Patients and their carers are the reason the health service existsand therefore they should be at the heart of our services. Serviceredesign and improvement generates opportunities to involveservice users who will provide a different perspective on theservice, so that we can better understand whether our serviceor improvements make any difference to the patient.Only when we understand patient’s needs – by asking them, notsecond guessing – can we work in a way that meets those needsand ensures they get maximum benefit from our service.
3Improving Home Oxygen Services - EmergingLearning from the National Improvement ProjectsContentsForeword 4Executive summary 5Emerging learning 9Phases of work 9Data review and management 9Establishment of a formal assessment service 11Service integration and sustainability 13Testing hypothesis 14Emerging learning 14Issues and challenges 15Improvement stories 16NHS Newham and Newham University Hospital NHS Trust 16Royal Free/Waltham Forest PCT/NECLES HIEC 19West Hertfordshire COPD Service 23NHS Sheffield 26NHS Hull and the City Health Care Partnership 28NHS Gloucestershire 31Milton Keynes PCT Community Services and Milton Keynes Hospital 33NHS Blackpool 37Wirral Integrated Oxygen Service 39Sherwood Forest Hospitals and NHS Nottinghamshire County Community COPD Team 43NHS South Staffordshire 46NHS Birmingham East and North and Heart of England NHS Foundation Trust 49Appendices 53Data for improvement projects 53Newham LTOT pathway 57Royal Free/Waltham Forest PCT/NECLES HIEC Flow chart 58Royal Free/Waltham Forest PCT/NECLES HIEC invitation letter to patients 59Royal Free/Waltham Forest PCT/NECLES HIEC patient proforma 60Royal Free/Waltham Forest PCT/NECLES HIEC follow-up proforma 61Wirral COPD and Oxygen Service Process Map 62NHS Birmingham East and North Process Map (CURRENT STATE) 63NHS Birmingham East and North Process Map (FUTURE STATE) 62Acknowledgements 65References 66
4 ForewordForewordSince July 2010, NHS Improvement – The publication also contains informationLung has worked with a number of for healthcare professionals and thoseclinical teams across England as part of working in commissioning or interfacingthe Department of Health Respiratory with COPD services. This includes thoseProgramme. Its aim has been to support who are:the development of patient centred, • Involved in the care of patients whoevidenced based and clinically led services require COPD servicesby identifying and sharing innovative • Responsible for commissioning COPDways to reduce variations in care and servicesimprove the quality and experience of • Managing COPD services Professor Sue Hillpatients with chronic obstructive • Local or regional leadspulmonary disease (COPD). The project sites were encouraged toThe national improvement projects have employ a range of service improvementtested approaches at key stages of the tools and techniques. These includedclinical pathways which have included: process mapping, demand and capacity• Improving home oxygen services and data analysis, the application of Lean• Early accurate diagnosis principles, process redesign and the• Transforming acute care human dimensions of change. NHS• Managing COPD as a long term Improvement - Lung also supported the condition testing of new ideas and pathways• Improving end of life care through site visits and project team peer support.Following the first six months of the Dr Robert Winterimprovement programme, this There are lots of practical examples withinpublication signals the mid-way point in this report to support clinical teams inthe project cycle and has been written to delivering quality and productivityshare the learning from the testing phase benefits to patients and a wider range ofof the work. Through a series of case stakeholders. Over the next six months,studies and examples, it aims to highlight NHS Improvement – Lung will continue toareas of innovative and emerging good test the key principles for change andpractice that can be used locally to deliver implementation. As this learningimprovements for COPD patients and emerges, it will be shared with COPDtheir carers. services and the wider NHSIn order to address the paucity of current We would like to take this opportunity toevidence, particularly around the models thank the project sites for their hardand principles of implementation, the work, dedication and commitment andprogramme will continue to adapt and look forward to the full extent of therefine the learning. However, these improvement work as it comes to fruition.lessons will be of value now to any teamworking to improve the care it deliversand commissions for people with COPD. Professor Sue Hill Dr Robert WinterThis publication contains a number of Joint National Clinical Directorsexamples that demonstrate value for for the Respiratory Programmemoney, increased productivity andapproaches that can sustain improvementsover the long term.
Executive summary 5Executive summaryNational position and Thus the overarching aim of this This has led to a workstream 1/3 Ruleworkstream context workstream is that patients receive Savings, testing a hypothesis which accurate quality assured oxygen therapy states:Home oxygen therapy is provided to through optimised assessment and reviewabout 85,000 people in England at a cost models which ensure the right people are ‘One third of the total costof approximately £110 million a year1. in receipt of the right dose of oxygen efficiencies (savings and avoidance) therapy. can be realised through the firstMany Primary Care Trusts (PCTs) do notundertake quality assured clinical In developing the project outline the phase of a three phase process withassessment and review of their patients scope of the project work was framed efficiency gains reaching a plateauneed for long term home oxygen such that teams would consider: and prescribing costs capped byincreasing the potential for poor quality implementation of all three phases.‘care and waste. • The most appropriate (competent) staff to undertake assessment and reviews Placing an emphasis on the assessment ofThe Department of Health estimates that • Assessment and review location clinical need, and ongoing clinical review,around 30% of people prescribed oxygen settings provides an opportunity for healthcareeither derive no clinical benefit from it or • Guidance on correctly documenting professionals to more comprehensivelydo not use their oxygen2. Quality and and interpreting diagnostic results inform and educate patients about theirproductivity in the home oxygen service • Guidance on accurately prescribing condition. In addition if home oxygencan be improved significantly. Gross oxygen therapy is deemed appropriate then thissavings of up to 40% - equivalent • Providing the patient with written interaction also facilitates patientnationally to £45 million a year, or information regarding their oxygen education about equipment use, risk and£300,000 per PCT can potentially be therapy their own responsibilities as regards theachieved according to recent analysis safe use of oxygen at home.carried out by the Department of Health The project teams made extensive use ofthrough the established of home oxygen British Thoracic Society Home Oxygen Project teams will use or develop easy-to-services and oxygen register review and Services Standards3 and early drafts of the read, quality literature to educate patientsformal clinical assessment4. Department of Health Good Practice about the appropriate use and potential Guide4. In addition to the above the (fire) safety risks associated with usingThe rationale for the work of the project project teams have also utilised the work oxygen at home.teams is provided by recommendation 14 of NICE5 and IMPRESS6 to inform theirof the Chronic Obstructive Pulmonary thinking. This educational process is in alignmentDisease (COPD) Strategy Consultation with recommendation 11 of the Chronicdocument1, which states: Summary of emerging learning Obstructive Pulmonary Disease (COPD) Strategy Consultation document1, which‘All people with COPD and Early indications are that the project work states:hypoxaemia should be clinically spans three phases:assessed for long-term oxygen ‘Good-quality information should 1. Data review and data management be provided at diagnosis andtherapy and reviewed at regular 2. Establishment of a formalintervals, and existing home oxygen assessment service delivered in a format that anyregisters should be reviewed’. 3. Service integration and person can understand’ sustainability
6 Executive summarySome emerging themes arising from the Royal Free/Waltham Forestwork to date include: PCT/NECLES HIEC Introduced a review of all COPD short• Data coordination - Clinical team burst oxygen therapy (SBOT) prescriptions access to data and collaboration in the Waltham Forest PCT area offering between clinical and managerial/ patients full assessment of their administrative staff to review/challenge requirement for long term oxygen and oxygen patient data counselling or advice on alternative• Consistent messages to patients - In interventions for the management of rationalising local oxygen services breathlessness and the supported project teams have been engaging GPs withdrawal of the oxygen supply. and other healthcare professionals (HCPs) to develop a consensus in West Hertfordshire COPD Service respect of the appropriate initiation of Introduced a system of identifying home oxygen therapy for COPD healthcare professionals inappropriately patients. This is often summarised by prescribing home oxygen to patients with the simple message that ‘oxygen is not normal oxygen levels and undertaking a treatment for breathlessness’ targeted group education around good Milton Keynes PCT Community• Service integration - This is achieved practice in prescribing. Services and Milton Keynes Hospital by developing a pathway and Introduced pre and post of clinic set up prescribing consensus between the NHS Sheffield evaluation for the ambulatory oxygen home oxygen service assessment and Developed a detailed business case assessment clinic and also a quality review (HOS-AR) team, GPs, and service specification for integrated patient questionnaire pre and post use of commissioners and non respiratory HOS-AR in line with best practice. In patient information leaflet to see if specialists. This leads to the alignment addition, they introduced a system of patient experience improves. of the HOS-AR service specification oxygen usage data coordination and within a wider respiratory care pathway review in order to control prescribing NHS Blackpool and improved patient safety risk costs. Developed a an accurate oxygen usage assessment which is enshrined within a register and systematic use of data to wider (PCT) governance framework NHS Hull/City Health Care Partnership manage performance and extended Introduced a new commissioned HOS-AR formal assessment and review by theSummary of site projects service and so the project work provided introduction of HOS-AR based within a an opportunity to monitor improvements community setting.NHS Newham and Newham to the delivery of appropriate and cost-University Hospital NHS Trust effective oxygen therapy to COPD Wirral Integrated Oxygen ServiceEstablished a system of oxygen usage patients and develop safety protocols and Developed oxygen care pathways for nondata coordination and review in order to procedures through a multi-stakeholder COPD patients in collaboration with noncontrol prescribing costs and performance project group. respiratory specialist colleagues. Inmanage suppliers. In addition, they addition, they developed systematic riskintroduced systematic review of existing NHS Gloucestershire escalation procedures and protocols.acute hospital oxygen clinic patients and This team has focussed on developing adeveloped plans and protocols for future detailed business case and service Sherwood Forest Hospitals and NHSintegrated home oxygen service - specification which incorporates best Nottinghamshire County Communityassessment and review (HOS-AR) practice and learning from more established COPD Teamspanning primary and secondary care. teams on issues such as workforce and Established multidisciplinary HOS-AR competences, set-up and ongoing costs, within a community setting and data management and governance. collaborated with GPs and PCT managers to review oxygen usage.
Executive summary 7NHS South Staffordshire already undertaken on Quality Innovation • Introduction of HOS-AR - establishingDemonstrated the quick win potential of Productivity and Prevention (QIPP) a cycle of assessment and review,systematic review of oxygen usage data programme and the additional improvement of an existing service toin order to re-categorise costing and alter opportunities presented in the Equity and the standard articulated within thetherapy to achieve prescribing efficiencies Excellence: Liberating the NHS. Good Practice Guide, introduction of awithin one locality. This approach will new service to a locality in whichnow be extended across the PCT. In relation to the QIPP challenge, the NHS HOS-AR currently absent has been developing proposals to • Patient education packages - safetyNHS Birmingham East & North and improve the quality and productivity of its and risk considerations explained toHeart of England NHS Foundation services since the challenge was first patients and carers, captured withinTrust articulated in May 2009. The proposal is easy-to-read literature and mutualIntroduced transparent systems for to ensure that the NHS continues to responsibilities (both patients andsharing information relating to home make quality improvements a reality healthcare professionals) understoodoxygen users across the local health during a period in which growth in and documented within localeconomy and a pathway with guidelines expenditure within the NHS will be agreement documentssupporting the process of initiating restricted despite increasing demand. • Pathways for the treatment of nonoxygen therapy for new patients and COPD patients on oxygen -withdrawal/cessation where appropriate. Many of the measures outlined in this engagement of generalists and non document are designed specifically to respiratory specialists to establishQuality, Innovation, Productivity and support the NHS to meet the QIPP optimal care pathways for non COPDPrevention (QIPP) and expected challenge, either by identifying where patients in need of home oxygenoutcomes resources might be released or by therapyThe demand for services is increasing and improving understanding of the key • Principles of a good service model -there are areas where we could increase interventions that have greatest effect. development of new ways of workingthe quality, efficiency and value for by examining use of different types ofmoney of services as well as improving The work has demonstrated that the workforce along the pathway inoutcomes for people with chronic annual total spend across nine project different settingsobstructive pulmonary disease (COPD). sites can be reduced by a minimum of • Effective use of data – collaborationFocus needs to be centred on these three £600k. This applies for both new and between clinical and managerialfactors to make this a reality. First, established home oxygen services who professionals to integrate, review andimproving quality whilst improving implement oxygen usage reviews and interpret financial, administrative andproductivity by enforcing the principles of therapy optimisation. On a national scale, clinical data in order to optimise care,the Quality, Innovation, Productivity and the work compliments the Department of rationalise prescribing, overseePrevention (QIPP) agenda by using Health estimated gross savings of up to governance and performance manageinnovation and prevention to drive this 40% for each PCT. the oxygen suppliersforward and interlink these values.Secondly, having local clinicians and The expected outcomes in these project Potential for future workmanagers working together in a sites will be: The initial quick win cost efficienciesmultidisciplinary approach and across • Minimum of £600k prescribing attributable to the first phase of HOS-ARboundaries in order to spot the savings - achieved through therapy improvement work (data review and dataopportunities and manage the change. rationalisation, list cleansing, avoidance management) are becoming self evident.And thirdly, to act now, for the long term. of inappropriate prescribing and However, more work is needed to withdrawal of clinically unnecessary conclusively establish that the 1/3 RuleThe goal is to achieve efficiency savings therapy Savings hypothesis has been verified,of up to £20 billion for reinvestment over specifically in relation to the costthe next four years. This represents a very efficiencies realisable from thesignificant challenge to be delivered establishment of HOS-AR and by itsthrough the detailed work the NHS has integration within the broader service commissioning framework.
8 Executive summaryIn addition, further narrative is needed non COPD patients, often challengingaround the demonstrable benefits in colleagues when they appear not to bequality of care patients may derive from adhering to their own specialty areaoptimised home oxygen therapy. The guidelines. Thus there may be scope foreffective use of administrative, financial future projects to more thoroughlyand clinical data relating to oxygen usage investigate the potential cost savingsfurther promotes the use of disease achievable from rationalisation of homeregisters and flags up opportunities for oxygen therapy in non-COPD patients.more effective patient record linkage. Future work will also thoroughly explore Phil DuncanAn identified gap in the current work is and test ‘how to’ implement a gold Director, NHS Improvement -establishing whether or not improved standard pathway of HOS-AR as defined Lungcare resultant from formal oxygen by the Good Practice Guide in terms ofassessment and review results in fewer new services, but also in relation toadmissions to hospital. Although initial driving up quality for existing services.workstream metrics were devised toexplore this, linking information about Finally, further consideration will beindividual patients in receipt of home given to the following areas:oxygen with information from hospital • Stakeholder engagementpatient administration systems continues • Developing local incentives toto present a challenge. commission HOS-AR • Varying the workforce employed atThe reasons why a patient with COPD is different parts of the pathwayadmitted to hospital are varied and in • Describing optimal models of care in Ore Okosiaddition COPD patients on long term urban/rural geographies National Improvement Lead, NHS Improvement – Lungoxygen tend to have more severe disease • Developing a consensus aroundand thus and increased risk of provision/withdrawal of home oxygenhospitalisation. As such it may not be to persistent smokers who have apossible to establish whether optimised clinical need for oxygenhome oxygen therapy resultant from • Establishing ownership of HOS-ARsystematic clinical assessment and review governance and performanceis an effective admission avoidance management within the emergingstrategy. However, this topic is certainly commissioning structuresworthy of more consideration in future.Many HOS-AR teams have begun toestablish effective dialogue with non- Phil Duncanrespiratory specialists in respect of the Director, NHS Improvement - Lungmanagement of non COPD patients inreceipt of home oxygen therapy. As those Ore Okosirelationships mature, the HOS-AR teams National Improvement Lead,have been able to explore with their non NHS Improvement - Lungrespiratory colleagues the reasons forinitiation of home oxygen therapy in
Emerging learning 9Emerging learningPhases of work Data review and data Don’t forget ‘better’ is not measureable. ‘More’, ‘faster’, ‘safer’ or ‘cheaper’ can allIn attempting to broadly categorise thetype of work being undertaken by the management be measured but only if you know how The overwhelming message from all many, how fast, how dangerous or how12 ‘improving home oxygen services’ expensive things were to begin with. Wenational project teams it has been useful national chronic obstructive pulmonary disease (COPD) project sites in all need to establish factual data andto think in terms of three phases: measures to demonstrate what has been workstreams (not just oxygen) when starting improvement work was that achieved.1.Data review and data management• Data access there was difficulty in getting hold of data and information. As the COPD How did oxygen sites work• List cleansing with data?• Invoice reconciliation with projects commenced, sites reported limited access to data on their day to day Project teams grappling with this phase concordance reports spent much of their time ensuring all• Case prioritisation activity, and very poor access to overall information covering the respiratory appropriate staff had access to the full pathway. range of information available and then2.Establishment of a formal developing effective ways of utilising this assessment service information in order to understand and• Address assessment backlog Fortunately, there are many resources available that can support COPD project modify local processes and ensure• Establish assessment and review cycle financial control.• therapy modifications sites understand and compare their local• Withdrawals respiratory services with others, and many of these are freely and easily accessible. This included information provided by• Education oxygen suppliers and or PCT/regional Local data on oxygen can be combined home oxygen service (HOS) leads in the3.Service integration and form of quarterly concordance reports, sustainability with nationally available data on secondary care and primary care in order monthly invoices, copies of completed• Robust referrals home oxygen order forms (HOOFs) and• Multidisciplinary team process to build up a picture of local services. bespoke performance reports. mapping resulting in agreed pathway• Demand matches capacity Why is data important? Data and measures are important to In order to provide oversight in respect of• Service specification aligned with both clinical appropriateness and financial governance and commissioning demonstrate that change has occurred or needs to occur. NHS Improvement - Lung control it is necessary for clinical members• Effective communication with of the home oxygen service assessment healthcare professionals, patients and focuses on the delivery of quality measured improvements which are and review (HOS-AR) team to be able carers review individual patient details contained aligned to national priorities and strategies. In line with the national within the completed HOOFs received byIn reality, many project teams have the oxygen supplier.undertaken activities in parallel and so Quality Innovation Productivity andmay span these phases which are now Prevention (QIPP) initiative, it is essentialoutlined in more detail. that all system changes are measured and recorded. Whether the change was a success or did not demonstrate the anticipated outcomes, you still need to demonstrate its effect and learn from it.
