A guide to commissioning cardiac surgical services

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A Guide to Commissioning Cardiac Surgical Services
Eight NHS Trusts supported by their local cardiac networks were involved as demonstration sites in the Cardiac Surgery National Priority Project. It includes practical examples of where local teams have delivered innovation in their service to improve the efficiency and experience for patients and staff ie how to reduce length of stay; ensuring patients are fit for surgery and reducing delays and discharge planning.
(Published March 2010).

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  • 1. NHS NHS ImprovementCANCERDIAGNOSTICSHEARTLUNGSTROKENHS Improvement HeartA guide to commissioningcardiac surgical services
  • 2. ContentsForeword 3 Discharge planning 35Introduction 4 • Improving the patient experience for cardiac surgery pathways 36Improvement to the patient pathway -summary of recommendations 5 • Reducing length of stay of elective cardiac surgical patients to a one night stay post operatively 39Access to surgery 7 Quality - the current context 42Elective pathways 8 Supporting Information 49• Redesign of the cardiac surgery patient pathway 9 Cardiac Data Dashboard 50• Ensuring patients are fit for surgery and reducing delays in the cardiac surgical patients pathway 15 The Sustainability Toolkit 51• Process changes significantly increase 18 week performance NHS Improvement System 52 in cardiac surgery 18 Good planning can inspire change that• Tackling change - the teamwork way 20 leads to improvements 53• Cardiac surgery and 18 weeks - a pan network approach 22 References and supporting information 54Cardiac surgery trends - the national picture 24 Acknowledgements 56Non-elective pathways 29 Cardiac Surgery National Project Team 57• ‘Urgent or non urgent’, that is the question 32
  • 3. A guide to commissioning cardiac surgical servicesForewordThere has been substantial progress in It is a clinical challenge, since it is, in thecardiac surgery over the last ten years. end, clinicians that spend the money. So,Surgeons are operating in a more timely every clinician is required to examine theirfashion on more people with higher levels practice and actively look for ways toof risk and co-morbidity, yet they are deliver care more efficiently, removingdelivering better outcomes. waste and saving money.The national audit has been a major In my last foreword (Improving the patientdriver for success and so has the work of experience: Developing solutions toNHS Improvement where a focus on delivering sustainable pathways in cardiacsystems that deliver high quality care has surgery, March 2009), I pointed out that Professor Roger Boyle CBEbeen pivotal. there are still long delays in the non- elective pathways that lead to heartNow we face an even bigger challenge. surgery. These delays have not gone awayOver the last ten years, we have benefited and still need to be addressed. Many offrom higher levels of growth in NHS the issues regarding pre-assessment andexpenditure than at any time in its history theatre scheduling are other examplesand cardiac services have been substantial where the priority projects have addressedbeneficiaries. Today, we have to recognise the key efficiency measures over the years.that it is inevitable that the wider financial Now, we cannot rest on our laurels, theresituation is going to impact on each and remains much to be done.every one of us. This challenge, to delivercontinuing high quality care while at thesame time delivering it much more Professor Roger Boyle CBEefficiently, is the biggest challenge that National Director for Heart Diseasehas faced us in the history of the NHS. and Stroke, Department of Health www.improvement.nhs.uk/heart 3
  • 4. A guide to commissioning cardiac surgical services Introduction A superficial view would suggest that This has increased from 10% in 1999 and The focus of work undertaken by the cardiac surgery has changed little over the has brought challenges in terms of current project sites considered to be last twenty years – we still spend most of increasing co-morbidity but results constraints within the management of our time in theatre grafting coronary following surgery continue to improve. smooth patient flows includes the arteries and replacing heart valves. Mortality following CABG has fallen from following: However, closer inspection shows marked 1.9% in 2004 to 1.5% in 2008. The changes in the type of patient being seen changes in cardiac care set out in the • Pre-admission provision. by surgeons. The era of operating on National Service Framework have also had • Referral management services. patients with heart valve disease only a marked effect on the way patients are • Scheduling. when their symptoms became severe has treated we have found that we are • Discharge and post operative care passed and now many patients are operating on many more patents on an management. Steve Livesey operated on specifically to prevent urgent basis as appropriate treatments are deterioration rather than improve now available much earlier in the time This report aims to share the successes symptoms. This change means that course of patients’ disease course. with the wider NHS providing a range of patients having heart valve surgery are not excellent examples of where local teams having their operations when they have The attention focused on cardiac have delivered innovation in their service begun to slip down the slope of clinical diagnostics and 18 week pathways as part to improve the efficiency and experience deterioration when ‘risky’ surgery is the of the portfolio of work led by NHS Heart for patients and staff. only prospect of survival but when they Improvement during 2007/08 highlighted are well. a need to shift attention to cardiac surgery to develop sustainable solutions. Eight Steven Livesey This change has occurred alongside a NHS Trusts supported by their local cardiac National Clinical Lead justified increase in the expectations networks have been involved as NHS Improvement - Heart patient have of what can be done for demonstration sites during 2008/09 them and as evidence of this we are testing out new approaches to care and operating on an increasingly elderly improvement to frontline patient services. population of patients. In 2008, 25% of all patients undergoing coronary artery bypass surgery were over 75 years of age.4 www.improvement.nhs.uk/heart
  • 5. A guide to commissioning cardiac surgical servicesImprovement to the patient pathway - summary of recommendations one:Lessons drawn from project 1. Service prioritiesdemonstration sites suggest that 2. Models of care and idealised 1. Referral management servicesquality improvement to elective patient pathways There is often an information gap between referring provider units andcardiac surgery services requires 3. The approach to the change the tertiary centre:smarter working, a data driven initiative and the identification • Manage variation in the referral process from provider units andapproach to understanding process of root cause issues and in-house reducing multiple referral points through development ofperformance and process variation, solution development agreed referral criteria to relieve pressure on waiting times for surgery.the enhancement of staff roles and a 4. The methods/approaches to • Develop central systems for optimising referral efficiency byshared overview of the patients’ change management streamlining administrative process and referral management linkingjourney and patients experience • Strategically in gaining clinical teams across secondary and tertiary care to triage referrals andacross referring providers and the agreement to change service advise on appropriate tests/investigations.tertiary centre. models and contractual • Introduce pooled referrals across consultants as this significantly arrangements; impacts on waiting times.Cardiac networks continue to be • Operationally in the application • Use appropriate clinical staff to confirm referrals are complete anduniquely placed to assist with the of improvements including the discusses work up criteria with referrer.delivery of the quality agenda by adoption of processes that hold • Introduce a single point of contact at the tertiary centre for referrerslinking clinicians, managers and and sustain the gains. and patients. The role of the trained clinical coordinator is pivotal incommissioners together in every tracking individual patients and in ensuring the consultant team keptaspect of the patients’ journey This document identifies a range of informed of significant events.through primary, secondary and initiatives that have been successfullytertiary care. employed in meeting the challenge of 18 weeks in elective surgery whichNetworks are well positioned to inevitably required the focus toreflect local relationships between extend to systems and processes thatclinicians across organisational support the whole surgical process,boundaries to further develop safe elective or otherwise.and effective surgical pathways ofcare for patients by providing an The detailed case studies within theopportunity for clinicians and publication aim to share themanagers to work together on the knowledge and learning from theseredesign agenda and to gain pilot sites which breaks down into theagreement on: following four areas: www.improvement.nhs.uk/heart 5
  • 6. A guide to commissioning cardiac surgical services two: three: 2. Pre admission provision 3. Scheduling • Manage variation in pre assessment services. • Move toward Day of Surgery admission as the standard of care for • Adopt investigation guidelines which state agreed timeframes from test to elective surgery as this can improve the patient experience considerably. planned date of surgery and only carry out investigations which are • Maximize theatre efficiency by reducing waste in the system for relevant, indicated and likely to alter management. example right staff in place at the right times with the right equipment. • Introduce ‘one-stops’ for outpatients to avoid wasted clinics for medical • Optimise theatre capacity by reducing slot cancellations (clinical/non staff and patients. clinical) and by scheduling procedures that assist with patient flow • Maximize opportunities for multidisciplinary team assessment and through ITU/HDU. emphasise use of technology an example would be use of video link • Where ever possible pool lists to reduce waiting times. between hospitals. • Procedure complexity scores developed to assist with scheduling • Maximize pre assessment opportunities as they help manage patient health developed as part of MDT. and reduce risk. • Maximize pre admission diagnostics particularly in referring district general hospitals by establishing agreed pre operative protocols. • Maximize patient work up prior to admission and agree the schedule for four: each clinical scenario for example surgery for coronaries, mitral valve, aortic 4. Discharge and post operative care management valve and combination. This has a beneficial effect on waiting times. • Manage variation in post operative clinical management practice. • Train and support key clinical and managerial staff to deliver some of the • Manage variation in discharge patterns reducing length of stay. work undertaken by junior doctors reconfigure services to develop • Start discharge planning at pre assessment to identify requirement for opportunities for other health care professionals to widen their skills and support and home aids to reduce requirement for delayed discharge. scope of relationship with patients. An example is the patient ‘navigator’ • Involve a range of health care professionals for example occupational role which benefits patients and families by providing information and therapists in discharge planning at pre assessment particularly where support following attendance at outpatient and pre assessment clinic. patients and in particular the elderly may have complex needs. • Maximize the scope of extended practice for nursing roles working in pre • Discharge assessment should form part of the central patient record operative assessment clinics functioning as part of the consultant led team available throughout the patient journey to all staff groups. to streamline cardiac surgery patient care. • Move toward nurse led discharge. • Maximize inclusion of different staff groupings for example anaesthetists involved in pre assessment to ensure that all patients presenting for surgery will be adequately assessed as this can reduce cancellation rates, improve operating theatre efficiency and increase patient satisfaction. Note: The resources developed by these pilot sites are available • Continue to provide information and support. through the web links and NHS Improvement system at: www.improvement.nhs.uk/heart/sustainability6 www.improvement.nhs.uk/heart
  • 7. A guide to commissioning cardiac surgical servicesAccess to surgeryThe reductions in waiting times envisaged The need for non-medically qualified staffby the NHS Plan are now a reality and in to play an even greater role in patients’order to meet the expectations of shorter assessment and treatment is becomingwaits, the way in which patients are apparent as the effects of the reduction inmanaged and referred from one junior doctors hours are starting to bite.department to another as their treatment It is vital that training organisations workprogresses has had to improve. with trusts to ensure the workforce continues to develop to ensure timelyAs a result, the majority of units in the delivery of care in the future.country have adopted a network-agreedsystem of investigating and referringpatients on for further treatment, such ascoronary artery bypass graft (CABG).The rapid progress of patients through thesystem has been greatly facilitated by theadoption of common protocols forinvestigation and agreed timelines forreferral. Many of the steps in thepathway are now overseen by specialistnurse practitioners rather than juniordoctors and this has contributed greatly tothe efficiency of the process. www.improvement.nhs.uk/heart 7
  • 8. A guide to commissioning cardiac surgical services Elective pathways Elective care refers to care that is Before cardiac surgery can be carried in advance of cardiac surgery, The detailed case studies included pre-arranged (planned). Managing out a range of resources have to be including clinical examination, history here demonstrate their progress, elective and emergency patient flows brought together at the right time taking, arranging radiological and outlining practical strategies for from decision to admit to discharge and the right place: surgical staff, haematological investigations in continuous improvements in the can prove challenging for nursing staff, anaesthetist, theatre accordance with Consultant or quality of care which has benefited organisations as they work to deliver time, beds. Remove any one of these departmental guidelines. The patients in reducing delays, tackling a number of national and local components and the operation has to development of new roles allows bottlenecks and enabled patients and quality and performance targets be cancelled. The sharing of staff consultant time to be effectively freed carers to access clearer information among them 18 week referral to and resources to support elective and up permitting more appropriate use alongside the achievement of targets. treatment admitted pathways, four non-elective care treatment can place of surgeons’ time. (Staffing hour A&E target and locally agreed an added stress to elective work as Cardiothoracic Units Developing a The dilemma of balancing both reduction in length of stay and urgent cases should take precedence workforce for the 21st century. elective and non elective/emergency interhospital transfer times. Yet resulting in cancellation of scheduled Livesey, S. Bartley, T. April 2007). work led some sites to adopt a whole looking at the pathway of care from elective surgery causing frustration system approach to their quality the patient’s point of view making it and delay felt by staff and patients Across the country project sites improvement work due to the smoother, more accessible, less alike. However, as there is a showed wide variation in their knock-on effects of the provision of complicated and less subject to delays permanent need to provide for non- achievement of admitted waiting non elective care to planned activity. is necessary given the volume of elective care contingencies can be times and started their journeys to patients who receive care. built into the system. improvement from differing baseline positions based on local With cardiac surgery often coming at Pre operative assessment ensures that circumstances. In understanding how the end of a lengthy diagnostic the patient is as fit as possible for the patients flowed through their service pathway the delivery of shorter surgery and anaesthetic and with a particular focus on referral waiting times completed within 18 minimises the risk of late management services, pre admission weeks is increasingly demanding. cancellations by ensuring that all provision, scheduling and post Specialty beds often occupied by essential resources and discharge operative care management these medical outliers and a lack of requirements are identified and essential facets have supported intensive care beds due to coordinated. With appropriate achievement of continuous emergencies or the clinical status of training nurses can effectively improvements in elective care patients intensify the complexity of manage the care of patients referred pathways. delivering smooth patient flows. to the pre operative assessment clinic8 www.improvement.nhs.uk/heart
