Cardiac Network – 1418 Week Whole Pathway ProjectSussex Heart Network – 18 Week Whole Pathway Project 17South West London Cardiac Network – Cardiac Surgery: Referral to 18Treatment in 12 Weeks (average) projectTrent Cardiac Network – Derby Hospitals Angioplasty Pathway Project 20Trent Cardiac Network – Tertiary Referrals Pilot Project for Cardiac Services 22Trent Cardiac Network – Reducing Waits for Cardiac Diagnostics 24Trent Cardiac Network – Partial Booking of Follow Ups Project 26Anglia Cardiac Network – Achieving 18 week Referral to 29Treatment pathways by March 2008Anglia Cardiac Network – 18 Weeks Whole Patient Pathway 32Data CaptureResources and Project Team Membership 35 www.improvement.nhs.uk/heart
  4. 4. 4 18 Weeks Whole Pathways Introduction To ensure that by 2008 ? The scope of the project covers the main ? no one waits more than 18 weeks from GP referral to hospital treatment. Operating framework 07/08: 18 week bottlenecks/constraints including: • • • • Outpatients (OPD) Diagnostics Secondary to tertiary care interface Some sites taking a whole pathway Priority 111: Access to services: PSA13 approach. This project has reviewed, identified and supported the practical implementation of I think that consultant buy-in is ? ways to reduce the waiting time from GP referral to definitive treatment, exploring in absolutely crucial to the success detail what really works. The specific project of the 18 week project but not aims and objectives have been to: surprisingly consultants vary in • Work with identified demonstration sites their views of the importance of within cardiac networks to capture this project. Were not going to learning get ten more consultants and • Implement a peer support action learning there is no new money so we’ll group drawn from members across the demonstration sites to facilitate the just have to think of ways to do sharing of ideas and solutions in order to this better, quicker, slicker and reduce duplication and to accelerate look to how we are actually improvement doing our jobs. • Develop a range of practical resources including demonstration site case studies to assist the wider health communities to achieve required sustainable improvements • Provide input and advice to the Department of Health (DH) 18 week Programme ? Dr Gordon Murray, Consultant Cardiologist and National Clinical Lead, NHS Heart Improvement In addition, a number of projects have looked at specific sub process issues team based on demonstration site particularly in relation to patient data, progress regarding issues, challenges and tracking and the Interprovider solutions with implementing 18 weeks. Administrative Minimum Data Set (IPTAMDS). The demonstration sites involve seven cardiac networks and some 25 NHS Trusts (including foundation trusts).www.improvement.nhs.uk/heart
  5. 5. 18 Weeks Whole Pathways 5Being part of a national priority project has been good in that its?helped people in the organisation feel really motivated. When theyachieve something like bringing waiting times down they get areal sense of achievement.now beginning to demonstrate: ?Julie Juden, Service Development Manager, Frimley Park Hospital NHS Foundation TrustWith the project into its 8th month sites are • Improved audit, monitoring and internal reporting processes • Shared learning of the practical• A significant release of slots and beds implications/ramifications of the into the system improvement initiative as a resource for• Reduced whole pathway waiting accelerating change. times (with certain sites showing significant reductions in referral to In conjunction with the demonstration treatment times (RTT times) sites NHS Improvement (which now• Streamlined clinical and incorporates the Heart Improvement administrative pathways Programme) has developed a range of• Improved communication between products and resources including: healthcare staff and patients• The development and testing of • Pocket clock start/stop cardiac pathway information systems to support the scenarios complete with RTT status code collection of IPTAMDS for RTT (including a indicators demonstrator site for web based tracking • An updated online interactive 18 weeks system) resource and• More efficient use of OPD and diagnostic • An interactive cardiac data dashboard clinic slots with corresponding falls in capturing the national data returns for DNAs and clinic cancellations RTT and diagnostic data.• Reduction in angiography and PCI waiting times with increased catheter lab In addition, products produced across the efficiency demonstration sites are being collated and• Improved patient experience catalogued as a resource for sharing with • Streamlined pre assessment and post the wider health community. These products procedure protocols complement the established demand and • Improved, more responsive patient capacity, statistical process control, and centred booking processes patient pathway analyser tools available via (diagnostics) the national team. A list of these resources • Efficiencies created via the introduction together with a brief summary and the of one stop/single assessment clinics relevant link(s) is available towards the end and rapid follow up slots processes. of this document. • Better informed patients particularly with regard to surgery The current projects are phased for • Reductions in bed usage with protocols completion from March 2008 onwards with allowing surgical patients to be work continuing with demonstration sites to admitted on day of procedure ensure delivery solutions are implemented • Improved equity in terms of waiting and that sustainability is in place. times with the removal of urgent, soon Consequently, the summaries that follow and routine classifications. only capture a proportion of the work to• Creative approaches to staffing and date. The resulting case studies and workforce issues associated resources (process maps, policies,• Potential for reductions in surgical examples of questionnaires etc) will be cancellations through improved multi available on the NHS Improvement website disciplinary team (MDT) working and as the projects are validated. consent processes. www.improvement.nhs.uk/heart
  6. 6. 6 18 Weeks Whole Pathways Key Findingswww.improvement.nhs.uk/heart
  7. 7. 18 Weeks Whole Pathways 7Our biggest challenges - one was accessing data, our PAS?systems across the trust are quite old and we weren’t ableto put our hands on good 18 week data. AnonymousKey findingsDuring December 2008 cardiac networks tookpart in a voluntary audit to survey the nationalpicture of 18 weeks - a cardiac stock take. Theaim of the stock take was to raise awareness, ? In this environment many projects or initiatives simply ground to a halt in the face of the myriad of competing pressures, priorities and agenda’s with local teams struggling with the size,demonstrate progress and inform national complexity and time needed to address the tasksstrategy with regard to implementation of the presented. Again this echo’s the experiences of18 week initiative. 87% of cardiac networks the cancer waiting time initiatives and thecompleted the survey, the results of which pivotal nature of a comprehensive strategy.acknowledge how complex and challenging 18weeks is as it seeks to deliver improved patient Its interesting to note that where gains haveexperiences and outcomes across diverse been made that the initial strategic catalystpathways, healthcare providers, and emanated from a variety of sources whether itorganisational environments. be SHA, commissioner, provider or network (top down, bottom up and everything in between).Summarising the learning itself becomes a Again this is evidenced from informationchallenge as the subject matter is equally diverse obtained through the network 18 week stockso for the purpose of this document only the take; 16% of approaches measured wereheadlines have been articulated. The 18 week attributed to network initiatives, 13% to wholeonline resource, developed by the NHS Heart health economy, 18% to provider with theImprovement Programme, provides top tips and remaining 7% being attributed to ‘other’.more detailed approaches in an interactiveresource that runs to over 150 pages so please It’s clear that truly inclusive health economyfollow the link at the end of this document. strategies, together with complementary operational plans delivered in time forExperiences gained from within the NHS Heart sustainability to be addressed will remain aImprovement Programme, across the challenge for the country as a whole.demonstration sites and findings from the stocktake have summarised critical success factors as Buy in, understanding, inclusivitybeing: and communication 18 weeks is such a wide ranging challenge that• Comprehensive shared strategy and plans for all staff need to understand what it represents to implementation the organisation, to patients, to customers and• Buy-in, understanding, inclusivity and of course to themselves. communication• Robust project management Successful initiatives have an overall vision to• IT system architecture and data collection work to and have worked though strategies for within 18 weeks creating the required understanding. Detailed communication plans are key to this – withComprehensive shared strategy and plans specific methods of communication beingfor implementation as a whole developed to mitigate risks (across the fullIt became evident in the early stages of the spectrum, individual, team, organisational andoverall priority project that the development of stakeholder) and which are threaded into thelocal 18 week strategy hadn’t been addressed in organisations strategic plan.any meaningful way. This is demonstrated by thefact that the priority project membership Robust project managementreduced by 40% over the six months to This requires highly visible leaders, a can doDecember 2007 with the root cause for this attitude and a willingness to challenge existingdrop off being the lack of an appropriate norms.mandated local strategy and implementationplan. www.improvement.nhs.uk/heart