10 Emerging learningGaining access to home oxygen Implementing ongoing monitoring Data reconciliationorder form data for oxygen Open Exeter enables the reconciliation ofNHS Connecting for Health provides The NHS Home Oxygen Service Manual9 monthly files of invoices from the Homedesignated users (authorised by individual states that in order to effectively monitor Oxygen suppliers against the patientsPCTs) on-line access to individual patient activity within the home oxygen service, recorded in their NHAIS system7.HOOFs held on the National Health PCTs need to have in place a systemApplications and Infrastructure Services capable of capturing a range of The system uses information contained(NHAIS) system database via Open Exeter information about each patient on receipt within the completed HOOF to calculatea web-enabled viewer7. of oxygen, specifically: the appropriate cost band from the specified delivery mechanism, the numberNew users have to complete a Data Users • Who oxygen was ordered for of litres/hour and the duration and thisCertification Form (available from • Date of birth can be checked against the cost bandwww.connectingforhealth.nhs.uk/nhais/ • NHS number invoiced by the supplier7.products_and_services/vaprodopenexe) • Patient’s GP practiceand get the form authorised by the PCT • Who placed the order Open Exeter has a suite of reports which(or shared services agency) data controller • When was the order placed support data reconciliation:who will then process the form on-line or • What was orderedforward it for authentication. • Urgent, next day or standard supply • Deducted patients by • Primary or secondary supply • Patients not found on the NHAISGetting access to oxygen cost data • Flow rate • Inconsistent cost bandsIn addition to Open Exeter, the majority • Hours per day • Identical provisions for patient at sameof PCT home oxygen service leads and • Status (new or existing patient) addressmedicines management teams have • Estimate of cost • Cost band totals by practiceaccess to on-line home oxygen therapy • Holiday ordersreports from the NHS Business Services The Wirral and Milton Keynes project • EmergencyAuthority Prescription Pricing Division teams have each had to independently • Light weight ambulatory orders(NHSBSA PPD). develop local ‘databases’ which enable • HOOF entered but not matched to a the HOS-AR team to monitor service supplier order recordThese reports provide information on the activity but with limited ability to link • No HOOF entered for supplier orderpayments made to suppliers for provision information from other clinical recording recordof oxygen and differentiate payment sources to specific oxygen data sources.claims made for the supplier in respect of The improvement stories from the Hull,patients residing within the contracted A key component of their work has been Sheffield, Sherwood Forest and BlackpoolPCT area and claims for out-of-area to establish a system of HOOF project teams are all examples of howpatients8. management which ensures that there is clinical team members developed an either a centralised or a coordinated understanding of the prescribing costAccess to these reports is obtained by approach to HOOF completion and that categories.completing a PCT prescribing reports user copies of all HOOFs are available for theregistration form and sending it a signed clinical specialists to review. They also illustrate clinical and non-letter from the PCT senior officer to clinical colleague collaboration in order toInformation Services Department of NHS undertake the almost forensic analysis ofPrescription Services in Newcastle. modalities of oxygen supply associatedwww.nhsbsa.nhs.uk/PrescriptionServices/ with individual patients.3091.aspx
Emerging learning 11Armed with this information the clinicians The South Staffordshire project teamwere able to work alongside other non have illustrated the quick win productivity Establishment of aclinical colleagues in order to: gains achievable through primarily this formal assessment first phase of work.• Identify patients in receipt of oxygen service who are not known to the specialist This team joined the programme five This work centres on trying to ensure that team months into the first phase of the project all patients currently in receipt of oxygen• Reconcile invoice information with cycle and over the course of two months are receiving care management in information held on local systems undertook an inspection of individual alignment with published standards on• Review patients on multiple modalities patient oxygen usage data (and other assessment and frequency of review.• Scrutinise the various charge bands recorded clinical information) for 91• Ensure deceased patients were Cannock Chase locality patients known Following the data exercises undertaken removed from lists to the community COPD team. in phase one it is possible to identify in• Stop charges arising from the supply receipt of oxygen but unknown to the of oxygen to patients living outside The data inspection was coupled with specialist team. the PCT catchment area telephone patient contact and face-to-• Set up patient recall and review systems face review in a limited number of Using this information together with• Identify non-usage, under-usage, instances. information about the existing specialist over-usage team caseload and the volume of new• Identify sources of inappropriate As a result, 10% of patients were moved referrals for a formal assessment. Some prescribing within both primary and to a less expensive tariff with forecast analysis of demand and capacity can be secondary care individual savings in excess £1,000 per undertaken in order to inform clinic year, the total annual forecast cost scheduling/home visits necessary toData management and QIPP savings attributable to the review of the address the backlog of previouslyThe NHS Newham project team cite their 91 patients in Cannock Chase locality unassessed patients.use of the Open Exeter reporting function amounted to £57,573.in validating monthly supplier costs and These patients are contacted by therealised productivity savings of £12,057 Cannock Chase is only one locality within project team in order to arrange iffrom April to November 2010 purely from South Staffordshire and so the PCT is necessary a review and therapy altered oraccurate data management. exploring whether even greater withdrawn if deemed inappropriate. productivity gains can be achieved if thisThis included removal of deceased approach was spread to other localities. This phase involves liaison with thepatients, removal of duplicated patients patient’s GP surgery as many existingand removal of out of area patients. oxygen patients received therapy as a result of a GP completing the originalThe improvement stories contained home oxygen order form (HOOF).within this publication illustrate theeffectiveness of clinicians working incollaboration with managerial andadministrative colleagues (especially thedesignated PCT home oxygen servicelead) in respect of the financialreconciliation process.
12 Emerging learningThe Department of Health Good PracticeGuide10 sets out very clearly and Part of the Oxygen Care Pathway from the Home Oxygen Service –comprehensively the gold standard Assessment and Review: Good Practice Guide. Department of Health,pathway for oxygen assessment and Final version 24th November 2010review. A condensed summary of the • Access exercise capacitypathway is set out below: • Access adequate correction of exercise de-saturation • Determine flow rate • Discuss with patient if immediate ambulatory supply or derfer until later1. Referral to formal assessment service • Assessment of social situation and referral to social services if required following determination of • Assessment of compliance hypoxaemia using pulse oximetry Full assessment Discuss HCP led (SaO2 level is below 92%) • Hypoxic • Borderline oxygen LTOT assessment Consider assessment for additional equipment options with Educational session with Completed HOOF sent to HOS assessment ambulatory oxygen patient/carer provider2. Full assessment for long term oxygen • Complex patient therapy (LTOT) including spirometry • Confirm hypoxaemia • Spirometry • Arrange training for carer if not in and measurement of arterial blood • ABG • CO2 retention - attendance • Provide written Discuss follow-up gases (with LTOT prescribed for 15 consider need for NIV patient information • Patient to confirm arrangements and book first understanding appointment hours per day in clinically stable of training patients where the arterial blood Check oximetry if not No hypoxaemia B F transfer back oxygen measurement is at or below yet done to referrer Inform/GP consultant and 7.3kPa, or under 8kPa if oedema referring HCP of management plan present)3. Determination of safety, flow rate and Borderline cases C SaO2 92-93% duration of oxygen for patients in G whom oxygen is indicated4. Further assessment (if appropriate) to determine the patient’s capacity for exercise, and whether they should be prescribed additional ambulatory Models of service: The clinical teams The Sherwood Forest team operate a oxygen within this initial cohort of oxygen model which involves specialist5. Clinician orders appropriate oxygen projects are varied in terms of their assessment available from community supply device from oxygen suppliers locations and workforce composition. clinic locations. following discussion with patient6. Follow-up home visit should be The Hull, Wirral and West Hertfordshire The Wirral project team operate from undertaken at four weeks by a project teams are all led by respiratory specialist clinics and more recently have healthcare professional to assess the nurse specialists in contrast to the begun undertaking clinical reviews from patient’s clinical status, compliance Sherwood Forest and Birmingham East within GP surgeries in order to evaluate with the oxygen therapy regime and and North teams which are led by a this approach in terms of reducing the to determine whether further action is clinical scientist and a consultant number of patients who fail to attend necessary respiratory physician respectively. their scheduled consultation.7. Regular clinical status reviews should be undertaken However, all the teams do operate within The Newham project team are developing a. Every six weeks after admission a multidisciplinary framework with a mixed model which utilises both or exacerbation different workforce competences secondary care specialists and community b. Every six months oximetry should available at various points in the care matrons at different point within the care be carried out pathway. pathway and facilitated by the use of c. Every twelve months patients point-of care arterial blood gas testing should have their arterial blood equipment. gases measured.
Emerging learning 13The choice of model being tested and Hertfordshire COPD service are also In attempting to establish a moredeveloped often reflects the geographical attempting to ensure sustainable financial integrated model of care, teams have hadconsiderations of the area with Acute management by educating GPs about the to overcome perverse incentives withinHospital clinics being the locations of benefits of formal assessment. ‘payment by results’ which mightchoice within the more compact and potentially encourage duplication,highly urbanised Birmingham setting in Teams such as the Wirral COPD and redundant processes or unnecessary stepscontrast to community clinic settings Home Oxygen Service are engaging non- in pathway.being considered by more dispersed respiratory specialists in discussionspopulations such as NHS Gloucester. around the care pathway for patients NHS Birmingham East and North are receiving oxygen for non COPD related developing a local payment tariff whichAt a recent peer support meeting the conditions and jointly developing care will encourage multidisciplinary working12 national project teams reached a pathways. by both being fair compensation to theconsensus as regards models of service service provider and financiallydelivery which is encapsulated within the Having achieved significant therapy sustainable by the commissioner.phrase ‘Varied models but standardised changes and therapy withdrawals amongprocesses’. This means strict adherence to existing oxygen patients, through the In developing a new service or model ofbest practice as articulated within the work of phases one and two, teams such care it is important to ensure clarity at theDepartment of Health Good Practice as Hull and Wirral have begun to tackle outset in relation to costs. InvolvementGuide but flexibility in respect of location the challenge of addressing therapy with this programme of work enabledand staffing. modification in patients who resisted all NHS Gloucestershire to significantly initial invitations for clinical review and re-evaluate their business case.Service integration and ensure patient safety risks uncovered by the earlier work is documented and The NHS Improvement - Lung seniorsustainability integrated within the wider analyst was able to guide them on howA number of the project teams are organisational risk management to use their own quarterly concordanceattempting to leverage the oxygen cost framework. report data to understand potentialsavings achieved through rationalisation patterns of service demand.of processes to raise the profile of oxygen The NHS Birmingham East and Northservices among local commissioners. team are ensuring that safety risk In addition, the Gloucester project lead recording and follow-up procedures are was able to review the serviceIn areas such Sheffield and Gloucester the firmly established within the existing PCT specifications of more established teamstype and scope of oxygen service was not governance framework in order to ensure and through interaction with colleaguespreviously well defined within local transition to the newly emerging GP during regular peer support meetingsrespiratory service specifications. The commissioning consortia. gain greater insight in to workforceproject team were subsequently given an considerations.opportunity for the local health economy However, the risks are not just thosestakeholders to collectively address this by associated with patient safety, there are This dialogue also enabled previouslyutilising the emerging learning from the also financial risks posed by poor data unconsidered ‘hidden costs’ (such asproject work and the Department of management and coordination. equipment upkeep) to be identified.Health Good Practice Guide to informnew business cases or revise service Project teams such as Sherwood Forestspecifications. are devolving oxygen prescribing budgetary management to GP localities inThe quick win cost savings achievable by order to preserve the discipline ofundertaking phase one work is obviously financial management during the localattractive to commissioners but the more NHS transition and further engage GPs inestablished teams such as the West discussions around the care pathway.
14 Emerging learningTesting hypothesis Emerging themes Consistent messages to patients – In rationalising local oxygen services projectCost savings have been achieved by a Data coordination – In order to ensure teams have been engaging non-number of project teams. Teams such as tight financial control and appropriate respiratory specialists, GPs and otherSheffield, South Staffordshire (Cannock oxygen prescribing the home oxygen healthcare professionals in order toChase locality) and Newham have realised service - assessment and review (HOS-AR) develop a local consensus in respect ofsignificant quick win cost savings team need to liaise effectively with oxygen therapy initiation.attributable to the first phase of work managerial and administrative staff towith forecast annual savings of £120K, jointly review information contained Much of this engagement has taken the£57.5K and £12K respectively. within oxygen supplier concordance form of education in respect of the reports and monthly invoices. benefits of formal assessment, the healthWhilst project teams with more and safety considerations and wasteestablished HOS-AR teams such as Hull, Collaboration between designated PCT incurred by inappropriate prescribing.Wirral and West Hertfordshire either home oxygen service (HOS) leads andcontinue to achieve a reduction in HOS-AR teams has enabled supplier Project teams have identified thatspending (as compared with the period reports to be used effectively, picking up inappropriate prescribing occurs in bothprior to the service being established) or anomalies within prescribed oxygen and primary and secondary care and so teamsexperience very modest fluctuations in challenging unnecessary multiple such as the West Herts COPD servicemonth-on-month costs. modalities. undertook targeted educational visits as part of their cost avoidance strategy.The following hypothesis is now being Some HOS-AR teams have establishedtested by the workstream: agreements with local primary and During the periodic peer support secondary care stakeholders that they act meetings facilitated by NHS Improvement1/3 Rule Savings: one third of total cost as ‘gatekeeper’ for the completion and - Lung the 12 project teams jointlyefficiencies (savings and avoidance) amendment of the home oxygen order identified two simple messages that allrealised through first stage of three stage form (HOOF). project teams need to reinforce withinprocess with efficiency gains reaching a their local health economy, these were:plateau and prescribing costs capped by This has reduced inappropriate oxygenimplementation of all three stages. prescribing by healthcare professionals i) Oxygen is not a treatment for who are not able to accurately determine breathlessnessData collected during the final phase of a patient’s need for oxygen nor the ii) Think oxygen/think of us - yourthe project cycle will establish what therapy which most appropriately meets home oxygen service!proportion of overall cost efficiencies is that need.achievable during the three phases. Service integration - As with many In addition to granting HOS-AR teams other areas of healthcare the projectThe results from Sheffield, Staffordshire access to the national invoice teams are confirming that sustainableand Newham lend support to the 1/3 interrogation system ‘Open Exeter’, many models of care require an integratedRule Savings workstream testing project teams are attempting to create a approach across primary and secondaryhypothesis. However, quantification of database which is jointly accessible (and care as well as across medical specialties.the productivity gains achievable from jointed populated) by clinical andeach phase of work will be more evident administrative staff, thus enabling links towhen a sufficient body of data is available be made between a patient’s clinicalfrom the total project cohort upon information and other administrativecompletion of the 12 month project cycle. information.