  • 9. A guide to commissioning cardiac surgical servicesSt George’s Healthcare NHS Trust and the South London Cardiac and Stroke NetworksRedesign of the cardiac surgery patient pathway reduces length of stayThe problem • Analysis of the theatre diary showed • A small number of patients treated atIn December 2008, the opportunity to cases rarely started on time and often St George’s travelled from Jersey –take part in a National Priority Project overran. due to flight restrictions imposed byprompted the St George’s cardiac • There was no policy for theatre the airline these patients were unablesurgery team to address how they scheduling. to fly home until at least ten daysmight deal with some of their • Patients were given little notice of after their surgery. This resulted inlongstanding problems to help the unit their surgery date; often less than their stay in hospital being extendedperform at an optimum level, meeting one week. to ten days post surgery as opposedboth national and internal trust to usual routine of five days.standards for issues such as length of 3.Electronic referral system,stay, cancellations, and notice period of inpatients and interhospital 4.Admission on the daysurgery date for patients. transfer patients • In Q3 2008/09, only 10% of elective • The electronic referral system, cases were admitted on the day.Both the elective and non-elective adult primarily developed for the referral of • An admission on the day project forcardiac surgical pathways had room for non-elective patients from district ‘second on the day cases’ had beenimprovement, particularly within the: The issues included: general hospitals into the tertiary successfully piloted in 2006, but had• pre-assessment service; centre (interhospital transfers) that not been sustained.• management of length of stay, 1.Pre-assessment had been implemented in 2006 was theatre cancellations and slot • During 2007/08 fewer than 60% of not being utilised. 5.Length of stay (LoS) scheduling; elective cardiac surgery patients • Paper referrals made from referring • In Q3 2008/09, the average LoS for• referral management processes attended the pre-assessment clinic. sites were frequently mislaid. elective patients was 8.8 days. internally and from referring district • Anecdotally, this was contributing to • Little and inconsistent • In Q3 2008/09, the average LoS for general hospitals. difficulties with planning patient correspondence between referring non-elective patients was 15.7 days. admission, scheduling and sites and St George’s was common • LoS needed to align with the trustAchieving and sustaining the 18 week anticipating date of discharge. place. target of elective patients beingtarget for elective surgery and the • Referring centres were unsure of the discharged on day five. Non-electiverequirement to meet the trust’s internal 2.Theatre scheduling work-up required for surgical patients LOS should also be reduced inpriority to reduce length of stay across • In Q3 2008/09, the average number resulting in patients often transferred recommendations with the NCEPODboth the cardiology and cardiac surgery of non-clinical cancellations was 10% into St George’s unprepared for guidance.care groups felt challenging. A review of all elective cases. surgery. • The cardiovascular division wasof baseline data, gathered using • These were commonly due to theatre • Length of stay was longer than required by the trust to make a savingpathway mapping, demand and overruns and lack of beds. optimum for admission to referral, of 10 beds.capacity analysis, and interviews with • Patients were often cancelled the day referral to transfer, transfer tostaff across their respective work area of before, or on the day of their surgery; treatment and treatment to dischargethe patient journey, highlighted a there was no cancellations policy to or transfer back to DGH.number of system and process issues. prevent or support the decision. www.improvement.nhs.uk/heart 9
  • 10. A guide to commissioning cardiac surgical services The solution 3) Compliance with the national and Team members attended the national A project team was established and local agenda including 18 weeks, cardiac surgery priority project peer “ chaired by the unit’s general manager cancellation on the day and support meetings which inspired with clinical and managerial reduction in length of stay. members to share existing good Working together on this project membership including service 4) That the cardiovascular service is as practice within the unit and to develop managers, heads of nursing, matrons, efficient and forward thinking as any solutions to challenges shared across has brought the team together and clinical nurse specialists, clinical audit, other tertiary centre in the country. the peer group. I’m so proud of what we’ve transformation project manger, 5) That the staff within the unit are consultant cardiologist and cardiac proud to work in the unit and feel The new pathway featured: achieved. We were all sceptical surgeon. Project management support valued and part of a team. • The pre-assessment of all elective to begin with and I was was provided by the South West cardiac surgery patients by September uncomfortable admitting we had London Cardiac and Stroke Network. Highlight reports were produced for 2009. each team meeting and provided the • A theatre scheduling policy problems with our service, but Baseline data was collected to identify mechanism for monitoring each introduced in October 2009, hearing from other colleagues areas for improvement work. It was workstream against key goals, actions, including improving notice to patients clear the project had developed into a risks and progress against timeline. of their date for surgery. around the country reassured me whole pathway redesign and was Analysis of the data to show evidence • Regular monitoring of theatre that we were not any different and subdivided into five key workstreams. of the improvements was supported by cancellations to reduce the number Project team meetings were held every the trust transformation manager and non-clinical cancellations we all had the same issues. fortnight and leads were nominated for clinical audit staff members on the • Implementation of the use of Working on this project with the each work-stream to be responsible for team. electronic referrals for non-elective Network and the Heart the work. cases by January 2010. The work was also informed by the • Implementation of admission on the Improvement Team has encouraged A set of key values that reflected the analysis of qualitative data from patient day as normal practice. us to start a similar project trust’s own strategic vision were agreed and carer diaries which were used by a • The recruitment of two additional and integrated within the team’s vision number of patients and their family staff; a pre-assessment nurse and a addressing issues in cardiology – established to deliver the improvement members from the time they attended cardiothoracic nurse practitioner: we’re now looking forward to a work across the patent pathway: their pre-assessment, throughout their • Whilst these new posts required ” similar success story! stay in hospital, and for a few weeks funding overall the project was cost 1) To ensure that all patients have after their discharge. neutral – as savings were gained equal access to the service. due to the improvements made by 2) That the patient journey is safe and each work-stream, in particular, Jane Fisher free from complications. reductions in LoS and cancellations. General Manager10 www.improvement.nhs.uk/heart
  • 11. A guide to commissioning cardiac surgical services• Implementation of new discharge • Locum theatre manager in post. • Electronic referral system used for IHT 4. Admission on the day planning for Jersey patients. • Annual/study leave booked a non-elective patients. • 2006 pilot reviewed. minimum of six weeks in advance. • All in house and IHT non-elective • Admission on the day exclusionBelow is a summary of the work and • Consultants’ rota set at six weeks referrals addressed to ‘dear surgeon’ criteria agreed.achievements in each workstream: ahead. and managed by cardiothoracic nurse • Policy agreed and signed by all • Improved theatre start and finish practitioner, rather than to a named cardiology, cardiac surgery and1. Pre-assessment times. surgeon. anaesthetic care groups.• Reviewed demand and capacity • The notice period given to patients • All referrals also processed through • Commenced 31 July 2009. within pre-assessment clinic. about their surgery date increased nurse practitioner, who then contacts• Employed second clinical nurse from one week to three. referrer to confirm receipt and discuss 5. Length of stay (LoS) specialists to increase capacity. • Outpatient referrals pooled for first work-up criteria. • Analysis of LoS compared with peers• Converted all pre-assessment clinics time CABG to ensure equity of • Nurse practitioner liaises with and national standards was used to to nurse only clinics. waiting times – this had an impact on pathway co-ordinator to arrange estimate where beds could be saved.• Worked with admissions co-ordinator general 18 week waiting times. dates for surgery, keeping referring • The transformation project manager to formalise process between • Implementation and enforcement of hospital informed. worked closely with each workstream acceptance onto waiting list and theatre scheduling policy. • The matron and nurse practitioner to measure where LoS was saved. admission to hospital. also worked with the Jersey Hospitals • Alignment of the project to the• Developed patients information sheet 3. Electronic referral system, and staff at St George’s to develop strategic direction of the trust to to explain process, now sent to all inpatients and interhospital transfer and implement a new discharge specifically save 10 beds increased patients when added to the waiting patients routine for Jerseys patients – the team engagement at senior level. list. • Cardiothoracic nurse practitioner post designed a clinically safe and practical developed and recruited to. protocol to discharge patients on day2. Theatre scheduling • Met with referring hospitals to discuss five to stay in a local hospital with• Theatre lists published weekly, ten new cardiothoracic nurse practitioner regular nurse check-ups until day ten, days in advance and with slots role, established direct contact of before flying home. This was done in available for emergency or inpatient individual who would take collaboration with the Jersey referring cases. responsibility for each referral. hospital, who were pleased with the• Set up weekly MDT meetings to • Training sessions delivered to staff (at team’s dedication to safe practice and review lists for following week and each site) on how to use referral clinical effectiveness. identify possible issues/over runs/ system. resources. • Electronic referral system used for in-• Implementation and enforcement of house in-patients between cancellation policy. cardiologists and cardiac surgeons at St George’s. www.improvement.nhs.uk/heart 11
  • 12. A guide to commissioning cardiac surgical services The results Increase in admission on the day The new pathway has resulted in: Theatre Scheduling - Cancellations (non clinical) from an average of 9.9% of cases per The improvements have lead to an month in Q3 2008/09, to 24.6% of 20 overall increase in productivity – theatre Cardiac Network cases per month in Q3 2009/10. project commenced scheduling, increased pre-assessment 18 Cancellation policy implemented and admission on the day, reduced This equates to 69 patients admitted on 16 cancellations and length of stay have all the day in 2009/10 to date; at £200 per Number of cancellations contributed towards an increase in 14 bed day this makes a saving of Surgical pathway activity by £103k to date. coordinator in place £13,800. 12 Rota set at Transformation six weeks team involved Reduction in non clinical 10 cancellations from an average of 8 10.1% of cases per month in Q3 2008/09, to 2.3% of cases per month 6 in Q3 2009/10. 4 Improved start/ finish times 2 AoD commenced 0 Apr08 Jun08 Aug08 Oct08 Dec08 Feb09 Apr09 Jun09 Aug09 Oct09 Dec09 May08 Jul08 Sep08 Nov08 Jan09 Mar09 May09 Jul09 Sep09 Nov09 Non-clinical (actual) Non-clinical (target) Linear (non-clinical actual) Baseline figures Percentage of non-clinical cancellations Mean Median Range April - March 2008/09 8.3% 9.0% 3-15% April 2009 - present 3.7% 4.0% 1-7% Oct - Dec 2008/09 average 10.1% 10.3% 5-15% Oct - Dec 2009/10 average 2.3% 1.9% 1-4%12 www.improvement.nhs.uk/heart
  • 13. A guide to commissioning cardiac surgical services Reduction in length of stay for elective cardiac surgery patients, reduced from Admission on Day of Surgery an average of 8.8 days in Q3 08/09, to 7.6 days in Q3 2009/10. 60 Length of Stay - Elective Cardiac Surgery 50 11 Surgical pathway Cardiac Network coordinator in place project commenced 40 10 Percentage Transformation Surgical pathway team involved coordinator in place 30 9 Transformation Cardiac Network team involved Days project commenced 8 20 7 10 AoD commenced 6 AoD commenced 0 Apr08 Jun08 Aug08 Oct08 Dec08 Feb09 Apr09 Jun09 Aug09 Oct09 Dec09 5 May08 Jul08 Sep08 Nov08 Jan09 Mar09 May09 Jul09 Sep09 Nov09 Apr08 Jun08 Aug08 Oct08 Dec08 Feb09 Apr09 Jun09 Aug09 Oct09 Dec09 May08 Jul08 Sep08 Nov08 Jan09 Mar09 May09 Jul09 Sep09 Nov09 % CS AoD (actual) % TS AoD (target) Linear (% CS AoD) Cardiac Surgery Elective LoS Linear (Cardiac Surgery Elective LoS)Baseline figures Percentage of admitted on the day Baseline figures Length of stay for elective cardiac surgery Mean Median Range Mean Median RangeApril - March 2008/09 8.5% 8.0% 1-15% April - March 2008/09 8.8 8.8 8-11 daysApril 2009 - present 20.9% 21.1% 10-31% April 2009 - present 7.4 7.7 6-8 daysOct - Dec 2008/09 average 9.9% 7.7% 2-20% Oct - Dec 2008/09 average 8.8 8.3 8-9 daysOct - Dec 2009/10 average 24.6% 25.0% 19-30% Oct - Dec 2009/10 average 7.6 7.8 7-8 days www.improvement.nhs.uk/heart 13