  8. 8. 8 18 Weeks Whole Pathways Involvement with the project has helped us get the DGH and ? the tertiary centre to understand what’s important for each organisation, and get the clinicians together to decide and agree what should be done at each part of the pathway. Julie Juden, Service Development Manager, Frimley Park Hospital NHS Foundation Trust. Develop robust project management routines – ensure senior clinical/management involvement and ensure that projects become the business of the board. Ensure that the problem and scope of the project have been well described with data patient waits. While a great deal of data exists within organisations, this data can be fragmented, un-validated, activity focused and contained on separate, supplemental databases (such as PRISM, TOMCAT) often managed by ? (ditto the goal) and ensure that the ‘work before different departments. the work’ has been completed to assess the do ability of the project. A review of all existing data collection systems and databases with an aim to moving towards a Develop affective: strategy that enables these systems to add • Project teams ensuring appropriate team greater value by integrating with existing members with the requisite information to systems should be contemplated as a driver for allow them to buy in and commit to the change. Consideration should be given to who project. Commissioner involvement/ manages these separate data sources; use of a communication and finance involvement has common; user-friendly language across systems; become a prerequisite (particularly with regard linking and tracking patient episode data across to tariff, contract or organisational budget (and within) organisations using unique changes). Patient and carer involvement identifiers (NHS or HES identifier); linking to within the project to capture experience diagnostic data sources. encouraging patient led redesign • Communication and project risk mitigation PAS system developers should be involved at an plans early stage to consider additional field • Measurement and data collection plans and requirements or reusing of redundant PAS understand process performance (SPC) and screens. However, some of the initial and Demand and Capacity measures. Set baselines. ongoing data collection will require manual Process map and collect Voice of the customer intervention and will need to be resourced data. appropriately. The work will be intensive and • Ensure that solutions have been subject to require input from all staff groups within and pilot testing and have been subject to some across sites related to the specific pathway of form of Failure Mode Effects Analysis1 care. • Introduce process control routines/ dashboards and appoint a process owner It is important to understand the ‘real’ demand whose role it is to ensure that new processes and capacity (as opposed to just the activity) of a remain in control and that corrective action is service to enable improved service planning taken as appropriate. through modelling and gap identification. • Maintain project visibility – publish learning and successes no matter how small. Note that significant progress has now been made in the development and roll out of Examples of these are available on the processes and protocols that support NHS Improvement System at information that follows the patient through www.improvement.nhs.uk/improvementsystem their pathway. This includes solutions to the Inter Provider Transfer Administrative Minimum Data IT system architecture and data set together with the transfer of clinical data collection within 18 weeks and diagnostic imaging. Case studies describing One of the key success factors of any 18 week these initiatives are currently being worked up piece of work has been to establish good data and will shortly become available on the collection to accurately measure the reality of Improvement system. 1 Failure Mode Effects Analysis ensures that processes have been subject to stringent failure and risk mitigation testswww.improvement.nhs.uk/heart
  9. 9. 18 Weeks Whole Pathways 9Moving forwardSustaining 18 week cardiac pathways Collaborative working between NHS2008/09 and beyond Improvement (Heart Improvement Programme)The 18 week stock take2 conducted across all and the DH 18 week team together with othercardiac networks together with experiences key stakeholders will continue to progress thegained from the 18 week priority projects (and development of practical sustainabilitycancer 31/62 day waits ) has identified resources that will complement the existing suitesustainability as a major issue in holding 18 of resources found on the NHS Improvement.weeks post December 2008. website.The reasons behind this are complex but forthe purpose of this document can besummarised as: The peer support meetings have• Lack of cohesive local implementation plans and strategy for 18 weeks• Lack of any real redesign and a reliance of doing ‘more of the same’ rather than focussing on redesign across the whole pathway ? been extremely valuable for all sorts of reasons. I’ve been able to help them to a certain extent with my clinical input but equally I have learnt an• Increased operational and/or organisational pressures, especially in light of numerous ‘vital enormous amount from the signs’ identified in the Operational projects themselves they have Framework really been excellent and I’ve• Clinical engagement• Hugely variable IT system, data and patient been able to take home lots of tracking capability the ideas and implement them• Contingent capacity where process efficiency has been optimised. locally and that’s been very helpful for me personally andIn response to the factors outlined above the my directorate in movingcurrent 18 Week Whole Pathway Priority Projectwill extend its focus to the approaches required towards delivery of the 18to deliver sustainable cardiac pathways post week project.December 2008. The developing initiative will ?be supplemented with a spotlight on cardiac Dr Gordon Murray, Consultant Cardiologist andsurgery (elective and non elective). National Clinical Lead, NHS Heart Improvement ProgrammeThe intention will be that experienced membersof the 2007/08 Diagnostics Priority Project willjoin this revised project in order to fully capitaliseon the experience and expertise developedthrough the existing demonstrator sites.Additionally it is anticipated that there will be arequirement to develop a number of newdemonstrator sites as existing projects draw toan end.2 Cardiac Network 18 week stock take December 07 – a comprehensive strategic and operational assessment of approaches tothe target covering both current and planned activities within 26 Network health economies. For more information follow thelink on the NHS Improvement System. www.improvement.nhs.uk/heart
  10. 10. 10 18 Weeks Whole Pathways Project Summarieswww.improvement.nhs.uk/heart
  11. 11. 18 Weeks Whole Pathways 11Redesigning the Whole Patient Pathway for Cardiology PatientsLancashire Teaching Hospitals NHS Foundation Trust(Royal Preston Hospital and Chorley District General)Lancashire & South Cumbria Cardiac NetworkIssues to addressAfter mapping the various pathways forangiography, cardioversion and pacemakerimplantation it was clear that complete redesignof cardiology pathways were needed. Withoutthis patients would not be able to be treatedwithin 18 weeks, particularly for those whowere referred on for tertiary care.Baseline position• 12 week waits for first cardiology outpatients (OPD)• Separate waiting list for cardiac diagnostics often commenced after first OPD• Frequent cancellations of elective cardioversions if no available coronary care Key results/outcomes unit (CCU) bed or available anaesthetist • Referral to treatment times down to eight• No waiting list for cardioversion existed weeks• Frequent cancellations on pacemaker lists as all • All patients seen in one-stop cardiology clinics patients required beds on Friday • Dedicated sessions created for cardioversion• Considerable administrative delays for letters with managed waiting list and referrals. • Utilisation of catheter laboratory up 30% • Diagnostics pre selected by clinicalActions taken physiologists to ensure results available for• Established one-stop clinics for all four first OPD cardiologists • Treatment plan given and catheter lab• Redesigned diagnostic pathway booked at first OPD.• Located regular venue and anaesthetic sessions for cardioversion Contact information• Changed pacemaker booking from single list Kathy Blacker to end of angiography list to reduce Kathy.blacker@lsccn.nhs.uk cancellations due to lack of available beds• Trained clinical physiologists and receptionists to access Choose and Book and• Gained agreement from cardiologists for clinical physiologists to pre select diagnostics• Changed booking system for catheter lab procedures. www.improvement.nhs.uk/heart
