Improving the quality and safety of home oxygen services: The case for spread

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Improving the quality and safety of home oxygen services: The case for spread

  1. 1. NHSCANCER NHS Improvement LungDIAGNOSTICSHEARTLUNGSTROKENHS Improvement - LungImproving the quality andsafety of home oxygen services:The case for spread
  2. 2. Improving the quality and safety of home oxygen services: The case for spreadContentsImproving the quality and safety of homeoxygen services: The case for spread1: Introduction 41.1 Context 41.2 Summary of workstream learning 41.3 The case for spread 81.4 Use of data 92: Learning from the prototype projects 122.1 Components of a quality HOS-AR model 122.2 Practical service models 152.3 Issues and challenges 172.4 Overall project cost savings 173: Case studies 193.1 Oxford 193.2 Hampshire 213.3 Derby 233.4 Salford 253.5 Stockport 274: Additional information and resources 29Appendix 1: North East procurement of HOS-AR provider – 29a case studyAppendix 2: Project team process maps and other lung 32improvement resources5: Acknowledgements and references 34 3
  3. 3. Improving the quality and safety of home oxygen services: The case for spread1: Introduction1.1 Context Home oxygen services have been a The prototype work placed a great particular priority within the emphasis on the safe and appropriateThis prototype project final report respiratory programme as earlier use of home oxygen and as such wasbuilds upon the learning from the work had revealed significant waste well aligned with NHS Outcomesinitial testing phase projects. The in the use of resources with many Strategy Domain 5 - Treating andlessons learned from the earlier work patients either not using, or receiving caring for people in a safeare documented within two no clinical benefit from, supplied environment; and protecting themimproving home oxygen services therapy. This problem was from avoidable harm6.workstream publications entitled compounded as an estimated 20% ofEmerging Learning from the National patients requiring therapy were not The prototype project teams wereImprovement Projects1 and Testing receiving it5. widely dispersed across England andthe Case for Change2. this report features case studies from The testing phase work sought to five sites: Hampshire, Oxford, Derby,The earlier publications highlighted establish the case for change i.e. that Salford and Stockport.the work of 12 multidisciplinary quality assured prescribing of homeproject teams based in various sites oxygen therapy through structuredacross England. As part of the assessment and ongoing clinical 1.2 Summary of workstreamnational chronic obstructive review not only improves safety and learningpulmonary disease (COPD) project quality but also increases costcohort these sites were supported in efficiency. A key objective of the prototypethe practical use of service project work was the refinement ofimprovement methodology in order The results from the testing projects the testing phase approach in orderto implement home oxygen service - successfully proved this concept and to identify the first steps clinicalassessment and review (HOS-AR) as so the goal of the prototype phase networks should undertake whenspecified within the national good was to establish the case for the trying to improve the home oxygenpractice guide3. spread of good practice and so pathway and also to define the key establish HOS-AR across the country. success principles of practical serviceBoth the national COPD project work implementation.and the development of the good The work presented within thispractice guide were constituents of a publication was undertaken by the These ‘first steps’ and ‘successwider respiratory programme of work six project teams comprising the principles’ have been publishedsupporting the introduction of the prototype phase of the national separately but are included withinOutcomes Strategy for COPD and COPD projects improving home this document for completeness.Asthma4. oxygen workstream.4
  4. 4. Improving the quality and safety of home oxygen services: The case for spreadFirst steps to improving chronic obstructive pulmonary disease (COPD) care LIVIN First steps to improving chronic obstructive pulmonary disease (COPD) care G WIT H What you can do Why it matters How to do it 7. Do not Home oxygen is a treatment for Promote the message to staff prescribe chronic hypoxaemia and NOT a and patients that ‘oxygen is not oxygen for treatment for breathlessness. It a treatment for breathlessness’ ‘breathlessness’ is a drug and should only be and that there are often more prescribed where clinically appropriate ways to manage and ensure indicated otherwise it is of NO breathless patients. prescribing benefit and potentially harmful remains to some patients. Ensure only patients who have clinically been assessed by a specialist appropriate In PCTs that have introduced a service are prescribed oxygen and and cost review of their oxygen registers that they receive ongoing review. effective coupled with the introduction of This involves measuring both through a formal assessment service up oxygen saturations and blood formal to £400,000 has been saved in gases and reviewing other clinical one year. If the scale of savings data together with supplier data assessment were replicated across England, on usage, flow rate, duration and ongoing it is estimated that they could and equipment. review amount to between £10-20m. Rationalise therapy in line with clinical need and undertake supported withdrawal of oxygen providing no clinical benefit. 8. Oxygen Some patients with COPD or Oxygen alert cards and 24% alert cards other long term chest conditions masks (recommended in the should be can become sensitive to medium BTS 2008 guideline) can avoid provided for or high doses of oxygen. This hypercapnic respiratory failure does not happen to everyone by alerting healthcare at risk with these conditions, only a professionals that patients are patients small number, therefore, if sensitive to oxygen. Oxygen oxygen is needed by these alert cards should be issued patients, it should be given in a to all at risk patients on controlled way and monitored discharge as part of the carefully. discharge planning process. 5