  • 14. A guide to commissioning cardiac surgical services Reduction in length of stay for non-elective cardiac surgery patients, from an Top tips b.The core team held the five points average of 15.7 days in Q3 2008/09, to 13.3 days in Q3 2009/10. 1. Engagement at senior level and outlined as a shared vision of alignment of the project to the change, and worked together to strategic direction of the trust achieve these goals. specifically saving 10 beds. c. As well as for planning purposes, Length of Stay - Non-Elective Cardiac Surgery 2. Regular reporting to senior the team meetings were important 23 management supported by robust for boosting morale for when the 21 data across a defined set of work was facing opposition or Cardiac Network project commenced measures agreed early on in the difficulties. 19 project to ensure focus. d.As a result of the project, Surgical pathway coordinator in place 17 3. Access to data. A member of the relationships and communications team with access to data was vital to throughout the team and across Days 15 measuring improvement as the the pathway boundaries have 13 network project manager struggled been improved. 11 to gain access to data, being 5. Keep in the forefront that perceived as an ‘outsider’. The improvement does not need to come 9 Transformation internal data manager was able to at a financial cost – but that by team involved AoD commenced 7 retrieve and analyse data shared working more efficiently and more Apr08 May08 Jun08 Jul08 Aug08 Sep08 Oct08 Nov08 Dec08 Jan09 Feb09 Apr09 Mar09 Jun09 May09 Jul09 Aug09 Oct09 Sep09 Dec09 Nov09 across the project team to drive the productively, patients can receive work. better care that is value for money. Cardiac Surgery Non-Elective LoS Linear (Cardiac Surgery Non-Elective LoS) 4. Interdisciplinary core project team was reflective of the key staff vital to Contact details: implementing and maintaining Jane Fisher, changes being tested. General Manager, Cardiovascular, Baseline figures Length of stay for non-elective cardiac surgery a. The core team consisted of the St George’s Healthcare NHS Trust lead for each work stream; these Jane.Fisher@stgeorges.nhs.uk Mean Median Range individuals were the people who would plan and measure the Laura Gillam, April - March 2008/09 15.5 15.4 10-21 days Senior Project Manager, South London changes – they were the people April 2009 - present 13.2 13.3 10-16 days who could really make a Cardiac and Stroke Networks. difference. Laura.Gillam@slcsn.nhs.uk Oct - Dec 2008/09 average 15.7 16.0 14-17 days Oct - Dec 2009/10 average 13.3 13.1 12-15 days14 www.improvement.nhs.uk/heart
  • 15. A guide to commissioning cardiac surgical servicesUniversity Hospitals Birmingham NHS Foundation Trust, Heart of England NHS Foundation Trustand Birmingham, Sandwell and Solihull Cardiac and Stroke NetworkEnsuring patients are fit for surgery and reducing delays in the cardiac surgical patients pathwayThe problem clinics and with some patients attendingAchieving the national target of 90% of a further appointment at pre-admitted cardiac surgery patient assessment clinic. The pre-assessmentpathways being completed within 18 clinic workforce did not have theweeks was proving a challenge across required skills to support a fullorganisations within the Birmingham, assessment, including history taking,Sandwell and Solihull Cardiac and patient examination and assessment.Stroke Network. One of the most Therefore, an SHO was required tocommon delays in the patients’ review all patients.pathway at Good Hope Hospital wasthe time between angiography and case Attendance at pre-assessment clinic wasreview by the multidisciplinary team often more than four weeks before the(MDT). On average the wait was four date of surgery which resulted in theweeks but at it’s longest nine weeks, need to duplicate chest x-rays andparticularly if the MDTs were cancelled. blood tests on admission. This createdSurgeons from the tertiary centre were unnecessary expense to the Trust and There was also some pressure to reduce A patient progress tracker wasrequired to travel across the city to inconvenience to the patient the overall length of stay and improve appointed by the network to track theattend the MDT meetings held at the efficiencies in the patient pathway, as patients through their journeys using areferring provider centre to review There was no anaesthetic service in the the tertiary centre is reducing its overall live database to help map the pathwayindividual cases requiring surgical pre-assessment clinic, resulting in number of beds on the cardiac surgical and identify delays in the journey.opinion. Clinical commitments often clinical problems often identified late in ward from 39 to 32. Tracking patient pathways also helpedmeant that attendance at these MDTs the patient pathway; on admission to to demonstrate that patients sometimeswas not possible. Not all patients were the tertiary centre problems had been The solution attended more than one surgical/discussed at MDT and the process of identified following assessment by the A surgical steering group was set up cardiology appointment.ensuring that patients were fully anaesthetist. This often resulted in the which included cardiologistsworked up for surgery prior to referral patient being declared unfit for surgery representing the tertiary centre and A new pathway to support theto the MDT was not supported by an and the operation cancelled. The clinic district general hospital, a cardiac achievement of 18 weeks wasagreed protocol. was not working to full capacity, flow of surgeon, an anaesthetist, management developed and agreed by all key patients through the clinic was low and representation from both trusts, a stakeholders. Baseline data wasThe system of ensuring patients were a review of the pre assessment services cardiothoracic nurse practitioner and collected to help define the problemfit for surgery was characterised by illustrated that not all slots were being tertiary centre cardiac audit clerk. The and scope of the project.inconsistency and variation across the fully utilised. Birmingham, Sandwell and Solihullsurgical teams with pre-screening not Cardiac and Stroke Network providedcarried out in all surgeons’ outpatient project management support. www.improvement.nhs.uk/heart 15
  • 16. A guide to commissioning cardiac surgical services The project objectives were: potentially adding weeks to the • Introduction of weekly electronic pathway and unnecessary waits for Cardiac Surgery Pathway - RTT 18 Weeks MDTs using: the patient. • telemedicine to allow the transfer 2 WEEKS 5 WEEKS 2 WEEKS • An increase from 0% of patients of images between referring units Referral Received in Rapid Access Diagnostic MDT (referral previously reviewed by an anaesthetist and the tertiary centre; Rapid Access Chest Chest Pain Clinic Tests to tertiary in pre-assessment to72% over a short Pain Clinic Appointment centre) • teleconferencing between the period of time. We are working referring consultant cardiologists 9 WEEKS towards 100% of patients being and tertiary centre surgical teams assessed by an anaesthetist in pre Surgical Diagnostic Pre-Assessment Cardiac Surgery for the purpose of weekly MDT Outpatient Tests Clinic assessment clinic. case review. Use of technology was Appointment • Clinic nurses undergoing practitioner thought capable of reducing MDT training to enable implementation of Secondary care to tertiary care - 9 weeks cancellations and increasing the Tertiary care to definitive treatment - 9 weeks a cardiothoracic advanced nurse number of patients discussed at practitioner role in the pre-assessment MDT; clinic and to help address demands • introduction of a pre-referral on clinical service brought about by protocol to ensure patients are fully Progress • Development of the pre-referral EWTD. worked up prior to referral to the The tertiary centre has four core protocol to support the referring • Capacity at pre-assessment clinic has tertiary centre. purposes. Therefore, it was imperative cardiologist. This will ensure that all increased from approximately 12 to • Redesign of the pre-assessment that any project undertaken to improve the required information is available 30 available slots per week, resulting process with patients: services should be underpinned by the at the point of referral including in increased activity. This has been • attending the clinic no more than following four principles. presenting history, past medical achieved by increasing the number of four weeks before the date of history and a summary of appointments, and reducing time pre- admission for surgery at the tertiary i) Excellent patient care investigations and outstanding assessment staff spent on centre; ii) Clinical quality outcomes results. It also specifies the indications administration duties, to enable them • being assessed in pre-assessment iii) Research and innovation for undertaking core investigations to focus on clinical duties. clinic by a cardiothoracic advanced iv) Education and training. such as trans-thoracic echo, carotid • Telemedicine system is in the process nurse practitioner and an duplex scans and lung function tests. of being installed. anaesthetist to ensure they are fit These have been achieved in the Implementation of this protocol will • Development of a patient for surgery on admission to the following ways: ensure all necessary investigations are questionnaire survey to gather an tertiary centre, with a view to completed before referral to the understanding of the patients’ reducing the cancellation rate and tertiary centre, reducing the risk of experience from referral for cardiac optimising use of inpatient beds. the patient being referred back to the surgery to admission for surgery. DGH for the tests to be undertaken,16 www.improvement.nhs.uk/heart
  • 17. A guide to commissioning cardiac surgical services Top tips Contact details: • Mapping the existing pathway is Emma Billingham essential in understanding timelines Group Manager and delays in the system.“ University Hospitals Birmingham • Strong clinical leadership (cardiology NHS Foundation Trust and cardiac surgeons). emma.billingham@uhb.nhs.ukUniversity Hospitals Birmingham is still in the process of fully rolling out • Obtain baseline data to identify if a problem exists and build in robustthe project. However, we have already seen benefits to patients with the data collection mechanisms toexpansion of pre-assessment and pre-screening clinics as well as the support improvement work. • Understanding the fundingdevelopment of anaesthetic-led pre-assessment clinics. We look forward implications and identifying who isto receiving comments from patients about their pre-operative pathway going to fund what (things like annual service costs for a piece of kitso that we can evaluate our success so far and identify any further etc) as early as possible in the projectimprovements to be made. We also welcomed the opportunity to work to avoid issues later on. • Develop a communication plan towith a local referring cardiology centre to identify bottlenecks in the facilitate the dissemination of projectpatient pathway and are currently working to resolve these. information to all admin and clerical/managerial and clinical staff involved in the pathway as this helpsI feel the project group has benefitted from networking with other to foster support and buy in to thecentres who have identified similar issues and we have learnt from improvement work making it everybody’s business.their experiences how to overcome these to ensure the overall • Bringing together key stakeholders ”success of the project. from the referring provider unit and tertiary centre together to identify issues and problems and develop joint solutions. • Understanding the patient/carerEmma Billingham, Group Manager experience is fundamental to the success of any quality improvement work. www.improvement.nhs.uk/heart 17
  • 18. A guide to commissioning cardiac surgical services Royal Brompton & Harefield NHS Foundation Trust in collaboration with North West London Cardiac and Stroke Network Process changes significantly increase 18 week performance in cardiac surgery Overall there was a considerable amount These meetings also highlighted of incomplete data on the inpatient concerns around how the IPTMDS forms waiting list (KH07). The position of were being completed. These patients along their 18 week pathway discussions resulted in a revised surgical was not known due to clock starts being patient pathway and process changes found/given/used too late. Data flow of featuring: patients after going on KH07 was not recorded accurately. These • Patients seen at the pre-operative inconsistencies meant that Royal assessment clinic (POAC) being Brompton & Harefield NHS Foundation declared ‘fit for surgery’ before being Trust had little chance of achieving the added to the surgical waiting list. 18 week admitted referral to treatment • Agreed and standardised use of the pathway target. 18 week suite of rules across referring The problem • Clinic outcomes were often not providers and the tertiary centre. The trust performance for referral to documented following the patients The solution • Inter-trust contacts for administrative, treatment pathways for cardiothoracic attendance at the pre operative The trust employed 18 week clerical and nursing staff were surgery, within 18 weeks between assessment clinic (POAC), a crib sheet co-ordinators to assist the 18 week exchanged so that in future clock April - August 2008 had remained was developed for the clinic staff to project manager and received project start requests were sent to the right consistently below the 90% national show what rules can/cannot be management support from the North people. target, sitting in the low 30-50%. A applied in different situations. West London Cardiac and Stroke • Support and training on application review of the elective surgical pathway • 18 week clock stops were not always Network to focus on the cardiac surgery of the 18 week rules for key admin for planned care illustrated the following used appropriately, for example pathway. personnel and nursing leads of the issues: patients requiring referral for pre-assessment service to help reduce conditions on a new clinical pathway The surgical pathways were mapped variation and ambiguity in their • Patients were typically added to the such as haematology often resulted in from the point of referral made by the application. surgical waiting list before they had an inappropriate continuation of the secondary care provider through receipt • Patients at other trusts who were been assessed and declared ‘fit for 18 week clock. of referral to treatment by tertiary care under investigation were recorded on surgery’ which resulted in extended • These patients were not recorded on centre which helped to identify RBHfT PAS as ‘active monitoring’, wait times for definitive treatment a central list and were at risk of bottlenecks in the surgical pathway. effectively stopping the clock on their well beyond 18 weeks. getting lost ‘in the system’. cardiac surgery pathway. The cardiac • The understanding and application of • A number of patients had already A series of meetings with the referring nurse practitioners would follow the the 18 week suite of rules varied breached their 18 week pathway by trusts and the tertiary centre helped gain progress of the patient through their among staff within administrative, the time the referral was received by a common understanding of how to appointments and tests ensuring that clinical and managerial roles at the the tertiary centre, this was partly due apply the 18 week rules suite and there were no unnecessary delays, tertiary centre and referring providers. to the accompanying Inter Provider develop a shared agreement for applying once declared fit for surgery they Transfer Minimum Data Set (IPTMDS) clock-starts and stops across providers. would be added to the waiting list. form being incomplete or incorrect.18 www.improvement.nhs.uk/heart
  • 19. A guide to commissioning cardiac surgical services• Redesign of the clinic outcome form week rules and how to apply them Comparative data of performance for a four month period year on year with fields developed to show a range effectively. of scenarios and how the clock rules • There has been an improvement in apply. both the number of IPTMDS forms April - August 2008 Performance• The integrity of data on KH07 was sent through and their data closely monitored. Appropriate and completeness. Apr May Jun Jul Aug Average effective data management and • Improved communication between communication significantly improved staff has also helped reduce delays in Wexham Park 71% 80% 79% 44% 50% 64.8% the accuracy of the data used to referrals, transferring and sharing of Lister 60% 66% 41% 46% 12% 45% monitor performance. information and the booking of• Where possible clock starts were appointments. Luton and Dunstable 0% 16% 20% 25% 21% 16.4% found prior to booking POAC. The 18 week database was used by pre- Top tips operative administrative staff to plan April - August 2009 Performance • Communication between providers the patients clinic attendance date in and across staff groups including line with trust targets and appropriate Apr May Jun Jul Aug Average administrative and clerical, clinical and to breach date.• Through discussion over the 18 managerial is key to ensuring full Wexham Park 86% 100% 97% 100% 96% 95.8% week rules and the use of medical understanding of the 18 week rules management it transpired that and effectively applying them. Lister 70% 88% 74% 70% 86% 77.6% referring trusts treat the majority of • Developing and strengthening Luton and Dunstable 100% 92% 86% 84% 96% 91.6% their patients before referring working relationships between the them on. cardiac nurse practitioners and the surgical medical teams helped poolResults the expertise to support a full • A thorough understanding between Contact details• By December 2008, the trusts 18 pre-operative assessment clinic. how the information systems and Gemma Snell week admitted performance met the • Access to the 18 week co-ordinator operational processes correlated by Service Improvement Project Manager minimum 90% which continues to be contactable by bleep increases their the 18 week co-ordinator had a huge North West London Cardiac and sustained, often peaking above the accessibility for staff to flag queries impact on improving data quality and Stroke Network 95% target. Pro-active tracking of and problems regarding interpretation hence performance issues. Email: gemma.snell@nhs.net patients along their pathway has of the rules. • Building relationships and improving ensured there have been no • Meeting regularly with teams along communication channels with unwarranted delays. the surgical pathway for example the referring trusts had a considerable• There has been a far greater theatre scheduler who booked impact on improving performance as understanding within the hospital staff elective and non-elective cases, there was a sense of shared and between referring trusts of the 18 helped reduce avoidable delays. responsibility. www.improvement.nhs.uk/heart 19
