A guide for review and improvement of hospital based heart failure services

697 views
571 views

Published on

A guide for review and improvement of hospital based heart failure services
The information in this document has been put together by NHS Improvement, to help hospital teams to review their heart failure (HF) service.
(Published June 2011)

Published in: Health & Medicine
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
697
On SlideShare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
3
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

A guide for review and improvement of hospital based heart failure services

  1. 1. NHSCANCER NHS Improvement HeartDIAGNOSTICSHEART NHS ImprovementLUNG A guide for review and improvement of hospital basedSTROKE heart failure services
  2. 2. ContentsSection 1 3 Introduction 3 The impact of heart failure 3 Recommended components of a heart failure service 4Section 2 5 Service review 5Section 3 7 Heart failure management issues in secondary care 7Appendix 1 13Appendix 2 13AuthorsDr David Walker, Consultant Cardiologist, Hastings and Rother NHS Trustand NHS Improvement National Clinical LeadElaine Kemp, National Improvement Lead, NHS ImprovementAcknowledgementsDr James Beattie, NHS Improvement National Clinical LeadDr Mark Dancy, NHS Improvement National Clinical ChairMs Janine O’Rourke, NHS Improvement National Clinical AdvisorMr Michael Connelly, NHS Improvement National Clinical LeadDr Nigel Rowell, NHS Improvement National Clinical Lead
  3. 3. A guide for review and improvement of hospital based heart failure services 3Section 1Introduction Figure 1: LOS/readmission ratesThe information in this documenthas been brought together by NHSImprovement, to help hospitalteams to review their heart failure(HF) service.Nationally, there is marked variationin the length of stay andreadmission rate for heart failure in-patients (fig 1). It might be arguedthat a longer than average length ofspell reflects close attention todetail, to ensure that care isoptimised prior to discharge.However, if this is the case it shouldbe reflected in a low readmissionrate, which often it is not.Alternatively a short length of stay The national heart failure audit1might indicate a very efficient The impact of heart also highlights that:service – or conversely one where failurepressure on beds leads to • Within a year of admission forinappropriate early discharge before Heart failure affects one in a heart failure, 32% of patientsmanagement is complete. The hundred people in the UK, around died“Holy Grail” of short length of spell 620,000 people, increasing to • Mortality is significantly better forand low readmission rate does exist around 7 percent over the age of those who have access tobut is currently rare in the UK. 75. In 2009/10 Hospital Episode specialist care i.e. those seen by Statistics (HES) data showed there cardiologists or specialist heartFor providers where both of these were 73,752 hospital spells for heart failure services (23 per cent).indicators are above the national failure (coded in the first position)average, a systematic review of with a mean length of stay of 11.76services may help to identify days and a median of 8 days. Tenproblem areas and direct percent of patients (8,385) were In 2009/10, Basildon andsubsequent improvement work. The readmitted with heart failure in Thurrock University Hospitaltwo main aims of completing a under 29 days. The government reduced their heart failurereview are to optimise the time a proposal not to pay hospitals for this admissions median length ofpatient spends in hospital, with type of readmission in the future stay from 12 days to fourearly diagnosis and treatment, and means providers will be under days, releasing 1,249 bed daysto maximise the effective use of pressure to reduce unnecessary per year, a cost saving ofresources within the trust and wider readmissions. As an example a £312,250.NHS community. hospital where 20 patients are readmitted with an average 5 days This was achieved by stay could cost £30,000. speeding up the diagnosis, optimising care quickly and linking in to community services for early discharge.1National Heart Failure Audit, 2010 www.improvement.nhs.uk/heart
  4. 4. 4 A guide for review and improvement of hospital based heart failure services Recommended 1. System for early accurate diagnosis of outpatients components of a heart a.Serum NP testing to streamline referrals from primary care failure service b.Rapid Access HF Clinic (in primary or secondary care) c. Echo on the day of clinical assessment NHS Improvement has reviewed d.Management plan produced on the day many successful heart failure e.Ensure confirmed HF patients go on heart failure registers services (HF) services over the last few years, and this has revealed considerable consistency in their 2. Optimisation of treatment organisation. Certain key a.System for uptitrating medication – hospital or community based ‘components’ are usually present b.Agreed care plan and these are outlined in the tables c. Patient education to facilitate self management on the right. These components are d.Access to cardiac rehabilitation by no means confined to secondary e.Access to implantable cardiac devices care settings, and indeed in many cases are successfully delivered in primary care. Even though this 3. Identification of heart failure