  5. 5. Improving the quality and safety of home oxygen services: The case for spreadSuccess principle 10: Home oxygen NHS 10 NHS Improvement Success principles Lung Making a real difference TEN: FIND I Home oxygen NG O UT Home oxygen therapy is provided to about 85,000 people in England, costing approximately £110 million a year. Home oxygen service assessment and review (HOS-AR) is variable as patients in many LIVIN Primary Care Trusts (PCTs) do not receive a quality assured clinical assessment and a review of their ongoing need for long term home oxygen. G WIT The variation in provision of HOS-AR increases the potential for poor quality care and waste and it has H been estimated that 24% to 43% of home oxygen prescribed in England is not used or provides no clinical benefit. N THING HE Gross savings of up to 40% - equivalent nationally to £45 million a year or £300,000 per PCT can S W ! GO potentially be achieved through the establishment of home oxygen services, oxygen register review and WRO formal clinical assessment. N G TO W Reducing variation in service provision can help tackle health inequalities and ensure consistency in the A safety and efficacy of services. RD S THE E 1. Implement Home Oxygen Service – Assessment and Review (HOS-AR) in line with nationally ND identified good practice Why - In order to ensure quality of care, safe use of oxygen and the avoidance of waste. How - Review the learning from the national COPD projects improving home oxygen service workstream available at www.improvement.nhs.uk/lung Liaise with your respiratory clinicians and make use of national good practice guide and the Department of Health commissioning specification for HOS-AR in order to construct a business case and devise a service specification. Example: NHS Nottinghamshire County Community COPD Team, Sherwood Forest Hospitals NHS Foundation Trust and County Health Partnership: ‘Patient review provides the ideal opportunity to re- categorise the oxygen supply according to changing clinical and social needs.’ 2. Use both clinical and oxygen supplier data systematically to support the assessment and review process Why - Data review enables the identification of patients who may potentially require therapy rationalisation or the supported withdrawal of oxygen. It also helps identify sources of inappropriate prescribing and maintain tight cost control.6
  6. 6. Improving the quality and safety of home oxygen services: The case for spreadHow - Provide HOS-AR teams with access to oxygen usage data from suppliers and ensure they work collaborativelywith managers and information specialists to routinely review the usage, flow rate, duration and equipment of homeoxygen patients.Example: NHS Hull and the City Health Care Partnership: ‘Using cost and usage data from the oxygen supplier isthe smartest way to determine a starting point for assessing and reviewing patients.’3. Integrate HOS-AR within the wider respiratory care pathway and coordinate activities with non-respiratory specialtiesWhy - Oxygen therapy assessment and ongoing review provides the opportunity to optimise all other aspects ofpatients COPD management (or their other long term conditions).How - Undertake process mapping and also demand and capacity analysis to understand the whole pathway andidentify opportunities for new ways of working. Ensure that HOS-AR is explicitly detailed within the respiratory servicespecification and that the HOS-AR team activities are aligned with other respiratory services such as pulmonaryrehabilitation. Ensure coordination exists with non-respiratory services such as cardiology, neurology and palliativecare.Example: Wirral University Hospital NHS Foundation Trust and NHS Wirral: ‘Using a model that integratesoxygen assessment and review with COPD and Pulmonary Rehabilitation services and is supported by secondary carehas contributed to the success of this community based service.’4 Promote the message that ‘Home oxygen is a treatment for chronic hypoxaemia and NOT atreatment for breathlessness’Why - Oxygen is a drug and should only be prescribed where clinically indicated otherwise it is of NO benefit andpotentially harmful to some patients.How - Establish ongoing and effective communication between the HOS-AR team, primary and secondary care andalso patients groups through education sessions and Forum meetings. A continuing dialogue should occur in respectof best practice, treatment goals and HOS-AR referral criteria.Example: NHS Birmingham East & North and Heart of England NHS Foundation Trust: ‘Engage GP consortia toensure the project has support and buy-in, engagement with the clinical lead may assist in terms of reinforcing themessage to patients and clarifying the indications for oxygen therapy’5. Work collaboratively to formalise policies and procedures around the safe use of home oxygenWhy - Oxygen therapy is highly flammable and can result in serious injury or even death if not used safely.How - Ensure patients and carers receive instruction in the safe use of home oxygen during the assessment and reviewprocess and provide support to stop smoking. Work in partnership with oxygen suppliers and local Fire Rescue Servicesto promote consistent messages around the safe use of oxygen and to establish risk identification, risk managementand clinical governance policies and procedures.Example: NHS Hull and the City Health Care Partnership: ‘Working with the Fire Brigade has helped tackle thechallenges experienced by the team in educating patients and carers of the risks around health and safety and ondangers of smoking to themselves and others, making such discussions more impactful’ 7