  • 20. A guide to commissioning cardiac surgical services Essex Cardiothoracic Centre, Basildon and Thurrock University Hospitals NHS Foundation Trust in collaboration with Essex Cardiac and Stroke Network Tackling change - the teamwork way The problem 1.Collegiate system for review of The Essex Cardiothoracic Centre (CTC) is patient referrals. a relatively new unit which opened in 2.Process for allocation of ‘pooled’ July 2007, with many of its clinical patients to consultant surgeons pathways and their supporting systems resulting in longer waiting lists for and processes having been developed certain procedures. early in the organisations history. The 3.Pre-assessment clinic not working to trust faced challenges with meeting its full potential due to the skills of the national target of 90% admitted staff carrying out the clinic. pathways completed within 18 weeks of referral to treatment with performance Baseline audit of the current service was often running between 30-40%. carried out in relation to theatre Review of the surgical pathway was cancellations and theatre day/time. An seen as paramount to the continued audit tool was developed which allowed success and growth of the unit, all sections of the theatre to be evidenced by internal audits that had measured, for example time taken to identified areas for development and call for patient, time in anaesthetic improvement. room, knife to skin time. This audit • Patients often needed to make more The solution helped to identify timing delays and The elective cardiac surgery pathway than one visit in the pre operative A Surgical User Group (SUG) was identified sections of the theatre day was seen as a key area of focus to part of the surgical pathway as a established with members drawn from where improvements to efficiency could review systems and processes in the result of surgical outpatients and across the multidisciplinary team to be made in order to optimize theatre following areas of the pathway: pre-operative assessment clinics spearhead the development of the usage and reduce surgical cancellations (POAC) being held separately. surgical service. An action plan with as a result of clinical and non clinical • Surgical collegiate system, a process clear timescales was produced, the matters. The picture of theatre of clinical review to ensure correct ECTC were able to focus on problems current service was discussed and ideas cancellations was broken down into the procedure and surgeon determined several audits were carried out which generated for future developments and following: for all cardiac surgery referrals, carried identified areas where improvements improvements planned. All changes to out by surgeons prior to the patient were required in order to streamline the the service were approved by the SUG. • Interhospital transfer patients attending an outpatients’ appointment. service, improve patient experience and Additional project support was provided received at the unit were often not Challenges in sustaining the collegiate improve efficiency and effectiveness. by the Essex Cardiac and Stroke fully optimised. system, based on two surgeons The unit were keen to maintain high Network. • Unfit elective patients. reviewing each referral on a bi weekly patient satisfaction levels whilst • Anaesthetic cove.r basis, were related to ‘buy in’ and maximizing the use of in patient beds Mapping of the current pathway • Availability of intensive care beds. agreement from the surgical teams. and theatre utilisation. highlighted issues with: • Theatre over-runs.20 www.improvement.nhs.uk/heart
  • 21. A guide to commissioning cardiac surgical servicesA retrospective audit of 40 case notes • Improve 18 week referral to treatment • Reduction in unnecessary duplication Contact details:was carried out across six consultant times for admitted pathways. of tests. Tests performed at POAC, Jenni Brownsurgeons during a three month period – • Improve efficiency within theatre day. CXR, blood tests and ECGs now Matron, Essex Cardiothoracic Centre -this illustrated the problem of delay remain valid from time performed Basildon and Thurrock Universitypatients experienced between being The new service now provides: until admission into ECTC. Hospital NHS Foundation Trustseen in pre operative assessment clinic • Same day outpatient clinic and pre- • Reduced waiting times for cardiac Jenni.brown@btuh.nhs.uk(POAC) and their admission for surgery assessment. surgery from nine weeks to six weeks.which often resulted in tests being • Dedicated lead pre-assessment nurse. • Timely POAC to admission hasrepeated, an unnecessary expense to • Forum for monitoring and auditing reduced length of stay by one day forthe Trust. The case note audit measurables to improve service. some groups of cardiac surgicalhighlighted in some cases the time • Same day admission for cardiac patients with same day admission.interval was 10 weeks between POAC surgery.and admission for surgery which • Super multidisciplinary team (MDT) for Top tipsinvalidated the tests necessitating them review of complex cardiac surgery • Working together in ato be repeated on admission. cases with joint cardiology and surgical multidisciplinary team and assessment of the patient presented. collaborating with key stakeholdersUnderstanding our cardiac surgical within ECTC and with referringpathway by using service improvement Results District General Hospitals (DGHs)techniques and data helped us to 18 week admitted pathways are now meant everyone understood eachidentify service improvements and areas performing consistently at 90% as a others perspectives.where patient experience could be result of: • Engagement with staff across a rangeimproved. • Improved working relationships and of disciplines and at all levels MDT working have developed as a including consultant surgeons,Our overarching aim was to: result of the involvement of all anaesthetists, nurses, perfusionists• Reduce the time frame between disciplines within ECTC as a result of and management team. attendance at pre operative the development of Surgical User • Strong leadership and senior assessment clinic and admission for Group. management support. surgery by four weeks. • Reduction of in -hospital theatre • Schedule meetings to meet the needs• Reduce theatre cancellations to cancellations from 20% to 10%. of all disciplines to ensure attendance. below 10%. • Reduction in wait from pre operative • Production of robust data collection• Reduce waiting times from nine assessment clinic (POAC to admission and analysis to support the project, weeks to six weeks for cardiac for elective cardiac surgery from nine drive key changes and ensure the surgery. weeks to six weeks. work remained focused. www.improvement.nhs.uk/heart 21
  • 22. A guide to commissioning cardiac surgical services Cardiac and Stroke Networks in Lancashire and Cumbria Cardiac surgery and 18 weeks – A pan network approach The problem • Collection of base line data which The aim was to reduce the time from During 2008/09 the network took part included theatre cancellations (clinical DGH referral to surgery from 14 weeks in the national 18 Week Diagnostic and non clinical) and a 12 month to under nine weeks. Priority Project, which highlighted that review of the number of patients on patients on the cardiac surgery pathway the surgical waiting list (CABG and Early on in the project timeline a (from the point of District General valves) to establish trends. meeting was held with 18 week leads Hospital referral to surgery) were likely • Mapping of the surgical pathway at from each of the trust’s referring their to breach the 18 week target. The Lancashire Cardiac Centre (LCC) with patients to the tertiary centre which network had previously notified chief outcomes shared. resulted in agreement to ensure executives that the 18 weeks target was uniformity of referral processes and at risk of not being met due to issues Monthly progress reports were collection and transfer of RTT data surrounding the surgical component. submitted to the national team and across the network. Work undertaken in relation to measures for monitoring progress were An electronic theatre scheduling tool diagnostics, one-stop clinics and bed agreed as the number of patients on the was piloted in December 2008 to allow days for the cardiology part of the agreed standard of a nine week spilt waiting list for CABG, the number the booking of theatre cases to be pathway had already been completed in between cardiology and cardiac surgery waiting for valve replacement surgery, ccoordinated actively with theatre June 2008. providers. and the waiting time from referral by resources and capacity, with the aim of DGH Cardiologist to the day of surgery, reducing both over and under runs. The surgical waiting time from referral A project steering group, with and the surgical cancellation rate (clinical to surgery at the start of the project multidisciplinary membership, was and non clinical). A flow tool analysis of the 20 bedded stood at up to 14 weeks and was established to oversee the project and Cardiothoracic Intensive Therapy Unit characterised by variation in the surgical monitor progress. Project management The aim of the project was to ensure (CITU) was completed to help express referral patterns and length of surgeon support was provided by the network. that the time from referral by a bed occupancy and activity on an hourly specific waiting lists, both compromising Initial steps to baseline the project cardiologist to the patient undergoing basis, and was measured over 24 hours factors in the delivery of 18 week included mapping the referral pathways surgery was limited to nine weeks. for one month. The report was surgical pathways. to define the problem and focus of the Scope of this project was confined to the submitted to the tertiary centre and work. This included: surgical element of sustaining the 18 highlighted that the CITU runs at The solution • Identification of the main challenges week pathway, i.e. from the approximately 80% occupancy, with the Following successful recruitment to the in meeting the 18 week target for cardiologist’s decision to refer for surgery pattern across the study period cardiac surgery national priority project, admitted pathways. to the day the patient received surgery. indicating that there could be capacity work began in August 2008, with the • Mapping of all cardiac surgical Specific areas of focus agreed by the to accommodate extra cases at certain support of all stakeholders across the pathways in DGHs from point of GP project board were: times. A repeat analysis is scheduled for networks constituent organisations. referral with the outcomes from the • The interface between secondary and March/April 2010 to monitor the effect Management of 18 weeks across the mapping activity fed back to the tertiary care. of four high care beds introduced in network health economies led to an service. • Subsequent scheduling of theatre cases. March 2009.22 www.improvement.nhs.uk/heart
  • 23. A guide to commissioning cardiac surgical servicesThe trust has implemented the advanced • Agreed protocol across the networknurse practitioner role into this area to standardising pre operative diagnostic Number of Patients on Cardiothoracic Waiting Listsassist with case management and we are investigations were in place. by Intended Procedure Type - April 2008 to January 2010hoping that the flow tool will help direct • Pooled waiting lists were introduced 140 CABG Valve Otherthis exciting new role within the unit. at Lancashire Cardiac Centre for first 120 referrals and those patients with oneThe new surgical pathway featured: and two vessel disease. Count of Hospital Number 100• Agreed and standardised pre • Patients on the waiting list were given operative procedures. a date for surgery at their out[patient 80• An increase in surgical outpatient clinic appointment with the surgeon. capacity though implementation of • An electronic theatre scheduling tool 60 surgical satellite clinics at two of the has been implemented resulting in a 40 referring District General Hospitals. more even spread of the intensity of• Multidisciplinary team review of work across the week, and through 20 patients referred for cardiac surgery individual theatres. carried out via videoconferencing. 0• Implementation of an electronic Top tips Apr 08 Jun 08 May 08 Jul 08 Aug 08 Oct 08 Sep 08 Dec 08 Nov 08 Feb 09 Jan 09 Apr 09 Mar 09 Jun 09 May 09 Aug 09 Jul 09 Oct 09 Sep 09 Dec 09 Nov 09 Jan 10 theatre scheduling tool. • Engage with all staff from the outset. Date Elective Admission List Census• Pooled waiting lists fro first referrals • It is essential to get consultant ‘buy and those patients with one and two in’ to drive through improvements. vessel. • Scope the project fully and support Activity Versus Cancellations - February 2009 to January 2010 with robust data. 250Results • Projects that span more than one Activity CancellationsBy the end of the project: organisation require sign up at• The waiting time for surgery had executive level. 200 reduced to six weeks across the board. Contact details: 150• The number of patients on the Jennifer Watts waiting list at the start of the project Associate Programme Director – 100 was 120 and had reduced to 79 by Service Improvement 9 March 2009. Cardiac and Stroke Networks 50• The percentage of surgical cases Lancashire and Cumbria cancelled for clinical reasons has been Jennifer.watts@csnlc.nhs.uk 0 Feb 09 Mar 09 Apr 09 May 09 Jun 09 Jul 09 Aug 09 Sep 09 Oct 09 Nov 09 Dec 09 Jan 10 reduced. Month www.improvement.nhs.uk/heart 23
  • 24. A guide to commissioning cardiac surgical services Cardiac surgery trends - the national picture Referral to treatment times cardiothoracic admitted 18 week pathways Referral to treatment times cardiothoracic admitted pathways. Referral to treatment times for cardiothoracic surgery admitted. Standard: 90%. National position (data November 2009) Standard: 90%. Position by Strategic Health Authority (SHA) (data November 2009) Treatment - Cardiothoracic admitted Referral to Key Performance Indicator by Strategic Health Authority 100 100 90 National Average 80 95 70 Percentage Standard: 90% 60 50 90 40 30 85 National 20 10 80 0 Apr 08 Jun 08 Aug 08 Oct 08 Dec 00 Feb 09 Apr 09 Jun 09 Aug 09 Oct 09 Dec 09 Feb 10 Month 75 North South London East West East of South South North Yorkshire and East West Midlands Midlands England Central East West the Humber Source: NHS Improvement Data Dashboard, January 2010 (data from November 2009) Strategic Health Authority Source: NHS Improvement Data Dashboard, January 2010 (data from November 2009)24 www.improvement.nhs.uk/heart
  • 25. A guide to commissioning cardiac surgical servicesOverview of waiting list numbers for CABG since April 2004 Coronary Artery Bypass Graft (CABG) - England - Total Waiters by Strategic Health Authority - April 2004 to December 2009 www.improvement.nhs.uk/heart 25