in patients resource is designed mainly for secondary care, it is essential to look a.Serum NP and early inpatient echo at the totality of the service b.Management in dedicated area with expertise – Junior docs/nurses including the interaction between c. Close liaison/collaborative working with community over discharge community and hospital. planning Optimisation of the primary- d.Discharge with a care management plan secondary care interface around referral and discharge is critical for 4. Multidisciplinary team working the efficient use of resources. a.Case management discussions across primary-secondary care interface - early discharge, admission avoidance - seamless service b.Consultant lead/+GP/hospital HF nurse(s)/community HF nurse(s) etc c. Designated care co-ordination 5. Supportive and palliative care a.Unnecessary admission avoidance at end of life - preferred priorities of care b.Palliative care involvement c. End of life models for example - Liverpool Care Pathway or the Gold Standards Framework - community d.24/7 generic end of life care provision in the community into which heart failure specialists contributewww.improvement.nhs.uk/heart
  5. 5. A guide for review and improvement of hospital based heart failure services 5Section 2Service review 2. Characterise the current Using the heart failure audit as service provision an accurate measure of aA service review provides key Document and characterise the successful heart failure service isstakeholders (such as health current service by each hospital site. only appropriate if it isprofessionals, service managers and This should include the current representative of all heart failurepatients) with a baseline assessment length of stay and readmission rate patients.to determine how well a service is in comparison with the nationalcurrently provided and how benchmark. This local HES data can An audit of patient notes confirmseffectively it interfaces with patients. be provided by the trust information where in the patient pathwayThis information can then be used department (Appendix 2). constraints repeatedly impinge uponto prioritise and plan changes for patient care or effective use ofimprovement and measure the Hospital Episode Statistics (HES) resources and can be used to checkimpact after implementation. data are generated by the hospital the accuracy of HES coding. coding team, using information from patients’ notes. Commissioners 3. Share the baseline with key1. Engage key stakeholders use HES data to calculate the stakeholdersKey stakeholders include anyone payments a service receives. Sharing baseline details with keywho is responsible for, delivers part Apparently inaccurate hospital data stakeholders will help validate theof, is a user of, or is affected by the requires further investigation data and inform the team. Note -heart failure service. As a minimum supported by the originating clinical avoid making comparisons betweenthis team should initially include team, rather than outright rejection. providers or clinical teams as thererepresentation from the admitting If HES data is incorrect, payment for may be errors in the data orand receiving medical teams, the services will be incorrect. clinically appropriate reasons forlead clinician, nurse specialists, the differing indicators.service manager and patients. This The National Heart Failure Auditcomposition of the team may need provides information on heart 4. Map out the processto be adjusted during the review to failure treatment across the UK, The basic improvement cycle can beconsider specific aspects of the including patient profiles, length of described as ‘PDSA’ – plan, do,service. hospital admission, interventions, study, act. For more details and for a medication and outcome. Data wide range of improvement toolsIt is important that as well as entry into the national heart failure and techniques click here»accurate audit data, the opinions of audit is a Care Quality Commissioneach of these groups are captured quality indicator. However, currently Involve all stakeholders in creatingand form part of the baseline. not all trusts are entering every and authenticating the process map.Patient centred care should form the heart failure patient. Patients onbackbone of any change and there whom data has not been collected Map out and record the steps whichare many ways to ensure that are more likely to be those admitted occur in a standard patient pathway,patients and carers views drive under specialities other than making sure to measure how longimprovement. For further advice and cardiology. It is also likely, and each takes and where there areguidance click here» supported by the audit itself, that handoffs (management of care or these are the patients with longer paperwork changes hands). This will lengths of stay and poorer highlight time where there is no outcomes. added benefit to patient care. www.improvement.nhs.uk/heart
