An integrated approach: the transferability of the winning principles: sharing the learning


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An integrated approach: The transferability of the Winning Principles - Sharing the learning
Highlights the learning from the integrated test sites demonstrated that the principles are appropriate, relevant and transferable across the health and social care setting (Published July 2010).

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An integrated approach: the transferability of the winning principles: sharing the learning

  1. 1. NHSCANCER NHS ImprovementDIAGNOSTICSHEARTLUNGSTROKETransforming Inpatient Care ProgrammeAn integrated approach:The transferability of the WinningPrinciples - Sharing the learning
  2. 2. An integrated approach: The transferability of the Winning Principles - Sharing the learning | 3Contents Foreword 4 Introduction 5 Transferring the Winning Principles through integrated working 6 Testing the transferability of the Winning Principles 8 Winning Principle 1 and 4 - Single point of access for cancer patients 9 Winning Principle 1 - How existing good practice in long term 14 conditions can benefit lung cancer patients Winning Principle 1 - A primary and secondary care clinical 18 management pathway for all patients with acute urine retention Winning Principle 4 - Self management programme 21 for cancer patients and carers Lessons from other integrated working communities 24 A practical service improvement framework to support 25 integrated working Challenges faced and overcome 26 Key learning - Patient and carer experience 27 Achieving integration - 12 recommendations 28 Conclusion 29 Appendices 30 Websites and useful reading 32 Acknowledgements 33 Further information 34
  3. 3. 4 | An integrated approach: The transferability of the Winning Principles - Sharing the learning Foreword Every person affected by cancer should receive world class services at each stage of their cancer journey. (The Cancer Reform Strategy, 2007). A patients’ journey involves many stages, and they encounter a large range of staff from different organisations providing services to them. The provision of integrated services that provide care in the right place, at the right time and through the right person or team is paramount. An integrated approach – The transferability of the Winning Principles shares the learning and challenges drawn from the experiences of the integrated working communities involved in this work. The integrated working communities involved a vast range of staff from Acute Care, Primary Care, Social Care and the third sector communities. All of whom aim to improve services for their patients, carers, service users and their families. This improvement work is part of the Cancer Transforming Inpatient Care Programme and highlights that although ‘integrated community working’ can be challenging the opportunities and benefits are great for patients and their families. Dr Janet Williamson National Director NHS Improvement
  4. 4. An integrated approach: The transferability of the Winning Principles - Sharing the learning | 5IntroductionNHS Improvement tested the transferabilityof the four quality driven WinningPrinciples (NHS Improvement 2008). Theaim was to explore if the spread of theprinciples could be accelerated throughtaking an ‘integrated’ working approach tosupport the drive to enhance health andsocial care integrated working.The learning from this testing supports thenew governments ‘commitment to thecontinuous improvement of the quality ofservices to patients’ (The Coalition; Ourprogramme for the Government 2010)and continues to support the delivery of theCancer Reform Strategy, TransformingInpatient Care Programme (2007).
  5. 5. 6 | An integrated approach: The transferability of the Winning Principles - Sharing the learning Transferring the Winning Principles through integrated working Five integrated test communities took on the challenge to spread. The learning from the integrated test sites demonstrated that the principles are appropriate, relevant and Winning Principles transferable across the health and Winning Principle 1 social care setting. Unscheduled (emergency) patients should be assessed prior to the decision to admit. Emergency admission should be the exception not the norm. There has been a decade of publications and policies that indicate Winning Principle 2 the benefits of health and social care All patients should be on defined inpatient pathways based on their integrated working. However the tumour type and reasons for admission. case studies in this publication Winning Principle 3 indicate this is not easy to achieve and Clinical decisions should be made on a daily basis to promote proactive involved significant challenges, case management. learning , vast amounts of time and they have had varying degrees of Winning Principle 4 success and shown that integrated Patient and carers need to know about their condition and symptoms to working can be achieved, provided: encourage self-management and to know who to contact when needed. • Relationships are built • Agreements are reached and communicated, with services and systems that are aligned • Partnership working and decision making is clearly understood, what this means and the values that underpin this • Responsibility for the improvement of services is shared.
  6. 6. An integrated approach: The transferability of the Winning Principles - Sharing the learning | 7The case studies, share the learning fromfive ‘integrated’ working communities, Figure 1: Discipline of staff involved in integrated workinginvolving acute care, primary care, socialcare, and tertiary services. Over 360people, including patients, carers andstaff were involved (Figure 1). Staff disciplines 0 10 20 30 40 50 Number of staff involved GP Practice Managers Ambulance Call Handlers Training Co-ordinator End of Life Facilitators NHS Direct Clinical Illustraion PCT Commissioners Pharmacists Clinical Governance Staff Service Improvement Staff Information and Data Analysis All Managers Across All Organisations Voluntary Organisation Staff Therapists Benefits and Employment Specialist Nurses/Hospitals/Community Hospice Staff Doctors/Consultants/GPs Walk-in Centre Staff ‘There are many powerful examples of ways to improve quality in the NHS while encouraging better productivity. Together, we need to identify these examples of excellence, understand why this kind of approach is successful and actively diffuse this good practice across the whole health service’ Jim Easton NHS National Director for Improvement and Efficiency
  7. 7. 8 | An integrated approach: The transferability of the Winning Principles - Sharing the learning Testing the transferability of the Winning Principles The integrated working communities tested the transferability of the quality Winning Principles, 1 and 4. The following case studies share the integrated working communities learning and experiences.