  12. 12. 12 18 Weeks Whole Pathways Angiography ‘Fast Works’ Rapid Redesign Project King’s Mill Hospital Trent Cardiac Network Issues to address Waiting times for diagnostic angiography were found to be too long, with the waiting times between cardiologists showing high levels of variation. Additionally, the productivity of the catheter lab was not optimal with significant list size variation between consultants; unused slots during angiography sessions; under-utilised nursing capacity allocated to the catheter lab. Without improved productivity/increased activity in the catheter lab, the wait time would not reach the trust target figure. Baseline position available via the Improvement system website. Waiting time for a diagnostic angiography took A process map of the existing pathway was on average five weeks, with a range of 0 weeks developed and agreed and a large amount of to 18 weeks (data for five months March to July data analysis was carried out, presenting 2007). evidence of where there was some room for possible service improvements. Productivity of the catheter lab evidenced 75% utilisation over 12 months (May 2006 to May A patient survey was also conducted to gather a 2007). baseline of the existing angiography service The list size of each session showed a variation provided at King’s Mill Hospital from a patient ranging between one to six angiography perspective. A total of 50 patient names were procedures per list, with a mean of four. selected at random to be included in the survey, all of who had undergone angiography at King’s Based on a target minimum of four patients per Mill Hospital within the previous six months. session, there were found to be 244 unused The survey received an 86% response rate and a slots over 12 months to May 2007 and 44 lost detailed report produced outlining the findings lists over 12 months due to under-utilised is available via the Improvement website. nursing capacity allocated to the catheter lab. The throughput of the Lab in May 2007 was on Following the work of the time-limited project average 12 patients per week, based on four group, a two-day event was held inviting angiography lists per week. colleagues working within the trust, who had involvement in some way with patients requiring Actions taken angiography. Problems identified by the fast A ‘Fast Works’ rapid redesign project group was works project group were considered and established, comprising representation from recommendations/solutions agreed by attendees clinical and non-clinical staff working within, at the event. At the end of the two days, these or supporting the running of, the catheter lab. recommendations and related actions were An independent fast works facilitator and a presented for approval to a panel, comprising of member of the NHS Heart Improvement the Trust Chief Executive, Director of Nursing, Programme led the project group, supported by Consultant Cardiologist, Cardiology Manager, the Trent Cardiac Network. Nine (two hour) and the Divisional Manager. A number of weekly meetings of the group were held, during recommendations were approved by the panel, which problems with the existing part of this which have subsequently led to a number of patient pathway were identified. A Project service improvements. Charter was developed by the group which outlines the project in more detail and iswww.improvement.nhs.uk/heart
  13. 13. 18 Weeks Whole Pathways 13Key results/outcomes • Pre-assessment, including gaining of patientSeveral service improvements have been consent, is now carried out during theimplemented since completion of this project, patients’ OP clinic appointment, meaningwhich have led to a reduction in waiting times patients are available to fill slots at short noticefor angiography to a maximum of six weeks as (e.g. cancellations or additional clinics), whichat February 2008. Productivity and activity has led to minimised lost slotswithin the catheter lab has also increased, • Improved and standardised referral process,resulting in a minimum of four patients now with enhanced referral forms. Proposal for allbeing booked per list, often having a fifth or referrals for angiographies to be centrallysixth patient booked in as emergencies. Finally, coordinated by the Central Waiting List Officethe number of lost angiography lists has • Development of new patient informationsignificantly decreased due to the introduction leafletof ‘flexible rotas’. Over a recent six week period, • Introduction of a ‘catheter lab coordinator’nine out of 12 lists were covered, which would role to ensure communication is optimisedpreviously have been ‘lost slots’. This equates to within the lab, allocate daily responsibilities,an additional 36 routine angiography procedures ensure things run to time etcbeing scheduled during this time period, which • Increased turnaround times within theprior to the project would not have been carried catheter lab due to new pre-assessmentout. process, flexible working patterns of staff, improved communication within the lab,A summary of the changes that have resulted in improved audit systemsthese developments so far are: • Introduction of ‘flexible rotas’, resulting in catheter lab slots being utilised to maximum• All angiographies are now fully booked from capacity, with on-calls and leave covered by OP clinic appointment consultant colleagues wherever possible• Introduction of ‘partial pooled lists’ for • Development and introduction of a written angiographies, which has reduced patient competency based training package for waiting times and decreased the variation in cardiac nurses has increased the skill mix of waiting times between cardiologists (NB To nursing staff within the catheter lab, enabling ensure continuity of care, the treatment plan cross-cover and increasing utilisation of remains under the patient’s main consultant, it nursing capacity within the lab. is purely the angiography procedure that is pooled) Further examples detailing the ‘Fast Works’• An enhanced post angiography process means approach to rapid redesign project involving that, wherever possible, all results are Thames Valley Cardiac Network angiography discussed with the patient on the same day as and booking waits, and Leicestershire, the angiography (with their main consultant) Northamptonshire and Rutland Cardiac Network and next steps agreed reductions in unnecessary follow ups project can be found via the Improvement System. Contact information Jo Evans Joanne.evans@sfh-tr.nhs.uk www.improvement.nhs.uk/heart
  14. 14. 14 18 Weeks Whole Pathways Leicester Northamptonshire and Rutland Cardiac Network and University Hospitals Leicester 18 Week Whole Pathway Project University Hospitals of Leicester (3 sites) Leicester Northamptonshire and Rutland Cardiac Network Issues to address The time taken between original GP referral to date of procedure in cardiac surgery exceeded a year, for patients being treated within cardiology by PCI the journey time was around 28 weeks. This extensive wait was similar whether the patient had their entire journey within the tertiary centre or if the patient was initially investigated at a secondary centre and then referred onwards. Baseline position A retrospective baseline audit took place in June 2006 looking at 50 sets of patient notes including all treatment options and referral sources and repeated in October 2007. The Actions taken common bottle necks were identified as: The project was launched by raising awareness of the current bottlenecks and demonstrating • The administration time between actions, the current actual referral to treatment times which progress the patients pathway took an (RTT), in comparison with the target. In addition average of four weeks. For example, awaiting raising awareness of 18 week wait measurement typing and acceptance of referral letters or and associated rules. This was implemented receiving diagnostic reports. through posters, meetings and contact with • A 12 week wait