  7. 7. Improving the quality and safety of home oxygen services: The case for spread1.3 The case for spread Improving the landscape in respect In devising a spread strategy it was of assessment and review was important to align the approach withSharing the learning: The home acknowledged as important in both the DH service specification foroxygen workstream national supporting the efforts of the HOS-AR5 (part of the COPDimprovement lead sought widespread Department of Health and the regions commissioning toolkit7) and thecollaboration with stakeholders. These as they sought to re-procure and national COPD project learning.stakeholders included the Department successfully transition the oxygenof Health home oxygen team, the supply contracts. This ensured a premium was placedregional respiratory programme teams on quality by emphasising:and also the regional home oxygen In many localities the strengthened • structured assessment for accurateservice (HOS) leads. This collaboration clinical input, better data management diagnosis and appropriatewas important in the promotion of and overall service coordination prescribing;nationally endorsed good practice and provided by HOS-AR also assisted the • information management; andthe spread of the emerging learning oxygen supply companies with the • patient and professional educationfrom the national COPD projects. transition process. around the goals of treatment.As such, the national improvement In addition, the important service Safety was prioritised bylead (NIL) participated in numerous coordinating role undertaken by HOS- emphasising:home oxygen best practice workshops AR teams together with their role in • ongoing review of clinical need;hosted by respiratory clinical networks educating both patients and • instruction in the safe andand regional respiratory programme healthcare professionals and also their appropriate use of oxygen; andteams. role in supporting risk management • risk assessment and clinical contributed in small part to the success governance.The workstream publications were also of many regional transitionwidely disseminated in both print and programmes. It also strengthened the Productivity was addressed by:electronic form. The project teams case for HOS-AR to be available more • rationalising therapy to reducealso played a major role forming an widely. waste; andinformal virtual network for spread • matching prescribing to clinicaland sharing their experiences with The goals of HOS-AR spread: Using need.colleagues across the country in local intelligence gained from initial surveyseducation sessions and communities of of HOS-AR coverage, undertaken bypractice the Department of Health (DH), an In order to ensure the spread estimated 60% of Primary Care Trusts strategy met these aims fourCollectively this meant that even (PCT) had established some form of principle objectives for thebefore a formal spread programme HOS-AR by the time a formal spread spread of HOS-AR werewas established many localities and programme was launched in established:regions were enabled to adopt much September 2012. These estimates areof the learning and implement being revised as a more robust survey 1. Adopt formal assessmentimprovements in their home oxygen is currently underway. and review;prescribing procedures, data 2. Reduce variation;management and cost control. It is difficult to establish exactly what 3. Commission services for the coverage was prior to the start of sustainability; and the testing phase project work but is 4. Improve safety and generally accepted that HOS-AR patient care. covering the whole population served by each local PCT was not widespread.8
  8. 8. Improving the quality and safety of home oxygen services: The case for spread1.4 Use of data Examples of home oxygen project service improvement measuresHome oxygen is an area of the NHSthat has a wealth of data available for 1. What proportion of HOOFs were completed by the HOS-AR team?it to use, with invoice data, supplier 2. How many patients have potentially clinically inappropriate supply,concordance reports, and local patient for example:caseload information. Oxygen usage • Over four hours of SBOTdata from supplier companies is made • Under eight hours of LTOTavailable on a regular basis to • Over or Underuse of prescribed oxygencommissioners in the form of large 3. How much is spent on home oxygen supply per month?spread sheets. 4. How many patients receive home oxygen each month? 5. What is the service activity – e.g. How many therapy commencementsThese large spread sheets can be and removals?difficult for a non-expert to use andinterpret and often there is so muchdata that it is difficult to identify anarea to focus. As a result, HOS-AR The project metrics used wereservices often lack key metrics that dependant on the informationmight more usefully inform service received from the suppliers, and somedelivery and drive improvement work. required further local data collection.Metrics and measures The data requirements forDuring the improvement projects, commissioning HOS-AR may differteams were encouraged to focus on from those used in a servicedriving the quality and appropriateness improvement project. The serviceof the supply of oxygen, and improve specification in the Department ofthe efficiency of services. Health Home Oxygen Assessment and Review Commissioning ToolkitProject measures were chosen that suggests a number of commissioningwere appropriate to the goals, these key performance indicators and a fewincluded: of these are listed below:• rules to check for patients potentially on inappropriate supply and outside • The percentage of eligible people booked for their HOS of national clinical guidance; assessment who attend their appointment.• process measures to count the • The percentage of people prescribed oxygen therapy who have number of patients reviewed; a follow up home visit within four weeks.• a measure on the referral source of • The percentage of people on long-term oxygen therapy who the new HOOF; and have had a review in the last nine months.• outcome measures including total • The number of inappropriate oxygen prescriptions identified spend and change to size of on assessment. caseload. 9