Emerging learning 15Having undertaken a comprehensiveprocess mapping of the existing patient Issues and challenges Project teams have utilised clinical guidance from a number of sources andjourney, project teams such as Newham Data access/use/coordination they have engaged local governanceare exploring new ways of working for A number of project teams had to stakeholders in order to frame atheir community and acute based staff on overcome barriers in order to access consensus around withdrawal protocols,the basis of standardised assessment and directly patient data held by the supplier. risk assessment and escalationreview processes undertaken by different Suppliers often expressed great procedures.staff groups, matching competencies reluctance to share information withidentified within the Department of personnel other than the designated PCT Despite this many project team membersHealth Good Practice Guide10 to specific HOS lead and many protracted expressed a sense of ‘exposure’ especiallyparts of the care pathway in different discussions and emails had to be engaged in the face of challenges from either asettings. into in order to unearth information. patient, relative, carer or even another healthcare professional.A number of project teams (Birmingham The lack of a national database whichEast & North, Blackpool, Sheffield) are contains both clinical and administrative A particular area of concern is thelooking at different ways of using hospital information and which could be jointly withdrawal of therapy in hypoxic patientstariff costs in order to support accessed and populated by both clinical who smoke. The project teams welcomemultidisciplinary working and sustain and administrative staff is a bug bear for the references made to this topic in theservice enhancements. many teams resulting in some teams most recent draft of the Department of attempting to devise their own systems Health Good Practice Guide10 but feel theFor many teams the project work has locally. topic is worthy of further discussionprovided an opportunity to strengthen nationally.links with oxygen suppliers, local fire This lack of record-linkage functionalityservices, PCT executive committees, social impairs a joined up study of a patient’s During recent peer support meetings theservices and emerging GP consortia whole system care. 12 project teams jointly agreed some top-especially with regards to patient safety tips in respect of facilitating oxygengovernance issues. Gaining agreement around the HOS-AR therapy withdrawal in patients deemed a team acting as HOOF gatekeeper OR fire safety risk:Both the Wirral team and the team from ensuring coordination of HOOFHull have developed local therapy completion across a local health economy • Offer patient intensive step-up smokingwithdrawal protocols and risk escalation is something that requires specialist teams cessation supportprocedures in collaboration with other to invest time in engaging with local GPs • Utilise a multidisciplinary approachlocal stakeholders and sought the and non-respiratory specialists on an on- including social servicesapproval of local governance committees. going basis to ensure harmonised • Consider possible child protection prescribing. issues where patient is also a carerTeams such as NHS Gloucester, aspiring to (e.g. smoking grandparent whoestablish a new HOS-AR service have Access to specialist information support regularly looks after grandchildren)been able to better inform their business (Trust or PCT based) appears very variable • Undertake both a risk assessment andcases and service specifications with real with many teams experiencing challenges a (mental) capacity assessment ifworld intelligence from the established around data collection and analysis. appropriateHOS-AR teams within the project cohort, • Instigate a case conference aroundstrengthening these documents in respect Governance unmanageable risksof the data support required and Many of the project teams expressed a • Document all the factsbuilding-in ongoing ‘hidden costs’ in strong desire for central guidance in • Consider the use/development of arespect of equipment. respect of healthcare professional liability red card warning system prior to and the legality of therapy withdrawal. withdrawal
16 Improvement storiesImproving the prescribing and ongoingmanagement of patients on home oxygen therapyNHS Newham and Newham University Hospital NHS TrustThe NHS Newham and Astra Zeneca joint The pathway of care The first page of the draft home oxygenproject on improving chronic obstructive Newham had localised the COPD therapy pathway is shown below.pulmonary disease (COPD) services within pathway using the ‘Map of Medicine’ butthe local healthcare community (LHC) it did not incorporate any details The project aims and objectivescomprised Primary Care, Secondary Care, regarding the prescribing or the ongoing The aim of the work was to improve theCommunity Health Care (provider arm of management. There were gaps in the prescribing and ongoing management ofthe PCT), Public Health and service being provided and these would patient on home oxygen therapy.Commissioning. be identified during the development of the oxygen pathway.The background to their serviceOxygen is prescribed by primary andsecondary care clinicians. Prescribing ofoxygen by secondary care (the chest Home oxygen therapy - requirement suspectedclinic) is based on structured assessment Newham Development Zone > Thoracic medicine > Home oxygen therapy (HOT)and a database is kept of the patientsthat are under their care.Primary care prescribing may also bebased on an effective assessment butthere is no evidence to verify this.There were no formal managementarrangements of the oxygen service inNHS Newham. Ongoing review of oxygenpatients were not being preformed forany patients. There was no standarddatabase kept of patients on oxygen andthe information was not being sharedbetween the patients being managed inprimary care and by the chest clinic.Oxygen invoices were managed by themedicine management team and therewas no reconciliation between thedatabase and monthly invoices providedby the service provider. Also, there waslack of evidence whether any actionswere taken to act on the reportsproduced or provided by the oxygensupplier e.g. compliance reports, out ofarea reports etc.
Improvement stories 17Specific objectives: The other challenge has been the current Workforce considerations• To produce/manage the oxygen data reorganisation of the PCTs. As a The review of the chest clinic oxygen base and check on a monthly basis for consequence there is a risk that no patients is being supported by two accuracy by April 2010 project support will be available from suitably trained and clinically supervised• To develop and implement an April 2011. This has been reported to the second year medical students which assessment and review process for chief executive. poses risk to the ongoing sustainability of patients on oxygen therapy by the work. Agreement has been reached December 2010 Implementation of the reviews has to add capacity in the form of• To reassess and review 25% of presented capacity issues but these have Community Matrons to review primary patients on oxygen and record any been resolved by temporally increasing care oxygen patients. Once all the changes to their oxygen therapy by the capacity to clear the back log. patients have been reviewed it should be April 2011 possible to maintain the ongoing reviews• To reduce wastage in oxygen The testing they did and key learning within the current workforce. prescribing and secure a 20% to date, including the overall benefits reduction in cost September 2010 The plan to review of patients on oxygen Potential/actual QIPP and cost compared to the 2009/10 cost has commenced and it is anticipated that savings /avoidance – defined as• To update and expand the localised at least half of the patients (approx 80) quality, innovation, productivity pathway (to include development of a managed by the chest clinic will be and prevention new Home Oxygen Service pathway) reviewed by the end of March 2011. The The oxygen database has been produced and promote its implementation data will be collected and analysed on a and is updated on a monthly basis. In across the local healthcare community monthly basis and the work will be addition, the information is shared with by April 2011 amended accordingly. the acute so that the information is• To incorporate the COPD strategy consistent. objectives into the redesign as Similar process will be followed for appropriate monitoring of blood gases for patients Productivity savings of £12,057 have who attend as day cases. Outcomes of been secured from April to NovemberThe process of improvement they this initial phase will be used to plan the 2010 purely from accurate dataundertook and overall approach to work for patients not being managed by management. This included removal ofaddress the issues. the chest clinic. It is anticipated that all deceased patients, removal of duplicated oxygen prescribing will be under the patients and removal of out of areaA steering group was setup including specialist respiratory service but this is patients.primary and secondary care clinical leads dependent upon pathway changes beingto address the issues and take forward agreed. An assessment and reviews form hasthe outcomes of the stakeholder event been developed to use across the localwhich incorporated patient Commissioning considerations healthcare community. In addition, localrepresentatives. Extensive discussions have occurred in oxygen protocols have been agreed and order to try to achieve change. If these incorporated into the review form. ThisIssues and challenges they faced changes are not achieved or result in should result in improved quality ofwith potential solutions protracted meetings and discussions then management of patients on oxygen andThe main challenge to potential solutions notice to terminate the contract will be is projected to provide productivityhas been negotiating change in the given. This has already been considered savings of approximately of £80k.current way of working with the and the final decision will rest with thesecondary care managers. The clinicians GP Commissioning Board.have been willing to redesign the service.
18 Improvement storiesReview of the patients being managed by • Incorporate compliance reports into thethe chest clinic has commenced and database and organise reviews asoutcome data is being collected. It is appropriateanticipated that the target of reviewing • Production and use of standard reports:25% of patients by April 2011 will be - Confirm out of PCT catchment areaachieved. patients are registered within the PCT - Open Exeter reports – deductedThe purchase of three Point of Care patients, duplicated patients,Arterial Blood Gas (ABG) meters will identical provision at the samefacilitate with the oxygen reviews and will addresseliminate day case attendances for ABG • Consider purchase and use of ABGmonitoring. This innovative approach Point of Care meters to facilitateshould result in net productivity savings of oxygen prescribing, reviews andapproximately £250k for a full year whilst optimising therapy includingimproving the quality of the service for discontinuation as appropriatepatients. Any generic learning (LTC) that weDiscussions are also being held to extrapolate from the work e.g. how thismanage the oxygen on a sector wide could be applied to other areas:basis to further secure productivity gains. • Ensure engagement of the clinical leadsData collection, a summary of what it at the outset and get them to lead theshowed and overall evidence processincluding any charts • Agree metrics and ensure ease ofBaseline data has been collected and as availability at the outsetthe oxygen review data becomes • Ensure robust data collection plan andavailable it will be analysed to establish implement as soon as possible -quality and productivity improvements. sufficient time needs to be allowed forInitial data indicates that the cost of the data team to incorporate this intohome oxygen service is not increasing. their workload • Engage commissioning to ensure thatEmerging workstream principles, you are aware of the current contractincluding ‘top tips’ and who is monitoring itTop tips for the management of theoxygen service are: Project lead contact details for further information• Engage with IT to produce a database Bob Arora which allows a quick method of Map of Medicine Programme Manager updating with the oxygen provider Telephone: 0207 059 6524, invoice Email: firstname.lastname@example.org• Share a common database with other services (chest clinic, community matrons) to allow immediate database management
Improvement stories 19The feasibility and impact of withdrawal of ShortBurst Oxygen Therapy (SBOT)Royal Free Hospital NHS Trust, NHS Waltham Forest & North East London, NorthCentral London and Essex Health Innovation Education Cluster (NECLES HIEC)Background to the service facilitator for the theme) and NHS Discussion then took place with theThere is considerable data available and Waltham Forest (Anne Crawford (AC)). patient about alternative interventions forpublished, that the use of short burst Other members of the team included the management of breathlessness.oxygen therapy (SBOT) or intermittent Robyn Hudson (RH), Charles Bruce (CB), Patients were offered supportedoxygen at home for the relief of Gavin Donaldson (GD). withdrawal of the oxygen supply andbreathlessness, in patients without followed up with an appointment at anchronic hypoxemia is not effective and The gold standard pathway vs. local interval of one month. Arrangementscostly to the NHS. pathway were made to withdraw the oxygen The gold standard pathway is that long supply with the contractor.This pilot was undertaken to address the term oxygen therapy is assessed byissue of the prescription of SBOT for arterial blood gases, resulting in a If SBOT patients were unwilling to havepatients with chronic obstructive prescription of oxygen for 15 hours over a the oxygen withdrawn, then they werepulmonary disease (COPD). Although 24 hour period. However, for short burst offered an appointment with thecurrent guidance relating to long term oxygen therapy (intermittent oxygen) no respiratory consultant for furtheroxygen prescription does not support such assessment has been formalised and discussions and assessment. Furtherprovision of SBOT, there is considerable short burst oxygen is usually prescribed assessment of patients unwilling to beevidence from the home oxygen service for breathless patients without oximetry. withdrawn from SBOT were offered.data and surveys that that SBOT is still Appendix 1 illustrates the pathway for All patients will be followed at six monthsprovided in this way and wastes the NHS Waltham Forest oxygen to assess outcomes such as quality of life,resources. assessment service. arterial blood gases, primary care visits and any hospital admissions.Furthermore, there are other more The project aims and objectiveseffective ways that can be utilised to treat The aim of this project was to review all The process of improvementbreathlessness and thus use of SBOT COPD SBOT prescriptions, of more than undertaken and overall approachleads to sup-optimal care. It is estimated three months, in the Camden and to address the issuesthat up to 25% of the home oxygen Waltham Forest PCT areas, in order to Meetings and telephone review toprovided in England and Wales is in the reduce SBOT prescription by 75% over support this work:form of SBOT. However, there is no data the course of one year (July 2010 to Julyavailable on withdrawal of SBOT in 2011). This figure was aimed high as we • In the early stages of the project, twopatients without hypoxaemia and also no are aware that most SBOT patients (once meetings took place (14 June and 30information regarding how successful palliative prescriptions have been July 2010) with NHS Improvement Lead,withdrawal is, in this patient group, both excluded) have no clincial indication for Ore Okosi and various members of thein the short term and longer term e.g. six SBOT. team (JAW, CB, CM, GD, AC, RH) tomonths. Patients may become dependent discuss and plan the projecton SBOT and thus considerable education Patients in the palliative care category • AC, CM, RH attended the NHSwill be required, both for the patient and were excluded for the purpose of this Improvement - Lung launch on 16 Julythe healthcare professional, about other analysis. The intention was to obtain data 2010 and AC & CM attended the NHSinterventions for breathlessness. Such from the PCTs and contractor, regarding Improvement System training day on 28data on withdrawal will also inform current prescription of SBOT in each of July and 19 August respectivelyhealth economic evaluations and aid the study areas. • AC attended the oxygen peer supportfuture guidance on home oxygen services. meeting at Edgware Community Hospital Patients with a prescription of SBOT were on 23 September. CM attended theThe original intention was that the project offered an appointment with a respiratory oxygen peer support meeting at Miltonwould take place in two sites - one site in specialist to discuss their use of oxygen Keynes in NovemberNorth London: Royal Free Hospital NHS and where indicated, full assessment of • AC, CM had a telephone review 13Trust (Christine Mikelsons (CM) & their requirement for long term oxygen August and two half day meetings on 28Professor Wisia Wedzicha (JAW)) and NHS was performed. In cases where no clinical October 2010 and 27 January 2011Camden, and the other site in North East need was identified, patients were • In addition, there have been regularLondon: Whipps Cross University Hospital counselled and advised that they did not telephone updates between AC and CMNHS Trust (Professor Mike Roberts - HIEC need to continue with oxygen at home. (13/8/2010, 27/8/10; 3/9/10; 15/10/10)
20 Improvement storiesData collection was started at Waltham The testing was performed and the Data collection summaryForest on 15 October 2010, following the key learning to date, including the October to December 2010 results:development of: overall benefits A total of 25 patients on SBOT in the• A flyer inviting participation Patients in NHS Waltham Forest on short borough of Waltham Forest with a (see appendices) burst oxygen (CC2a and CC2b) have primary diagnosis of COPD were• A letter of agreement of patients to been reviewed and assessed. The data identified. Appointments were sent and take part (see appendices) has been collected and analysed. patients, who agreed to participate in the• An updated patient assessment Metrics and measures included numbers project, visited in their homes: proforma (see appendices) receiving SBOT, three months• A patient follow-up proforma retrospective data to understand demand • Two patients have had their SBOT (see appendices) and capacity, actual hours SBOT use, successfully withdrawn• An agreement with local GPs to support FEV1,SaO2 and ABGs, SGRQ, HAD and • Nine patients (47.3%) were actions within the project BORG scores, number of reviews, number exacerbating at the time of assessment• Written details informing GPs of of admissions related to respiratory • Two patients were withdrawn from the patient’s involvement in this NHS condition, number of patients with study :one unwilling to comply with Improvement - Lung project maintained withdrawal at six months and interventions, one recently bereaved improvement stories to include patient’s and worsening of short term memoryIssues and challenges faced with experiences. losspotential solutions • One patient was dying and refusing• Issues of maintaining up to date HOOF Potential/actual QIPP and cost savings hospital admission and one refused data and an oxygen database in /avoidance – defined as quality, assessment Waltham Forest PCT as administration innovation, productivity and • One withdrawn from SBOT as required support ceased at the end of August prevention long term oxygen therapy 2010. Discussions with the medicines There are potential cost savings from • One was in hospital having been management lead was required in withdrawal of SBOT and in addition admitted with pneumonia order to determine continuation and further cost savings could be identified as • The remainder are awaiting assessment agreement of support to the oxygen a result of performing ABG sampling in service the community thus obviating the need The results of 19 patients are presented• Access to data proved to be a challenge for patients to attend hospital for this below for HAD, SGRQ, FEV1 (morbidity) which resulted in the following email reason. and oxygen SaO2 at assessment on first trail: visit. • Commissioners at Camden PCT three times (CM) • Home oxygen service at Department of Health (CM) 1 October 2010 - 31 December 2010 - Waltham Forest PCT HAD • Clinical lead for respiratory medicine 35 NHS London (CM) • Oxygen lead for NHS London (CM) 30 31 28 • Strategy team NHS London 25 26 24 • Commissioners at Camden PCT 20 21 20 HAD 15 17 (JAW) 14 10 9 5 6 7 7 5 0 0 0 0 0 0 0 -5 A B C D E F G H I J K L M N O P Q R S NOV Patients Waltham Forest PCT Waltham Forest PCT