for clinic with only a key staff culminating in a well attended proportion of diagnostics being pre ordered. multidisciplinary event on 28 September 2006 Poor co-ordination of diagnostic being where members agreed how to progress completed before the first outpatient towards an 18 week wait. appointment and results being made available on time. Process mapping took place along with demand • Diagnostics wait of 17 weeks (max) which and capacity calculations for each individual area didn’t always include the reporting time. of delivery along all of the cardio respiratory • A high percentage of patients were going patient’s pathways. This information quantified around the outpatient and diagnostics loop which bottlenecks would have the highest two to three times before the correct impact on delivering 18 weeks and indicated the information was assembled for clinical staff to order in which 18 week wait changes should be make a diagnosis and progress to treating the addressed. patient. This translated in some cases to a delay of as much as three to six months from The work was then divided into manageable original referral to initial diagnosis and a stages and staff assigned to working groups, treatment plan being agreed. with clinical, service improvement and a • The capacity to admit patients for treatment managerial lead. These groups looked at the: was stretched in addition initiatives were used to meet reductions of waiting time targets. • Primary care interface • Outpatients and diagnostics • Chest pain and valve treatment • Arrhythmia treatment • Paediatric and congenital • Respiratory • Thoracic pathways.www.improvement.nhs.uk/heart
  15. 15. 18 Weeks Whole Pathways 15To ensure continuity and cohesive working Initially the changes would be implemented inbetween the groups a steering group formed to adult cardiology because of the large patientoversee progress chaired by the directorate base and then tailored where necessary andgeneral manager. rolled out to other specialties and sites.Each group set specific goals, the example Key results/outcomesdescribed in more detail here is the highest The clinical annual and study leave policy wasimpact area, identified as the outpatient and updated and re established with clear processesdiagnostics portion of the patient pathway. The and monitoring. This meant that delivery areasaim was to deliver - referral to decision to treat were able to plan and protect capacity for the(or other outcome), inclusive of the outpatient next four weeks without change and theappointment and basic cardiac diagnostic testing associated delays or rescheduling.in less than four weeks. The waiting time for diagnostics has beenThis deliverable was further quantified as: reduced to six weeks through waiting list initiatives, validation, demand management and• Wait for an outpatient appointment of less recruitment drives. The reduction is continuing than four weeks down to two weeks, supported by ongoing• Deliver the majority of same day diagnostic demand and capacity work. The network has testing with a maximum wait of two weeks trained operational staff to calculate demand• Electronic diagnostic test management and and capacity within their own areas. Tests are shared cross site waiting lists booked upon request reducing the• Single assessment clinics administrative workload and providing patients• Reduce the number of follow-up patients to with a planned date. release outpatient capacity• Partially book follow-up patients to reduce A partial booking of follow-ups system has outpatient wastage been developed using the example of the• Protected capacity for a minimum of four Sherwood Forest Hospital pilot (outlined on weeks through a clinical annual leave policy page 22 - Partial Bookings of Follow-ups.• Deliver preadmission in clinic on day of Implementation was delayed due to trust wide decision to treat including fully booking the 18 week wait planning but will be delivered in admission date. May 2008. It is expected to reduce the number of wasted appointments which will release capacity for the single assessment clinics. For the network as a whole A change to the diagnostics IT system is under? the different trusts are now ? looking at pre planning tests as much as they possibly can. way; this will enable more staff to access diagnostics information about appointments and results. It will deliver better co-ordination between tests and outpatient appointments but also allow the diagnostics waiting lists to be shared across the three delivery sites. This reduces the waiting times and improves equity of access. Elaine Kemp, Cardiac Service Development Manager, Leics, Northants & Rutland Cardiac Network www.improvement.nhs.uk/heart
  16. 16. 16 18 Weeks Whole Pathways Preadmission services have been redesigned to The changes at Leicester are being supported deliver medical preadmission on the day of the through the cardiac network by sharing learning patient’s outpatient appointment. With the from trusts such as Kettering, who have option of further psychological support and implemented outpatient and diagnostics information either on the same day or later changes, Sherwood Forest with their successful before admission. This means patients are partial booking and in turn the learning at prepared earlier for admission reducing Leicester will help support the Northampton cancellations. It is planned to fully book team in developing their single assessment pilot. admissions once the preadmission changes have been embedded. Contact information Elaine Kemp Single assessment clinics have been trialed over Elaine.Kemp@northants.nhs.uk 17 clinical sessions with 84 new and 230 follow- up patients. Most tests were pre planned however on the day 54 patients were put forward for an additional 63 diagnostics; echo, ETT and Tapes. All patients were given the opportunity to stay and have tests on the day or return at a later date, only one patient declined. 40 out of the 63 diagnostics were completed on the day; those not done were due to the timing of the diagnostics working day compared to clinic appointments which can be resolved. 16 out of the 54 patients using the single assessment clinic were discharged and five patients were given a decision to treat of admission. Single assessment clinics will deliver a reduced waiting time for patients, less visits to the hospital and additional capacity in clinic. Implementation of all the above changes will deliver the aim of a four week wait, the project unfortunately has overrun due to operational pressures and several changes in the trust management team. It is projected that single assessment clinics, preadmission changes and partial booking will be implemented before June 2008. The less quantifiable change which will help deliver 18 weeks is the move from a culture in diagnostics and other delivery areas, of using waiting lists to flex the amount of work delivered to match the capacity which is available. Now the capacity is being flexed to match the amount of work required to deliver the waiting time on a shorter pathway.www.improvement.nhs.uk/heart
  17. 17. 18 Weeks Whole Pathways 1718 Weeks Whole Pathway - SussexEastbourne District General Hospital, Royal Sussex County Hospital(part of Brighton and Sussex University Hospitals NHS Trust), HailshamPractice Based Commissioning (PBC) ClusterSussex Cardiac NetworkIssues to address• Need to achieve 18 week target for cardiology and cardiac surgery patients from the Eastbourne area. Delays and bottlenecks were contributing to the target not being met.• Need to demand manage referrals from primary care to sustain 18 week target when achieved.• Waiting times had hidden elements in them as GP to acceptance on waiting list was not being recorded.Baseline positionAt July 2007:• Maximum wait for new outpatient appointment was 11 weeks Key results/outcomes• Maximum wait for diagnostic echo was 26 • At EDGH 85% of all patients are being weeks referred and treated within 18 weeks• Maximum wait for angiogram was 19 weeks. • New referral pathway has been rolled out to other referring DGH’s.Actions taken• Extra activity to address backlog Cardiac surgery waits are reducing and they now• Following an assessment of demand and include the hidden waits. capacity extra investment was made into equipment for 24 hour testing Contact information• Development of a triage clinic in secondary Lisa Fairclough care to triage referrals from primary care. Aim Lisa.fairclough@bsuh.nhs.uk is to reduce unnecessary consultant outpatient appointment, facilitate direct access to diagnostic investigations e.g. angiography and refer patients back to GP with a management plan if no intervention required• Develop a proposal for a community cardiology service in one area of Eastbourne. Service to be run by a GP with an interest in cardiology and clinical governance arrangements support from secondary care. Aim is to for all cardiac referrals to be sent to the service and following assessment, the GP will either refer on to secondary care immediately or undertake some diagnostics tests in community and then refer back to original GP with a management plan or refer onto secondary care.• Process mapped the referral pathway for cardiac surgery. A new pathway was developed. All referrals are now faxed or emailed the same day as the diagnostic investigation. Referral is actioned on receipt by the waiting list office and an OPA made within 48 hours and occurring within two weeks. www.improvement.nhs.uk/heart