  • 26. A guide to commissioning cardiac surgical services Overview of waiting list numbers for valves since April 2004 Valves - England - Total Waiters by Strategic Health Authority - April 2004 to December 200926 www.improvement.nhs.uk/heart
  • 27. A guide to commissioning cardiac surgical servicesWaiting times for CABG since April 2004 Coronary Artery Bypass Graft (CABG) - England - Waiters by Time Band - April 2004 to December 2009 www.improvement.nhs.uk/heart 27
  • 28. A guide to commissioning cardiac surgical services Waiting times for valves since April 2004 Valves - England - Waiters by Time Band - April 2004 to December 200928 www.improvement.nhs.uk/heart
  • 29. A guide to commissioning cardiac surgical servicesNon-elective pathwaysThe care of patients with acute Options to consider before transfercoronary syndromes has changed Signposting to Improving Cardiac Interhospital Transfers (September 2007)dramatically over the last ten years asa result of the improvementsintroduced by the Coronary HeartDisease National Service Framework.As a result, many more patients arebeing referred for surgicalrevascularisation whilst hospitalisedfollowing an acute coronarysyndrome. In many units thiscomprises up to 40% of theworkload and in order for thesepatients to be accommodated withinoperating schedules effective systemsneed to be in place.As many of these patients are initiallyadmitted to DGHs and have coronaryangiography there they then wait fortransfer to a surgical centre and arecommonly referred to as interhospitaltransfers. These patients areconsidered high risk, assessed asbeing too ill to be discharged home,so wait for treatment on an inpatientwaiting list for transfer for diagnosticangiogram, angioplasty, heart surgeryor other procedures such aspacemakers or electrophysiologicalmanagement. www.improvement.nhs.uk/heart 29
  • 30. A guide to commissioning cardiac surgical services In order to minimise delays for the Escalation policies to help manage investigations. Clarity is needed about patient and to maximise efficiency waiting times across a local health which tests should be carried out we recommend the following: economy and to accelerate patient prior to transfer, where they should flow have been developed by several be carried out and what • Use of network-wide agreed clinical networks and are aimed at setting documentation should accompany protocols, to establish the need for locally agreed performance targets the patient on transfer (Making surgery and referral. which are monitored and if exceeded Moves, Heart Improvement • Use of a risk stratification system to allow for alternative arrangements to Programme, 2006). determine priority for treatment. be made to treat patients. The Essex • Use of existing electronic referral Cardiac and Stroke Network systems to refer and transfer summarise the benefits of developing patients for urgent cardiac surgery. a network wide policy as providing: • Network standards for waiting “ times. • A framework to ensure that numbers of patients waiting, Considerable work led by cardiac waiting times and disruption to So far, improvements in the pathway and transfer arrangements have networks in local health economies trusts is kept at a minimum. undertaken across each part of the • Reassurance for patients on saved the equivalent of some 959 NHS beds each year across England. patient journey to improve the anticipated waits for their We know that there is a lot more that can be done to take this further experience and outcomes for this procedure. saving the NHS a great deal of money and patients a great deal of stress group of patients and staff; to reduce ” the impact of avoidable bed days and Delays in the patients journey can and worry. associated challenges for trusts and occur if the patient is not fit for ambulance services around accident surgery following their transfer. These and emergency (A&E) waits and delays can be caused by a number of Professor Roger Boyle CBE, National Director for Heart Disease and Stroke achieving category ‘A’ targets has reasons including absence of MRSA Signpost to Improving Cardiac Inter Hospital Transfers, been captured within Signposts to and dental screening, or completion Heart Improvement Programme, (2007) Improving Cardiac Interhospital and availability of pre operative Transfers (HIP 2007). investigations and tests. These delays can be addressed through joint policies on issues such as MRSA screening, anticoagulant treatment and pre operative tests and30 www.improvement.nhs.uk/heart
  • 31. A guide to commissioning cardiac surgical servicesImproving interhospital transfers • Single point of contact • Electronic referral systems. • Robust communication links • Standardised referral method • Ownership of the problem • Central management of referral • List scheduling • Minimum dataset Making • Ensure treatment according to clinical priority • Image transfer.(Angiogram) the referral Transfer • Provide timely and accurate information • PACS system co-ordinator • Medcon work • Ambulance crew type • Paramedic crew • This can improve communication for • Technician crew referring centres and help manage: • Intermediate crew • Numbers waiting Assess • Transfer crew • Waiting times Agree local patient needs • PTS crew • Disruption escalation policy and match to • Skill-mix appropriate to patient needs. • Identification of anticipated waits for to manage transfer type • Escort required. procedure waiting times Interhospital • Type of vehicle Transfers: Making Connections • Dedicated transfer code agreed with Ambulance service • Referral pack for patients awaiting transfer: • Time ready agreed with Ambulance • Physical/psychological preparation service • Discharge requirements • Emergency or Urgent? Blue light – 8 • Video Communication mins/ or longer. • Agreed pathway for high-risk patients Information with • Network-wide policy agreed. Includes Ambulance emergency transfers/balloon pump transfers Service • Agreeing pre-transfer patient work-up • Standardised documentation between units to ensure patient is fit for procedure. This should include guidance on: • MRSA Fit for • Dental screening procedure? • Medication • Anticoagulation • Tests • Documentation www.improvement.nhs.uk/heart 31
  • 32. A guide to commissioning cardiac surgical services Glenfield Hospital, University Hospitals of Leicester NHS Trust in collaboration with East Midlands Cardiac and Stroke Network ‘Urgent or non urgent’, that is the question The problem The project steering group included: from this forum centred on length of Glenfield Hospital is a tertiary centre • General/service and operational wait and communication. providing specialist investigations and management. • ‘Better communication is needed’. treatment. More specifically the • Heads of service for cardiothoracics • ‘seemed to be a lot of waiting around department performs approximately and cardiology. with nothing happening’. 1,200 cardiothoracic cases per year. • Clinical leads from both • ‘Why couldn’t they have waited at For some time now the department has cardiothoracics and cardiology. their referring hospital’. worked towards a balance of meeting • Heads of nursing and matron for • ‘Why have I been waiting so long?’ national targets such as 18 weeks department. referral to treatment and 13 weeks for • Service improvement manager from Themes from the patient and carer coronary artery bypass surgery (CABG). the East Midlands Cardiac and Stroke focus group were discussed within the Local targets such as 11 week CABG Network. steering group and helped us to shape and seven days for urgent inpatient • Members of Leicester City PCT. the direction of some of our work. surgery and an internal standard to • Consultant cardiologists from accept patients within 48 hours of referring centres. An initial task was to look in detail at referral for inter hospital transfers. This the current processes and establish has had to balance with the increasing Additional data illustrated the total LOS Regular steering group meetings were where problems and bottlenecks were numbers of non-elective referrals which for all urgent inpatient (non emergency) held to discuss the progress of the in addition to understanding aspects of are both in-house and interhospital surgical referrals as 33 days which project and to table products such as the process we were doing well. Using transfers from referring district general included a 10 day post operative LOS. revised pathway algorithms. The role of information gathered from a local hospitals (DGHs). Non elective referrals the group was to agree an action plan, database helped establish evidence have averaged approximately 30% of all Inter hospital transfer patients coming oversee changes to current practice and around the size of the problem for the adult cardiac surgery activity during the into the department were also exposed agree newly designed pathways and non elective patient group length of period 2008-09. to these delays as the majority are documents. stay highlighting a median pre-operative referred directly to cardiology without length of stay of 19 and a mean of 23 With the assistance of the East Midlands being fully assessed and the appropriate Agreed solutions to our identified days. Cardiac and Stroke Network a number investigations being completed. problems included the following: of key areas were identified within the • Learning from patient and carer current non-elective care pathway The solution experience of the current service by resulting in a higher than average pre- A steering group was established from facilitating a patient forum. Patients operative length of stay. A review of the project outset with multidisciplinary and relatives were invited to share data extracted from a local data base team membership drawn from staff their experiences of Glenfield Hospital identified a median pre operative working across the pathway of care. and what it was like to wait for length of stay (LOS) of 19 days and a Staff not directly involved in the cardiac surgery as an inpatient. An mean of 23. pathway were also invited to contribute. emergent common theme identified32 www.improvement.nhs.uk/heart
  • 33. A guide to commissioning cardiac surgical servicesDetailed process mapping of both the • Complexity of the referrals process Referral pathways • A formally agreed set of criteria wasin-house urgent and interhospital due to variations in practice, referral Referral pathways were redesigned to developed to provide guidance ontransfer pathways of care was carried patterns and relationships formed reduce variation. A central point of why some patients would not receiveout. The mapping exercise helped between clinicians. referral was agreed whereby all surgical surgery within the agreed seven dayidentify the following areas as potential referrals with the exception of true pathway. This includes those patientsbottlenecks within the current system: The following were identified at all levels emergencies arrived via this point. awaiting multiple dental extractions,• Admin and clerical delays (three days across the unit as being a requisite of any Initially hand delivery for in-house patients admitted with extensive from dictation to receipt of letter) service redesign within our department. referrals, faxed by referring DGHs then Myocardial Infarction where surgery• Decision making process, PCI vs with a view to electronic referrals. The has not been performed as an surgery. If surgery, then how urgent? Referral proforma’s central referral point also gave the emergency and require a period of• Inequity of access to surgical care and • To streamline admin and clerical delays opportunity to provide referring recovery, failed PCI. treatment in both pathways was caused by traditional dictated and clinicians with waiting list/time evident with variations in referrals typed referral process: information before making the referral. Algorithms processes occurring without • Referral proforma’s were developed • Following a number of steering group consideration of constraints upon and designed to be available to • Two referral pathways were designed; meetings and discussions with the service such as waiting list clinical staff on each of the wards. one for external referrals and another Glenfield Hospital cardiologists and commitments and availability. The proformas provided guidance for internal ones. Both providing clear DGH consultants, the general• Inconsistent pre-operative assessment about the type of clinical information guidelines about how and when to consensus was that they did know processes across consultant surgical required by the surgeons at the point refer patients to a cardiothoracic what information the surgical teams teams with variation in the pre- of referral and went through a surgeon. Each of these also provided required from them when making a operative requirements of individual period of piloting and refinement. two arms by which guidance was surgical assessment. cardio-thoracic surgeons. Their use enabled the operational offered for both urgent and unstable • Likewise the cardiac surgical• Delays in obtaining some diagnostic manager to audit the referral process referrals and those urgent but consultants also felt that the pre- investigations due to uncertainty of with regard to the level of unstable. operative assessment was often requirements. information available on referral of • Referral pathways aimed to provide inadequate for the purpose of• Referring district general hospitals the patient to the surgical team; clarity for referring clinicians with deciding the course of treatment. This were unclear about Glenfield • Proforma’s also enabled the team to regards to whether patients are often proved to be costly in terms of Hospitals referral assessment criteria re-direct surgical referrals to the transferred directly under the care of delays in the decision making process. and medical staff at these centres surgical team with the necessary a consultant cardiac surgeon with a were also uncertain of the timing of clinical skills and theatre availability provisional date for surgery. Or surgical referrals, who and where to reducing the inequity that previously whether they are transferred under refer them to. existed. the care of a cardiologist for further assessment then referral internally. www.improvement.nhs.uk/heart 33
  • 34. A guide to commissioning cardiac surgical services • Three algorithms were developed Results for urgent in-house surgery. To maintain • Build in the overall strategic direction providing advice regarding the Many aspects of this project have been patient’s safety a number of these of the department to the project assessment and investigations drafted and agreed at steering group referrals were outsourced to other work. required to make a safe decision and cardiothoracic board level. cardiothoracic centres across the • Define a clear set of measures, in regarding the eligibility and readiness midlands region. Despite this situation these circumstances length of stay, of a patient for: • MDTs, surgical referral proforma’s and the work currently undertaken has been administrative delays, quality of 1. Coronary Artery Bypass Grafting the central referral point have in everyday use, i.e.; the referral patients’ experiences. (C.A.B.G). provided a more successful forum for proforma’s, algorithms, and referral • Engaging with stakeholders at an 2. Heart Valve Surgery. the discussion of surgical referrals. point. early stage to form and strengthen 3. Patients admitted with Acute They have promoted better relationships across secondary and Coronary Syndrome (ACS). communication between DGH The new referral pathways will tertiary care as this helps to consultants wishing to make referrals commence following discussion at manage the internal dynamics of a Multidisciplinary team meetings into Glenfield Hospital as they are board level and are likely to be in department which may be challenged A weekly multidisciplinary team provided with referral data, time general use by the end of February during the project work. meeting (MDT) to review patients with frames and waiting list information. 2010. This delay has been largely to treatment choices and complex The central referral point also provides ensure we sustain a balance between Contact details: treatment decisions was already in a means of advice pertaining to patient safety and our national and Steven Peck existence at Glenfield Hospital for surgical specialities within the local targets. Operational Manager, urgent and elective referrals. department. Department of Cardiothoracic Surgery, However, this takes place weekly and • The surgical referral pathways have Top tips Glenfield Hospital, with the number of potential urgent been drafted, redesigned and agreed • Develop a project steering group from University Hospitals Of Leicetser referrals we as a steering group believed across the clinical and managerial the outset of the project with the Steve.peck@uhl-tr.nhs.uk it would be prudent to start a second teams within the department and relevant members. MDT. This would largely discuss internal with external referring centres. • Agree clear aims and objectives, and DGH referrals and so we aimed to retain some flexibility as events can invite DGH consultants, anaesthetists From August 2009 to January 2010, change. and other clinical staff. Glenfield Hospital was identified as the • Map processes at the beginning of National Centre for Extra Corporeal any project involving the review of Membrane Oxygenation (ECMO) current processes. treatment for the H1N1 Virus resulting • Carry out a demand and capacity in a large proportion of our exercise to support the project with cardiothoracic surgery/intensive care robust data as this will provide the service being consumed by ECMO. This steering group with the information meant an increase in the length of stay they need to direct potential changes34 www.improvement.nhs.uk/heart