  6. 6. 6 A guide for review and improvement of hospital based heart failure services It is suggested to start the map from Ensure that these proposals are the time of presentation to the agreed with all the clinical team and trust, noting where the referral by patient representatives. Support comes from, through to the time of from the management team is also first follow-up post discharge. The essential to make sure the changes stages can be divided, for example, are in line with trust policy. into presentation and diagnosis, treatment and optimisation, It is important to set goals for your discharge and follow-up. improvements. There is very little point in making changes if you Review the impact of services which cannot accurately assess whether feed into and receive patients to the impact made is positive. Set a and from the in-patient service, such baseline for each of your as the system for referral from improvements, then regularly primary care and how patients are measure this goal after the discharged to community services. improvement is implemented to ensure it is effective, finally embed List and quantify the impact of any this measurement into the regular constraints identified in the process. running of the service so as the For example, if waiting for an in- ensure that the improvement is patient echo causes delay, record maintained. An example might be the waiting time and the number of to reduce the wait for an inpatient patients waiting. Calculate how echo from the baseline median of many bed days are wasted each six days, down to two days. year and what this costs, then compare this with the cost of 6. Action and reassess providing additional echo resources, Implementation is a key step. For to help inform subsequent further advice and guidance look on decisions. the NHS improvement heart failure website here» 5. Prioritise and plan improvements Examples of how other heart failure Create a list of where improvements service providers have implemented are required and the order in which change within their service can be these should be implemented. accessed here» Section 3 describes some of the common challenges and suggests how these might be tackled. Once you have confidently identified and measured the constraints on the service, agree with the key stakeholders what actions should be taken to optimise care and which should be implemented first.www.improvement.nhs.uk/heart
  7. 7. A guide for review and improvement of hospital based heart failure services 7Section 3Heart failure management issues in secondary careOutpatients: Early accurate diagnosis and treatment 1. System for early accurate diagnosis of outpatients a.Serum NP testing to streamline referrals from primary care b.Rapid Access HF Clinic (in primary or secondary care) c. Echo on the day of clinical assessment d.Management plan produced on the day e.Ensure confirmed HF patients go on heart failure registers 2. Optimisation of treatment a.System for uptitrating medication – hospital or community based b.Agreed care plan c. Patient education to facilitate self management d.Access to cardiac rehabilitation e.Access to implantable cardiac devicesClose integration of HF services Inpatientsacross primary and secondary care is Reorganisation of heart failure careessential at all stages of the patient for inpatients raises a number ofpathway. New patients presenting issues. In an ideal situation, all HFto hospital with advanced HF or patients should be managed whenknown patients presenting with in hospital, by a team led by apoorly controlled symptoms may be consultant cardiologist or HFan indication that some patients are specialist, on a specialist wardnot being identified early enough (cardiology or HF).and treated effectively. The protocolfor initial investigation and However, at present, in manysubsequent referral of suspected hospitals in the UK, HF patients arenew HF patients to specialist spread throughout the medical andservices must be easily accessible to care of the elderly wards. Theall in primary care. Once the reasons for this are many, butdiagnosis has been confirmed, there include elderly age, the presence ofmust be an agreed care plan which co-morbidities and the variability ofcovers support, up-titration of presentation (and subsequentmedication, subsequent follow up difficulty in rapid identification).etc. to make sure that patients do Occasionally the influence of co-not fall through the net. Rapid, morbidities is so significant thatcomprehensive intervention in this management based on a care of theway can often avoid the need for elderly ward is more appropriate.admission in this high risk group. www.improvement.nhs.uk/heart
  8. 8. 8 A guide for review and improvement of hospital based heart failure services Identifying patients admitted with heart failure 3. Identification of heart failure in patients a.Serum NP and early inpatient echo b.Management in dedicated area with expertise – Junior docs/nurses c. Close liaison/collaborative working with community over discharge planning d.Discharge with a care management plan The crucial first step in the reorganisation of inpatient services In April 2009, West Herts Hospital introduced an integrated HF is to identify patients presenting pathway in which patients received urgent serum NP testing on with heart failure. There are two admission, followed by rapid access to echo. Daily cardiology main options here: ward rounds were then organised to advise on these patients and optimise treatment and this lead to a significant reduction in (i) Identification at the front readmissions. door Serum NP testing also helped identify patients admitted under This is the ideal situation. Patients another specialty, reducing the time nurse specialists spent with breathlessness or oedema locating patients and reducing