  8. 8. An integrated approach: The transferability of the Winning Principles - Sharing the learning | 9Winning WinningPrinciple 1 Principle 4Integrated testing model: Single pointof access for cancer patientsSherwood Forest Hospitals NHS Foundation TrustBackgroundTrusts local baseline data (2008) on all Figure 2: Emergency referrals by typecancer related admissions showedthat approximately 70% of cancer 120inpatient admissions were non 100 Number of patientselective. Average length of stay forthese patients was 6.5 days (April – 80Dec 2009) and the majority of these 60admissions came via A&E (Figure 2). 40The most common reasons for 20emergency admissions were:• Shortness of breath 0 Accident Emergency Emergency Other• Pain & Emergency Outpatient GP Immediate• Collapse Referral type• Diarrhoea, constipation, dehydration, nausea and vomiting Source: SFHFT Health Informatics DepartmentAs a testing community we agreed totest the assumption that many of thepatients admitted as emergenciescould have been treated in alternative Integrated testing community -care settings and admission into what was it?hospital could have been averted. The testing community includedBringing care closer to home and 22 organisations across thevaluing patients time. community (Figure 3). Figure 3: Integrated working community Sherwood Forest Hospitals NHS Foundation Trust Kirkby Walk in Centre GP Practices Nottingham University Hospital NHS Trust East Midlands Cancer Network Beaumond House Hospice CNCS Crossroads Social Services Lloyds Pharmacy MacMillan Local independent pharmacy Patients and carers Crossroads Notts County Teaching PCT Department of Work and Pensions NHS Direct Job Centre Plus EMAS Nottinghamshire Community Health Nottinghamshire Health Informatics Service John Eastwood Hospice
  9. 9. 10 | An integrated approach: The transferability of the Winning Principles - Sharing the learning Key stakeholders from the What was tested? organisations were identified early on To address the issues identified it was Included in the scope of testing was in the work to assist in building agreed to test a single point of access the out of hours provision (OOH) and momentum and planning for an (SPA) communication model. This the measures of impact were: integrated cancer service. supported the testing of the • Valuing patient time reducing transferability of Winning Principles 1 unnecessary waits and delays Fact finding and visioning events were and 4 and built upon the concept of • % reduction of inappropriate held during the first four months of Recurring Admission Patient Alerts admissions to hospital 2009 to establish areas of (RAPA) that had been successfully • % of appropriate care delivered commonality, identify problems that implemented in the Trust. nearer to home. needed to be investigated and highlight where testing may be The single point of access was After considering several options the needed. supported by patients and their carers most appropriate provider for testing as during the visioning events they the model of a single point of access Across the community the main stated that they: were Central Nottinghamshire Clinical ‘issues’ indentified were: Services (CNCS). They were able to • Poor communication and integrated offer dedicated nurses to answer calls, working between health and social and already had information sharing care ‘Did not know who agreements with the trust and an • Inappropriate and rigid systems of understanding of primary and diagnostics and treatment within to contact and how secondary care. Therefore this was a care pathways • Lack of patient empowerment with to access services use of resources already in place rather than new financial investment. care needs. • Unclear management of emergency after the end of the admissions working day.’ • Lack of a clear clinical pathway • Lack of development promoting Patient carers statement patient self management support. Figure 4: The Single Point of Access (SPA) Patient makes call to Single Point of Access (SPA) SPA arranges for SPA SPA SPA SPA SPA SPA No immediate admission to refers to refers refers to refers to refers to refers to care required surgical & medical oncology clinical walk in GP for social crossroads for Advice given assessment units. ward nurse centre assessment services independent or signposted NOT A&E specialist and/or visit social care Automated call outcome sent via email to appropriate CNS