  • 35. A guide to commissioning cardiac surgical servicesDischarge planningManaging and maintaining patient them together with their family (if medical and anaesthetic staff hugely aspects that impact on the individualflow within the acute setting requires appropriate) to consider their improves the process as together they patients discharge and thea focus on discharge whilst discharge plans and place of care. were able to identify patients suitable requirement for advance planning tomaintaining an approach that is Discharge planning should embrace for early discharge home. Their ensure that services and support arefocussed on the individuals discharge physical, psychological and social combined knowledge and expertise available on discharge.needs. Assessing the patients aspects of the patients care. was used to jointly assess the patientdischarge needs pre operatively, pre and post operatively to identify The case study presented byeducating patient and family about All of the case studies within this any specific needs or issues to be Papworth Hospital NHS Foundationrecovery at home and informing document contain elements of addressed. The multidisciplinary Trust outlines how they reduced theirthem about care they receive once discharge planning and address the team developed a range of decision total inpatients length of staydischarged is important to include importance of: support tools to complement the through using audit of delayedwithin the pre operative assessment patient assessment process supported discharges to reduce variation in postclinic service. Optimising the patients • Securing admission/discharge by a series of home visits by the operative practice and addressdischarge can help improve the protocols between providers. specialist nursing team. patient focussed discharge at prepatients’ experience, reduce the • Providing information packs for operative assessment clinic.overall inpatients length of stay; patients and carers. One mechanism for optimisingimprove patient flow and efficiency in • Establishing intermediate care discharge planning is to improveuse of beds. processes. ward efficiency by reducing and • Seeking the patients and carers eliminating unnecessary avoidableDelayed discharges are a frustration views and involving them in delays by using visual managementfor patients and staff alike. discussions to inform change. systems (VMS) to track patientEstablishing the cause of delay and progress, trouble-shoot and progresshow to overcome issues preventing The following two case studies chase. An example of this approach isdischarge is important to understand illustrate an interesting approach to demonstrated within the Papworthand recognises the need for discharge planning. case study. VSMs bring together thecollaborative working across the multidisciplinary team to planhealth professions if you are to The case study presented by Trent discharge/transfer focussing the teamimprove patient experience and Cardiac Centre illustrates how on the steps required to supportpatient flow. An important part of recognising the need for collaborative timely and safe discharge/transfer.the discharge process is to discuss the working with physiotherapists, They help improve the knowledgepossible options before the patients intensive care practitioners, cardiac among the multidisciplinary team ofadmission for surgery, encouraging rehabilitation nurses, pharmacists, the wider health and social care www.improvement.nhs.uk/heart 35
  • 36. A guide to commissioning cardiac surgical services Papworth Hospital NHS Foundation Trust in collaboration with Anglia Cardiac and Stroke Network Improving the patient experience for cardiac surgery pathways The problem post operative day, which is Papworth’s The solution Making sure that patients are coronary artery bypass graft standard). To streamline the adult cardiac surgery discharged home when they are A number of areas where the pathway pathway for patients prior to admission medically ready to go and avoiding any could be improved and a higher quality and at discharge; thereby using unnecessary system delays, was the patient experience could be achieved inpatient beds more appropriately and purpose of a project undertaken at was identified and focused on the efficiently to maximinise available bed Papworth Hospital in July 2009. processes related to: capacity for admissions, sustain the achievement of 18 week referral to Achieving the challenging 18 week • Variation in practice across the treatment times for admitted patient target in cardiac surgery requires surgical team with regards to: pathways and improve the patients inefficiencies to be removed from the • Removal of pacing wire, central experience. patient pathway. Papworth Hospital has venous catheter and urinary an older and more complex case mix catheter; The Anglia Cardiac Network funded a than most cardiac surgery units and • Post operative checks (sternal project manager to review the adult Overall we wanted to identify therefore had a greater challenge. stability, bowel movement, wound elective cardiac surgical pathway for pre sustainable solutions to reducing and stair assessments). admission and discharge. A project unnecessary delayed discharges: The Papworth Team undertook a project • Repatriation process to district steering group was set up, an action • To ensure the appropriate and safe to streamline the cardiac surgery general hospitals and liaison with plan produced identifying several early discharge of patients either to pathway and began with an audit of local services for discharge e.g. streams of work, baseline measurement their own home, referring provider or 220 patients. Patient and carer intermediate care. carried out and the current pathway provider unit nearer to their home satisfaction are high among cardiac • Multidisciplinary team communication mapped and a new pathway developed without reducing the quality of surgery patients at Papworth and work and co-ordination regarding discharge and agreed. patient care. with a focus group showed that and expected discharge date. • To maximise the use of beds at appropriate, early discharge and the This work helped to identify processes Papworth, increasing throughput for reduction of health acquired infection As part of the audit we calculated that carried out prior to admission which both elective and non-elective risk were important issues for patients. a reduction in length of stay by one day could be done either in a more admissions for cardiac surgery. Add this to the fact that patients can per patient would result in cost saving streamlined way, e.g. combining pre travel long distances to Papworth, and of £530,000/year (based on a bed day admission and outpatient’s clinic, or discharge nearer home was also an costing £250). carried out in alternative locations. important patient driver. The audit identified that up to 45% of patients experienced delays in their discharge (discharged after their 8th36 www.improvement.nhs.uk/heart
  • 37. A guide to commissioning cardiac surgical servicesThe new pathway was approved and • Multi disciplinary team involvement inpiloted and now features: the admission and discharge Cardiac Surgery: Post Operative Length of Stay• Initiation of discharge planning at pre processes. admission (or within 24 hours of • Information for patients, relatives and 14 admission): carers about discharge from hospital 13 • Comprehensive discharge in the form of leaflets and DVDs. 12 assessment documentation within the surgical integrated care On going work 11 pathway; In addition to work completed around LOS (Days) 10 • Outlining options and the delayed discharge, there were several availability of support services to other areas identified which are being 9 patients; addressed: 8 • Patient referral to intermediate care • Reviewing and updating discharge services from pre admission clinic. policy. 7• Same day admission for routine • Piloting an improved intermediate Elective LoS post op (CABG & Valve) Elective LoS post op (CABG) 6 elective adult surgical patients , to care referral system. Elective LoS post op (MVR) Elective LoS post op (AVR) include those patients who are • Trialing nurse led discharge within 5 second on the list, single procedure, cardiology. Jul 09 Aug 09 Sep 09 Oct09 Nov09 Dec09 non diabetic with no co-morbidities • Preparing a business case for a Month with a plan to extend to a greater discharge co-ordinator role. patient population.• Standardisation of surgical discharge Results • Improved patient participation and • Length of stay from 9.01 days to criteria. Agreement of the Improvements to the pathway have the communication regarding estimated 8.0 days for elective coronary artery post-operative process in terms of potential for improving the patient discharge date and schedule for post bypass graft, equating to a removal of pacing wire, central experience for 2,300 patients per year. operative procedures and checks. potential cost saving of £506,010 venous catheter and urinary catheter This new pathway has meant patients • Improving the quality of the patient (based on 2007/08 activity figures); and completing post operative checks will benefit from: experience has also identified • Length of stay reduced from 10.74 earlier in the patients post operative • New information on discharge, which productivity gains, which include (cost days to 9.7 days for elective valves, recovery period. is discussed early in the patients’ savings are based on a bed day equating to a potential cost saving• A traffic light visual management pathway. Documentation was costing £250): of £521,040 (based on 2007/08 system to identify an estimated developed and given to all patients. • Total length of stay from 9.98 days activity figures). discharge date on the third post • Appropriate and safe early access to to 8.5 days for all elective cardiac operative day. intermediate care nearer to patients’ surgery equating to a potential cost homes, due to an improved referral saving of £741,480 (based on system. 2007/08 activity figures); www.improvement.nhs.uk/heart 37
  • 38. A guide to commissioning cardiac surgical services • A 52% reduction in the number of • The reduction in length of stay is bed days lost due to delays in being achieved by increased repatriation (n = 107 to 51) a cost communication between professions saving of £14,000 during the life of and implementing small changes the project (non inclusive of costs which are easily sustainable. associated with loss of activity). Contact details: Top tips Nadine Hazelwood Key to the service re-design was Assistant Directorate Manager (Pathways) working in collaboration with the Papworth Hospital NHS Foundation Trust Cardiac Network, NHS Improvement - nadine.hazelwood@papworth.nhs.uk Heart and other key stakeholders to identify and implement the necessary improvements. • Working with patients, carers and staff to seek their views on the discharge process. • Agree data set and communicate baseline measurement early in the project. • Strong leadership both clinical and managerial. • Aligning the work within the organisations priorities. • Setting out project aims and assigning responsibilities. • Collecting, and analysing robust data monthly, and making necessary adjustments to the new process. • Having pre-set meetings with clinical representation.38 www.improvement.nhs.uk/heart
  • 39. A guide to commissioning cardiac surgical servicesTrent Cardiac Centre, Nottingham University Hospitals NHS Trust in collaboration with East Midlands Cardiac and Stroke NetworkReducing length of stay of elective cardiac surgical patients to a one night stay post operativelyThe idea for a shorter spell in hospital postThe average length of stay for people operatively potentially being dischargedundergoing cardiac surgery at the Trent home following a one night stay inCardiac Centre is around five to seven hospital. A shorter length of stay woulddays. The typical elective surgery equate to saving four post operativepathway includes review of the patient bed days per patient stay and a total ofin outpatients by the cardiac surgeon 320 acute beds per year.where the decision to undertake surgeryis made and the patients added to the The solutionwaiting list. A week before surgery The Trent Cardiac Centre at Nottinghampatients are invited to attend the pre- University Hospitals NHS Trust, set up aoperative assessment clinic where they project team with multi-disciplinaryare seen by the surgeon, anaesthetist membership representing the tertiaryand cardiac rehabilitation nurse. At this unit, primary care and the nationalappointment the full range of pre- improvement lead for cardiac surgery.operative tests are undertaken. This group was led by a consultant surgeon with project managementPatient and carer satisfaction levels are support from the East Midlands Cardiachigh at the Trent Cardiac Centre and and Stroke Network.feedback from patients had indicatedthat some were keen to leave hospital We employed service improvement Potential risks to patient safety were Having identified the potential risks toearlier and return to their usual techniques to look at the current highlighted through a risk assessment early discharge and the changesresidence. We decided to test out patient process by undertaking process process which helped us to consider required to ensure patient safety in thewhether we could send selected low mapping and asking patient and carers each of the identified risks and steps pre and post operative surgicalrisk elective adult cardiac surgical to share their views on the current required to mitigate these. To help us pathway we:patients home after a one night stay patient experience along the usual understand the concerns patients andpost operatively following coronary pathway of care. A new patient pathway carers may have regarding early • Developed a set of inclusion andartery bypass surgery, valve surgery or was agreed detailing what tasks, support discharge from hospital we held a exclusion criteria used to select therepair of atrial septal defect. An audit of and mechanisms would need to be in workshop to identify their views and appropriate patients.patients stratified as having a low risk place and delivered by who for patients experiences of the current service and • Produced staff handbooks assembledprofile for cardiac surgery whose to be safely and appropriately discharged to gather views of the proposed shorter to contain the full set of protocols,operation was performed in the home. The project team agreed to work pathway. information and processes to supportprevious 12 months highlighted that toward testing out a one night post staff training in the pilot.approximately 10 percent (80 patients) operative stay with 10 patients selectedof all elective referrals may be eligible against criteria. www.improvement.nhs.uk/heart 39