unnecessary echo’s. suggestive of HF should have an immediate serum NP measurement. Patients with a positive or borderline Readmissions result should then receive echocardiography in <24 hours to confirm the diagnosis and suggest an underlying cause. Once patients have been identified they can be directed to the appropriate cardiac or HF ward, where this is not currently available aiming to cluster HF patients onto the same ward should be a priority. Where there are multiple problems or major co- morbidities the patient can receive shared care on a medical or care of Cost of bed days saved = £69,000. Cost of providing serum NP = £38,800. the elderly ward. Overall saving of £30,200 in one year. Rapid identification and assessment at the front end of the hospital may also make it possible to avoid admission for some patients, with (ii) Identification of patients picture, in-patient echocardiography the Acute Heart Failure Nurse on the wards is usually requested. Referral for (AHFN) adjusting treatment and The reality of the current situation is echocardiography without serum NP arranging early follow up with the that in many hospitals HF patients screening can often overwhelm in- community HF nurse (CHFN). are scattered throughout the wards. patient capacity and delays in Access to serum NP for in-patients diagnosis ensue. This inevitably remains infrequent, and so where delays definitive treatment plans HF is suspected from the clinical and prolongs hospital stay.www.improvement.nhs.uk/heart
  9. 9. A guide for review and improvement of hospital based heart failure services 9 Although inevitably this system is Note: Redesign of the inpatient more fragmented and time Note: Acute management is echocardiography service to consuming than option (i), once best delivered on a cardiac or prioritise these patients can identified by the AHFN, patients can heart failure ward where the have a significant benefit on receive appropriate input to their nursing and junior medical staff, length of stay. Definitive management and discharge can be are familiar with the protocols facilitated via discussions with the treatment is often not instituted and can respond to CHFN. before echocardiographic complications. This is likely to confirmation of diagnosis and Questions you might consider: underpin the improvement in this is expensive for the NHS • Are there a high percentage of mortality seen in the HF Audit and potentially serious for the patients presenting with NYHA for patients managed on cardiac patients. For further information class 4? (NYHA explained - wards. www.abouthf.org/questions on how to calculate demand _stages.htm). and capacity click here» • Are the patients presenting to A&E new presentations, or known Acute management HF patients decompensating? The more severely unwell patients • Should the patient be presenting usually require complex treatmentIn this situation, the role of the earlier/elsewhere? regimes which include intra venousAHFN specialist is critical. They need • Once admitted, is the process (IV) diuretics - either by intermittentto make sure that all patients are geared towards rapid diagnosis? injection or by continuous infusion.known to the HF team and receive • Is serum NP used as a predictor to Daily assessments of these patients,input from the HF consultant. Often enable patients to enter the is essential to ensure appropriatethis requires "trawling" of the correct pathway at the door? fluid loss without excessivewards which is time consuming, • Is echocardiography available impairment of renal function, oralthough providing a "hotline" for within 24hours of admission/ electrolyte imbalance. In the currentwards to inform the AHFN of positive serum NP? system in the NHS where juniorsuspected patients can reduce theworkload. Additionally some form medical staff, frequently change Specialist assessment firms, experienced nursing staffof alert system via the hospital IT Once identified, all patients should have a major role to play insystem which is activated when be assessed by the HF specialist monitoring the patients during thisknown HF patients are admitted is team (consultant/nurse) as early as stage. The HF specialist should bealso useful. possible in their admission, to make available for advice on a daily basis. appropriate management plans. When the patient is not on a cardiac Subsequent input from the HF team ward, the AHFN is ideally placed to can then be stratified according to liaise between the HF specialist and clinical status i.e. severity of the ward staff. presentation (new patients) or deterioration (previously diagnosed patients). www.improvement.nhs.uk/heart