  18. 18. 18 18 Weeks Whole Pathways Cardiac Surgery: Referral To Treatment in 12 Weeks (Average) Frimley Park Hospital St George’s Hospital South West London Cardiac Network Issues to address According to an 18 week pilot study conducted at St Georges Hospital in 2006 by the South West London Cardiac Network, patients (n=5) referred from Frimley Park Hospital waited up to 54 weeks from initial referral (18 week clock start) until treatment at St Georges Hospital (clock stop). Data collected since the project started indicated that average referral to treatment (RTT) times was about 30 weeks on average (n=24). In addition, anecdotal reports of poor communication between the two organisations, one indication of which was the poor performance in terms of sending discharge A comprehensive cardiology redesign workshop summaries to the secondary centre after patients was held at Frimley Park Hospital in June 2007. had completed their course of treatment at the As a result the following changes were made: tertiary centre. Also, there were problems in terms of administrative process delays (with (1) Direct booking for angiography and pre- patients sometimes being ‘lost’ in the system), assessment from outpatient clinics was and moving patients to the next stage of instigated treatment. (2) Rapid follow-up slots and more one-stop clinics were introduced Actions taken (3) The trust admissions team was made The project started officially on the 20 March responsible for booking all diagnostic tests 2007 at the first steering group meeting and is and procedures (treatments) in the catheter due to end on the 31 March 2008. Below is a laboratory selection of improvements made to date. (4) An induction to cardiology was introduced for junior doctors at each rotation From March 2007 demand and capacity analyses (5) Diagnostic waiting times are monitored on a were undertaken at Frimley Park Hospital and weekly basis strategies were identified to reduce the backlog (6) The multidisciplinary team (MDT) meeting of patients waiting for diagnostic tests, was redesigned so that all necessary outpatient appointments and inpatient diagnostic tests are performed before the admissions. Work was also done to ensure cross- patient is seen jointly by the cardiologist and cover by staff at critical steps in the pathway, surgeon. Test results and treatment options and to identify the flow of patients and time are discussed and a treatment plan agreed requirements for each component of the with the patient. A dedicated administrator pathway. is responsible for ensuring the efficient coordination of the joint cardiac clinic and At the first steering group meeting an elective handling onward referrals to the tertiary cardiac referral form was devised and agreed. centre. Frimley Park Hospital started using the form in May 2007 and it has since been through several Mapping of clinical and administrative processes modifications, most recently to reflect the has taken place at St George’s Hospital over the publication of DSCN 44/2007 in December lifetime of the project, and systems put in place 2007. to facilitate the reliable transfer of referral data and early booking of patient appointments.www.improvement.nhs.uk/heart
  19. 19. 18 Weeks Whole Pathways 19The cardiac network decided to do a joint project between two main?hospitals to look at the cardiac surgery pathway. We started off from abaseline of 32 weeks on average, that’s the time from when the patient isreferred by the GP until they actually have their surgery in a tertiary hospital.Adrianne van Heerden, Service Improvement Manager, South West London Cardiac and Stroke Network ?Plans have been initiated to pre-assess all cardiac trust to admit patients on the day of theirsurgery patients so that they can be admitted on procedure, rather than the day before, therebythe day of surgery rather than the day before. saving valuable bed days.An 18 weeks training workshop was held forcardiac secretaries at St George’s Hospital, and a St Georges Hospital performs around 1,150 cardiacprocess will be trialled where they will email surgery procedures per year, and could thereforedischarge summaries and 18 week referral forms potentially save this number of bed days per year.(with clock stop dates, where appropriate) back As patients are better worked up at the secondaryto the referring organisations. centre in advance of transfer for surgery, we expect the number of surgery cancellations to decline, asKey results/outcomes patients unfit for surgery will not be transferred.Patients are having their initial contact with aconsultant much sooner than before the project Since tertiary care clinicians can access diagnosticstarted (now within four weeks), and the images at the secondary centre directly via NHSdiagnostic tests required are now sometimes done extranet, extra slots for echos, angiograms andon the same day, or at most within a few weeks of dopplers will become available at the tertiary centrerequest. (The internal target set is two weeks for as the need for repeat diagnostic tests are reduceddiagnostic tests. This is being achieved in most in number.instances, and plans are being put in place toensure these waiting times can be sustained.) This Both Frimley Park Hospital and St George’s Hospitalallows the clinician to make a diagnosis much are aiming to complete their part of the cardiacsooner and develop a treatment plan with the surgery pathway in an average of six weeks, giving apatient. Patients are better informed about the total journey time of 12 weeks (on average). Datasurgery pathway and the number of visits they analysis to date suggests that the average referral toneed to make to St George’s Hospital has been treatment (RTT) time has reduced from 32 weeks (onreduced by redesigning the multidisciplinary team average) to 9.4 weeks (on average) since the projectmeeting at Frimley Park Hospital. We believe this has started. This has had a positive effect on staffresulted in a better patient experience and we will morale, as they can see the results of their hardgive patients the opportunity to feed back by means work and experience the satisfaction of providing anof a patient questionnaire in the near future. improved patient experience.The redesign work has also benefited the NHS Contact informationorganisations involved. St Georges Hospital is Adriaan van Heerdenmoving to a position where all cardiac surgery adriaan.vanheerden@stgeorges.nhs.ukpatients attend pre-assessment. This will enable the www.improvement.nhs.uk/heart
  20. 20. 20 18 Weeks Whole Pathways Derby Hospitals Angioplasty Pathway Project Derby Hospitals NHS Foundation Trust Trent Cardiac Network Actions taken A planning workshop, followed by two further workshops, was held with attendance from cardiologists, cardiac clinicians and other clinical and non-clinical colleagues working in or alongside the catheter lab. The workshops were led by the Trent Cardiac Network and resulted in the development of a robust action plan, which was taken forward and implemented by all relevant members of the cardiology team working in the trust. To support the progress of implementing the action plan, ad hoc meetings were held as necessary to focus on moving specific issues forward. This included meetings with IT, cardiology secretaries, cardiology managers, attending the cardiologists’ monthly meeting etc. The cardiac network maintained a regular record of progress against the action plan throughout the project period. Issues to address In addition, at the start of the project nine sets The trust 18 week steering group collected data of patient notes were scrutinised to map actual to determine the high priority areas to focus on patient pathways. Findings from this work with regards to ensuring compliance with the 18 reflected the issues raised during the process weeks initiative. The angioplasty pathway was mapping exercise, highlighting key areas for identified as one of these key areas, having a improvement. A further 12 sets of patient notes comparatively low achievement rate in respect of were again scrutinised at the end of the project the 18 week target. to provide a robust comparison of where service improvements to the patient pathway had been After initially process mapping the patient made. pathway, it was identified that activity relating to referrals to or from the catheter lab was one of Key results/outcomes the key areas for concern. • Several service improvements have been implemented since completion of this project, Baseline position which have led to a reduction in waiting times Catheter lab waits peaked at a maximum during for angiography and PCI procedures, early August 2007, around the beginning of the consequently reducing the overall length of project, with patients waiting up to 17 weeks pathway for this set of patients for angiography and up to a further 15 weeks • As at the beginning of March 2008, the for their angioplasty procedure. maximum wait time for angiography from date of listing had reduced to six weeks, with As at January 2007, 44% of angioplasty (PCI) five weeks being the maximum for PCI. The patients were recorded as receiving treatment percentage of patients being treated by PCI within 18 weeks of initial referral*. This within 18 weeks of initial referral increased instigated the establishment of this project. to 65% * Using most accurate data available at the time, acknowledging limitations of existing IT systems in recording and reporting 18 week clock statuses.www.improvement.nhs.uk/heart