  10. 10. An integrated approach: The transferability of the Winning Principles - Sharing the learning | 11 Figure 5: Amount of patients that called SPA (including multiple times)Testing ran for 12 weeks (October2009 – January 2010) and involved 82 Tumour site In hours Out of Calls (total)cancer patients from four tumour hourssites: Gynaecology, Breast, LowerGastro Intestinal (LGI) and Urology. Breast 16 16 32 Lower GI 3 5 8Calls were received by SPA callhandlers at CNCS, were dealt with Urology 13 4 17and then an automated message sent Gynaecology 7 2 9directly to both an email account and Total 39 27 66the smart-phones held by the clinicalnurse specialists (CNS), which linkedto the existing successful RAPAmethodology of automated alerts this Figure 6: Calls to SPA who answered in and out of hoursaided clear communication channelsto the relevant clinicians. 5%Of the 82 patients, 66 calls weremade: 24%• 41% of the calls were made in the Central Nottinghamshire Clinical Services out of hour’s period (5pm – 9am), a Cancer Nurse Specialists timeframe which currently provides little support outside of emergency Both CNCS & CNS (separate occasions) 71% care and can be confusing for patients and carers to navigate• 34% of calls resulted in a possible or definite emergency averted admission• 9% of all calls resulted in a primary care intervention and averted a non elective admission• 4% of patients had an expedited Figure 7: Distribution of calls by outcome emergency admission, bypassing A&E and resulting in a shorter bed 25 stay 22• A further 5% of calls resulted in a 20 possible averted admission, all cases Amount being resolved in primary care. 15 13 11 10The following tables and graphs 6 7provide a detailed breakdown of the 5 5activity involved. 1 1 0 Info 999 Doctors Tested at Home Nurse District Non CNCS to key Emergency Advice Primary Visit Advice Nurse Calls worker Care Centre (CNS & Tech Faults) Outcome
  11. 11. 12 | An integrated approach: The transferability of the Winning Principles - Sharing the learning Averting emergency admissions Figure 8: Averted and possible averted non elective admissions and A&E attendances definitions Where we have confirmed that had Tumour site Averted non-elective Possible averted the patient not contacted the SPA and admission non-elective admission that 999 would have been called, we have classified this as ‘averted’. Breast 5 4 Where we have not been able to Lower GI 0 0 directly confirm whether an emergency admission was averted but Urology 2 0 that it was indeed possible we have Gynaecology 1 0 classified this as ‘possible’. Total 8 4 Benefits and impact Potential cost savings/capacity Figure 9: Potential cost savings/capacity releasing releasing Based on local data from Sherwood Cash flow release Potential bed days released Potential Forest Hospitals NHS Foundation Trust £ (A&E only based across four tumour groups inpatient bed day health informatics department standard tariff of (using average LOS of 6.5 cash flow release (February 2010) from January 2010 £80) days & average tariff of £340) across the four tumour sites involved Test (3 months 6.5 days x 8 patients = 52 bed days x £80 x 8 = £640 in testing, there are approximately and 82 patients) 52 released bed days £340 = £17,680 4,255 active cancer patients. Averting eight A&E attendances during testing resulted in a saving of £640 (standard A&E tariff = £80). Valuing patients time • Patient safety, less exposure to risk Adding the four possible averted A&E For those patients that were admitted of hospital acquired infection attendances brings the total to £960. during the test, the average LOS was • Improved communication model Based on eight definite A&E averted 1.5 days. This was five days less than meaning call handlers can attendances out of 82 test patients the original average length of stay. communicate directly with all (9.75%) over a 12 month period the This can potentially be attributed to integrated areas. potential cash flow release at a using the special patient notes and standard tariff for active cancer improved communication set up for Productivity patients in the test tumour sites the integrated testing work. • Reduction in length of stay from 6.5 equates to approximately £33,200 a to 1.5 days for those patients year. The benefits identified from needing a hospital admission testing the SPA • Potentially released 52 bed days Quality • Potential cash flow release of • Delivers care in the most £17,680 appropriate setting • Reduces pathway delays – three Valuing patients’ time and patients admitted straight to ward experience missing out A&E and EAU • Values patients’ time and addresses • SPA standardises in hours and out of patient and stakeholders hours care expectations • Special patient notes aid clinical • Delivers care at home where decision making as does oncological necessary and where appropriate emergencies training for call handlers
  12. 12. An integrated approach: The transferability of the Winning Principles - Sharing the learning | 13• Enables patients to access information and guidance allowing for increased ability to self manage• Reassurance of speaking to a person rather than being met by an answering machine enhanced their confidence and assisted in reducing anxiety• Reduction in numbers of delayed transfers of care demonstrated by patients going directly to the ward where appropriate.