Improvement stories 21 Since December 2010, a further four1 October 2010 - 31 December 2010 - Waltham Forest PCT patients have been assessed:SGRQ 25 • One patient was depressed and 20 21 21 21 declined to participate 20 17 18 • One patient was depressed with short 15 14 15 14 term memory loss and withdrew from SCRQ 12 10 11 the study 9 5 • One patient refused to have SBOT and 0 0 0 0 0 0 0 was removed from the study 0 • One patient agreed to removal of SBOT -5 A B C D E F G H I J K L M N O P Q R S which was replaced with ambulatory NOV oxygen Patients • One patient assessed earlier Waltham Forest PCT Waltham Forest PCT subsequently withdrew from study • One patient has not been seen due to frequent hospital admissions1 October 2010 - 31 December 2010 - Waltham Forest PCTMorbidity Summary 80 Out of a small sample of 25 patients, three patients have been removed from 60 63 SBOT. 40 42 40 There were a variety of reasons for non- FEV1 37 37 37 30 31 20 29 removal of SBOT including: 18 0 0 0 0 0 0 0 0 0 0 • Current exacerbations (not recovering) -20 • Frequent exacerbations A B C D E F G H I J K L M N O P Q R S NOV • Dying Patients • Depression and memory loss Waltham Forest PCT Waltham Forest PCT • Eligible for LTOT but declined this therefore SBOT left in • Patient intermittently desaturated, therefore needed SBOT1 October 2010 - 31 December 2010 - Waltham Forest PCTOxygen Assessment First Visit 100 95 96 98 88 88 85 95 96 96 94 94 94 93 90 80 60 64 66 Sa02 on air 40 20 0 0 0 -20 A B C D E F G I J K L M N O P Q R S NOV Patients Waltham Forest PCT Waltham Forest PCT
22 Improvement storiesEmerging workstream principles, Any generic learning (LTC) that can be Project leads contact details forincluding ‘top tips’ extrapolated from this work i.e. how further informationThe issues relating to withdrawal of SBOT this could be applied to other areas Christine Mikelsonsare complex and multifactorial: these • The need to ensure that Consultant Respiratory Physiotherapisttend not to relate to sub-optimal communication between the Tel. 0207 794 0500 ext 34068management, but rather, to the fact that community and hospital on discharge is or bleep 1041this subgroup of patients have severe improved for seamless care Email email@example.comCOPD, are unwell, are maintained at • Patients who are prescribed SBOT mayhome and are too sick to consider not have been seen by a clinician Anne Crawfordremoval of oxygen. The majority of specialist in oxygen therapy and may Team Lead, Respiratory Nurse Specialistpatients in this study had SBOT prescribed not have been told how long the Telephone 0208 430 8255for over 12 months (often following an prescribed oxygen should be used. Email firstname.lastname@example.org) which had also led to some Often this results in an instruction frompsychological dependence over time. the engineer in the use of the oxygen according to what is recorded on theHowever, it is worthy of note that the HOOF (e.g. for two hours, or morningtime frame for this study has spanned an and evening regardless ofexcessively cold period resulting in high breathlessness). Hence it may not beincidents of acute exacerbations where the case that the patient has had anpatients genuinely needed their SBOT instruction to use it for 5-10 minutewhich was justified. bursts to relieve breathlessness (which is a commonly held assumption byThe following points have become clear clinicians). Further information in theduring the study: HOOF comments box needs to explain how the prescribed oxygen should be• Communication issues around administered discharge of complex patients who have oxygen requirements at home: Future work e.g. incorrect oxygen prescription on The plan for the next six months includes discharge which has lead to the following: readmissions• Patients discharged with no • Continue to look at new starters on information and no support regarding SBOT six weeks post exacerbation their oxygen therapy with a view to reassessment• Patients who are commenced on SBOT • Document the SBOT patient journey via for exacerbation need to be reviewed a process map to indicate the referral six weeks for assessment, education routes and possible gaps in the care and support with a view to removal of pathway oxygen (as it is clear that long term • Develop a questionnaire relating to SBOT encourages psychological access to oxygen data and circulate it dependence) to other members of the NHS• Whilst there is an assumption that Improvement - Lung - ‘Improving patients on SBOT have been given it Oxygen Services’ group so that an erroneously, this study has understanding of the difficulties demonstrated that in the majority of regarding access can be gained these cases this has not been the case• There needs to be clarity about the correct prescription of LTOT, given the complexity of removal of SBOT
Improvement stories 23Improving home oxygen servicesWest Hertfordshire COPD ServiceThe background to their service The project aims and objectives The process of improvement theyThe West Hertfordshire community Aims: undertook and overall approach tochronic obstructive pulmonary disease To reduce the amount of inappropriate address the issues(COPD) service is a service commissioned home oxygen prescribing and reduce the A project team was established andby NHS Hertfordshire and provided by cost of home oxygen within West project monitoring integrated withinBarnet Community Services. The service Hertfordshire. existing key performance indicatoris integrated across care settings and reporting to the Trust Director oforganisational boundaries and provides Objectives: Operations and PCT Commissioners.patients with home oxygen assessment • Identify where and who isand review, hospital-at-home, respiratory inappropriately prescribing home The clinical team continued to review onconsultant clinics and pulmonary oxygen to patients with normal oxygen a weekly basis all sources of new oxygenrehabilitation. levels prescribing and collaborated with the PCT • Review all patients commenced on home oxygen services lead in reviewingUpon the commencement of the service home oxygen within four weeks of monthly prescribing reports and quarterlythe West Hertfordshire team very commencing and alter oxygen supplier concordance data, ensuringpromptly began assessing new patients prescription to match patient needs in clinical oversight around the modalities offor oxygen therapy and reviewing most cost effective way oxygen received by patients.patients already in receipt of oxygen, • Target education at groups of cliniciansdocumenting changes to the home who are prescribing home oxygen Inappropriate prescribers were identifiedoxygen order forms (HOOFs) and inappropriately within both primary and secondary caremonitoring the associated changes in • Develop an educational package and and so the first phase of work centred onoxygen prescribing spend. competency assessment tool providing education sessions within • Produce proposal for the introduction target GP surgeries.NHS Hertfordshire supply the service with of a register of home oxygendetailed reports around activity and cost prescribers who have undergone The second phase of work currently inwhich are free of ‘ghost patients’ (e.g. training and competency assessment development is educational sessionspatients listed as in receipt of oxygen but with the aim of improving the quality targeted within the local Acute Hospitalare actually deceased) and clinicians have of prescribing and the teams have secured a place onaccess to a weekly list of new oxygen the teaching rota for new doctors andorders and the identity of the clinician educational sessions booked with higherinitiating the prescription. grade healthcare professionals - specialist registrars, foundation year one andAs at July 2010 the new service had foundation year two.reviewed 40% of the 800 patients inreceipt of oxygen therapy and The feedback and experienced gainedundertaken therapy modifications and from this work will inform thewhere clinically appropriate therapy development of an oxygen prescribingwithdrawal in a number of the reviewed educational pack and competencypatients. assessment.Having achieved these quick wins theservice sought acceptance from NHSImprovement - Lung in order to facilitatea shift in focus from cost savings to costavoidance.
24 Improvement stories Issues and challenges they faced with The West Hertfordshire Care Pathway potential solutions Data collection: Current service key Sp02 <92% on air performance indicators (KPIs) are in a or different format to the requirements of breathless on exertion thought to be NHS Improvement - Lung and therefore it due to oxygen desaturation has been a challenge to find time to transform the data from one format to another. Refer patient for home oxygen assessment in COPD clinic or at home • Arterial blood gases Solution: A local measures matrix was • 6 minute walking test discussed and agreed with the oxygen projects national improvement lead (NHS Improvement - Lung) and so appropriate data has been collected to demonstrate Patient requires Patient does not progress in respect of the specific project oxygen require oxygen aims and objectives. Secretarial support and a budget has HOOF completed If patient breathless Acute Hospital and GP been agreed and secured from the and faxed to BOC consider referral and PCT medicines prescribing, weekly to pulmonary rehab project team’s own organisation so data management list to community team or breathlessness can be put into a format suitable for administrator clinic or community project reporting. consultant clinic Potential/actual QIPP and cost savings Reassess 02 requirements /avoidance – defined as quality, and alter HOOF if indicated Patient followed up innovation, productivity and at home within Identify HCP who prevention four weeks of Patient education and advice on safety and coping with 02 are prescribing Cost savings have been achieved from commencing home inappropriately and oxygen by when the project commenced, with the target education community COPD Monitor patient and monthly spend on oxygen prescribing sessions to team feedback to GP improve prescribing showing a consistent decline. The October 2010 spend represented a 12% Provide patient with contact reduction on the monthly spend in April number for clinical support 2010. Patient registered on clinical home oxygen database Adult home oxygen service (HoXAM) and COPD database Monitors patient and provide Community feedback to GP respiratory nurse follows patient up Reassess 02 requirements and at 6 and 12 months alter HOOF if indicated in first year then 6 monthly COPD review and develop self-management plan
Improvement stories 25 Key learning West Hertfordshire prescribing spend Model of care: An integrated model of care prevents duplication and is a cost 2 effective solution to managing the home 0 oxygen service. The assessment and Apr 10 May 10 Jun 10 Jul 10 Aug 10 Sep 10 Oct 10 follow-up of patients on home oxygen -2 can be undertaken by a nurse led service Percentage change provided there is integration with -4 respiratory physicians so that prompt -6 review when indicated can take place. -8 Workforce competences: The analysis -10 of the sources of oxygen prescribing and subsequent educational sessions have -12 revealed that home oxygen is often -14 prescribed by junior medical staff who have insufficient knowledge of best -16 practice guidelines. Month Data coordination: The data provided by the suppliers is not deemed user- friendly and there also appears to be aThis has been accompanied by a reducing trend in the actual numbers of reluctance on the part of the oxygenpatients on home oxygen. supplier to directly provide service clinicians with the data even when the PCT agree that this is appropriate. Number of patients on home oxygen in West Hertfordshire The project team feel that a home oxygen 900 database (such as the proprietary HOxAM 890 system) is necessary for service 880 professionals to efficiently monitor the large numbers of oxygen patients who Number of patients 870 require follow-up. 860 850 Project lead contact details for further information 840 Glenda Esmond 830 Respiratory Nurse Consultant Telephone 07908 846033 820 Email: email@example.com 810 800 Apr 10 May 10 Jun 10 Jul 10 Aug 10 Sep 10 Oct 10 Month
26 Improvement storiesHome oxygen service improvement projectNHS SheffieldThe background to their serviceNHS Sheffield as part of their AchievingBalance Health Strategy (2010) identifiedthat they had the highest projectedforecast spend on home oxygen therapywithin the region.There was no local requirement forpatients to have an oxygen assessment inadvance of therapy being ordered/prescribed and patient’s ongoing needfor oxygen therapy was not alwaysreviewed.The project aims and objectivesAim: By July 2012, all NHS Sheffieldchronic obstructive pulmonary disease(COPD) patients newly prescribed homeoxygen have had an initial quality assuredassessment and all COPD patients withhome oxygen are systematically reviewedin line with British Thoracic Society/NICEguidelines resulting in the correct therapy The team carefully studied the • Patients not receiving a formal(home oxygen order forms (HOOFs) and concordance report data and monthly assessment and or not undergoingequipment) leading to improvement in invoices to understand the scope and regular review or risk assessmentpatient quality of life, increased activities scale of the issues. They were then able • Changes in clinical need not beingof daily living as well as increased life to break this down to GP in order to communicated to the supplierexpectancy, reduced unscheduled analyse ordering or prescribing at a local • Holiday home oxygen order formadmissions and robust oxygen cost level. (HOOF) not being cancelledcontrol. • Inefficient time of removal follow death This enabled oxygen under/over usage to • No locally commissioned servicesThe process of improvement they be identified together with non-usage • No designated home oxygen therapyundertook and overall approach to and anomalies in the oxygen modalities manageraddress the issues assigned to individual patients. • No robust systems, process or pathway,A project team was established including fire risk assessment(comprising clinicians, medicine An initial process mapping workshop wasmanagement technician and managers undertaken to understand the sources of Some initial demand modelling has beenfrom both primary and secondary care) oxygen prescribing, the basic patient undertaken and this has been coupledand the NHS Improvement - Lung work journey and service gaps. with some analysis of the costs ofintegrated within Sheffield’s Achieving different parts of the pathway.Balanced Health Strategy initiative. Initial scoping work identified areas of potential efficiency improvement within This work together with information fromThe project manager, medicine home oxygen provision: the Department of Health Good Practicemanagement technician, and specialist Guide has been used to inform a businessnurses were assigned to the project and • Oxygen being supplied when not case and draft a new service specification.together undertook a detailed analysis of requiredthe home oxygen register and HOOFs.
Improvement stories 27Issues and challenges they faced with This approach is known to have a marked addition oxygen devices were removedpotential solutions impact on quality adjusted life years and from patients’ homes where it wasInitially the project experienced some life expectancy. established they were no longer needed.challenges gaining access to some of thedata needed to record baseline measures. The proposal will enable a greater This has resulted in a saving of £10k per proportion of assessments to be carried month, with a forecast saving of £120kProtracted telephone and email contact out in the community. This will avoid per year and subsequent years.with the oxygen supplier was required in potentially high cost associated withorder to assure the supplier that project respiratory outpatient tariffs. Key learningteam members (who were not the Cross functional working has enabled theoriginally designated PCT home oxygen Draft outline of new model project to move more quickly and takeservice lead) were legitimately entitled Level 1 (Community): the pressure off core team membersto access. • Pulse oximetry at a GP practice level for because others are working on behalf of the timely identification of hypoxia the project.Persistent and on-going liaison with the • District nurses – ongoing assessmentoxygen supplier has resulted in better for at risk groups An example of this is the additional helpdata access. sought from the internal audit team in Level 2 (Community): order to undertake an in-depth analysisCommissioning considerations (where • Short bust oxygen therapy (SBOT) for to help support our initial findings. Thisappropriate) the assessment and removal of SBOT is supported by our finance andThe multidisciplinary project team have • Ambulatory (AB) for assessment, performance directorate.worked together and along side the provision and ongoing monitoringDepartment of Health Good Practice • Assessment for long term oxygen therapy Early on in reviewing the data,Guide, Home Oxygen Services – anomolies were seen which needed toAssessment and Review (HOS-AR) have Level 3 (Secondary care team input be understood and assessed in relationdeveloped a successful business case to with community based follow-up): tto see if they were system, processgo forward to commission a HOS-AR in • LTOT assessment of complex patients. errors or adverse occurrences.Sheffield The team are setting in place internal By approaching the fraud team the styleThis will be a long term conditions measures to help mitigate risk (for of data required has been specificallyHOS- AR and will integrate with other example financial and oxygen patient requested so that it is easy to read andcare pathways such as cardiology, register management systems) and have meaningful to the end user.palliative care, neurology. It will link with devolved responsibility, for registerand complement part of a COPD Quality, management and referral for fire risk This has enabled the team to helpInnovation, Productivity and Prevention assessment to the practice based shape change and to very quickly gain(QIPP) redesign which is currently consortium and local GP practices. organisational support, setting the bartargeted at those patients with mild and high for the vision of improved oxygenmoderate disease. Workforce considerations services. Staff shortages in the wider team (2WTE)The oxygen service business case are making resources limited. This is motivational to the core projectoutlined the de-commissioning and team as improvements that have beenre-commissioning of a new integrated Potential/actual QIPP and cost savings set in place have now been realised.evidence based quality led HOS-AR /avoidance – defined as quality,service that promotes efficiencies and innovation, productivity and Project lead contact details foreffectiveness and will serve the other end prevention further informationof the continuum for adult patients with Through improved data management and Sue Thackraysevere and very serve COPD across the data cleansing a number of patients were Respiratory Project Leadprimary secondary care interface. identified who upon consultation were Telephone: 07773790915 able to have therapy modified and in Email: firstname.lastname@example.org
28 Improvement storiesHome oxygen service improvement projectNHS Hull and the City Health Care PartnershipThe background to their serviceHistorically, NHS Hull did not have astructured or funded oxygen assessmentand follow up service, with patients’predominantly prescribed long-term,ambulatory and short burst oxygen ondischarge from hospital without formalassessments and structured follow upreview.In addition, GPs issued oxygen therapy topatients on a ‘want’ rather than needbasis usually for breathlessness withoutany form of assessment.From April 2010, following a tenderingprocurement process, NHS Hullcommissioned a new home oxygenassessment and follow up service. This is Picture features Home Oxygen Clinical Team only - the full project group compriseda new service for the city; the provider PCT commissioners, smoking cessation, patients, oxygen supplier and the Fire Brigadesuccessful in the procurement processwas City Health Care Partnership. • Risk assess patients/carers prior to and The project team work was integratedHull had approximately 800 patients in during their use of oxygen therapy within wider COPD pathway servicereceipt of oxygen therapy at the • Work with the local fire brigade to development work being undertaken bybeginning of April 2010. The new service produce and develop a workable local the PCT.had a total of 260 patients referred into policy on smoking and oxygenthe service within the first three months provision Data metrics were agreed by the projectof being operational. • Educate patients on health and safety team and data collection processes issues surrounding smoking and oxygen established and information provisionThe project aims and objectives therapy responsibilities assigned.To contribute to a reduction in • Develop a written (signed) contractunscheduled hospital admissions and between patient and health care Invoices from the oxygen supplier (Airoptimise chronic obstructive pulmonary professional (HCP) with clauses to Products) are received by NHS Hull homedisease (COPD) patient care through the remove provision on grounds of health oxygen services lead within thedelivery of appropriate and cost-effective and safety or no clinical need/benefit commissioning department and the homeoxygen therapy to COPD patients oxygen service (HOS) also has access toidentified as being in clinical need The process of improvement they these and the concordance reports. Thedetermined through assessment by undertook and overall approach to Service checks against the Open Exetertrained healthcare professionals. address the issues home oxygen order form (HOOF) Following acceptance from NHS database and reviewed by the specialistSpecific objectives: Improvement - Lung in June 2010, a nurses who also review flow and• Remove inappropriate oxygen multidisciplinary project team was formed provisions rates). provision, ensuring correct equipment with experienced respiratory nurses, and therapy is delivered to new and smoking cessation specialists, The administration team within the existing patients on oxygen commissioners, oxygen providers, a service also data cleanse the invoices and• Reduce unnecessary costs of oxygen patient, and the fire brigade report back to the oxygen provider with and equipment errors and updates as necessary.