  21. 21. 18 Weeks Whole Pathways 21• The changes that supported and influenced • Introduction of outcome forms in the the improvement of the angioplasty pathway catheter lab, recognising that clocks could at Derby include: potentially start, stop or keep ticking at • Clinical and non-clinical engagement from point of angiography. This supports more the outset, including consultant accurate recording of RTT data cardiologists, managers, nurses and admin/ • Robust audit, monitoring and internal clerical staff. All members took ownership reporting processes re waiting lists. of relevant issues / actions which strongly supported the success of the project. Contact information • Equity for patients requiring angiography Jo Evans (removed inappropriate use of ‘urgent’ from Joanne.evans@sfh-tr.nhs.uk RACPC and individual consultants, which resulted in more appointments becoming available for the routine referrals and, therefore, these could be seen more quickly) • Admin delays removed for ‘discussion patients’ wherever possible when interventionalist on site. Most cases are now discussed and treatment plans agreed directly with the interventionalist working on that particular day, rather than awaiting a monthly meeting or writing to a specific consultant for opinion • Improved post angio process – patient letter template developed for those patients whose treatment plan cannot be agreed on day of angiography. Removes the need to bring the patient back for follow-up outpatient appointment just to inform them of the outcome (reduces length of patient pathway and frees up follow-up outpatient appointments) • Raising registrars’ awareness of 18 weeks has led to improved efficiency in reviewing of diagnostic results process - now checked a minimum of twice a week as opposed to previously checking once a month • Retraining of staff (both internal and external to the trust) to ensure that new referrals for OP and/or diagnostics are correctly addressed and delivered, consequently reducing administrative delays • Exercise tolerance test (ETT) request forms updated – enable direct referral for angio following positive ETT (removes the need for patients to attend outpatient appointment, again reducing the length of patient pathway and freeing up outpatient appointments) www.improvement.nhs.uk/heart
  22. 22. 22 18 Weeks Whole Pathways Tertiary Referrals Pilot Project for Cardiac Services King’s Mill Hospital Nottingham University Hospitals Trent Cardiac Network Issues to address The national Inter Provider Transfer Admin Minimum Data Set (IPTAMDS) was developed to support the efficient management of patients whose pathways involved an inter-provider transfer, in particular facilitating the transfer of the necessary data to enable receiving providers to meet their mandatory Referral to Treatment (RTT) reporting requirements. Trusts were advised that implementation of the MDS would be mandatory from 1 January 2008. Locally, it was recognised that preliminary work needed to take place in order to ensure sufficient and accurate collection, recording and ‘accurate as possible’ information using the data transfer of the MDS information. Work needed available on the existing PAS electronic database to take place to identify: or manually looking through patient notes. • Where the relevant RTT data could be found Actions taken • The ease of this data collection A specific time-limited project group was • Who would be best placed to complete the established, with representation from Sherwood MDS forms/receive completed MDS forms Forest Hospitals NHS Foundation Trust (SFHFT), • How they would be best transferred across Nottingham University Hospitals (NUH) and Trent sites, for example, electronically, by post, fax Cardiac Network. Members of the group agreed etc. project aims and objectives including how the MDS data would be collected transferred and by The trusts would also need to move away from whom, along with the key outcomes to be focusing on the previous ‘stages of treatment’ monitored and reported on at the end of the and individual hospital responsibilities, working project. Data monitoring commenced on 1 together to provide one smooth patient focused October 2007 for two months, with a final pathway of care. review process in December 2007. Regular communication was maintained and project Baseline position group meetings continued throughout the Prior to the publication of the MDS, there was project period. no standard referral information specified for inter-provider referrals between these hospital The project focused solely on those patients sites, particularly with regards to data relating to being referred from King’s Mill Hospital (KMH) the 18 week whole patient journey. The (acute trust) for tertiary cardiac care at individual trusts and hospital sites worked Nottingham University Hospitals (NUH) (Tertiary towards their specific targets for their individual Centre). All referrals were captured via the stage(s) of treatment and did not provide any catheter lab at KMH following angiography and related waiting time or complete pathway included only those being referred on for referral data when transferring to another selected treatment, namely angioplasty (PCI) or provider. surgery (CABG). Patients referred to the tertiary centre for diagnostics were not included in this Because the above data was not being provided project. across sites, specific 18 week pathway information could not be monitored for this set The pilot focused on the specific stage within of patients. Also, existing IT systems did not the patient pathway, when the patient’s care provide the facility to enable such information to was transferred from the secondary to tertiary be recorded accurately. Trusts were capturing as care centre. It was agreed that any issueswww.improvement.nhs.uk/heart
  23. 23. 18 Weeks Whole Pathways 23 Example of an 18 week pathwayidentified at either side of this should be transfer of the MDS and clinical referraladdressed locally by the relevant trust outside information, method of collection of robust RTTthe project group. data, dealing with referrals for diagnostics, and ‘roll-out’ to other specialties or trusts.In addition, members of the project groupacknowledged the local commissioning targets The actual lengths of patient pathways, fromthat were hoping to be achieved by March 2008 referral to treatment, were accurately capturedand, with this in mind, the information collected by manually scrutinising patient notes. Thisthroughout the project was used to trace and enabled key areas for any breaches to the 18manually plot care pathways for all patients week target to be identified and reasons forincluded within the pilot project, identifying time these delays to be addressed. Using the actualtaken between each stage of treatment and any patient journeys that were mapped, examplerelated delays. pathways could be developed to help provide clarification around clock starts and stops.Throughout the two-month project period,27 patient pathways were monitored, with A full report detailing the project approach,respective MDS forms completed and issues, findings, recommendations and ‘roll out’electronically transferred from KMH to NUH. have been produced following this project and shared across Trent Cardiac Network. ExampleKey results/outcomes pathways, developed as a result of plotting realThis project enabled data completeness of the patient journeys, have also been shared acrossMDS forms to be monitored, highlighting which the network.data requirements were difficult, or even notavailable at the time of the project, for collection As a result of the work carried out within this(e.g. due to awaiting implementation of PAS project, both trusts are able to use the findingsv20). A list of concerns / problems was recorded to support implementation of the MDS across alland all issues were fed back to the relevant trust specialties. The project outcome also identifiesfor them to locally agree next steps and action key areas for further service development workpoints, in order to address the problems and within cardiac services, both locally and workingensure pathways were reduced to the shortest across provider sites, in order to achieve the 18clinically appropriate. week initiative. Other trusts within the network are also now using the project report to supportA series of recommendations was also produced, their implementation of the MDS.learning from any difficulties encountered aspart of the project. These mainly related to Contact informationensuring efficient and effective preparation and Jo Evanscommunication prior to implementation of the Joanne.evans@sfh-tr.nhs.ukMDS, selecting the most appropriate method of www.improvement.nhs.uk/heart