  9. 9. Improving the quality and safety of home oxygen services: The case for spreadThe benefits of using data to Sample Dashboarddrive improvements in HOS-ARAs has been established during thetesting phase national project work,the establishment of HOS-AR has apotential to save money alongsideimproving quality of care.Effective use of data is a criticalsuccess factor in realising these dualbenefits. Systematic use of supplierand clinical data coupled with thedevelopment of locally appropriateservice metrics are the foundations ofthis approach. Below are listed a fewpractical tips on data managementarising from the national projectwork:1. Use concordance data, but not in isolation. Project teams found that looking at the waste through using the concordance data was an excellent start, but combining this 4. Review how HOS-AR teams use data issues surrounding both the alongside looking at quality of their time – often surprising results improvement project work and the prescribing enabled them to were discovered in inefficient transition in oxygen supply. identify many areas for administrative processes, and time improvement managing oxygen supplier These dashboards together with2. Who commences oxygen is a good relations. other locally devised data process measure. In some areas management initiatives supported the with low spend and well managed Making the data useable – home oxygen teams in making oxygen use, teams found that over systems and approaches. clearer patient care decisions and 90% of commencements had The data environment described motivated service change. been initiated by a specialist from above meant that national COPD their HOS-AR team. project teams needed support from Visual management is an important3. Review how many patients are the NHS Improvement - Lung team in tool in using data to drive supplied oxygen outside of order to harness oxygen usage data improvement. While project sites guidance, where it may not be in a meaningful way to facilitate often thought that they understood clinically appropriate. For example, appropriate prescribing, cost control their services well, improvements in consider those on over four hours and clinical governance. the analysis and representation of of short burst oxygen a day, or these large amounts of data often under eight hours of long term To this end the work stream was ably identified hidden issues. oxygen therapy. supported by the NHS Improvement - These improvements also enabled the Lung senior analyst who worked sites to provide evidence of with the project teams in the improvement to themselves and their development of a monitoring commissioners. dashboard and helped them understand and overcome the10
  10. 10. Improving the quality and safety of home oxygen services: The case for spread visits’ (Which include refills, By using a simple desktop database Here are a few points to installation, risk assessment and such as Microsoft Access, the NHS bear in mind when removal of equipment) and Improvement - Lung senior analyst developing a local data equipment rental charges (itemised was able to increase the efficiency dashboard by type of supply). and quality of the data provided to the HOS-AR teams. The resulting • Choose a few, focused Knowing where to start, and working Access database tool enabled: metrics to drive with the comprehensive data now improvement. supplied by the oxygen suppliers is a • Automation of simple data • Be pragmatic – it’s not daunting and intimidating task for processing tasks. easy to get perfect data, many. • Reduction of the repetition of data and often simple data is processing in Excel. more useful. Many teams start with the • Introduction of ‘reports’ to highlight • Present the data in a spreadsheet, adding filters, patients to review, and combining simple way that makes the highlighting rows of interest, and also key data onto a single patient page. progress and goals clear. adding columns to total costs. This • Production of more complex reports We found a dashboard would often be a complex procedure, – summarising transactions, was a helpful tool. and is usually reliant upon one identifying outliers and risky data. • Remember data is an individual to process the data. • A single page helpfully summarising essential part of HOS-AR – the oxygen usage data for a patient without it, we often do The data often resides in separate which was well received by not know who our tables for transactions, patient clinicians. patients are or whether invoices and concordance reporting, our patients are receiving and so linking data items together Use of the Access database tool at benefit from this life requires the home oxygen service times required the support of data prolonging therapy. lead to swap between different files, experts to set up – but it was writing down patient ID’s to anticipated that any future compare. It became evident that maintenance would be minimal as support to process and analyse the the data supplied from the oxygenFuture work – tools to interrogate data was required. providers has an established format.oxygen supplier data under thenew contractThe new contracts for home oxygensupply commenced at the end of the Key learning arising from using this database approachhome oxygen improvement projects,which made it difficult for some 1. There are sometimes discrepancies between the number of cylindersproject sites to provide consistent charged for by providers and the number of cylinders ordered fordata during the transition. patients. 2. The types of cylinders provided may not those specified on theThe new data provided by oxygen order form.suppliers is very comprehensive and 3. Large numbers of cylinders are still being held in patient homes,includes information on the ordered highlighting potential danger.supply, the reported use of the supply 4. Patients are often receiving visits for refill of cylinders multiple timesand a waste estimate. In addition, it per month, sometimes multiple refills per week.now itemises the number of ‘service 5. There is frequent use of urgent supply services. 6. Clinically inappropriate supply is still occurring in some instances. 11