  10. 10. 10 A guide for review and improvement of hospital based heart failure services Appointment of an AHFN and concentration of HF patients on two wards has reduced in patient mortality in Hastings. Concentrating HF patients on two wards - General Cardiology and Care of the Elderly Cardiology, with patients being identified by an acute HFN ‘trawling’ medical assessment ward (without availability of serum NP), has resulted in a reduction in hospital mortality. Mortality in hospital 1998-2009 y=4.2955x + 93.886 R = -0.744 Discharge planning Ideally the rehabilitation team Questions you might consider : Discharge planning should begin as should review the patients prior to • Are heart failure patients admitted soon as the patient is admitted. discharge, in the same way that to different wards/specialties and Early discussion between the AHFN patients are assessed after are there differences in their and the CHFN facilitates early myocardial infarction. readmission rate and/or length of discharge, without a prolonged stay? period of observation after The content of the discharge • Are patients who are admitted to conversion back to oral medication. summary is also critical. Clear details non cardiology wards referred for Most of this communication can of the treatment provided in a specialist opinion and how long take place by phone or email, but it hospital and plans after discharge does this take to happen? is beneficial for the hospital based should be included, including details and community HFN to meet on a of monitoring and follow up weekly basis to discuss difficult arrangements. Where the patients management problems with the are discharged on sub-optimal doses consultant lead, as part of the multi- of medication (e.g. ACE inhibitors) disciplinary team. the reasons for this should be clearly specified, as should any requests for assistance from the GP/practice nurses with subsequent up-titration.www.improvement.nhs.uk/heart
  11. 11. A guide for review and improvement of hospital based heart failure services 11 4. Multidisciplinary team working a.Case management discussions across primary-secondary care interface - early discharge, admission avoidance - seamless service b.Consultant lead/+GP/hospital HF nurse(s)/community HF nurse(s) etc c. Designated care co-ordinationMultidisciplinary team working This role is often best carried out by • Are there out of hours patientA multidisciplinary team approach is the CHFN in the patients home, but support services comparable withuseful at all stages of the patient where this service is not available the support available duringpathway. We have already alternatives include hospital based working hours?highlighted the role of the HF team clinics run by the AHFN or practice • Is the follow-up of inpatientsin the management of in-patients. nurses trained in HF. designed to ensure thatRegular MDT meetings (ideally inappropriate readmissions areweekly) make discharge planning Questions you might consider: avoided?easier for the more complicated • Is there sufficiently robust • Is cardiac rehabilitation availablepatients, and also facilitate discharge planning including for heart failure patients?management of patients in the weekends so that patients are • Can patients be discharged earlycommunity (with the potential for discharged at the earliest with confidence that they will beavoidance of admissions). opportunity? reviewed and have renal function • Are patients educated in their checked within a week?Questions you might consider: condition to allow active • Do community nurses have access• Do you have a team approach to participation in their care and are to hospital information systems to heart failure management - if so, they confident about who to check results? who makes up this team? contact when things start to• Are there mechanisms in place deteriorate? and sufficient capacity for all inpatients with HF to be managed by the specialist team?• Are MDT meetings taking place Equity and inclusiveness regularly between primary and secondary care? It is fundamental that the AHFNs work is not confined to the cardiac wards, nor to younger age groups. In the current situation where manyFollow up arrangements patients with HF are admitted to non-cardiac wards, it is these patientsRapid follow up after early who have the highest mortality. It is sometimes easier for the HF teamsdischarge greatly reduces the risk of to fall into the trap of delivering a very high quality service to a relativelyreadmission. All patients should be small proportion of the in-patient population with HF, whilst a largerseen within a week of discharge, group remain unsupported and without specialist input.and this should include assessmentof fluid status (including weight) In addition all types of HF should be included in the service. Patientsand renal function. Timely with preserved ejection fraction (HFPEF) deserve identical input - and areintervention at this stage can often often more difficult to manage.prevent patients becomingdehydrated and developingimpaired renal function oralternatively rapidly regaining theoedema they have lost in hospital. www.improvement.nhs.uk/heart
  12. 12. 12 A guide for review and improvement of hospital based heart failure services Supportive and palliative care 5. Supportive and palliative care a.Unnecessary admission avoidance at end of life - preferred priorities of care b.Palliative care involvement Supportive and palliative, also sometimes referred to as ‘End of life care helps all those with advanced, progressive and incurable conditions to live as well as possible until they die. It enables the needs of both patients and family to be identified and met throughout the last phase of life and into bereavement. It includes physical care, management of discomfort and other symptoms and the provision of psychological, social, spiritual and practical support’ Experience from previous NHS Improvement national projects, shows that service providers often address process issues and service delivery before undertaking end of life challenges. This may in part be attributed