  13. 13. 14 | An integrated approach: The transferability of the Winning Principles - Sharing the learning Winning Principle 1 How existing good practice in long term conditions can benefit lung cancer patients NHS Coventry Background Figure 10: Hospital Episodes statistics Data Working in partnership NHS Coventry, University Hospitals Coventry and Emergency Ended in death Ended in Ended in Ended in Warwickshire (UHCW) and Coventry admissions on day of death by death by death by City Council, had developed an (Lung) admission day one day five day seven integrated model of care – Care Outside of Hospital for Long Term 140 12% 24% 45% 50% Conditions, (LTC). The aim of the integrated testing was Testing approach: Getting Collating baseline information to build on this existing infrastructure baseline information for better for better decisions and test the transferability of the LTC decisions The learning from this process and the model to improve services for lung A systematic service improvement reality of the experience is shared in cancer patients. approach was used for testing, this figures 11 and 12 and shows the included a baseline analysis, and a Acute and PCT process. What was the issue for lung retrospective notes review on the cancer patients? initial lung cancer patient cohort. Coventry had the highest number of Many of these patients were deceased emergency admissions for lung cancer and notes were held off the hospital patients across the West Midlands site. Although a well established Strategic Health Authority (SHA), and approach, the process of undertaking of the patients admitted 50% died this initial review proved difficult and within seven days, suggesting that affected the momentum and they were in the end of life phase of engagement across the integrated their illness. working community. Figure 11: The Acute process Replicated Safe guardian of Room identified Head of Info Notes again process as per notes niminated - where notes requested to requested PCT map Director of Nursing review needs to order patient (16 Feb 2009) & Medical Director take place notes (9 Feb 2009) Head of Info: Notes to be Head of Info: Acute Trust delegated notes available by liaise with PCT Executive retrieval end of week to order intervention required
  14. 14. An integrated approach: The transferability of the Winning Principles - Sharing the learning | 15 Figure 12: The PCT process HES data Patient identifiers Caldicott Request sent Clarity required obtained requested approval to audit if this is ‘audit’ (Nov 2008) from PCT data needed at PCT department or ‘research’ department Request sent Caldicott Guardian PCT data Paperwork not Need to back to service sign off request department received in request Caldicott redesign quality given issue job no. 247 relevant Guardian sign director for clarity (Jan 2009) department off again All paperwork Caldicott Guardian PIDs identified Sent to acute resent approval given from PCT Head of trust to order (Feb 2009) Info (Feb 2009) notes Finance Process No budget Agreement from available service redesign quality within PCT director to pay for notes requestIdentifying the real problems, Figure 13: Main presenting symptoms The event included staff membersissues and areas for testing from the acute and communityAlthough the notes review was a Presenting Number of organisations, West Midlandspains taking experience they did symptom patients Ambulance NHS Trust and staff fromidentify that a high proportion of Shortness of breath 42 Coventry City Council.patients were admitted from one Pain 23 The pathway day was successful forparticular post code area, CV2. communication and engagement andPatients from this area presented as it was agreed that communicationemergencies with a number of and information would be the focus Gaining Re-engagement across thesymptoms, with the highest number of testing. Two ideas were taken communitybeing shortness of breath and pain as forward: A pathway event was held April 2009,the main reasons for admission. • Single point of contact for lung to share the results of the baseline cancer patients and to jointly determine across the • Community directory. community new ways of working.
  15. 15. 16 | An integrated approach: The transferability of the Winning Principles - Sharing the learning Single point of contact for lung cancer patients This involved GP practices and community service providers for the postal code area of CV2. A key improvement was to gain access to the ‘special notes facility’ available on Webaccess. Webaccess is a system that was already available for use in all GP practices across Coventry. This was utilised to share information regarding lung cancer patients included in the test cohort. It was a resource already available and required no further investment. Testing was due to commence in October 2009. However, technical difficulties delayed the start of the testing until January 2010. This delay affected the momentum and engagement in the work. The testing period was for six weeks and included 14 GP practices in the CV2 postcode area of Coventry, which at the time had 13 patients between them registered with a diagnosis of lung cancer. During the testing period the special notes facility was accessed for 31% of patients, none of these patients were admitted to hospital suggesting that the enhanced communication and knowledge of the patient, i.e. access to the ‘special notes facility’ may have averted the admission. The testing of the Webaccess system for lung cancer patients demonstrated that it can be utilised successfully, and does avert emergency admissions.
  16. 16. An integrated approach: The transferability of the Winning Principles - Sharing the learning | 17Community directory for staff • ’There were many issues to be This work fits with many nationalA community directory was developed addressed, but the ability to agenda’s, QIPP, Care Closer to Home,in partnership between primary and generate ideas and innovations for Encouraging Improvements in Medicalsecondary health care, social care and testing were not forthcoming Care and Decision Making. IntegratedCoventry City Council to enhance everyone seemed to think it was working supports the message thatcommunication. Notification of this someone else’s problem’ patient care does involve the wholewas emailed to all staff and GPs • ’An improvement project like this community. A key lesson learned frominvolved in the test site. relies on good baseline information, this work is that an important success but the delays in getting this factor is the organisations involvedIt is available to all with access