  11. 11. Improving the quality and safety of home oxygen services: The case for spread2: Learning from the prototype projects2.1 Components of a qualityHOS-AR model 1. Commissioned Service (including service specification and referral criteria)The Department of Health goodpractice guide3 published in 2011 All the project teams felt the need to reinforce the importance ofidentified a number of components having the work undertaken by HOS-AR teams explicitly outlined withinof a Home Oxygen Service the specification of a commissioned service.Assessment and Review and listedthem within appendix 6 of that same This would ensure the sustainability of the service and ensure quality isdocument. defined in terms of key performance indicators and articulated standards.The national COPD project worklooked at these components from a Historically, much of the oxygen assessment work undertaken acrossservice improvement perspective and the country has not been detailed within existing respiratory servicere-articulated them as seven critical specifications and in some respects it can be thought of as beingsuccess factors necessary for practical undertaken ‘at risk’ in terms of sustainability and quality assurance.implementation of an operationalservice model. These are: It is also very important to specify the local referral criteria and define the patients whose care will be managed by the HOS-AR team and those oxygen patients whose care is perhaps managed elsewhere e.g. cardiology dept. The Department of Health recently published a commissioning specification5 for home oxygen assessment and review which is also supported by a patient guide jointly developed by NHS Improvement and the British Lung Foundation and available at www.improvement.nhs.uk In addition to the commissioning specification the Department have also produced a costing tool which can be used to evaluate the potential benefits of introducing a commissioned service. Both of these resources are available at www.dh.gov.uk/health/2012/08/copd-toolkit 2. Initial formal assessment (in accordance with good practice) It is critical that patients are formally assessed in respect of their clinical need for oxygen before any oxygen supply is issued to patients. As well as determining whether the patient is hypoxic or not, the patient will be assessed to ensure they are receiving optimal care in respect of their condition and potentially referred to other specialist services if appropriate.12
  12. 12. Improving the quality and safety of home oxygen services: The case for spread3. On-going review (frequency laid down within guidance)The condition of many Oxygen patients is often subject to change and so it’s important that the therapy they arereceiving is still appropriate to their clinical need. Oxygen is a life prolonging therapy and so it’s vitally importantthat the prescription a patient is subject to is ‘fit for purpose’.The vast majority of oxygen patients are affected by respiratory conditions and as such the DH good practiceguide published in 2011 sets out the gold standard in respect of review frequency.However a significant number of patients are affected by other conditions such as Heart Failure or Cancer and assuch the healthcare professional (HCP) managing the patient’s condition should do so in line with their ownmedical specialty guidelines.4. Workforce competence in: (i) assessing and reviewing clinical need, (ii) modifying home oxygentherapy and (iii) identify complications or signs of deterioration needing additional’ management oronward referral to a specialist.Complications in respect of an oxygen patient’s condition often arise and so the HCP should be able to spotsignificant factors and either appropriately intervene or refer the patient to a colleague skilled in this aspect ofcondition management.Thus it is imperative that the HCP undertaking the assessment is competent to do so and that appropriate liaisonwith a consultant is an integral part of the HOS-AR.5. Integration with respiratory care and coordination with non respiratory specialtiesIntegration of HOS-AR within the wider respiratory care pathway provides opportunity for improved patientexperience as well as the opportunity to optimise clinical management.Multi-disciplinary team meetings, shared information systems and well understood patient pathways, treatmentgoals and care protocols all support service integration and also improve the responsiveness of services tochanges in a patient’s clinical condition.There are also natural synergies in terms of the organisation of care and a good example of this is pulmonaryrehabilitation and ambulatory oxygen assessment and provision.A significant proportion of home oxygen patients have non respiratory conditions such as heart failure orspecialist palliative care requirements. Whilst the HOS-AR may not necessarily manage the care of these patients(although some teams do operate shared care arrangements) it’s important to have good lines ofcommunication with these specialties. This ensures care is coordinated enables the HOS-AR team (andcommissioners) to understand the basis upon which these non-respiratory colleagues initiate oxygen and also thearrangements in place for patient follow-up by these specialties. 13