Improvement stories 29 Patients on ambulatory oxygen areThe service pathway recalled for an ambulatory assessment and the project has made cost savings Hull GP/Consultant or any health Review of current Community, respiratory, through this recall mechanism. care professional referral SBOT/ambulatory physiotherapist and The team analysed the long term oxygen oxygen patients pulmonary rehabilitation All patients initiated on LTOT who therapy (LTOT) patient data provided by are discharged from hospital (apart the supplier giving particular regard to: from palliative care patients) Review of disease management/need for oxygen • Multiple therapy combinations • Duplicate charging Oxygen assessment indicated Oxygen assessment • Deceased patients NB Patients will be not indicated • Out-of-area patient charges seen 5 weeks post discharge when • Under/over usage clinically stable if Patient known to oxygen team Patient education recovering from provided Since July 2010, a total of 428 patients an infection/ exacerbation have been assessed or reviewed by the Patient not known service with new therapy being initiated to oxygen team and appropriate changes to existing therapy made in terms of duration and/or Appointment for home Clinic Communication with referrer flow rate alterations, device changes and oxygen assessment appointment • Assessment results in some instances therapy withdrawal • Advice on follow up arrangements (when deemed of no clinical benefit). Assessment undertaken The team takes a proactive approach to managing the ongoing safety risks to patients in receipt of oxygen (or who Oxygen required No oxygen required pose a risk to others) due to potential fire hazards. Patient education provided A local risk assessment pro-forma is completed by the clinical team at every review and which has strong links with Communication with referrer HOOF/HOCF docs completed • Assessment/review results both the local oxygen provider and the • Advice on folllow up arrangements Fire Brigade, enabling issues and concerns to be highlighted and addressed. Follow up appointments made: Mechanisms for involving patients (and CBG clinic/home at month carers) in their risk assessment have been 1, 3, 6, then annually developed and the dangers of smoking (Spirometry, CBGs, clinical assessment, risk assessment, with oxygen are discussed. education) The team aim to undertake 40 risk assessments per month and the multi- stakeholder team have drafted a local policy on smoking and removal of oxygen provision.
30 Improvement storiesIssues and challenges they faced with The performance and delivery of the The total number of oxygen users in Hullpotential solutions service is monitored via these indicators is 763, at this current time, whichStakeholder agreement: bringing wider on a monthly basis. The commissioner includes palliation patients who are not instakeholders on board in respect of the and provider meet regularly to go the current service caseload, over half‘Smoking and Removal Policy’ has proved through this data and discuss service coming in to the service already.challenging and resulted in delayed policy delivery. The service was initiallydevelopment and continued risk of commissioned for two years, based on Key learningpossible incidents with patients. the data and patient outcomes reported Data can be utilised effectively to provide the commissioning organisation will look required analysis; at first it seemsThe team is attempting to address this by to extend this contract. Due to the impossible but with specialisedbringing all stakeholders together and changes in the way services will be performance analysts on board this canproviding evidence around health and commissioned in the future, the GP be done.safety, information on incidents occurred Consortia will need to be involved in thisand monitoring the clinical impact of process and future developments. Launching a new service in parallel withtherapy removal. undertaking a process improvement Workforce considerations project is very challenging - in hindsight itHealthcare professional compliance: Discussions have taken place with the may have been better to allow the serviceNot all local healthcare professionals are provider in terms of how they expand to develop then seek improvements.currently delivering care in line with their respiratory workforce. They However, the opportunity to take part infuture local policy, resulting in currently employ two specialist respiratory a national programme was a biginconsistent messages to patients, safety nurses and two oxygen nurses, as the incentive.risks and incidents. service expands they will be considering the options of having respiratory expertise Collaboration with NHS Improvement -The team are addressing through across their long term conditions service Lung has provided:education sessions developed (for all and training other staff in terms of • Greater clarity, structure and focus viahealthcare professions groups) around respiratory. project planningthe new policy and how it should be • Motivational interaction with peersimplemented into their working practice. Potential/actual QIPP and cost savings • Support for reviewing areas of /avoidance – defined as quality, weakness and development ofPatient refusal/anxiety regarding innovation, productivity and • The expansion of the future work planremoval of therapy: Strategies being prevention to include demand and capacityadopted to address this include educating Since July 2010, 428 patients have been analysis and the development of apatients via information leaflets, DVD, assessed or reviewed, prior to assessment prescribing costs ‘dashboard’verbally about the dangers and referring these patients had a combination of 601smokers to smoking cessation services. oxygen therapies in place. N.B. Please note that in respect of data and finance this report is as atProject team capacity: Pressures from After the assessments the combination of 15 December 2010.existing work are being offset through therapies was reduced to 433 and thereongoing development of a Project were 145 removals and 44 decreases in Project lead contact details forDelivery Plan with specified activities, oxygen flow rate. This has reduced the further informationtimescales and team member monthly invoice by £11,378. Toni Yelresponsibilities. Commissioning Development Manager In addition, 24 patients on oxygen have Tel: 01482 344772Commissioning considerations stopped smoking, due to COPD smoking Email: email@example.com,The service forms part of a community cessation specialists, and the home firstname.lastname@example.org with a service specification and oxygen service now have 404 patients onperformance indicators in place. their caseload and in the cycle of review.
Improvement stories 31NHS Gloucestershire home oxygen assessmentservice implementationNHS GloucestershireThe background to their service The process of improvement they Issues and challenges they facedThe existing respiratory service provider undertook and overall approach to with potential solutionsfunction is spread over a very large address the issues Participation with NHS Improvement -geography with a varying and diverse The project lead undertook a review of Lung has provided the opportunity tosocio-demographic. There is no formally service specifications for established discuss our locally proposed service planscommissioned community-based oxygen Home Oxygen Assessment and Review with more established teams. Throughassessment service; the only assessments teams by visiting a number of project the course of these discussions, it hasavailable being for a limited number of team sites. In addition, intelligence become evident that the original sumspecialist conditions and children all gathering on service costs, workforce identified and budgeted to fund the costwithin the acute hospital setting. arrangements and infra-structure was of the development does not in fact cover undertaken from a number of sources the true costs of the service as specifiedPrior to the commencement of the including the Department of Health Good and therefore does not support theproject there were approximately 1,000 Practice Guide10. business case and progression to openpatients on oxygen therapy who required tender.review and 150 new patients per year Work was undertaken to betterbeing referred for initial hospital (clinic- understand the current patient profile The findings have been presented tobased) oxygen assessment. and prescribing costs; this was achieved members of the NHS Gloucestershire by a detailed analysis of the concordance Executive and it has been decided thatThere are currently around 860 patients reports and monthly invoice data. small short-life working group will bereceiving home oxygen in established to focus on the top 10% ofGloucestershire, however the oxygen A process of obtaining ‘sign-off’ of a patients identified on the concordancesupplier data indicates that there are previous (2009) business case was report as not using their prescribedmore than a quarter of these patients undertaken with new (additional) costs oxygen.who are using none or very little of their identified through the project workprescribed oxygen. integrated within the proposal. The work of this group will utilise a plan- do-study-act cycle in order to monitor theThe project aims and objectives A service specification was drafted and reduction in oxygen usage with thisTo commission a high quality home then reviewed by the respiratory steering sample of patients.oxygen assessment service for patients in group. This was presented then to theGloucestershire Quality, Innovation, Productivity and The evidence collected will then be used Prevention (QIPP) management board, a to amend the original business case toSpecific objectives forum set up to assess, evaluate and reflect the success of the pilot project.• Produce a service specification which scrutinise all service development The ongoing challenges to this project details the expectations of the proposals that required pump-priming continue to be financial and the present commissioners with robust quality and/or recurrent funding. changing organisational situation. outcome and activity performance indicators In parallel to this work the PCT• Implement a service which enables all procurement team began the initial work new and existing patients on Home on proceeding with a tender process as it Oxygen Therapy to be appropriately was envisaged that the new service assessed, reviewed and monitored would be open to any willing provider.• Undertake a rationalisation of current prescriptions for oxygen in order to reduce unnecessary spend on oxygen within the county
32 Improvement storiesCommissioning considerations Although we have fairly robust numerical• The application of service improvement data from the concordance reports it will tools such as multi-stakeholder process be a challenge to identify the patients mapping must proceed carefully in a from this data and there will be a reliance health economy which may be on paper records and GP surgery considering putting out future services information to identify individuals. to tender• It is important that in seeking to However, once identified it is anticipated understand the existing oxygen patient that this cohort will be already be known journey (and uncover existing ‘hidden’ to the respiratory team both in primary oxygen services) the process of and secondary care. identifying areas of improvement does not in any way compromise a future Key learning tender process Although it may appear that NHS• It is evident that having worked Gloucestershire has not made rapid through the development a full progress during the first six months of business case, the full finance to this project, we do however have a much support the project service specification clearer understanding of the data that we is identified and earmarked early on, have and also the financial implications of otherwise a protracted tender process oxygen usage within the community. We might result no suitable bidders for the also have a clear understanding of the service potential impact to patients and services• The tendering process also takes a if we continue to do nothing to improve considerable amount of time e.g. a the service. minimum of five months and therefore it is unlikely that potential benefits Project lead contact details for from the service are not realised before further information the end of the project term Sandra Major Clinical Development ManagerPotential/actual QIPP and cost savings Tel. 08454 221434/ avoidance – defined as quality, Email: email@example.com, productivity andpreventionFollowing data analysis from both thePCT information team and the senioranalyst from NHS Improvement - Lung,we were able to demonstrate thepotential savings to the PCT would be inthe region of £250K. However, we doneed to confirm that these savings arematerial and could be achieved anddelivered.
Improvement stories 33Sustaining the efficiency and effectiveness of theMilton Keynes Home Oxygen Service - Assessmentand Review (HOS-AR)Milton Keynes PCT Community Services and Milton Keynes HospitalThe background to their serviceA PCT sponsored pilot project conductedin 2008, highlighted health inequalitiesand variation in usage of oxygen forpatients on home oxygen.Patient experience varied depending onwho prescribed their oxygen, with a two-tier oxygen service in existence and littleintegration of primary and secondary careacross the oxygen pathway.These clinical issues combined withserious financial control issues whichmeant that the PCT had highest cost perpatient within the SHA.In January 2009, a chronic obstructivepulmonary disease (COPD) co-ordinatorand an administrator were appointed(through using a ‘spend-to-save’ initiative)to support the redesign of the homeoxygen therapy pathway through servicemapping and process audit. In order to sustain and enhance the The process of improvement they benefits of this improved service, and to undertook and overall approach toProtocols were jointly developed with address outstanding areas for address the issuesclinical teams and the implementation improvement (most notably patient recallmonitored by the COPD administrator. mechanisms for long term oxygen Objective 1: therapy (LTOT) review and ambulatory Enhancement of existing care pathwayThe resulting service significantly oxygen assessment), the multidisciplinary for the HOS-AR service.transformed the care of patients on home team applied to take part with NHSoxygen within Milton Keynes, with newly Improvement - Lung and were accepted An initial process mapping exercise wasinitiated respiratory oxygen patients first on to the programme in the summer of carried out by the project lead by talkingsubject to a formal assessment and within 2010. to key personnel in the servicedramatically improved financial control. (consultant, admin, respiratory team) inPalliative care, cluster headache and The project aims and objectives order to understand the following.paediatric patients were not included in • Enhancement of existing care pathwaythis protocol but were supported and by the production of a (service) • New appointments lead timemonitored by the home oxygen service adoption ladder (approximately three weeks atteam. • Improve ambulatory oxygen January 2011) assessment by carrying out a pre and • The reasons why patients were not post of clinic set up evaluation for the being recalled for review (initial findings ambulatory oxygen assessment clinic indicate a demand and capacity • Development of quality patient mismatch combined with a problem on questionnaire pre and post use of hospital discharge a patient patient information leaflet to see if appointment requested but no follow patient experience improves up appointment made)
34 Improvement stories PCT protocol for primary and secondary care patients
Improvement stories 35• The clinical profile of patients who appear on monthly invoices but are not Ambulatory Oxygen Audit currently part of the specialist team (Data from Oxygen Concordance Report Jul-Oct 2010) caseload (ensuring assessment if appropriate) Total patient accounts analysed = 354 Total patients on AOX = 243From the findings, a business case is Total patients had AOA/walk tests = 50being prepared to improve patient follow Total RIP (on AOX) = 33up in the community by funding a Total paediatric (on AOX) = 9community matron for one day a week to Total patients cancelled = 6perform follow up home visits in line with Patients not had walk test = 145British Thoracic Society guidance. Thematron will also carry out a follow upassessment by Sp02 or CBG (CapillaryBlood Gas) depending on the initial Sp02 From these results further work will be The questionnaire was reviewed by (andoutcome. carried out to review the 145 patients gained approval from) the hospital clinical identified as not having a walk governance team. Use of theIn addition, close working with the test/ambulatory oxygen assessment questionnaire started in January-Marchrespiratory team, community matrons, (AOA). This will be carried out by the 2011, followed by (parallel) use of theNHS Improvement - Lung and regional HOS-AR lead as some patients may have patient information leaflet in order toleads is being maintained and work on had tests at other hospitals and this will compare outcomes and undertake a plan-the final adoption ladder (a model which be documented in the original audit do-study-act cycle of processwill allow any similar health economy to from 2009. improvement.rapidly implement specific changes toimprove their local oxygen services) is Objective 3: Issues and challenges they faced withplanned to commence in April 2011. Development of quality patient potential solutions information questionnaire.Objective 2: • Staffing issues – see workforceImprove ambulatory oxygen assessments This is for use pre and post introduction considerations(AOA) by carrying out a pre and post of a patient leaflet to assess if the patient • Lack of funding – project leadership hasreview evaluation of clinic set up and experience improves with the use of the been resourced from a previous (nonpatients. leaflet and if there is any other way of recurrent) PCT initiative and so improving patient experience. uncertainty has arisen in respect ofA clinic was started in October 2010 to project completion. The team arerun alongside the home oxygen service - A meeting with the project team and the trying to leverage the work to date inassessment and review (HOS-AR) clinic. NHS Improvement - Lung oxygen projects order to influence local decision-makersEvaluation of patients on AOA is national improvement lead to discuss a about the added value of the workundertaken by physiologist initial baseline possible questionnaire and its content continuinganalysis has been carried out with the occurred in September 2010. • Rapidly changing NHS landscape – it isfollowing results. currently unclear whether existing PCT Workload demands meant that project support structures will be substantive work on the questionnaire preserved within the new system commenced in November, with the team architecture incorporating the long term conditions (LTC) six questionnaire alongside 11 locally devised questions specifically around patient experience in the HOS-AR clinic.