to the information was not identified as a have the ability to relate to oneNHS Coventry website. The directory risk, but it had a significant impact another and have the capability andprovides a comprehensive list of on engagement’ willingness to partner and, there is a brief explanation of • ’Leadership has proven difficult as This small scale testing indicated theeach of these services with contact originally this area of work was potential, however to take thisdetails and what patients and carers initiated by only one of the forward and scale up the work,can expect form the service. organisations involved, with a engagement of all the organisations dedicated lead for the work, involved must be at the forefront.Lessons learned and reflections however when the individual movedThis improvement work was based on job roles there was no-onethe understanding that there was an identified to take ‘ownership’ of theexisting successful integrated model of workstream, it therefore lost itscare for long term conditions, and momentum’that the relationships already • ’During the lifetime of the project,developed through this work would other events (swine flu, HPVprovide a platform for testing development) took over the time,integrated working with cancer resources and the key playerspatients. However this did not provide available’the basis for testing with cancer • ’There was no strategic pressures onpatients as had been anticipated. The any of the organisations to fulfill thisquestion is why? The following are project’s potential’.observations and experiences fromsome of those involved that may helpothers when embarking on similarintegrated working.• ’It has proven difficult to identify a sense of a shared test initiative in spite of the involvement of different organisations and multi-disciplinary groups of staff’
  17. 17. 18 | An integrated approach: The transferability of the Winning Principles - Sharing the learning Winning Principle 1 A primary and secondary care clinical management pathway for ALL patients with acute urinary retention The Lincolnshire Experience Starting position • 119 (98%) patients had urine Lincolnshire Hospital NHS Trust, ward A baseline data analysis on 122 retention, some with additional representation, community nursing urology patients presenting to Lincoln symptoms such as abdominal pain leads, incontinence lead from the PCT County Hospital revealed: or haematuria, and three patients and director of provider services for • The average length of stay was five were admitted with a blocked the PCT. days with a maximum of 57 days catheter. and minimum of 0 days. After review of the baseline data it • The largest referral source was 45 A real time data collection confirmed appeared that a large number of % from GPs followed by: that a disparity in pathways existed for patients were being inappropriately • 15% GP out of hours patients with acute urinary retention. guided to acute hospital emergency • 23% patient, self referral Using an integrated approach the aim departments. The group agreed to • 8% unknown was to test Winning Principle 1 and plan a clinical management pathway • 4% via the nurse practitioner, new ways of working for patients which, if successful through testing, • 2% other A&Es, with acute urinary retention that would be a benefit to a large group of • 2% via outpatient clinic would benefit ALL patients with no patients who would/may go on to • 1% via nursing home carving out for cancer patients. have prostate cancer or not. • 113 (93%) of the 122 patients were admitted as emergencies and It was agreed, as numbers were catheterised as an in-patient An integrated task with an expected to be small, to initially test • These patients presented at three integrated team. all males in first time urine retention entry points An integrated task and finish group presenting from North West and • A&E 42% was established, the membership South Lincoln Practice Based • Emergency assessment unit 39% consisted of GPs, consultant urologist, Commissioning Clusters. Although • Straight to wards 19% clinical nurse specialist from United the group acknowledged co-morbidity Figure 14: Proposed primary care pathway for male patients with acute urine retention If TWOC unsuccessful Failed reinsertion catheter reinserted Patient referred directly to EAU at LCH Admitted to Community nurse completes follow proforma & faxes GP for alternative referral to urology team in District nurse to secondary care Minimum Symptoms pathway make contact Discharge to GP visit & liaise with GP District nurse GP to review if performs TWOC (Trial Without Successful Seen by GPSI Maximum Symptoms Patient Patient sent Discharged for necessary Catheter) TWOC GP in BPH clinic Referral to presents to A&E for district nurse 14 days after referral to inc Prostate urology team in to OOH catheterisation contact visit GP to prescribe patient to GPSI Symptom Score secondary care or GP within 48hrs Tamsulosin commences Flow Rate Referral faxed to (Alpha Blockers) Tamsulosin Bladder Scan one number as per proforma from A&E Intermediate Care If abnormal Copy of DRE Intermediate pathway to Care GP to see be given to within 24hrs patient PSA result to GP to initiate 2WW referral
  18. 18. An integrated approach: The transferability of the Winning Principles - Sharing the learning | 19reasons for admissions it felt that The group compromised from moving The two patients who had their trialthere was a need to test a pathway in the pathway entirely into primary care without catheter in the communityorder to: to having the first catheterisation in were seen by day 12 as per protocol United Lincoln Hospital NHS Trust and patient did not have to return to• Reduce inappropriate admissions to A&E department. Unfortunately, A&E acute trust for this procedure. hospital staff felt they were unable to• Provide an opportunity for accommodate the testing of the new The communication between all managing acute urine retention in pathway at the time. The group parties in primary care worked very primary care secured the Emergency Assessment efficiently. The patient who had a• Promote different ways of working Unit (EAU) as the single point of failed trial without catheter was and identifying opportunities for access for patients to have their referred to urology team in acute trust making services available in an catheters inserted. via the GP and this cut the wait for alternative setting. appointment from 42 days to 11 days.