  • 40. A guide to commissioning cardiac surgical services • Constructed a rating system to score • Instigated a series of pre-operative early discharge and patient self • The carer reported the back up the confidence of patients and carers home visits to assess the patients management have been applied to system and emergency telephone selected to take part in the one night home environment and carer patients on the traditional care contact number to seek advice was stay pilot which formed part of the circumstances and built in one to one pathway, for example, the patient used and worked extremely well. pre assessment process. education on use of the recovery at tools developed for breathing, • The second patient went home after • Produced a DVD ‘Moving right home plan and home monitoring coughing and mobilisation exercises a two night stay returning on the along’ aimed at informing patients’ equipment. and advice designed by the third night and was subsequently and carers about the post operative • Put in place a series of three post physiotherapists. discharged on the fourth night post- experience which included instruction operative home visits which helped to • Enhanced skill set for cardiac operatively. Whilst the patient did on using equipment for home support the processes aimed at rehabilitation nurses using the well, his oxygen saturation levels were monitoring of blood pressure, pulse ensuring patient recovery, safety and confidence rating to help assess lower than the set criteria, this was and temperature, pre-operative carer support. patient and carer confidence when the only reason for his re-admission. advice of what happens within each • Implemented early system of patient exploring participation in a one night The protocol has been adapted to stage of the patient pathway, review and assessment with the stay pathway. These results helped reflect checking the patients oxygen exercises to be undertaken and how surgical team at the Trent Cardiac establish if there was a link between saturations pre operatively as part of to safely move and information on Centre on the seventh post operative the patient’s pre admission the assessment criteria at rest and on how to record results and progress in day and then the patient was confidence scores and their completion of climbing the stairs in the self management recovery plan. discharged. experience post operatively for order to gain a better assessment of • Devised a patient/carer self • Composed a process for continuous example did high scores ofconfidence normal values for the patient. management tool to help them patient and carer feedback using correlate to being discharged on one • A DVD has been produced for monitor recovery at home. telephone interviews and an in-depth day after surgery. patients and carers to support • Created competency documentation Discovery Interview. • Feedback from patients and carers information contained within the to test the carers use of simple home who have completed the one night recovery at home self management monitoring equipment. Results stay pathway highlight the benefits work book. The DVD features video • Initiated the use of the patient hotel At the point of publication, two from their perspective as: of former patients and carers facility situated on site for the patient patients have completed the one night • The peace and quiet at home in performing a range of routine post and carer to stay one day before stay initiative following elective cardiac comparison to usual care in the operative activities including surgery rather than admitting them to surgery and results have demonstrated hospital environment; breathing exercises, recording core an acute ward bed. the following: • Opportunity to eat and drink what temperature, blood pressure and • Extended the role of the cardiac rehab • Whilst the work was focussed on a he wanted and when he wanted to; oxygen saturation levels and more nurse as ‘the nurse navigator’ to sub set of the elective patient • Access to own bathroom and toilet general activities designed to support ensure robust communication and population, the downstream effect facilities; their recovery. adherence to protocols and processes. has been that several of the processes • The added bonus of being able to and products developed to support walk in the garden and outside;40 www.improvement.nhs.uk/heart
  • 41. A guide to commissioning cardiac surgical services• Stair assessments performed by the • A further knock - on effect is a instrumental in providing home not directly involved can result in their physiotherapists are now routinely reduced risk of gaining a hospital visits pre and post operatively not adoption of several of the patient carried out for all patients on their acquired infection if patients are only to the patient but to the carer; tools, for example the recovery at third post operative day (where discharged earlier and recover at • Physiotherapists were instrumental home plan for use with patients on appropriate) rather than the fourth home. in supporting the patient breathing the ward. post operative day. and activity pre and post operatively • Developing a peer support• A consequence of the one night stay Top tips to aid recovery; mechanism to help staff recognise pilot appears to have resulted in an • Patients should be on a defined • Cardiac intensive care unit nurses and pick up new things from other overall reduction in the post operative inpatient pathway based on a risk were instrumental in supporting sites external to the organisation in length of stay for cardiac surgical profile. the patient immediately post which they work and in appreciating patients in general regardless of • Clinical decisions need to be made on operatively until they were their own good practice. whether or not they were part of this a regular basis pre operatively and discharged and were the point of pilot study. Typical established post should be part of the structure of emergency telephone contact; Contact details: operative pathways resulted in home visits, pre operative assessment, • Advanced nurse practitioners were Mr David Richens patients being discharged between in patient visits on a two to three instrumental in providing advanced Consultant Surgeon and five to seven days post operatively hourly basis on day of operation and assessment of the patient after Head of Service, and since commencement of the first post-operative day, daily home one night post operatively at home. Trent Cardiac Centre project we have seen an increase in visits with patient/carer self • Patient and carers need help to david.richens@nuh.nhs.uk the number of patients discharged monitoring to promote proactive case develop their understanding of within three days of their surgery with management. symptoms in order to encourage their Atiya Chaudhry-Green 15 patients discharged within three • Having a dedicated project team who self-management and to know who Service Improvement Manager, days between January to December work collaboratively to formulate to contact when needed. East Midlands Cardiac and 2009 in comparison with two patients ideas and processes to test. • Having strong leadership from a Stroke Network between January to December 2008. • Draw on the expertise and specialist consultant clinical lead. atiya.chaudhry-green@nhs.net We note there is a difference of knowledge of a wide range of staff • Using the Trusts patient and public earlier discharge of more patients in and professional disciplines involved reader panel to help gather the 2009 with a subsequent 24 bed days in the care and support of patients in patients perspective on information saved with equivalent cost saving of the pre and post operative pathway produced for patients and carers. £6000 and are assuming this has of care: • Working with patients and carers to resulted from dissemination of the • Cardiac rehabilitation staff were understand their experiences. local learning from the one night stay instrumental in navigating and co- • Don’t underestimate the knock-on project. ordinating the patient process and effects from the work and how education. They also were sharing works with the wider team www.improvement.nhs.uk/heart 41
  • 42. A guide to commissioning cardiac surgical services Quality - the current context The document ‘High Quality Care For Complementing this approach is the All’ next stage review published in ‘Quality and Productivity Challenge’ The Quality Framework 2008 set quality as the key which builds on the above domains organising principle of the NHS with Quality is our organising principle - the full national by extending the quality focus to ‘quality’ being defined under the enabling framework will be in place from 2010/11 include innovation, productivity and three domains of patient safety, prevention. Also described by the clinical effectiveness and patient First four NICE quality standards by April 2010 on stroke acronym ‘QIPP’ the intention is to Bringing clarity to quality experience. care,VTE prevention, dementia and neonatal care provide a mechanism through which better care and better value can be Over 200 quality indicators now available on the Since 2008, these domains have Measuring quality Information Centre website achieved through the reduction of begun to help define the way the waste and in the prioritisation of NHS drives forward quality First Quality Accounts to be published in 2010 effective treatments. Publishing on quality improvement and now feature as underpinning principles within all National CQUIN goals on VTE, patient-reported With the above in mind it is useful to Rewarding quality current NHS strategy including The outcome measures and patients’ experience summarise the learning from the Operating Framework 2010/11 (and surgical project sites aligned to these National Quality Board review of system alignment quality framework see below), World Raising standards principles. (Note: The author has Class Commissioning and the NHS omitted ‘prevention’ as this wasn’t Performance Framework (2009). Full CQC registration against essential levels of safety considered a primary focus of the Safeguarding quality and quality in place from April 2010 initiative). Measuring quality using these Connecting innovation to our core purpose - the Staying ahead domains is emerging with the quality and productivity challenge development of the Improving Quality Indicators (IQIs) by the NHS Source: Operating Framework 201011 Information Centre. Additionally many of the emergent Commissioning for Quality and Innovation schemes (CQUINN) are using these domains to define, manage and reward quality improvement within healthcare contracts.42 www.improvement.nhs.uk/heart
  • 43. A guide to commissioning cardiac surgical servicesInitiative:Pre-operative assessment Patient Safety Effectiveness Experience Innovation Productivity Page No.Same day outpatient clinic and pre-assessment 20Standardisation of network wide pre operative investigations 22Dedicated lead pre-assessment nurse 20Pre assessment processes / protocols 9, 18Anaesthetic assessment at pre assessment. 15Implementation of cardiac advanced nurse practitioner 15Revised pre – assessment algorithm’s (CABG , Valve , ACS) 32Nurse led pre – assessment clinics 9Patient information sheets 9 www.improvement.nhs.uk/heart 43
  • 44. A guide to commissioning cardiac surgical services Initiative: Referral management Patient Safety Effectiveness Experience Innovation Productivity Page No. Pooling of surgical waiting lists (first time graft) 9,22 Surgical pooling ‘Dear Surgeon’ 9 Standardisation of pre-referral/pre-assessment protocols 15 Revised inter provider transfer minimum data set (IPTMDS) 18 information capture and consistent application of 18 week rules across pathway Implementation of cardiothoracic advanced/nurse practitioner 9,15 Pro active patient tracking 18 Revised multidisciplinary team processes incorporating telemedicine 15 and teleconferencing Proactively manage inter hospital transfer - role of the nurse 9 practitioner Interhospital transfer admission/discharge protocols 9, 36 Revised surgical pathway 9 Increased surgical satellite clinics 22 Revised referral processes 32 Electronic referral system 9 Electronic referral system for inter hospital transfers 9 Role of the pathway coordinator 944 www.improvement.nhs.uk/heart
  • 45. A guide to commissioning cardiac surgical servicesInitiative:Scheduling Patient Safety Effectiveness Experience Innovation Productivity Page No.Admission on day of surgery 9, 36Inter hospital transfer non elective referral systems 9Improved theatre scheduling and associated policies 9Implementation of electronic theatre scheduling tool 22 www.improvement.nhs.uk/heart 45
  • 46. A guide to commissioning cardiac surgical services Initiative: Discharge and post operative care management Patient Safety Effectiveness Experience Innovation Productivity Page No. Interhospital transfer admission/discharge protocols 9, 36 Comprehensive discharge planning 36 Implementation of visual management system for patient discharge 36 Patient information packs 36 Intermediate care referral system 36 Revised post operative procedures 36, 39 One night stay for appropriate elective patients 39 Patient experience questionnaire 15 Development of a patient forum 32 Discharge protocol for Jersey Hospitals46 www.improvement.nhs.uk/heart
  • 47. A guide to commissioning cardiac surgical servicesInitiative:Key results Patient Safety Effectiveness Experience Innovation Productivity Page No.Reduced waiting times 20, 22Improved multi disciplinary team 22Improved audit 22Reduction in theatre cancellations 9, 22Reduction in wait from pre–assessment to admission for elective surgery 20Reduction in unnecessary tests 15,22Reduction in length of stay for non elective surgery 9Reduction in length of stay for elective surgery 9, 39Reduction in elective length of stay 36Reduction in elective length of stay - CABG 36Reduction in elective length of stay - Valves 36Reduction in interhospital transfer repatriation times 36Reduction in non clinical theatre cancellations 9Improved theatre utilisation 9Achieved and sustained 18 week target for admitted pathway 15, 18, 22Improved pre assessment clinic capacity and activity 15Increased anaesthetic input to pre assessment clinic 15 www.improvement.nhs.uk/heart 47
  • 48. A guide to commissioning cardiac surgical services The commissioning of world class In respect to this, Cardiac (and health services will require an Stroke) Networks, working with agreement between the purchasers clinical teams, managers and providers of cardiac surgical commissioners, patients and carers services to agree both: across the entire patient pathway continue to be uniquely placed to • The quantity of services to be support and drive this agenda. The provided. networks ability to work impartially • The quality of care to be delivered. and objectively across organisational and departmental boundaries has The formal introduction of been key to delivering the measurement for quality through requirements of the Coronary Heart initiatives such as IQIs and the CQUIN Disease National Service Framework programme (as a sub set of the (and other key cardiac strategies), quality framework) help to remove with the case studies and the often subjective nature of achievements in this document ‘quality’ by defining metrics through providing a mere snap shot of the consultation with a wide range of added value that these organisations stakeholders, service users, providers. bring. purchasers and the public. This together with a levelling up of NHS Performance Framework financial risk across health 2010/11 economies, changes in tariff and the introduction of the revised Performance Framework will provide the environment for quality improvement to flourish.48 www.improvement.nhs.uk/heart
  • 49. A guide to commissioning cardiac surgical servicesSupporting InformationNHS Improvement and specifically theHeart Improvement Programme havecollated a bank of useful resourcesaimed at providing local teams withsolutions to problems to support localimprovement work.The following pages highlight someof these practical tools, products,web links and references to help youin your quality improvement work.For further information go to:www.improvement.nhs.uk/heart www.improvement.nhs.uk/heart 49