  13. 13. Improving the quality and safety of home oxygen services: The case for spread 6. Clinical and supplier data management Collaboration between clinicians and managers around the effective use of data is vital to achieving safe, appropriate and cost effective home oxygen prescribing. Clinicians can advise whether patients flagged as outliers in terms of oxygen consumption are at risk or in receipt of inappropriate therapy. Managers and clinicians together can use the data to performance manage their local oxygen supplier and familiarity with equipment and charging mechanisms enables the identification of opportunities to appropriately rationalise therapy. 7. Education of patients and HCPs (treatment goals/safety/risks) The HOS-AR team’s role in supporting supplier performance management and their involvement in prescribing cost control are obvious incentives for commissioning assessment and review teams. Perhaps another equally value-adding function the HOS-AR team undertake is patient and healthcare professional (HCP) education. The goals of home oxygen therapy are often equally misunderstood by non (oxygen) specialist healthcare professionals and the general public alike, and much effort is expended on an ongoing basis to tackle through education the inappropriate prescribing of oxygen for breathlessness. In addition there are many risks associated with incorrect use of oxygen therapy especially as regards fire hazards and tubing-related trips and falls. The HOS-AR team are more likely to be aware of changes to home oxygen equipment and so they can support other specialists who perhaps need to prescribe oxygen for their patients.14
  14. 14. Improving the quality and safety of home oxygen services: The case for spread2.2 Practical service models The Oxfordshire project team during a process mapping eventThe five project teams undertakingthe prototype project work cover verydifferent geographical locations andemploy varied staff groups.Respiratory nurse specialists are by farthe most widely represented clinicalstaff group but teams do alsocomprise of respiratoryphysiotherapists, physiologists/clinicalscientists and pharmacists/pharmacytechnicians.In addition, the wider project teamsinvolved (and sometimes wereled by) non clinical managers a) the workforce has the The costing tool uses actual historicalfrom commissioning, medicines competences to: oxygen consumption in conjunctionmanagement, information • assess, review and modify home with old and new supply contractmanagement and finance. oxygen therapy prices and applies assumptions in • optimise or recommend strategies relation to workforce (reflecting theSome of the teams were based in for optimising a patients overall Oxfordshire model) clinic and homecommunity based premises whilst management visit frequency and duration in orderothers operated out a hospital • recognises when complex or to generate a model of the potentialsetting. The majority of teams had unusual presentations require cost impact of introducing HOS-AR.access to consultant physician advice specialist intervention.and worked as part of a wider The tool does not try to quantify therespiratory care pathway. b) the service is accessible and benefits arising from improved operates on a basis that reflects the patient care and whilst it does allowSome teams undertook other local populations need and you to tailor assumptions to morerespiratory management duties in to preferences. accurately reflect local priorities itaddition home oxygen assessment should be remembered that it is aand review and it also varied as to c) the service is viewed as responsive, model all be it a very useful one andwhether or not teams had clinical integrated, cost effective and can not for example convey theresponsibility for non–respiratory sustainable by local commissioners. importance of home oxygen as ahome oxygen patients. constituent part of an admission The Department of Health have avoidance strategy.A table summarising the variation in developed a COPD commissioningworkforce model is shown on toolkit which includes a best practicepage 16. service specification and costing tool to support the commissioning of aIn terms of service models what high quality home oxygen assessmentseems to be important in supporting and review service. These resourcesquality assured HOS-AR is that: can be accessed by visiting www.dh.gov.uk/health/2012/08/ copd-toolkit 15
  15. 15. A table summarising the variation in workforce models across the home oxygen project teams16 Service as at January 2012 Oxfordshire Derby Salford Stockport Hampshire Derbyshire PCT Andover Lymington Basingstoke, Fareham Southampton Portsmouth Isle of Wight (south) & Derby N.E Hampshire City PCT and Farnham HOS patients 520 600 480 340 640 Patient management 280 patient 381 patient 259 patient 400 patient 300 patient case load case load case load case load case load Respiratory Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Heart failure Yes Yes Yes Yes No Yes Yes No No No Cluster headache Yes Yes Yes Yes No Yes No No No Palliative care Yes Yes Yes Yes No Yes No No No No Paediatrics Do not Rx O2 Not clinically but No No No No No No No No No for paediatrics manage equipment but support & data once on O2 and monitor usage Workforce 2.6 WTE band Band 7 full Time Band 7 respiratory Band 7 COPD Nurse 2 x Community 2 WTE Band 7 1.6 WTE band 7 2 X Band ? 