36 Improvement storiesIn addition, the impact on the respiratoryteam and the HOS-AR service of a Variance in 2010/11 prescribing spendpotential merger of local hospital and 4community services is unknown at thispoint. 2The project team is proactively seeking to 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Febboth highlight the importance of this Percentage variance -2work (and thus raise the project’s profile)among the emerging GP commissioning -4consortia in order to ensure sustainability. -6Commissioning considerationsCommissioning will be approached to -8approve the extended HOS-AR service -10business case, which will be focusedaround QIPP rather than primarily cost -12savings which the previous spend to saveproject was based on. -14 MonthWorkforce considerationsCurrent project leadership (obtainedthrough fixed term contract workingassociated with previous PCT strategic Further savings through inappropriate the proprietary HoXAM database may beinitiatives) has reduced to 0.6 WTE and therapy withdrawal are less frequent as another for services setting up a newthis may be further impacted by the patient numbers have stabilised and the HOS-AR service. Further evaluation ofadditional workload required to project service undertakes the slow ongoing the utility of local, national andmanage the oxygen contract work of assessing the last few patients proprietary oxygen data collectionre-procurement process. who have repeatedly missed their home systems would be of value. oxygen appointments.Confirmation of continued funding has Contract control: This is central to thebeen agreed for the coordinator for this Key learning control of prescribing spend used toPCT (0.2WTE and the administrator Project planning: This has been a new generate cost savings that can go0.4WTE) the coordinator is also due to experience for all members of this multi- towards funding a HOS-AR service. Aofficially start as regional home oxygen disciplinary team as none of the project review of short burst oxygen therapyproject lead for the re-procurement of group had been involved in this type of patients in January has predicted a £6khome oxygen for the South East region systematic process improvement project cost saving and a further saving of £13kfrom April 2011. before. in AMB oxygen prescribing by reducing non users down to <1 hour a day beforePotential/actual QIPP and cost savings Having a clear project plan is the key to they are reviewed by the ambulatory/avoidance – defined as quality, success and this could have been more assessment service.innovation, productivity and robustly developed at the outset.prevention Project lead contact details forThe tight cost regimen established in Data coordination: Use of a HOS-AR further information2009 is still adhered to. However, the database is important to control what is Sue Channonproductivity gains seen from the initial happening with patients. The team COPD Co-ordinatorquick wins achieved have reduced as the currently use a locally developed Telephone 01908 650402,2010 monthly expenditure has stabilised. Microsoft Access database but use of Email: firstname.lastname@example.org
Improvement stories 37Improving the prescribing of oxygenacross NHS BlackpoolNHS BlackpoolThe background to the serviceThe PCT had a high proportion ofpatients using oxygen, 0.22% ofweighted population on oxygencompared with 0.18% regionally, withassociated higher (than the regionalaverage) prescribing costs.A preliminary audit undertaken incollaboration with secondary care in 2009revealed that only 30% of patients onhome oxygen had been assessed orreviewed by a clinical specialist.This identified the risk that patients maybe receiving oxygen inappropriatelyresulting in adverse clinical outcomes ifprescribed not matching the patient’sclinical needs or patient in receipt ofunnecessary oxygen.Undertaking a review of the servicethrough the work of NHS Improvement -Lung, provided the opportunity to The process of improvement they A paper data collection system wasimprove patient outcomes and increase undertook and overall approach to developed in advance of the homeefficiency. address the issues oxygen service (HOS) being established A project team was established, within a community setting.The project aims and objectives comprising of staff from the NHS• Develop an accurate oxygen register Blackpool and Blackpool Wyre & Fylde Project members visited the regional• Identify number of patients receiving Hospital, and with facilitation from NHS oxygen data clearing house (LaSCA) in oxygen who do not meet the guideline Improvement - Lung. The current oxygen order to understand the process and to criteria patient journey was process mapped in ensure data cleansing of the Blackpool• Identify the number of patients who order to identify gaps in the service and oxygen register and on-going monitoring have their oxygen therapy changed or potential risks. arrangements. discontinued• Conduct urgent review of individuals Clinical engagement and commitment to A referral pathway into the oxygen receiving high/low dose oxygen to the project was achieved through a assessment clinics was developed and ensure clinical risks are managed multidisciplinary team of stakeholders. work has begun on developing a data• Develop a structured assessment/follow Respiratory specialists from the acute collection system to capture patient up service which meets National service, practice based commissioning, numbe /type/oxygen and cost in terms Institute for Health and Clinical primary care and community clinicians of increase/decrease. Excellence (NICE) guidance and also included patient representation• Increase the proportion of patients and feedback. This information will be completed by the receiving a structured assessment from acute hospital HOS team and will be the current level (30%) to (80%) within stored on the PCT system for evaluation time frame of project pilot and reporting analysis.
38 Improvement storiesSelf-care plans and patient informationleaflets for long term oxygen therapy andambulatory oxygen have also beendeveloped.The clinicians within the oxygenassessment service are now more clinicallyinformed as they have access to OpenExeter which allows up-to date history ofindividual home oxygen order forms(HOOFs).Issues and challenges they faced withpotential solutionsIn the current climate attractingadditional resources to pump-primeservice developments is difficult so morework on demand and capacity is required.The project will need to provide evidence Initial invitations to attend this clinic Commissioning considerationsof improved cost effectiveness which can resulted in a large number of patients (where appropriate)be demonstrated through the bespoke who did not attend so the team • Developing a business caseoxygen prescribing (and service) data undertook phoning individual patients in • Developing a service specificationcollection system. order to give more information about the • Inclusion in commissioning intensions service and benefits of attending (75 for the acute contractIt has proved difficult changing culture patients have gone through assessmentand behaviour patterns within primary but as at time of writing we still have Workforce considerationscare healthcare professionals and also three weeks of data to calculate in order (where appropriate)with patients. However ongoing to confirm final numbers). The potential loss of key members of staffeducational opportunities to publicise the that are highly trained in their area ofevidence around the need for formal Key learning expertise poses a risk and so there is aassessment and review should address • The importance of developing an need to ensure other team membersthis and the project team are also integrated bespoke data collection work alongside them in order to up-skilldeveloping primary care clinical system that links to supplier data base through clinical supervision.champions and using them to guide and and will calculate ongoing cost changessupport others. • Developing a shared oxygen register Potential/actual QIPP and cost savings between the oxygen assessment clinic, /avoidance – defined as quality,The testing they did and key suppliers and LaSCA on a monthly innovation, productivity andlearning to date basis, that is up dated and linked with preventionTesting: In order to address capacity primary care on a quarterly basis in Initial analysis have led to monthly costissues an additional oxygen assessment order to ratify and data cleanse saving estimates of between £3,000 toclinic was piloted within a community • The importance of engagement with all £4,000 compared with previous monthlysetting. This increased the current service stakeholders including practice based spending patterns before the projectcapacity by an additional 17 patients per commissioning (PBC) as a potential work started.week and over 60 previously un-assessed forerunner of the GP Consortia.patients were invited to attend. Meetings that have focused on holistic Project lead contact details for patient care to reduce NELs for COPD further information have facilitated this process Ros Ince Lead Nurse Diabetes and Respiratory Telephone: 01253 651316 Email: email@example.com
Improvement stories 39Wirral integrated oxygen serviceWirral University Hospital NHS Foundation Trust and NHS WirralBackground to the serviceThe Wirral integrated service whichincorporates a non-acute chronicobstructive pulmonary disease (COPD)and pulmonary rehabilitation service, wasestablished in October 2009 following along consultation and negotiation processbetween primary and secondary care.The acute trust was commissioned byNHS Wirral to provide a comprehensiveassessment and review service forpotential and existing oxygen patients.Prior to the service, outpatient oxygenassessments were undertaken on anadhoc basis by the nurse consultant inthe secondary care chest clinic and followup was lacking in structure. There was nodatabase of patient assessment.Oxygen invoices were managed initiallyby the Wirral medicines managementteam (MMT) and later by the Cheshire Project aims and objectives • Unnecessary oxygen prescribing shouldHealth Agency. Concordance lists were Mission statement: By the end of July be eliminatedreviewed by the MMT but there were no 2011, all existing adult patients on Wirral • An on going education programme forresources to reconcile or manage oxygen prescribed oxygen will have had a health professionals about thelists. structured assessment. New patients will indications, prescribing and use of be formally assessed before oxygen is oxygen will be establishedSince becoming andr NHS Improvement - prescribed and all patients will have aLung pilot site, the Wirral Oxygen Service scheduled review programme. Patients Issue, challenges and solutionsestablished referral processes, who are prescribed oxygen will have the As an established service much of thedocumentation, oxygen patient lists and most clinically and cost effective groundwork had already been done ina database for recall and review. treatment. terms of setting up the service, developing referral and review processesThe oxygen lists were reconciled and Specific objectives: and documentation.obvious ‘quick wins’ were made by • All adult patients in Wirral should haveimproving data management. Clinics for a structured assessment prior to Oxygen patient data had been ‘cleaned’oxygen assessments were established and commencing home oxygen in line with and the obvious ‘quick wins’ in terms ofthe process of contacting existing national guidance. This excludes discontinuing inappropriately prescribedpatients began. patients for whom oxygen is palliative or no longer needed oxygen had been for terminal illness achieved. • Oxygen will only be prescribed if clinically indicated Since joining the NHS Improvement - • All adult patients on oxygen should be Lung project we have undertaken a reviewed at least every six months to review of our operational processes and ensure their prescriptions remains altered documentation. appropriate for their needs
40 Improvement storiesThe main aim of this was to record and A comprehensive risk assessment and Potential and actual QIPP and costreduce variance in assessment. escalation process for each patient on savings/avoidance oxygen has been developed and is The data collected shows a reduction inData collection and metrics have been awaiting approval by the PCT. overall oxygen use and a cost reductionvery challenging and obstacles still remain of £5k-£7k per month since the servicein providing the required data needed for Next phase challenges began in October 2009. In addition,NHS Improvement - Lung. Further ways As the team have now achieved most of following formal assessment, 80 patientsare being developed for recording and the quick wins, there is a need to have not proceeded to oxygen treatmentretrieving relevant data in a way that is continue to find ways of achieving further leading to further significant cost savings.effective and efficient. cost reduction or at least maintaining what has been achieved. This will be The number of non-specialist, non-The team have employed a dedicated non done by continuing to educate and palliative oxygen prescriptions eachclinical oxygen coordinator with promote the benefits of accurate month is reducing significantly. This isresponsibility for data collection and assessment and working closely with largely as a result of promoting themanaging the ‘oxygen list’. primary care. service at every opportunity through educational events and one to oneThe team have negotiated a pathway for Concordance data is being used to meetings at GP practices.referral for heart failure patients with the challenge under or non-users ofcardiac network group. prescribed oxygen and we are starting a The team have now completed an review clinic in two key GP practices assessment and review of 80% of allThis aims to ensure that prior to referral where this is a particular issue. It is hoped existing patients on oxygen. Remainingfor oxygen assessment, treatment will be that this approach will lead to joined up patient assessment will be completed byoptimised according to guidelines and working with GPs, help them to April 2011.existing heart failure patients on oxygen understand the issues better and provideand labelled as palliative for more than a template for how best to tackle patients The team are now collecting data onone year will be reviewed by a heart who are not using oxygen but refuse to potential cost savings made fromfailure nurse. have it discontinued. changing charge bands.A review of the pathway for oxygen with The service is now facing challenges from It is likely that costs will either level out orpatients who suffer from cluster patients who are on oxygen without any even rise in the next few years. Howeverheadaches is being developed with the clinical indication. The aim is to withdraw provided there is continuing support forregional tertiary care centre. This aims to oxygen without losing the trust of the oxygen service and dataensure that patients with cluster patients and GPs and inadvertently management, costs will be as a result ofheadaches who require a trial of oxygen increasing admissions or use of other better management and assessment.therapy have the most clinically and cost health services. We are starting to collecteffective option and receive regular data on patients who have had oxygenreview to ensure it meets their need. withdrawn to measure the effect.Ineffective treatment will be subsequentlystopped.
Improvement stories 41Data collection Adult patients on oxygen 1000 72 900 800 700 600 500 400 643 300 200 100 0 Baseline June 10 July 10 Aug 10 ``Sept 10 Oct 10 Nov 10 Dec 10 (Sept 09) Patients not yet reviewed Total patients on 02 SBOT LTOT Patients reviewed Cumulative savings 45000 40000 35000 Cumulative savings 30000 25000 20000 15000 10000 5000 0 Baseline June 10 July 10 Aug 10 ``Sept 10 Oct 10 Nov 10 Dec 10 (Sept 09) Specialist Palliative LTOT SBOT AOT Patients discontinued after review Dec 10 Nov 10 Oct 10 Sep 10 Aug 10 Jul 10 Jun 10 Baseline Sep 09 0 5 10 15 20 25 30 Number of patients Patients discontinued after review
42 Improvement storiesEmerging workstream principles Questions Unsatisfied/very Neutral Satisfied/very• Get the database right to avoid duplication of data collection COPD/02 staff checked 11 (5.8%) 12 (6.4%) 145 (77%)• Decide and agree metrics at the start so everything about my respiratory data collection is relevant problems at the start• Identify a dedicated data and/or oxygen coordinator to support clinical work I feel better in myself and I 11 (6%) 27 (14.4%) 130 (69.2%)• The process of review cannot be manage my condition since undertaken as a paper exercise starting with oxygen service• Patients sometimes suspect an ulterior motive to the reassessment process and The respiratory team provided 13 (8%) 12 (6.4%) 147 (78%) believe it is more about saving money me with all the information I that providing a quality service wanted to know about my• Engage with GPs about their patients condition from the start to get support with decision making I felt I was treated with dignity 9 (4.8%) 9 (4.8%) 148 (78.7%) and respectProcess mapping I had confidence and trust in the 9 (4.8%) 13 (6.9%) 146 (77.6%)Following a comprehensive service staff examining and treating meprocess mapping exercise in September2010, objectives for each part of theservice were drawn up and agreed. Thiswill be repeated annually (see Page 62).Service evaluationUsers of our total service (which includesCOPD and pulmonary rehabilitation aswell as oxygen assessment and review),have had their experiences evaluated byManchester Metropolitan University.A further series of patient focus groupsspecifically for patients on oxygen tookplace in March 2011 and a brief summaryof the results showed that 163 patientsseen by the team replied to the survey.Project lead contact details forfurther informationDenise WilliamsNurse Consultant and Service ManagerTelephone 0151 514 2244Email: firstname.lastname@example.org
Improvement stories 43Home oxygen – improving quality of careSherwood Forest Hospitals NHS Foundation Trust andNHS Nottinghamshire County Community COPD TeamThe background to their serviceThree specialist oxygen assessment(community-based) clinics wereestablished in 2006 for patients referredfor assessment by secondary care.These clinics form part of a high qualitycommunity chronic obstructive pulmonarydisease (COPD) service which is led by aconsultant respiratory physician andforms a constituent part of a managedclinical (COPD) network aligned topractice based commissioning consortia.A number of problem areas have beenidentified within the current oxygenpathway:• Oxygen prescribing is undertaken by COPD Team, Ashfield Community Hospital any local healthcare practitioner (HCP) LtoR: Ms Vanessa Leat, Physiotherapist, Dr Sue Revill, Clinical Scientist, Mrs Julie Willets, often without prior formal clinical Assistant Technical Officer, Mrs Diane Reynolds, Respiratory Nurse Specialist assessment• Misconceptions among HCPs and patients around the role and purpose • Patients missing out on therapies such The project aims and objectives of oxygen as pulmonary rehabilitation, anxiety The project aims to assess:• Poor knowledge of the assessment management and relaxation techniques process • Inappropriate prescription of intrusive, • The uptake of GP direct access to the• Variable patient education on the activity limiting therapy for some oxygen assessment services purpose, safe and optimum use of the patients • The workload implications of therapy • Premature deterioration in health due performing retrospective oxygen• Poor understanding of the ordering to decreased activity and sedentary assessment for patients never assessed process and the cost implications lifestyle imposed by the oxygen supply • The introduction of a standard pathway• Life-long therapy costing the local NHS equipment for patients discharged with oxygen £millions in inappropriate prescribing • Toxic effects of high levels of oxygen following admission• Only 52% of patients have evidence for some patients based reviews • Increased risk of fire and death due to The process of improvement they• Inconsistent messages and variable level cigarettes and oxygen undertook and overall approach to of patient information address the issues. Sherwood Forest Hospitals NHS Trust andThese issues generate a number of Nottinghamshire County Community Direct access: A direct access pathwayconcerns in respect of patient care: COPD Team jointly enrolled with NHS (see below) was devised for introduction Improvement - Lung. to GP practices on a rolling locality–by-• Sub-standard clinical service for non- locality basis. assessed patients – leading to Together they are undertaking a 12 month unnecessary life-long therapy for some improvement project to test a GP direct patients access oxygen assessment and review• Inequity of provision across the PBC service model and to improve oxygen areas – only 52% of patients have prescribing upon hospital discharge. evidence based clinical assessment
44 Improvement stories Cost control and data management: COPD home oxygen pre referral pathway Responsibility for data management is being devolved to the practice based commissioning (PBC) groups who are in NO Record %SP02 >92% No action** the process of organising invoice >92% reconciliation which will ensure deceased and out of area patients are identified Current chest infection? Refer for 02 Oximetry or antibiotics (for CI) <5 weeks assessment and removed from the billing system. (If % SP02 less than 88% The clinical project team commenced YES Review 5 weeks seek medical advice) FEVq <50% predicted from last antibiotics home oxygen order form (HOOF) amendment/oxygen charge band Review smoking status re-categorisation of patients known to Sprometry Primary care Check inhaler techs the service in August 2010. Patients COPD review Reviw medication attending for review have all oxygen Signs and symptoms* Flu/pneum jabs supplies re-categorised according to Self management plan clinical need. Exercise advice 1 or 2 /refer to local In October 2010, the clinical project team exercise scheme was granted access to the monthly MRC score oxygen supply invoice and commenced 3, 4 or 5 Refer to pulm work to resolve supply modality rehab anomalies. *Check for current chest infection. Patient should be clear of axacerbation and antibiotics for 5 weeks **If a patient has secondary polycythaemia or cor pulmonale refer directly to local COPD clinic. Issues and challenges they faced with potential solutions Primary care engagement: This has been challenging as follow-up meetings to the initial round of discussions (about the referral protocols and assessmentThe project team met with practice nurses Hospital discharge prescribing: process) were difficult to arrange andand managers to share the community Secondary care oxygen guidelines were feedback about the new direct accessreferral form, pathway and protocol. jointly devised between the respiratory pathway has been variable from one team and other medical departments and locality to the next.An active review of concordance lists was submitted to the hospital clinicalundertaken in order to facilitate patient governance officers. The project team exploring therecall and target practices for individual development of oxygen champions fromGP surgery education and engagement To improve the support provided at among general practice to assist in thevisits. discharge (for COPD patients following development of good practice among non-elected admission), a nurse-led their peers.Guidance notes were drafted for local GP clinical check list and dischargepractices on improving patient information pack is being developed. The Workforce considerationsconcordance and invoice validatio / pack will include prescribing guidelines The project team is comprised of a clinicalpatient register data cleansing was for discharge oxygen, self management scientist working in partnership with aundertaken by PCT finance and primary information and action plan, standard consultant respiratory physician and acare commissioning teams. patient information and follow up oxygen community COPD team. assessment appointment.