• Reduce unnecessary lengths of stay Stage one - Acute urine retention in acute hospitals and value patients pathway The task group felt reassured that time. Initially testing commenced for a three although numbers were small the month period. At the end of this principles of the pathway could workA pathway was initially developed to period only three patients had been and that the original hypothesis hadenable the total management of acute through the pathway, these numbers not changed. The clinicalurine retention in primary care but were less than the period which was management pathway had reducedafter long and in depth consultation analysed for the baseline. It was unnecessary admissions to hospitalthere were patient safety concerns intimated at the start by clinical and reduced the number of visits forand clinical governance issues stakeholders that numbers would be the patient. It was agreed to movesurrounding the training of small but they were lower than forward to the next phase and thatcommunity nurses about first time originally predicted. The evaluation of negotiations should continue with keycatheterisations in the community that stage one identified: people in order to commence the nextwere unable to be resolved. stage of testing. However, progress in this area has been slow. The membership of the group has increased inviting colleagues from the out of hours team to join. Meetings Figure 15: Stage one - acute urine retention pathway have been held with primary care PATIENT 1 colleagues to negotiate commencement of the next stage A&E with MI Went in Discharged with TWOC by community Successful Discharged unfortunately, to date there has still retention catheter nurse to GP been no sustainable and robust agreement made to establish the PATIENT 2 clinical management pathway for Presented Discharged Admitted with TWOC’d Successful acute urine retention across the to EAU with symptoms on the dischrge but health community. catheter related to ward has since upper GI died cancer PATIENT 3 Presented Cathetered TWOC by Failed TWOC to OOH by OOH GP community Referred back to urology nurse team. Seen in 11 days
  19. 19. 20 | An integrated approach: The transferability of the Winning Principles - Sharing the learning Good idea - tested - can deliver Buy-in - ownership - responsibility Despite all the challenges and patients receiving right care in the Gaining buy-in, ownership and difficulties, the principles of the right place at the right time - so responsibility from all key stakeholders pathway appear to be right and there what went wrong what have we is not easy and dealing with the are benefits that can be realised and learned diversity of agendas and differences is support the transferability of the difficult without strong clinical and Winning Principles. Clinical champion: During the initial managerial leadership. testing one of the clinical champions from the PCT left and it was difficult GP compliance to the pathway to find another to join with the High quality care does save money General Practitioner with Specialist and GP are in a good position to take Interests (GPSI) to help drive the work. this pathway forward and benefit The GPSI was a great support and more than cancer patients. helped refocus the group to work together to progress to next stage of testing Figure 16: The perceived benefits of the acute urine retention pathway Eliminating and managing the risk factors For Patients There was a reluctance to reach No attendance at A&E agreement surrounding first time No admission Not as many handoffs catheterisation in primary care and the as original pathway need to secure a safe environment as Direct referral back to urology per local clinical governance team catheterisation policy. The clinical governance issues became the focus point rather than re -examining the patient care pathway and these issues For Acute Trust Perceived For PCT were not resolved, but testing moved. Reduction in LOS Benefits Development of Reduction in of Acute Urine a clear pathway Further work in this area is required if inappropriate across the Retention care is to be delivered in the admissions Pathway Whole Health Community community. It takes time Not to underestimate the length of For Staff time it takes to ensure all key Reduction in representatives from primary and patients returning to acute trust for secondary care are round a table, trial without catheter engaged, have a clear communication A defined pathway Collaborative plan and signed up from the working beginning. Dedicated time was also allocated with individuals attempting to overcome ongoing reluctance to consider changing working practices.
  20. 20. An integrated approach: The transferability of the Winning Principles - Sharing the learning | 21WinningPrinciple 4Self Management Programme (SMP)for cancer patients and carersSherwood Forest Hospitals NHS Foundation TrustBackgroundPatients and carers had raised Figure 17: Out of hours pathway for cancer patients (EMCN 2008 - data period: 07/07/2008 - 31/12/08)frustrations regarding unnecessaryadmissions to hospital for symptom Collapse, slips, trips & falls 9 13 26management. Baseline analysis Diarrhoae, constipation 18 1 1showed that four presenting Emergency 1 4symptoms dominated, these were End of life 1shortness of breath, pain, Infection 2 6 2falls/collapse and diarrhoea, which Pain 18 15 4represented 65% of recorded SOB 33 4 4symptoms, 76% of these symptoms TIA 3 10were related or possible related to the Unable to cope 1patients cancer (Table 1 East Midlands Urinary/urology 6 3Cancer Network). Treatment related 11 3 1 Bleeding 7Taking an integrated approach Unwell 4 10 5to developing a patient Self 0 5 10 15 20 25 30 35 40 45 50Management Programme (SMP)A patient self management Related Possible Related Unrelatedprogramme (SMP) aimed to empowercancer patients and their carers inmanaging their own symptoms wasdeveloped for testing. The programme consisted of a total of • Fatigue five sessions each session involved an • Benefits15 different organisations were interactive element. • Social servicesinvolved in the development, bringing • Supporting the needs of carersdifferent perspectives and expertise. Range of topics covered in the self • NutritionThe Self Management Programme management programme • Cancer informationwould provide advice, support and • Pain management • Complementary therapiesinformation on symptom • Anxiety and coping • Look good feel bettermanagement, coping strategies and • Breathlessness • Support with cancer. • Exercise Figure 18: Integrated working community Sherwood Forest Hospitals NHS Foundation Trust Expert Patients East Midlands Cancer Network Crossroads North Notts Social Care Services Look Good Feel Better Macmillan Cancer Support Department of Work & Pensions John Eastwood Hospice Job Centre Plus Notts County Teaching PCT Complementary therapists Nottinghamshire Health Informatics Service Nottinghamshire Community Health Nottingham University Hospital Trust