  24. 24. 24 18 Weeks Whole Pathways Reducing Waits for Cardiac Diagnostics Sherwood Forest Hospitals NHS Foundation Trust Trent Cardiac Network many patients waiting up to two months or more from referral, particularly for echo. A workshop was held with all available members of the cardio respiratory team, using this data as a baseline. During the workshop a process map, reflecting the current referral to diagnostic process, was produced, following which problem areas were identified and suggestions for improvement made. As a result of the workshop an action plan was developed. In addition, the cardio respiratory manager worked closely with the Information Services Department to ensure relevant referral and waiting time data was received on a weekly basis. This enabled the department to move to Issues to address a more demand led service, which historically The maximum waiting time for some of the high had been more staff led. volume cardiac diagnostics was found to be too long. In order to improve patient experience, Significant work was carried out during and for patients to realistically achieve an 18 December 2007 to clear any backlog within the week care pathway, these waiting times needed system. All staff training for that month was to be reduced in line with Trust targets, which cancelled and clinical time maximised across the aimed for a maximum wait of four weeks for department. Use of all diagnostic slots was any diagnostic test by March 2008. maximised, with the administration team ensuring that all efforts were made to fill Baseline position cancellations as soon as they became apparent. In September 2007, echocardiography waits Any available slots in one service that had a were at around nine weeks, with doctor led ETT minimal waiting list would be converted to maximising at 10 weeks and other high volume accommodate another e.g. additional echo slots cardiac diagnostics not far behind. if trained staff available. NB. Dobutamine Stress Echo’s (DSEs) were Key results/outcomes recognised to be of comparatively low volume in The maximum wait time for any cardiac relation to the number of referrals received for diagnostic (excluding DSEs) as at the beginning other diagnostics and, although waits for this of February 2008 had reduced to three weeks, test were also too long, it was agreed that this which was actually less than the Trust target of area would be picked up as a separate project four weeks. (currently making significant progress). Due to the changes made within the Actions taken department, and the cardio respiratory manager Data was collected from within the cardio and team adapting to a new way of working, it respiratory department for the five high volume is anticipated that this short wait time will diagnostics (i.e. those receiving the most continue to be sustainable for the future. The referrals), which were 24hr BP, 24hr ECG, event new systems will ensure that clinical time recorders, echo and exercise tolerance testing continues to be maximised and that the (ETT). This data demonstrated that an average department continues to run as a demand led of around four weeks wait for patients was service. Information Services now provide data actually being achieved for many of these on a weekly basis, which enables the diagnostics, but evidenced a huge variation with department to continue to be demand led.www.improvement.nhs.uk/heart
  25. 25. 18 Weeks Whole Pathways 25More flexible working within the departmentand smarter working patterns enables capacityto be maximised, with all team members nowbeing aware of waiting times and targets.Cancellations continue to be filled whereverpossible by the administration staff andcompressed hours of some of the clinical staffare worked to advantage the department, byproviding additional slots at the beginning andend of the day for additional patients, or foranalysis and reporting work to be carried out.In addition, the two trainee staff have veryrecently qualified which has enabled capacity tobe extended. The more senior staff, who wouldpreviously have worked to support the trainees,are able to see patients separately whilst thenewly qualified staff can work withoutsupervision. The cardio respiratory assistant rolehas also been expanded to provide additionalcapacity within the department.Patients are now seen much quicker followingreferral for cardiac diagnostics. This meanspatients, and their carers, have less time tobecome anxious and are able to reach adiagnosis much sooner than before.This improvement has increased efficiency withinthe cardio respiratory department and has led tosignificantly reduced waiting times supportingthe trusts achievement of the 18 week initiative.These reduced waits at King’s Mill Hospital havealso provided the opportunity and additionalresource to progress towards achieving similarresults in relation to cardiac diagnostic waits atthe Newark Hospital site.Contact informationJo EvansJoanne.evans@sfh-tr.nhs.uk www.improvement.nhs.uk/heart
  26. 26. 26 18 Weeks Whole Pathways Partial Booking of Follow Ups Sherwood Forest Hospitals NHS Foundation Trust Trent Cardiac Network Issues to address There were found to be 1081 DNAs over the Trent Project ‘Cardiac Service Improvement’ same period, from 1 December 2004 and 30 (‘CSI’) was established as an initial response to November 2005, with 82% of all DNAs the 18 week wait target, which brought occurring from follow ups. together team members from Sherwood Forest Hospitals NHS Trust, the Trent Cardiac Network Planned clinic capacity was running at 64% and the National Heart Improvement utilisation prior to the project. Programme. The project aimed to deliver improvements that would make a contribution Actions taken towards achieving the target within cardiology An analysis was undertaken of the reasons for and one of the key problem areas identified was cancellations occurring more than six weeks the system for booking follow up outpatient before the appointment date. Most were due to appointments. the unavailability of medical staff due to annual leave, study leave or on-call commitments. A The booking process for follow up patients was new trust leave policy was consequently found to be inefficient, with patients being introduced, stating that a minimum of six weeks “fully” booked too far in advance (3, 6 or 12 notice was required. In line with this, clinic rotas months). This led to high DNA and cancellation and on call rotas were scheduled only six weeks rates, as well as to lots of rescheduling every in advance, rather than for several months, time an outpatient clinic was cancelled or enabling capacity to be more flexibly planned to reduced. The service was driven by the demand ensure clinics were always covered and, for new patient appointments, leading to follow therefore, removing the need for cancellation or up patient capacity being ‘squeezed’. This could rescheduling of clinics. result in patients being seen long after their ideal review date, often further delayed by A ‘go live’ date was set and publicity campaign having appointments moved forward due to launched via local hospitals and media. Initially, clinics cancelled or patients forgetting their almost 3000 appointments were cancelled, advance appointment and therefore not which had been scheduled for patients in attending. advance of six weeks. Each patient was sent a letter explaining why their appointment had As a consequence, consultants were unable to been cancelled and informing them of the follow up patients in a timely fashion according process via which their next appointment would to clinical need. The management of these be booked. A leaflet explaining and follow-up patients was not optimal and the highlighting the benefits of the new partial follow up to new ratio did not use resources to booking process was included. This process the maximum efficiency. resulted in less than 10 patient complaints. Baseline position The partial booking system worked by patients Between 1 December 2004 and 30 November requiring follow up more than six weeks in the 2005 there were 5397 cancellation events within future being partially booked and given a Partial the cardiology outpatient service. 4092 of these Booking Information leaflet. These patients cancellation events occurred more than six were added to a review list on PAS and allocated weeks before the appointment date. 1305 of a review date. Six to eight weeks before the these cancellations occurred less than six weeks review date a letter was sent to the patient, before the appointment date. inviting them to telephone to arrange an appointment. Non-responders were telephoned The follow up ratio was at 1 new to 2.57 and if no contact was made the case was (including RACPC) follow ups, with a range of referred back to the consultant for them to between 1:2.7 and 1:5.75. decide whether to discharge the patient or refer them back to their GP.www.improvement.nhs.uk/heart