  • 50. A guide to commissioning cardiac surgical services Cardiac Data Dashboard Developed by NHS Improvement, the Data currently available via the Cardiac Data Dashboard is an online Dashboard includes: tool that aims to provide • Referral to Treatment (RTT) - organisations with publicly available • Cardiology admitted and data on performance within cardiac non-admitted; service delivery against the national • Cardiothoracic surgery 18 week and diagnostic targets. admitted and non-admitted. • Diagnostic data - Transforming this data into • Echocardiography knowledge through the use of • Electrophysiology. maps, graphs and tables provides organisations with an opportunity The data is grouped together to to enable comparison and give a comprehensive view of benchmarking at a number of levels: performance by SHA, cardiac cardiac network, SHA, provider and network, provider unit and commissioner. The information can commissioner giving monthly updates also be used as an aid to service on performance against the 18 week improvement as it allows the user to target. monitor the effect and sustainability of changes made to the service. This online tool can be accessed via: www.improvement.nhs.uk/heart/dashboard50 www.improvement.nhs.uk/heart
  • 51. A guide to commissioning cardiac surgical servicesImproving Cardiac Patient Pathways: The Sustainability ToolkitThis interactive resource has been This pulls together resources in one The environment is changing rapidlydeveloped with the aim of supporting easily accessible and useable as new information comes to theNHS staff in their work to improve package. fore. This resource is not exhaustiveexisting cardiac pathways and sustain but does uphold the guidingthose improvements. The information contained here is principles of the 10 High Impact more than just currently available Changes, so most ideas contained inBased on a generic cardiac map the theory. We have taken this a step this package result from projectsuser can ‘interact’ with the site to further. The resource provides a which are:find a range of resources to help plan wealth of ideas and suggestionsyour service transformation work based on actual service • Patient-centred.based on projects undertaken by transformation projects undertaken • Propose changes that areexperienced cardiac service by experienced cardiac service evidence based.improvement project managers and improvement project managers and • Imply a systems view on serviceNHS Improvement national team NHS Improvement national team transformation.members. members over the last four years.To access the resource visit:www.improvement.nhs.uk/heart/sustainability www.improvement.nhs.uk/heart 51
  • 52. A guide to commissioning cardiac surgical services NHS Improvement System What is it? Which specialties are included? The NHS Improvement System is a The system can be used to support comprehensive, online tool to sustainable service improvement support sharing of quality service in any specialty. improvement resources in NHS services. Giving you direct access to What does it contain? useful information and stories from • Service improvement tools around the country, it will assist you and resources in your own service improvement • Practical guidance work. • Case studies • Useful contacts Why use it? • Signposting and links. The NHS Improvement System actively helps organisations to Where can I see a effectively achieve their objectives in demonstration of the system? line with World Class Commissioning. Demonstrations of some of the key It enables users to be more strategic modules are available on the and align long-term goals that can improvement system home page at: Who can use the system? help to deliver high quality, patient www.improvement.nhs.uk/ The system is free of charge and can focussed health outcomes. improvementsystem be used by all staff working for NHS organisations in England. How can I register to use the system? Access to the system is controlled by user ID and password. To request an ID contact support@improvement.nhs.uk52 www.improvement.nhs.uk/heart
  • 53. A guide to commissioning cardiac surgical servicesGood planning can inspire change that leads to improvementsLeadership and • Identify the key people to be involved early on in the workstream. Engagement with • Seek and build continuous and meaningful engagement withengagement • Who are the key stakeholders? public and service the public and service users, involve them in shaping services. • Clinical and managerial leadership is critical to success. users • Have an understanding of different user engagement options, • Have you included data and informatics and finance, including the opportunities, strengths, weaknesses and risks. primary care and social care? • Routinely invite service users and the public to respond to and comment on issues.Knowledge and • Establish the steering/working group. • Ensure that users and the public understand how their views willskills – the basics • Has the group got the people with the knowledge and skills? be used, which decisions they will be involved in, when decisions Can they make the decisions? will be made, and how they can influence improvement. • Do they have service improvements skills? • Knowledge of heath and social care processes? Test out your ideas • Communicate widely about ideas being tested. • Is there service user Involvement? • Test the idea (maybe more than one testing cycle). • Is their agreed local accountability and responsibility for delivery? • Capture results, benefits and measure the impact. Match across • Knowledge of commissioning? to your performance indicators. • Information gathered from all perspectives (service users, staff, • Capture the learning (the things that work and those that commissioners, partnerships etc). didn’t documenting reasons why). • Communicate regularly with the whole team and partnerships -Planning the • Identify, understand and define the ‘real’ problem not the keep the message short and snappy.improvement solution. • Ensure identified ownership of action points.workstream • Review data to understand demand, activity and variation in performance. Evaluation • Analyse the results and quantify the impact of actual and potential. • How are your improvements going to be measured and • Identify benefits- e.g. quality, cost, outcomes. monitored? Have you included qualitative and quantitative • Identify risks. performance indicators? • Evaluate the alternatives. • Match the collection of baseline data with the scope of the • Make recommendations. problem identified. • Build your business case on evidence. • Remember that no data will be perfect and beware of analysis paralysis (collecting everything that tells you nothing). Implementation - • Recommendations for implementation • Break the data down into sections of information to help spread and sustain (provide the evidence that supports your testing). you identify what needs to be collected and analysed. • Commissioners want to see the evidence. • Look for the 80/20 rule (Pareto principle) this happens to 80% • Celebrate your achievements. of our users; focus on the 80% first, look for trends in • Share the learning - publicise your work. retrospective data. • Prepare your spread/adoption strategy. • Keep clinicians, leaders and key people involved. • Include how you will measure sustainability. • Identify (visioning) and design the ideas to tested. www.improvement.nhs.uk/heart 53
  • 54. A guide to commissioning cardiac surgical services References and supporting information Department of Health (2000) Coronary Heart Disease NSF This is an interactive pdf document, aimed at commissioners, managers and www.dh.gov.uk/assetRoot/04/05/75/25/04057525.pdf clinicians within NHS trusts, primary care trusts, cardiac networks and the ambulance service and is produced by the Heart Improvement Programme working Audit Commission (2003) Review of Operating Theatres in partnership with cardiac networks, ambulance services, ASA and the DH. Compressive assessment of NHS operating theatres. www.heart.nhs.uk/heart/Portals/0/docs_2007/signposts_IHT.pdf www.audit-commission.gov.uk/nationalstudies/health/other/pages/operatingtheatres.aspx NHS Heart Improvement Programme (2007). Getting it Right - Department of Health (2003) Discharge from Hospital Improving the Consent Process for Cardiac Surgery Pathway Process and Planning A range of materials to support the implementation of the Ombudsmans www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuid recommendations for Consent in Cardiac Surgery: a good practice ance/DH_4003252 guide to agreeing and recording consent. www.heart.nhs.uk/consent Parliamentary and Health Service Ombudsman (2005) Consent in cardiac Surgery: a good practice guide to agreeing and recording consent NHS Heart Improvement Programme (2008) The issue of consent and communication of risk to patients is outined in this guide. National Priority Projects 2007/08 www.ombudsman.org.uk/pdfs/informed_consent.pdf Summary documents from the Heart Improvement Programme’s 2007/08 national priority projects are available to download from: NHS Heart Improvement NHS Heart Improvement Programme (April 2006). Making Moves Programme - 2007/08 Priority Projects: Results of a data audit and review of service improvements in interhospital transfer • Making Best Use of Inpatient Beds Project; arrangements for cardiac patients. • 18 Weeks Whole Pathways Project; www.heart.nhs.uk/Heart/Portals/0/docs_2006/Making_Moves_April_2006_HIP008.pdf • 18 Weeks - Focus on Cardiac Diagnostics Project; • 18 Weeks - Atrial Fibrillation in Primary Care. NHS Heart Improvement Programme (September 2006) www.improvement.nhs.uk/Publications/tabid/56/Default.aspx Web-based referral systems for interhospital transfers The summaries include descriptions, supporting information and key learning from This document provides a review and comparison the projects. Details of each project site are available in the summary documents, of systems in English cardiac networks and are linked to the priority project online. www.heart.nhs.uk/heart/Portals/0/docs_2007/signposts_IHT.pdf National Confidential Enquiry Patient Outcome and Death (2008) NHS Heart Improvement Programme (2007) - Signposts to Improving Coronary artery bypass grafts: The Heart of the Matter Cardiac Interhospital Transfers - ‘Get the right response to the right This NCEPOD report analyses the care of a sample of patients who in the majority patient at the right time’ did not survive to leave hospital following their CABG operation. It takes a critical This document focuses on the transport issues and signposts to potential solutions look at the selection of the surgery and the strategy and the organisational factors surrounding the complexity of the booking and transfer of non-elective cardiac involved in its implementation. The report is available to download from: NCEPOD - inpatients between hospitals for diagnosis and/or intervention. CABG: The Heart of the Matter Report (2008).54 www.improvement.nhs.uk/heart
  • 55. A guide to commissioning cardiac surgical servicesDepartment of Health (2008). High Quality Care for All: Department of Health (2009). NHS 2010-2015: from good to great.NHS Next Stage Review Preventative, people-centred, productive. This report describes practical measures toThe final report of Lord Darzis NHS Next Stage Review. It responds to the 10 SHA meet the demands of an aging population and the increased prevalence of lifestylestrategic visions and sets out a vision for an NHS with quality at its heart. diseases. The document is available via The Stationary Office at www.tsoshop.co.ukwww.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAnd or dowwnload fromGuidance/DH_085825 www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAnd Guidance/DH_109876Department of Health (2008). Using the Commissioning for Quality andInnovation (CQUIN) payment framework Department of Health (2010). Quality Accounts Toolkit: Advisory guidance forThis document is available to download from providers of NHS Services producing Quality Accounts for the year 2009/ 2010From The Stationary Office at www.tsoshop.co.uk or download at This toolkit is for NHS providers to assist with the production and publication of theirwww.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAnd Quality Accounts in 2010. It features best practice guidance and useful tools basedGuidance/DH_091443 on the findings from the Quality Reporting process in 2009 and discussions with stakeholders. It is an interactive document, designed to be used online.World Health Organisation Surgical Safety Checklist (2009) www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndThis checklist describes the process which should be used for every patient Guidance/DH_112359undergoing a surgical procedure. Lord Darzi helped develop the checklist, which isseen by WHO as one of the best ways to improve patient safety. Department of Health Quality and Productivitywww.nrls.npsa.nhs.uk/resources/clinical-specialty/surgery/?entryid45=59860 www.dh.gov.uk/en/Healthcare/Highqualitycareforall/Qualityandproductivity Measuring for Quality Improvement. High Quality Care for All proposed that clinicalDepartment of Health (2009). The operating framework for 2010/11 for teams should use clinical indicators to measure the quality of care they deliver,the NHS in England. highlight areas for improvement and track the changes they implement. IndicatorsThis document sets out the specific business and financial arrangements for the for quality improvement (IQI) were released on the NHS Information Centre websiteNHS during 2010/11 and describes the national priorities for the year. It is available with descriptive information and links to their sources and can be found NHSto download from Information centre website.www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAnd www.ic.nhs.uk/services/measuring-for-quality-improvementGuidance/DH_110107 or in hard copy from www.orderline.dh.gov.uk quoting:299522 the operating framework for the NHS in England 2010/11. Hospital Episode Statistics (HESonline) www.hesonline.nhs.uk www.improvement.nhs.uk/heart 55
  • 56. A guide to commissioning cardiac surgical services Acknowledgements The list represents the full list of organisations who participated in the Cardiac Surgery National Priority Project: Anglia Cardiac and Stroke Network St George’s Healthcare NHS Trust Basildon and Thurrock University Hospitals NHS Foundation Trust: University Hospitals Birmingham NHS Foundation Trust: Essex Cardiothoracic Centre Queen Elizabeth Hospital Blackpool, Flyde and Wyre Hospitals NHS Foundation Trust: University Hospitals Leicester: Glenfield Hospital Royal Victoria Hospital Birmingham, Sandwell and Solihull Cardiac and Stroke Network Cardiac and Stroke Networks in Lancashire and Cumbria Essex Cardiac and Stroke Network East Midlands Cardiac and Stroke Network Heart of England NHS Foundation Trust: Good Hope Hospital North West London Cardiac and Stroke Networks Nottingham University Hospitals NHS Trust: Trent Cardiac Centre Papworth Hospital NHS Foundation Trust Royal Brompton and Harefield NHS Foundation Trust South London Cardiac and Stroke Networks56 www.improvement.nhs.uk/heart
  • 57. A guide to commissioning cardiac surgical servicesCardiac Surgery National Project TeamNHS Improvement National Clinical LeadsWendy Gray Steve LiveseyNational Improvement Lead Consultant Cardiac Surgeonwendy.gray@improvement.nhs.uk steve.livesey@suht.swest.nhs.ukGarry White Gordon MurrayDirector Consultant Cardiologistgarry.white@improvement.nhs.uk gordon.murray@heartofengland.nhs.ukRhuari PikeNational Improvement Leadrhuari.pike@improvement.nhs.ukHeather LockettDirector of Communicationsheather.lockett@improvement.nhs.ukJim FarrellGraphic Designerjim.farrell@improvement.nhs.uk www.improvement.nhs.uk/heart 57
  • 58. A guide to commissioning cardiac surgical services58 www.improvement.nhs.uk/heart
  • 59. NHS NHS ImprovementCANCER DIAGNOSTICS HEART LUNG STROKENHS ImprovementWith over ten years practical service improvement experience in cancer, diagnosticsand heart, NHS Improvement aims to achieve sustainable effective pathways andsystems, share improvement resources and learning, increase impact and ensure valuefor money to improve the efficiency and quality of NHS services.Working with clinical networks and NHS organisations across England, NHSImprovement helps to transform, deliver and build sustainable improvements acrossthe entire pathway of care in cancer, diagnostics, heart, lung and stroke services. ©NHS Improvement 2010 | All Rights Reserved | February 2010Delivering tomorrow’s NHS Improvement 3rd Floor | St John’s House | East Street | Leicester | LE1 6NBimprovement agenda Telephone: 0116 222 5184 | Fax: 0116 222 5101for the NHS www.improvement.nhs.uk