Improvement stories 45Potential/actual QIPP and cost Future work: The next phase of thesavings/ avoidance – defined as project will examine how to include GPquality, innovation, productivity practices in the retrospective assessmentand prevention process (e.g.assessing patients withTo date, 36 patients have been re- oxygen supplies and no record ofcategorised by the clinical project team assessment). The partnership withresulting in a projected saving £24,209 Sherwood Forest Hospital will continue toper annum. develop and implement a discharge pack and assessment its impact on the oxygenRe-categorisation consisted of reducing assessment service workload will behours of usage, reducing oxygen flow or examined.removal of supply. Project lead contact details forKey learning further informationHealth inequalities: Analysis of the Dr Sue Revilloxygen patient data has highlighted the Clinical Scientist - COPD Servicesinequities of the current system where at Telephone 01623 785407least 50% of patients have the therapy Email: email@example.com without referral to the oxygenassessment service whilst the other 50%of patients receive an evidence-based,gold standard service.Service integration and productivity:The work of the project team to date hasdemonstrated the potential for makingfinancial savings from regular review andre-categorisation of supply. The savingswere achieved amongst those patientsknown to the oxygen assessment serviceand to the community pulmonaryrehabilitation service e.g. integratedcommunity services with shared specialiststaff.The clinical review and charge bandre-categorisation work will continue andfurther savings will be achieved; howevermaximising the potential savings isundermined by continuing oxygenprescription without referral to theoxygen assessment service.
46 Improvement storiesImproving home oxygen servicesthrough pathway redesignNHS South StaffordshireThe background to their servicePrescribing costs in South Staffordshirehave increased by 30% since 2006 andrecent analysis has predicted that thistrend would continue through 2010/11.The following issues with the currentservice were highlighted:• Lack of understanding amongst primary care clinicians regarding home oxygen order form (HOOF) completion coupled with inappropriate prescribing of oxygen for patients outside the guidelines• There is a lack of understanding amongst healthcare professionals regarding the prescription charges per oxygen flow rate• Poor compliance and extreme over/under use by patients on oxygen• Lack of specialist assessment for palliative care patients• Secondary care oxygen assessment occurring but follow-ups not meeting The project aims and objectives Objectives: national guidelines This project centres on the Cannock • Improve patient safety• Escalating costs due to clinical Chase locality having been approved by • Evidence based treatment prescribing anomalies invoicing errors: NHS Improvement - Lung in October • Improve quality of life and reduced invoicing for deceased patients, 2010 (commencing the following month), mortality (long term oxygen therapy incorrect oxygen mode charges, after the initial South Staffordshire project (LTOT) group) patients not registered in the PCT, in East Staffordshire locality failed to • Reduced LOS (LTOT group) patients with duplicate accounts, progress. • Cost savings oxygen that has been removed and still • Reduce inequalities being charged Aim: To address the issues arising from • Improve patient experience the lack of a comprehensive oxygen • Adhere to British Thoracic Society (BTS)537 patients were known to be in receipt assessment and review service through and condition specific clinicalof home oxygen within Cannock Chase pathway redesign in line with national guidelineslocality, of which 149 are known to the guidance and best practice.community respiratory team (127/149 The process of improvement theypatients having chronic obstructive The specific issues of patient safety, usage undertook and overall approach topulmonary disease (COPD). and compliance will be addressed to address the issues ensure appropriate prescribing of oxygen, The project team sought to demonstrate leading to cost effective and appropriate the cost-saving potential of the approach delivery of treatment and a reduction in outlined below and thus help inform hospital length of stay (LOS). wider health economy work on whole (respiratory) service redesign and Quality, Innovation, Productivity and Prevention (QIPP) efficiency.
Improvement stories 47The team undertook an initial data review Issues and challenges they faced with Review of these patients allowed theof all patients in receipt of home oxygen potential solutions project clinicians to review the clinicalin the Cannock Chase locality with phone The capacity of the project team to basis for the oxygen prescription andcontact reviews and face-to-face patient deliver the clinical reviews and to ensure where appropriate match actual oxygenreviews to all existing Cannock Chase returns are completed submitted in a usage to the prescribed oxygen usage. Incommunity respiratory team caseload. timely fashion has been an ongoing all instances where a change in challenge to the delivery of the project. prescription (and therefore tariff code)Patients not on the Cannock Chase was made, the resulting code wascommunity respiratory team caseload The project work is aligned to wider PCT cheaper.may be contacted where oxygen long term conditions (LTC) andprescribing data suggested: Department of Health LTC ignition At least 10% patients were moved to a projects and additional demands are now less expensive tariff with forecast savings• Over or under use of oxygen be made in respect of the cardiac and in excess £1k per year.• Multiple orders running concurrently stroke portfolio.• Anomalies in prescribed flow rate / The total annual forecast cost savings hours usage These issues will be offset slightly through attributable to the review of the 91 industry partnership working with Astra patients in Cannock Chase localityAt the time of writing the project team Zeneca who offered analyst support amount to £57,573.had reviewed 103 patients. For 91 of around data collection.these patients there were under use or Key learningclinical reasons to change the prescribed Workforce considerations Complexity: This work has uncovered aoxygen order to one more appropriate to Staff time: lot of complexity within existing datathe patients clinical condition and existing 91 patients reviewed at 30 minutes collection and administration systems foroxygen usage. In all 91 patients the per patient) home oxygen, which pre-date thechanges made to the oxygen order Total time for 91 = 45 staff hours creation of a single PCT from fourattracted a less expensive tariff, reflecting Cost saving per hour of staff time = separate organisations. Thus they aremore appropriate oxygen treatments with £1,265 complex, fragmented and difficult tooptimal cost efficacy. monitor. Potential/actual QIPP and cost savingsCommissioning considerations /avoidance – defined as quality, In addition, there is very limitedPCT based project staff are currently innovation, productivity and administration support to process orderssubject to a high degree of uncertainty prevention and invoices, with little analysis of dataand so in order to ensure sustainability of Each patient order generates a cost using provided and this function is remote fromservice improvements within the a tariff that reflects prescribed flow rate clinicians ordering home oxygen.emerging practice based commissioning and hours usage. This tariff has 47 codes(PBC) and the GP commissioning an with a range of ‘per day costs’ fixed Competences: Clinicians in GP surgeriesacceleration of the second phase of the against the prescribed flow rate and have limited knowledge of the typeproject will be required to create a robust hours usage. oxygen to order and in some casesand integrated clinical assessment and prescribe inappropriately. In somereview service. These costs are paid regardless of the instances the order form is completed by actual flow rate and hours usage and in non clinical staff. A GP training many instances the patients reviewed programme would help improve were not using their oxygen in keeping prescribing habits. The Cannock with the prescribed usage. respiratory team are uncovering a large number of inappropriate orders.
48 Improvement storiesA centralised and integrated oxygenassessment, review and ordering teamwould prevent this happening and relieveGPs of the burden of completing homeoxygen order forms (HOOFs), a taskwhich is often delegated to non clinicalstaff.Financial control: The PCT oxygenbudget has remained part of the overallpharmacy budget. However, oxygenspending is not monitored and PBCs haveremained unaware of the amount spentin their consortia. An initial reviewsuggests that one half of the PCT hasmore patients on home oxygen but thatthe other half of the PCT consistentlyspends much more per patient.By sharing the practice spend with eachPBC this will increase the interest in therobust management of this budget andthat systems are put in place to ensurethe right patients receive the right supplyof home oxygen, with a review system inplace.A future pathway redesign work priorityis to review the processes associated withthe prescription of the high cost supply ofoxygen on an emergency basis, i.e.delivered to the patient within four hours.Project lead contact details forfurther informationSally YoungLong Term Conditions LeadTelephone: 01283 507128Email: firstname.lastname@example.org
Improvement stories 49Improving home oxygen servicesNHS Birmingham East & North and Heart of England NHS Foundation TrustNHS Birmingham East & North (NHS BEN) Oxygen is predominantly initiated by The project team have process mappedand Heart of England NHS Foundation secondary care clinicians; however the the patient journey in terms of theTrust (HoEFT) are working in partnership processes vary across the sites (Heartlands current and future state and identifiedto change the way in which oxygen and Good Hope Hospitals). There are where gaps exist in current provision, andservices are delivered to our community. respiratory clinics which review and assess how in the longer term we envisage a patients referred however as initial home move towards single point of referral forThe project team aim to deliver and oxygen order forms (HOOF) are initial oxygen assessment and prescribing.embed a cohesive approach that leads to completely by any clinician the systemclinically effective and cost efficient can be quite fragmented. The project aims and objectivesoxygen management processes across the • To work in partnership to change thelocal health economy. Within NHSBEN the responsibility for way in which oxygen services are commissioning oxygen services has delivered to our community.The background to their service moved from primary care contracting to • To embed an approach that leads to aNHS BEN first embarked on addressing within the long term conditions team cohesive, effective and cost efficientthe way oxygen services were managed responsible for chronic obstructive oxygen management process across thein 2007; the approach taken at that time pulmonary disease (COPD). NHS BEN and HoEFT Health economy.was to aim to secure a designated post • Develop transparent systems forwith funding support from the British The information systems that support the sharing information relating to homeLung Foundation (BLF). management of oxygen across the health oxygen users across the local health economy reside within stand alone economyDifferences between the BLF funding systems that are inaccessible to the three • Agree a clear and transparent pathwaycycle and PCT business case development sites across the local health economy. and guidelines that support the processprocess prevented funding being within There was some enthusiasm to create a of initiating oxygen therapy for newspecified timelines and therefore no systematic approach to the review and patients and advises on the challengesfurther plans were developed to address assessment of patients that had been on of withdrawal/cessationthe review assessment pathway. oxygen for a number of years and to put • Scope the requirements for a single in place pathways and processes that database across the sites which willThe approach from that point forward demonstrate effective review of facilitate review assessmentwas to robustly manage the internal concordance reports. requirementsmechanisms and to ensure that • Involve the support of clinical healthcontracting information was kept up to For those patients commenced on oxygen psychology to establish an approachdate (removing out of area and deceased from hospital (under specialties other which is consistent with models of bestpatients) whilst this was an effective than respiratory) there is a need for a practice in reducing psychologicalapproach to data quality, the effective pathway that establishes confidence that dependencyassessment of all patients on home further review will take place as part ofoxygen could not be undertaken. the ongoing patient management. To support and underpin this there will be a review and revision of local guidelines for prescribing home oxygen therapy.
50 Improvement storiesThe project will review the information Issues and challenges they faced with The team commenced clinics on 5currently held at NHSBEN as this forms potential solutions January 2011, assessing approximatelythe basis on which contracting and One of the key issues has been the ability four to eight patients per week, it hascharging takes place. With the to secure continued commitment from been recognised that we will need ainformation from secondary care and community teams, particularly as the process to request the permission ofdata supplied from the oxygen provider project has taken place during the key other consultants prior to reviewing nonwe will prioritise those patients that stages of the Transforming Community respiratory patients.require a review assessment with the Services programme. There have alsointention of ensuring that only those been some issues to overcome in terms of One aspect of key learning to date relatespatients that meet the clinical criteria communicating the project in secondary to home oxygen order forms (HOOF)continue with this treatment. care, it was important that executive sign which have limited information recordedThe process of improvement they up translated into commitment and in terms of coding of patient diagnosisundertook and overall approach to engagement from the managerial and also the transfer of HOOF forms acrossaddress the issues. clinical teams to the objectives. organisations is fragmented. As such it is a challenge to clearly define and groupFollowing the development a project plan The transfer of information between sites patients in receipt of oxygen by theira programme board was established, has required input from information diagnosis.inviting members from across community governance leads in order to comply withand secondary care under the clinical legal requirements relating to information Commissioning considerationsleadership of a respiratory physician. sharing. A protocol for information As new funding is not anticipated the sharing is being developed and the team management of oxygen therapy has beenThe team have taken the approach of have been briefed in relation to the entered into the commissioningensuring multidisciplinary representation appropriate level of information shared intentions of both the acute andand this has gained the support of across organisations. community provider contract for 2011-respiratory physiotherapists and health 12. This project will enable us to test thisimprovement specialists. Of course the current organisational service and more accurately specify the turbulence has resulted in some loss of requirements for the future.The project has been communicated to momentum due to increasing workloadlocal GP localities in order to ensure they and conflicting priorities but due to the Workforce considerationsare aware of the intended outcomes and commitment and focus witnessed from The reviews are carried out by athis has also received positive feedback. the team this should not be a barrier. respiratory physiology technician supporting the respiratory consultant. The testing performed and subsequent This clinic will (once workforce is key learning witnessed has already confirmed) include a nurse and resulted in overall benefits encountering physiotherapist establishing a truly secondary care establishing a clinic with multidisciplinary approach. In the interim no waiting list and therefore it seemed patients who require nursing input are appropriate to re-assign it as a highlighted to the respiratory nurse multidisciplinary clinic with consultant specialists. input for the purpose of the project. A ‘test’ cohort was not chosen based on reviews highlighted in the concordance report and those who have previously had an assessment where clinically oxygen could have been withdrawn but patients were reluctant and fearful of relinquishing this.