  27. 27. 18 Weeks Whole Pathways 27Multidisciplinary slot management meetings • By January 2007, waiting times fell despitewere held every two weeks, which contributed increased referrals, indicating more efficientsignificantly to monitoring and improving the use of clinic capacityefficiency of the booking process. Related • There was the potential risk that follow-uppolicies and procedures were reviewed and ratios would increase with easier access, butupdated accordingly throughout the pilot period. this was not the caseAn electronic outpatient request form was also • Although the percentage utilisation of clinicintroduced. slots had not changed by the end of the project (remaining at 64% utilisation), theKey results/outcomes underpinning organisation of clinics wasDemand management for clinic appointments is improved with over bookings no longernow driven by the total demand in the system, occurring, a reduction in DNAs evident andnot just new patients. Those requiring a follow fewer patients having appointmentsup appointment within six weeks are generally rearranged. The clinic volumes are morethe first call on resources, with the second call predictable and so run more smoothly.being for follow ups coming up to review date(agreed boundaries are in place on what is an The project anticipated a further positive resultacceptable variance to review date, + or –). in that all follow up patients would be able toFinally, the remaining capacity is pooled on be seen when clinically appropriate and in broadchoose and book as new patient slots, with a chronological order by the end of the project,conversion ratio of two follow up equivalent which would then be sustainable.slots to one new patient. This system of slot Unfortunately, due to numbers of patientsmanagement now avoids under booking of exceeding the existing maximum overall clinicclinics due to unfilled new slots, as could have capacity and the pressures for new patients tohappened with the previous system. be seen without delay, there is currently insufficient space in clinics to ensure that this isThe key results and outcomes from this always the case and, therefore, the number ofproject include: follow ups outstanding is higher than desired as at March 2008. However, the way that these• A dramatic reduction in cancelled follow ups are being monitored and managed appointments (hospital and patient driven) – has dramatically improved as a result of the no follow up events cancelled more than 6 project, enabling this issue to be highlighted as a weeks before appointment as this is no longer priority area and providing evidence for a possible. Cancellation rates also reduced for solution to be identified and implemented by new appointments, from 13% in November the trust as a matter of relevant urgency. 2005 to 2% in September 2006.• An increase in patient choice with regards to To date, the project has brought many benefits time / date of appointment to both patients and staff working within the• A 50% improvement in DNA rates was trust. Patients have an improved experience demonstrated by the end of the project, with no cancellation of appointments and thought to be directly attributed to partial improved choice of follow up date, making booking for follow-ups them feel more involved and less likely to forget• The ability to flexibly plan capacity, with follow about their appointment. Better use of up demand being the driver resources means patients should no longer have• Improved cost efficiency, with the reduction in to wait as long as before. The clinical volume of staff resource required to cancel / management of patients with follow up has change clinics - the introduction of an improved, with many of them now being seen electronic outpatient request form reduced at a clinically appropriate time (although phone calls by 80 per month recognising the current issue outlined above). www.improvement.nhs.uk/heart
  28. 28. 28 18 Weeks Whole Pathways Every six weeks the service has a ‘clean sheet’ in terms of clinic bookings and flexible use of capacity enables the service to be more responsive to the demands and be less bound by previous clinic booking rules. Decisions are made about how to allocate resources in a more realistic time frame. Reduced DNAs has led to increased capacity in the service. Partial booking means that the majority of patients, who would previously DNA, do not respond to partial booking, hence no longer take up an appointment slot and consequently leave this available for another patient to occupy. This also leads to reduced overall waiting times. Since completion of this project, partial booking has been introduced for many more specialties across the hospital trust, benefiting significantly more patients and supporting the trust with its work to achieve the 18 week target. Contact information Sue Brewin Sue.brewin@sfh-tr.nhs.ukwww.improvement.nhs.uk/heart
  29. 29. 18 Weeks Whole Pathways 29Achieving 18 Week Referral To Treatment Pathways by March 2008James Paget University Hospital NHS Foundation Trust (JPUH), PapworthHospital NHS Foundation Trust, Norfolk and Norwich University Hospital NHSTrust (NNUH), Great Yarmouth and Waveney Primary Care Trust,Anglia Cardiac NetworkWe set an admissions target for?the team, achieving two week,one stop-clinics. We will spreadthis practice across our otherspecialties. ?Adrian Pennington, Chief Executive, JamesPaget University Hospital NHS Foundation TrustIssues to addressThe JPUH is a small district general hospitalsituated on the East Norfolk coast. It has apopulation catchment area of 220,000 andthere are high levels of deprivation.The NNUH, a neighbouring DGH offers an Reducing the outpatient wait was a majorangiography and pacemaker service to the JPUH aspect of this project and a demand andand percutaneous coronary intervention (PCI) to a capacity study at the beginning of the projectspecific group of patients. The majority of patients revealed the size of what lay ahead.however have to travel to Papworth, a cardiactertiary provider which is a 190 mile round trip. Each consultant had: • Different start and finish timesCardiologists: • Saw a varying number of patientsThere is one full time cardiologist, one part-time • Where middle grades were present they oftencardiologist (outpatient work only), one locum only saw a couple of patientsand one vacancy. There is insufficient outpatient • New slots were frequently closed tocapacity with the staffing levels as they are to accommodate follow upsreduce the outpatient wait to anything less than • There was so much wasted capacity both fromtwo to three weeks. poor utilisation of appointments and high DNA rates that it was clear a more efficientThe JPUH has a non-invasive cardiac diagnostic service was required urgently.department which means that the followingdiagnostics are available: ambulatory monitoring, A follow up audit undertaken to find out theecho, exercise tests, TOEs, Tilts etc. This reasons why patients were being booked todepartment has been very dynamic over the last return to clinic for a follow up appointmentfew years in that the manager has applied for revealed:funding from the SHA to take on a studentevery year for the last six years, she has • Inappropriate follow up practiceimplemented an in house echo training • Incorrect booking of patients who should haveprogramme and with additional service redesign been new not a follow uphas sustained all diagnostic waiting times at <2 • A high number of patients were being askedweeks for over eighteen months. Our challenge to return to discuss results of tests and thenof implementing one stop diagnostics was discharged requiring no further intervention ortherefore not reducing diagnostic waits but medical treatment. This was adding areducing outpatient waits. The Trust could not considerable delay in the pathway (i.e. youafford to waste diagnostic capacity so we were can’t stop the clock until the result is sharedunable to implement one stop diagnostics until with the patient and the outcome agreed).the outpatient wait almost matched thediagnostic wait. www.improvement.nhs.uk/heart

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