  21. 21. 22 | An integrated approach: The transferability of the Winning Principles - Sharing the learning Impact and outcomes A course evaluation (reproduced from Figure 19: How useful was what Figure 20: Where would you rate you learned? your overall experience of the course? the Glasgow Caledonian University Caring With Confidence, Knowledge and Skills Training For Carers) was 22% completed by all course attendees on 33% the final day of the programme and a focus group was arranged for six weeks following the end of the course 11% to evaluate learning. 67% 67% A pre-course evaluation was completed on week one and repeated three months post course to assess Extremely useful Very useful Very good Excellent the impact on the attendees everyday lives. The questions were all based on A little use symptoms and situations over the last two weeks and the evaluation was taken from Macmillan New Figure 21: Fatigue Perspectives course evaluation. Each 10 Pre SMP Post SMP of the evaluation areas was scaled 9 from 1-10 with 10 being a negative (10 being the most problematic) 8 Evaluation scale 1-10 result and 0 being most positive. 7 6 The questions were themed across the 5 following areas: Fatigue, Pain, Stress, 4 Daily Activities (chores, socialising etc) 3 and Exercise. Since attending the SMP 2 67% of all patients felt that their 1 levels of fatigue had decreased, 83% 0 of all patients felt that their levels of Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 pain and stress had decreased and Patient there ability to perform daily activities had increased. 100% of patients said that they had not changed the Figure 22: Pain amount of exercise they were 12 undertaking since the completion of Pre SMP Post SMP the course. (10 being the most problematic) 10 Evaluation scale 1-10 8 6 4 2 0 Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient
  22. 22. An integrated approach: The transferability of the Winning Principles - Sharing the learning | 23 The benefits identified from Figure 23: Stress testing the SMP 10 Quality Pre SMP Post SMP 9 • Reduces pathway delays - 8 Integrated working has ensured (10 being the most problematic) Evaluation scale 1-10 7 health and social sectors work 6 together identifying social problems 5 prior to crisis point as opposed to 4 the current pathway 3 • Offer a proactive new model of 2 care • Delivers care in the most 1 appropriate setting 0 Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 • 86% of patients prior to the course Patient were not receiving their full benefit entitlements. Figure 24: Daily activities Productivity 4.5 • 43% of attendees managed an Pre SMP Post SMP anxiety attack, where they had 4 previously attended A&E for (10 being the most problematic) 3.5 Evaluation scale 1-10 treatment 3 • Potentially released 19.5 bed days 2.5 (three patients x 6.5 day average 2 LOS) 1.5 • Potential financial cash flow release 1 of £6,870 (£80 A&E standard tariff 0.5 + £340 bed day tariff x 3 patients) 0 • Techniques taught resulted in Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 prevented anxiety related Patient admissions. Patient experienceAverted A&E attendances • Values patients’ time and addressesThere were 3 (43% of test patients) A&E attendances averted during the test patient stakeholder expectationsdue to techniques learnt at the SMP. • Delivers care at home where necessary and where appropriate • Empowers patient to access Cash flow release £ information and services across (A&E only based standard health and social care. tariff of £80) Test (six weeks and seven patients) £80 x 3 = £240 3 x average LOS 6.5 days = Potential bed delays released during test 19.5 bed days
  23. 23. 24 | An integrated approach: The transferability of the Winning Principles - Sharing the learning Lessons from other integrated working communities Two of the integrated communities • Integrated working is the future and were unable to produce case studies it can work and benefit the whole relating to their work as they felt the health community, but it will take work had not come to fruition. years, its a longer term strategy. Discussions with these organisations The testing has shown us how and other (non- test sites) who had difficult this can be but given us experiences of integrated working valuable lessons to build upon. highlighted the following complexities • There can be difficulties in and key areas of learning: establishing a shared purpose and • Integrated working across aligning priorities across organisations requires a high input organisations. This requires a of time and a dedicated resource to managed programme of change. accelerate the pace of delivery. • Keep the focus on • Local trusts and organisations are patient/client/carers benefits. under considerable pressure and need to balance the day to day This demonstrates the difficulties of work with trying out new ideas. The establishing a shared purpose and willingness is there but the reality is alignment of priorities across that often this is difficult. organisations and illustrates that • Strong leadership is vital for integrated improvement requires a integrated working. managed programme of change. • The cancer agenda is huge and although seen as a priority by some What theses two sites would have organisations it is not seen as a done differently? priority across all organisations • Join the work up - there are lots of involved. The alignment of priorities separate pieces of service can be difficult and all the improvement and redesign going integrated organisations want to on, but they are in silos, separate gain something from testing. projects. • Not all organisations want to share • Focus on service improvement that the burden of improvement. benefits all patients - whole • Bringing different organisations systems. together to work on a common goal • Cancer should not be seen makes common sense, but the separately, we are trying to fit it into different organisations have existing pieces of work. different values and cultures and • Dedicated individuals leading the this can get in the way of progress work. and needs time to understand. • Be realistic about the time - things • Forming relationships and trust is take much longer than expected. the key to successful integrated working. • Integrated working can expose the short-comings of organisations and people and there are those who will not wish to take this risk.