1.0 wte 37.5 Band 7 1 WTE 0.6 WTE band 6 nurses Nurse Practitioner nurse specialist (1.28WTE), plus Band Matrons Respiratory Specialist nurses and 1 band Respiratory Band 6 Physio 37.5 hours 6 nurse (at (1 WTE), Band 6 (1 WTE), Band 6 8a COPD Nurse (0.13 Nurses and 1 x WTE 6 nurse plus Respiratory Nurses Band 6 0.5 WTE recruitment Nurse Assessor (28hrs Specialist Pharmacy WTE), GPwSI 0.05WTE), Respiratory Specialist Physiotherapist (? WTE) Nurse 18.75 hours phase) week 0.75 WTE) Technician Band 3 Admin (0.5WTE) Physiotherapist led Amb. O2 assessments Dedicated 1 WTE Fulltime project Yes – post improvement Yes No Yes 19 hours No No 0.2 wte 7.5 Band 3 0.27 WTE 0.6 band administrative administrative support officer project – now have a per week Admin Admin assistant 2 admin support hours band 3 (1WTE) 10 hours Do the HOS-AR Yes No Yes – non O2 patients Yes Yes Yes Yes No No No Yes clinicians manage under ongoing review, other (non-oxygen) eg. ILD patients to respiratory patients? determine O2 need if not already on therapy Clinical support 1 hour per week Consultant Respiratory Nurse Respiratory Nurse Consultant 3 X Consultant Consultant Consultant Consultant Consultant Consultant of respiratory Physicians Consultant Consultant GP with a Physicians Physicians Physicians Physicians Physicians Physicians Physicians consultant input. Consultant specialist interest in Physicians respiratory medicine Integrated working Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes withwider respiratory pathway? Improving the quality and safety of home oxygen services: The case for spread Operations Clinic- Mon, Wed Home visits, Home Visits Monday to Daily clinics spread over Monday - Friday clinics Monday to Fri clinics Monday to Wednesday and Monday clinic and Thursday Community Clinics, Friday. Clinics once a 3 locations Home visits 08.00-16.00 in varying locations Friday incl. Friday clinics, Home Home visits Tuesday (9 to 5)Home visits – Acute Ward visits month at 3 venues Monday to Wednesday visits Monday to to Friday incl. Mon-Friday (9 to 5) across the city incl. Thursday clinic Friday incl. Clinic location Hospital and Hospital and Hospital Community Community Lymington New Hospital and Community Hospital Hospital Hospital and Community Community locations *3 Forest Hospital Community Community only at present Home visits Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
  16. 16. Improving the quality and safety of home oxygen services: The case for spread2.3 Issues and challenges The Derby team had historically had a The administrative and data challenge with inappropriate management requirements of HOS-Analysis of oxygen usage data, prescribing arising from General AR are a challenge that all teams heldprocess mapping exercises Practice. With support from the in common. Incomplete informationundertaken individually with project national programme senior data upon referral often meant that highlyteams and knowledge exchange at analyst and the use of data skilled clinical resource spent a lot ofcollective project cohort peer support dashboards they were able to time trying to establish a moreevents uncovered both differences establish that GP prescribing of home complete clinical picture of patients inand similarities as regards the issues oxygen was now significantly reduced advance of their appointment.and challenges faced by the teams in and that the current sources ofimplementing high quality HOS-AR. inappropriate prescribing were based In some instances this was addressed in the hospital setting. somewhat by more complete andHistorically, the clinic DNA rates in robust referral processes andboth Salford and Stockport had been In Oxford the process mapping documentation and by reinforcing/re-identified as problematic and so to exercises highlighted that slight launching referral criteria.this end both teams had searched for variations in practice had arisenways increase their capacity to among the team in response to However, the need to monitorundertake home visits. specific clinical scenarios. The team oxygen usage data and keep track of had a long-standing practice of guideline mandated review datesSalford, prior to starting the project holding regular clinical update and does require administrative support.had already reduced the number of knowledge sessions and so theyclinics they performed in order to provided a forum to ensure 2.4 Overall project cost savingsincrease their capacity to undertake consistency across the team was re-home visits. established. The HOS-AR teams included within the prototype project cohort hadHowever, by analysing the processes In Hampshire, both the data analysis already demonstrated to theassociated with an individual and the series of process mapping satisfaction of their localassessment clinic they spotted events with teams across the county commissioners their ability toopportunities to change practice and supported a gap analysis in respect of prescribe and rationalise homereduce the duration of the initial adherence to national standards, oxygen therapy in an appropriate andoxygen assessment. This enabled resource constraints and potential cost effective manner prior tothem to create additional capacity for variations in prescribing behaviour. embarking upon this phase of work.a dedicated clinic for palliative oxygenassessment. This information further informed the Prior to the project work many of the development of a Pan-Hampshire teams had already comprehensivelyStockport also reorganised their service specification and provided the reviewed supplier concordance andclinics and increased home visits basis for a service investment invoice data, cleansing the data ofcapacity. They overcame the business case. anomalies (such as charges forchallenge of requiring two staff per deceased patients, multiple datahome visit (in order to transport entries for a single patient etc) andlaboratory style blood gas analyser had married this data with clinicalequipment and concentrators) by the information to create home oxygenadoption of portable blood gas patient registers or actual databases.equipment 17