Improvement stories 51Potential/actual QIPP and cost Alignment with QIPP frameworksavings/ avoidance – defined asquality, innovation, productivity Quality This project will bring about whole system improvement in theand prevention clinical identification and management of patients on Oxygen.As mentioned above the PCT based Improving quality of service provision and patient QoL.oxygen database has been robustly This also includes the right treatment at the right time withmanaged in terms of data cleansing and appropriate patient support.quality. As such NHS BEN does notanticipate the significant savings that Innovation Whilst locally our organisations have attempted to address thisother organisations will experience. issue it remains largely disjointed, the approach of a structured Oxygen ‘snatching’ clinic creates a consistent approach thatHowever, the team recognise the addresses inappropriate interventions and creates a robustguidance in terms of indications for using framework for the future.SBOT and will be striving to appropriatelywithdraw this where possible. Productivity Improving this pathway through this project enables the organisation to maximise the benefit of every pound spent onAlso, as there are a number of patients management of this disease.who have not been reviewed we expectthe project to deliver a number of Prevention An emphasis on supporting patients to self care, is reflected incessations following review, unfortunately our strategic priorities, we will use existing services to supportthis is not easily quantified at this stage. this e.g. healthy incentive schemes, health trainers, BOH, Expert Patient Programme and disease specific education approaches.However, based on the current PCT spendon oxygen applying the nationally quotedsaving projections would result in a localreduction of approximately £200k. Emerging workstream principles, • Ensure commitment of secondary and including ‘top tips’ community care teams from the outset,Data summary both clinical and managerialBaseline activity has been collected from Top tips for the management of the • Explore the requirements foracross the three sites, there was an oxygen service are: information sharing acrossexisting list of patients who were • The earliest quick win for oxygen organisations and any associatedconsidered borderline for withdrawal therapy is active and robust data quality protocol neededfrom the first assessment and this group this requires a committed information • Establish how the system of managingare now being invited for review, whilst manager and establishment of HOOF forms works prior tothe team review concordance processes to reconcile disparities in implementing a projectinformation. information, remove deceased patients • Explore the establishment of a single and alert in terms of movement out of point oxygen assessment initiationThe information manager has produced the area process with secondary care to streamsome valuable and insightful reports from • If clinics will take place in secondary linethe contracting data held by NHS BEN. care agree on the tariff that will be • Consider psychology advice for thoseThis includes analysis on the number of applied patients who are particularly dependantadmission for patients on home oxygen • Input into the oxygen clinic to effect or lack coping skillsand those with a diagnosis of COPD. safe and sustainable service (by identifying high risk patients) with development of a system of ‘inappropriate oxygen cessation’ notices
52 Improvement storiesAny generic learning (LTC) that weextrapolate from the work e.g. how thiscould be applied to other area’s• Clinical leadership in the process is key, also the engagement of the wider specialist team e.g. respiratory physiology, nursing and physiotherapy• Evidence of other similar projects and their associated saving to engage finance leads and demonstrate good practice from elsewhere• Early identification of where the pathway would be placed in an established model e.g. community, secondary care or within a private provider• Engage commissioning to ensure that you are aware of the current contract and who is monitoring it• Data to align information with GP practices which is linked to concordance reports• Engage GP consortia to ensure the project has support and buy in, engagement with clinical lead may assist in terms of reinforcing the message to patient and clarifying the indications for oxygen therapyProject lead contact details forfurther informationYvonne RichardsStrategy and Redesign ManagerTelephone 0121 380 9084,Email: email@example.com
Data for improvement projects 53Data for improvement projectsWhat data is available to supporthome oxygen sites? Example of QOF dataPrimary care data is often seen as adifficult area to extract data, and our sitesfound it difficult to access primary caredata at first. However, a number ofresources are easily available which canprovide a picture of primary care which isvaluable for improvement work (furtherdetails on how to access this information,and how to analyse it, are in the datasection below).Quality and Outcomes FrameworkThe Quality and Outcomes Framework(QOF) is a voluntary annual reward andincentive programme for all GP surgeriesin England, detailing practiceachievement results. It is not aboutperformance management but resourcingand then rewarding good practice.QOF data is useful, particularly for QOF may be useful for COPD projects, as It also collects figures on the reportedbuilding evidence and understanding it provides annual information on the prevalence of COPD.around the diagnosis and community following indicators:parts of the patient pathway. QOF data is It is important that sites using QOF reviewparticularly valuable when compared to • The percentage of patients with COPD any exception reports, as it is possible toother indicators for chronic obstructive who have had influenza immunisation exclude patients.pulmonary disease (COPD), such as • The percentage of patients with COPDadmissions, or expected prevalence. with a record of FeV1 in the previousComparing the proportion of patients • The percentage of all patients withpredicted to have COPD against actual COPD diagnosed in whom thereported COPD on QOF may highlight diagnosis has been confirmed by postareas of unmet need, find missing bronchodilator spirometrypopulations, and suggest where to target • The percentage of patients with COPDsupport and future work. who have had a review, undertaken by a healthcare professional, including an assessment of breathlessness using the MRC dyspnoea score in the preceding 15 months
54 Data for improvement projectsNHS ComparatorsNHS Comparators has been muchdeveloped in the last year, and sites wereimpressed with the information itprovided, which helped provide basicbenchmarking and comparison forprimary care.For a general view of data, NHSComparators can provide suitableinformation for many areas. The siteprovides total admissions data on aquarterly or annual basis, from SHA toPractice level. The site includesfunctionality to plot data on charts andmaps. Data can also be exported for localuse in Excel.The NHS Comparators tool is free toaccess, and is not limited to NHS staff.There is a set of COPD measures, whichincludes: NHS Comparators mapping example• Total admissions for COPD• Emergency and planned admissions, The NHS Information Centre is planning• Reported prevalence compared to to improve access to GP information predicted prevalence through the development of a national GP data extraction service. For furtherGeneral Practice Systems information visit the information centreLocal investigation of primary care data website. www.ic.nhs.ukmay reveal more information. Project siteshave found value in interrogating theinformation held within primary care GSK POINTS audit toolsystems. The importance of accuratecoding has been emphasised by projectsites, sites have learned more about theexacerbations of their patients byensuring coding is correct.Primary care data can be explored usingthe reporting functions built into primarycare systems, or using external tools,examples of which include the POINTSaudit tool from GSK, and the OptimalPatient Care Project. Details on how toaccess these resources are in the dataguide.
Data for improvement projects 55 National Programme Budget Interactive Atlas – http://nww.nchod.nhs.uk (NHS Network connections only)Programme Budget Interactive Atlas For process improvement, it is often SHA benchmarking andA recent development is the Programme valuable to get this information at an Information packsBudget Interactive Atlas. This contains a individual level. This will be best used to The Department of Health in conjunctionvariety of indicators at PCT level, and can show individual variation in Length of with the ER PHO and Nationalbe useful in comparing PCT level data. To Stay, rather than the average. Programme Budgeting team haveaccess the Programme Budget Atlas, you produced a respiratory health informationrequire access to the NHS Network, and If you have access to an information pack for each SHA area. These packsaccess the site via nww.nchod.nhs.uk analyst who can extract the data from the cover a variety of indicators, that acute trust or commissioner databases, highlight the difference in expectedThe Programme Budget Interactive Atlas then you can have a more flexible prevalence, diagnosis, admissions, spendis a tool available to plot a number of approach to accessing admissions data. and outcome across all SHAs nationally.respiratory indicators and compare These can be downloaded for your SHAnationally, within an SHA, or with similar Public Health Observatories area from the NHS Networks site at:PCTs. This interactive tool cap map, and Each region has a Public Health www.networks.nhs.ukshow correlations between two indicators Observatory (PHO), who’s role is to(for example, cost and outcome). support clinicians and commissioners access information on the health of theAccessing HES data locally population. In addition, each PHO hasMany sites have found access to HES data areas of specialist interest. The Easternthrough using local performance reports. Region (ER) PHO has the specialist interestThese reports typically include averages for respiratory illness – and a number offor length of stay, numbers of admissions data sources and reports are availableand readmissions, and are typically used from their website at: www.erpho.org.ukfor performance management.
56 Data for improvement projectsTobacco Control ProfilesThe London Public Health Observatory Smoking profile tool examplehas produced a smoking profile, whichmay be useful for projects planning anddeveloping smoking cessation services.These are available online, at thefollowing addresswww.lho.org.uk/LHO_Topics/Analytic_Tools/TobaccoControlProfiles/Guide for building support from dataanalysts and expertsMany of our project sites haveemphasised the benefits from gettingearly support from a dedicated dataanalyst. This has helped projects inobtaining baseline information,supporting process mapping, andongoing support to monitorimprovement.The key tips for getting and keepinganalysts involved in projects are:Get your analyst involved earlySites that included analyst support fromthe beginning had a head start withdata, and rapidly built the evidencebase and understanding for the servicechange. Those sites without analystsupport struggled to understand theimportance of data, and later expressedregret as data revealed challenges or Seek formal support from the coders, data managers and contractmisunderstandings which could have analyst and manager managers, who exist in a variety of roles,been challenged sooner. Early Analysts are often seen as a valuable supporting the management of PCTs andinvolvement helps ensure that you and resource, and as such their time may be Provider trusts, with access to data beingthe analyst have a shared protected. Some sites have found a core part of their roles.understanding of the project. difficulties in maintaining analyst support in projects due to competing pressures Be clear on data requirements toInvolving analysts closely with the elsewhere in the organisation. Sites have information departmentsproject, rather than an external recommended that you ensure It helps to explain what you are trying tofunction management support is in place for the measure or demonstrate, as they may beThis close involvement ensured the improvement work, ensuring that analyst able to suggest alternative indicators. Asanalysts had a greater understanding of time is made available to support your well as information analysts, involve allthe purpose of the projects, and the work. those involved in delivering care toanalyst could input into the project goals contribute to a data collection plan.to ensure the aims are measurable and Look widely for your supportachievable. It is also valuable, as it may People with access and expertise to datareveal other sources of information or may not always be in analyst roles. Sitesapproaches which may be unknown to looking for information may wish tothe project team. contact performance managers, clinical
Newham LTOT pathway 57AppendicesThe following appendices are an initialsample collection of resources (letters to Newham LTOT pathwaypatients, care pathways and algorithms,assessment forms etc.) which may prove Long term oxygen therapy (LTOT)helpful to other NHS colleagues about to Newham Development Zone > Thoracic medicine > Home oxygen therapy (HOT)embark upon similar work. This initial setof resources will be substantially added towhen the final publication marking theend of the project cycle is published. IMPORTANT NOTE: Locally reviewed refers to the date of completion of the most recent review process for a pathway. All pathways are reviewed every twelve months, and on an ad hoc basis if required. Due for review refers to the date after which the pathway on this page is no longer valid for use. Pathways should be reviewed before the due for review date is attached.
Royal Free/Waltham Forest PCT/NECLES HIEC - Invitation letter to patients 59Royal Free/WalthamForest PCT/NECLES HIEC NHSInvitation letter to patients Outer North East London Community Services Waltham Forest Respiratory Service Telephone: 020 8430 8255/8266 Dear Re: NHS Improvement - Lung I am writing to invite you to join this new initiative that is being developed nationally to improve the care and services we deliver to people with lung disease. In Waltham Forest we are specifically offering an opportunity to people who have been prescribed oxygen to manage their breathlessness. Extensive research has shown that whilst oxygen is linked to breathlessness, there is negligible evidence to show that it is of benefit. Unfortunately dependence on oxygen frequently occurs which prevents patients developing techniques and skills that enables them to manage their breathless more efficiently -without the use of oxygen. I would like to offer you the opportunity to work with a Respiratory Specialist to help you to develop breathing techniques which enable you to improve the control your breathlessness. This will be managed through a time table of home visits to: • Discuss your use of home oxygen. • Offer full assessment of your requirement for oxygen therapy • Teach you techniques to manage your breathlessness and review your progress at regular intervals. • Address your concerns and work with you to build your confidence in the self management of your breathing without the use of oxygen. You will be supported throughout the process and encouraged to monitor and discuss your development at each stage. When this point has been reached, with your agreement the oxygen will be withdrawn. You will continue to receive support visits and telephone support for six months. If you feel you are unable to allow the withdrawal of the oxygen you will be offered an appointment with a Respiratory Consultant for further discussion and assessment. I hope you will take up this unique opportunity that has the potential to make a real difference to the management of your breathlessness. If you do not wish to take part please call me on 0208 430 8255. This decision will not affect your usual care. I look forward to working with you. Yours sincerely Anne Crawford Respiratory Nurse Specialist Team Leader Waltham Forest Respiratory Services
62 Wirral COPD and Oxygen Service process mapWirral COPD and Oxygen Service Process Summary’
NHS Birmingham East & North process map - Current state 63NHS Birmingham North & East process map - Current state
64 NHS Birmingham East & North process map - Future stateNHS Birmingham North & East process map - Future state
Acknowledgements 65AcknowledgementsNHS Improvement - Lung would like to In addition, the following people havethank all national improvement project provided a source of expertise andsites for their hard work and dedication support and their help is gratefullyto improve quality and care for people acknowledged:with COPD, and for their contributions tothis document. • Phil Duncan, Director, NHS Improvement - LungSincere thanks goes out to the members • Alex Porter, Senior Analyst, NHSof the publication working group namely: Improvement - Lung • Zoe Lord, National Improvement• Bob Arora, NHS Newham Lead, NHS Improvement - Lung• Denise Williams, Wirral COPD and • Catherine Blackaby, National Oxygen Service Improvement Lead, NHS• Yvonne Richards, NHS Birmingham Improvement - Lung East and North • Catherine Thompson, National• Rahul Mukherjee, Birmingham Improvement Lead, NHS Heartlands Hospital Improvement - Lung• Heidi Wilkinson, South Staffordshire • Hannah Wall, National Improvement PCT Lead, NHS Improvement - Lung• Sally Young, South Staffordshire PCT • Sandie Bisset, Home Oxygen Service,• Joan Manzie, South Staffordshire PCT Department of Health• Sue Channon, NHS Milton Keynes • Hamza Jamil, Home Oxygen Service,• Toni Yel, NHS Hull Department of Health• Julie Danby, Hull City Health Care • Viv Smith, NHS Western Cheshire, Partnership Home Oxygen Services Regional Oxygen Lead for Cheshire & Merseyside • Karen Hatch, NHS Central Lancashire, Regional Oxygen Lead - Cumbria & Lancashire and Greater Manchester • Judith McElroy, NHS Blackburn with Darwen, Oxygen Service Manager and Home Oxygen Service Lead For more information please contact: Ore Okosi, National Improvement Lead: firstname.lastname@example.org
66 ReferencesReferences1. Department of Health. Consultation 7. NHS Connecting for Health. Brochure on a Strategy for Services for Chronic LSD08088 Home Oxygen4: Open Obstructive Pulmonary Disease Exeter and Home Oxygen. (COPD) in England. Department of Health, 2010. 8. NHS Business Services Authority website. NHS Prescription Services,2. Department of Health. Consultation Home Oxygen Therapy Reports on a Strategy for Services for Chronic Overview. Accessed 24th February Obstructive Pulmonary Disease 2011 (COPD) in England: Consultation www.nhsbsa.nhs.uk/PrescriptionServices Impact Assessment. Department of /1990.aspx Health, 2010. 9. NHS Home Oxygen Service. Home3. British Thoracic Society (BTS) Working Oxygen Service Manual, Version 2 Group on Home Oxygen Services. (July 2007). Clinical Component For The Home Oxygen Service In England and Wales. 10. Department of Health. Home Oxygen British Thoracic Society, January 2006. Service – Assessment and Review: Good Practice Guide. Department of4. Department of Health. Home Oxygen Health, Final version 24th November Service – Assessment and Review: 2010. Good Practice Guide. Department of Health, DRAFT of 14 May 2010.5. National Clinical Guideline Centre. (2010) Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care. London: National Clinical Guideline Centre.6 . IMPRESS - Improving and Integrating Respiratory Services in the NHS. Rationalising oxygen use to improve patient safety and to reduce waste: The IMPRESS step-by-step guide. IMPRESS, September 2010.