to the difficulties associated with the timing of and delivery of end of life care. • Well structured multidisciplinary NHS improvement would like to NHS Improvement in conjunction team working is essential for acknowledge and thank all the with the national end of life care individualised, flexible patient teams who have willingly shared programme team published a Heart centred care their experiences for the benefit of Failure end of life implementation • Excellent communication between others. This is an evolving framework in July 2010. To view health professionals, patients and improvement resource which does this document click here» carers is fundamental to a good not claim to have all the answers. patient experience We would welcome feedback and The key messages highlight: • Most people but not all prefer not any additional information during • The disease trajectory for a heart to die in hospital, however this is the draft release of this document. failure patient is not easily where many people do die. predictable, and therefore also Please email these to timing of EOL care plans Whilst this resource focuses on the elaine.kemp@improvement.nhs.uk • Advance care planning supports inpatient service a large online by 30 September 2011. patient wishes about their future collection of work covering the care arrangements and whilst it is whole patient pathway, sometimes a difficult subject to commissioning QIPP and quality broach is often left too late standards can be found here»www.improvement.nhs.uk/heart
  13. 13. A guide for review and improvement of hospital based heart failure services 13Appendix 1 Appendix 2 The codes commonly associatedChecklist for a service review Key sources of information with heart failure are listed below. To review local information noteThe checklist below describes the There are several important sources that Heart Failure as a diagnosis cankey elements of a simple service of information and guidance for be entered as the primary orreview heart failure service providers which subsequent diagnosis. We would should be utilised when undertaking suggest initially reviewing data with1. Engage key stakeholders a service review: heart failure as the primary2. Baseline the current service diagnosis. provision • The National Heart Failure3. Share baseline with key audit 2010 - This provides • I50.0 Congestive heart failure stakeholders national comparative data to help • I50.1 Left ventricular failure4. Map out the service steps clinicians and managers improve • I50.9 Heart failure, unspecified (process map) the quality and outcomes of their • I11.0 Hypertensive heart disease5. Prioritise and plan improvements services - click here» with (congestive) heart failure with key stakeholders • I42.0 Dilated cardiomyopathy6. Implementation and • NICE clinical guidance 108 - • I25.5 Ischaemic cardiomyopathy reassessment Chronic heart failure: • I42.9 Cardiomyopathy,7. Sustained best practice management of chronic heart unspecified. failure in adults in primary and• Continuous communication is secondary care - This offers imperative at all times between all evidence-based advice on the care key stakeholders, especially where and treatment of people with there is patient hand over chronic heart failure, with between heath care professionals updated recommendations on or organisational boundaries. diagnosis, pharmacological treatment - click here» • NICE quality standards – Chronic heart failure – (to be published June 2011) There are a series of evidence based concise statements that show what high-quality care should look like. • The British Heart Foundation A charitable organisation providing amongst other things resources for both professionals and patients - click here» • Commissioning – NHS Improvement quick guide to commissioning the heart failure whole pathway of care - click here» www.improvement.nhs.uk/heart
  14. 14. 14 A guide for review and improvement of hospital based heart failure serviceswww.improvement.nhs.uk/heart
  15. 15. ContactsDr David WalkerConsultant Cardiologist, Hastings and Rother NHS Trustand NHS Improvement National Clinical Leademail: david.walker@esht.nhs.ukElaine KempNational Improvement Lead, NHS Improvementemail: elaine.kemp@improvement.nhs.ukSheelagh MachinDirector, NHS Improvement - Heartemail: sheelagh.machin@improvement.nhs.uk
  16. 16. NHSCANCER NHS ImprovementDIAGNOSTICSHEARTLUNGSTROKE NHS Improvement NHS Improvement’s strength and expertise lies in practical service improvement. It has over a decade of experience in clinical patient pathway redesign in cancer, diagnostics, heart, lung and stroke and demonstrates some of the most leading edge improvement work in England which supports improved patient experience and outcomes. Working closely with the Department of Health, trusts, clinical networks, other health sector partners, professional bodies and charities, over the past year it has tested, implemented, sustained and spread quantifiable improvements with over 250 sites across the country as well as providing an improvement tool to over 800 GP practices. NHS Improvement 3rd Floor | St John’s House | East Street | Leicester | LE1 6NB Telephone: 0116 222 5184 | Fax: 0116 222 5101 www.improvement.nhs.uk ©NHS Improvement 2011 | All Rights Reserved Publication Ref: IMP/comms019 - June 2011 Delivering tomorrow’s improvement agenda for the NHS

×