  24. 24. An integrated approach: The transferability of the Winning Principles - Sharing the learning | 25A practical service improvement frameworkto support integrated workingUsing a practical service improvementframework for testing, the integratedworking communities share thechallenges they faced, and makerecommendations for otherorganisations attempting to achieveintegrated working. Figure 19: Service Improvement Framework supporting integrated working Processing map Areas for testing Home to home reviewed for clarity Identify repetition and rework and agreed Data gathering Stakeholder event all Develop working Notes analysis organisations/services groups to take Patient discovery interviews involved forward testing ideas Analysis Identify Visioning Is it the Baseline from What are you Testing cycles right solution to what is the different trying to Test out address the real problem real problem? perspectives achieve? ideas Gather patients views Case for change Agree the Evaluation Evaluate Plan the redesign and Evaluate the and check Implementation implementation of the implementation benefits. What sustainability improvements of the tested idea is the difference? Spread and Outcomes Patient & staff adoption reported to questionnaires strategy executive groups Prepare business case What has been the based on outcomes impact of the testing. What the integrated sites did impact of testing Quantify
  25. 25. 26 | An integrated approach: The transferability of the Winning Principles - Sharing the learning Challenges faced and overcome The following identifies the challenges the integrated working communities faced and how they overcame them. Main challenges Overcoming the challenge Outcomes identified by all sites (what they did) Engagement/time Establish an executive steering group with appropriate Commitment and enthusiasm from Engaging strategic and leadership from all organisations involved stakeholders involved in this work. clinical leadership Engagement of all key Organise visioning events for all involved across the Tapping into to the power of stakeholders patient pathway - home to home. patients, extremely valuable Lead in time Ensure good planning build in realistic time frames Delivering the same Align the testing work with differing organisational message for different priorities that meet local/national indicators audiences/organisations Overcoming reluctance to Nominate a champion/s in each organisation - create change a culture of ownership Reluctance to consider Develop smaller working groups to take forward the change in working practices areas of testing Leadership Take a three pronged approach to leadership, Developing a culture that allowed Achieving appropriate executive, clinical and operational leaders all need to for working in true partnership leadership across ALL be involved organisations involved Executive steering groups are helpful for providing direction Communication & Develop communication pathways between all Sharing ideas and practices and coordination organisations involved improving knowledge of each Organisations need to others organisations understand each other and how they differ Building new and lasting relationships for future working Complexity of establishing Develop clear, concise, graphical communication and meetings with multiple process algorithms Improved communication with GPs organisations averted inappropriate admissions Ensuring all involved are A news letter is a quick and effective way to Patients and carers learn from peers aware of progress communicate to a wider audience as well as professionals Information/data Develop outcome measures at the start of the testing Sharing patient information across Measuring the impact of organisations involved has been change Agree methods for data collections relatively easy, with the support of the right people Integration of systems Involve people from your IT departments early in the work Governance differs across Involve the appropriate people, think wider than the organisations changes to the service delivery Distractions Review the scope of the work on a regular basis to Be realistic - some things may need keep the work on target to take a priority for a short period of time e.g. Swine Flu campaign
  26. 26. An integrated approach: The transferability of the Winning Principles - Sharing the learning | 27Key learning: Patient and carer experienceThe integrated working communitiesidentified common themes around thepatient/carer experience involvingCommunication;• Lack of and inconsistent Information• Unclear pathways of care that were difficult to navigate• Lack of clarity surrounding where and who to go to for support• Patients/carers continue to be confused about who to contact and where to go out of hours.Valuing patients time;• Admissions into hospital were not always necessary but became the default as patients did not know where to go• Easily managed symptoms were presenting as emergencies and could be managed at home• Unnecessary long lengths of stay for patients admitted as an emergency.Patient choice and preferredplace of care;• High numbers of emergency admissions ending in death within the first 24 - 48 hours of admission, as integrated working was not evident and patient choice and preferred place of care not activated or communicated.
  27. 27. 28 | An integrated approach: The transferability of the Winning Principles - Sharing the learning Achieving integration - 12 recommendations The integrated working communities demonstrated that integration can be achieved, but that integration in reality is stretching many organisations. The sites make the following recommendations 1. Communication: Develop a 10. Evaluate and measure: Agree robust communication mechanism the measurable outcomes across between all organisations to the different organisations. So all ensure engagement of all key achieve and can show stakeholders from the beginning. improvement in the quality, 2. Leadership: Do not commence efficiency and the patients unless executive, clinical and experience; remember to capture operational leadership has been and demonstrate the impact and identified across ALL agree what success looks like. participating organisations. 11. Time: Do not under-estimate the 3. Patient, user and carer time needed to establish and build involvement: Listen - Start the relationships. This is crucial and conversations with the users at without investment in time and the beginning they really know people, integration is unlikely to what happens, it happens to be successful. them! 12. Stability and sustainability: 4. Involvement: Cancer networks Keep testing the strength of the are a useful resource, they have integrations. A team is only as the ability to work across good as its weakest link. organisational boundaries and bring organisations together. 5. Integration champions: identify and establish a champion within each organisation. 6. Engagement and ownership: ‘It takes willingness, determination and a desire from all Equal playing fields, acknowledge the organisations, teams and disciplines of staff involved all the issues and ways of different working, identify the common to overcome the challenges if they are to win through to denominator with and across all organisations involved. deliver services in a truly integrated way to patients.’ 7. Win win: Identify the wins for each organisation aligned to the organisations strategic objectives. 8. Direction: Establish a steering group - ensure members have the necessary skills to action and influence decisions. 9. Assumptions: Dont make them and where you have, test them out- a solution identified as successful in one area may not work in another - adapt.