  17. 17. Improving the quality and safety of home oxygen services: The case for spread 3These teams were already routinely Best estimates seem to indicate that Although the prototype project sitesupdating these registers establishing the prototype teams were on target had completed thorough datacycles of patient therapy assessment to achieve an average of £100,000 validation exercises, there were stilland review and identifying candidate per site in HOS-AR related annual opportunities for further savings frompatients for therapy alteration/ prescribing cost efficiencies (based reviewing data on a regular basis.removal post clinical review. upon comparison with the annual spend in 2010/11), resulting in a This finding only serves to reinforceThe prototype works main thrust was collective workstream annual forecast earlier workstream learning about theto identify key elements in the saving of approximately £570, 000. need for HOS-AR teams to have aimplementation of quality assured, regular plan to review data and notsafe and appropriate home oxygen Despite the intrinsic cost efficiencies see it as a one off exercise.therapy. deriving from the new national oxygen supply contract, there is still The absence of regular data reviewHowever, NHS Improvement - Lung the potential for costs to rise if will inevitably lead to a slow increasewas also interested in these teams patients are not initially assessed for in costs. Although the new supplyability to continue the tight control of their need for home oxygen therapy contract does include large penaltiesany increases in expenditure by healthcare practitioners who are for supplier data errors, the newassociated with optimised therapy or both thoroughly familiar with the contractual arrangements are notuncovering unmet need. various equipment modalities and sufficient to deliver the data quality also acquainted with current charging improvements alone.It was therefore of considerable structures.interest that many teams were still This is particularly the case for thoseable to demonstrate cost savings HOS-AR team clinicians across the suppliers who are dealing with a(prior to oxygen supply contract country attend on an ongoing basis legacy of equipment and inaccuratetransition and its inherent contractual the oxygen device training sessions historic data.cost efficiencies) through appropriate held by the oxygen suppliers and sohome oxygen prescribing and therapy have a complete understanding ofrationalisation. the range of equipment available and also each device’s suitability for theDifficulties in ascertaining consistent different presenting symptoms anddata in the immediate aftermath of changing patient clinical needs.the supply transition (which for most HOS-AR teams are also best placed toteams took place during the mid- prescribe a treatment modality whichpoint of the project) made it difficult is both clinically appropriate but alsoto differentiate between savings from cost effective – a generalist or aHOS-AR related functions and those specialist clinician who has notbenefits deriving from a more undergone this training is unlikely toefficient contract. be able to do this on a consistent basis.18
  18. 18. 3: Case studies Improving the quality and safety of home oxygen services: The case for spread 3.1 Oxford Health NHS Foundation Trust Improving and fine tuning Oxfordshire’s Home Oxygen Service What was the problem? Oxfordshire’s home oxygen service has been operational for approximately three years and is recognised nationally for having successfully improved patients experience as a result of appropriate and cost effective oxygen therapy prescribing undertaken by trained professionals. Staffing changes had created an identified skills gap and the service was subject to an ongoing commissioning requirement to remain both high quality and cost effective. The team also identified areas for improvement such as smoking related incidents, out-of-hours coverage and • Develop a risk assessment tool in Through contact with clinical teams 100% underuse of prescribed oxygen order to formally risk assess patients across the country at NHS therapy in a large number of patients. who smoke Improvement-Lung peer support In addition, the team wanted to • Manage the transition to the new events the team were able to reflect make a smooth transition to the new oxygen supplier. upon their clinical practice and oxygen supply contract. capture ideas for potential new What did they do? ways of working. What was the aim? The team allotted project The project team sought to improve responsibilities and met regularly with What has been achieved? the quality and standards of the support from NHS Improvement-Lung Process mapping enabled the team to service in three areas: in order to refine their aims and examine differences in the service 1. To reduce the number of patients objectives, plan project activities, across the county and confirm the with significant (100%) underuse identify stakeholders, review the skills required at different parts of the of prescribed oxygen therapy by patient journey and undertake pathway. It was also instructive in 25% process mapping (with the ensuring that all members of the 2. To reduce smoking related commissioner in attendance). team were applying a consistent incidents clinical approach. 3. To reduce the cost of prescribed The team also undertook a demand oxygen by 10% over one year. and capacity exercise in order to better understand the impact of They planned to achieve this by travelling and administration on meeting the following objectives: face-to-face time with patients. • Review and update patient pathways • Develop a new competency framework • Train staff and ensure competency in key areas 19
  19. 19. Improving the quality and safety of home oxygen services: The case for spreadIn terms of the stated objectives What are the key learning points?the team: • The importance of risk• Reduced under users from 115 to identification (in general) and 54 (53% reduction) shared awareness among the team• Began development of a smoking in respect of patients who pose a risk assessment too higher risk due to smoking• Increased teams awareness of • Service improvement methodology smoker safety and general oxygen provides effective tools for safety identifying ‘risk’ areas and areas for• Developed greater awareness of quality improvement service demands • Knowledge exchange with other• Reduced oxygen costs by 12% teams (and opening pathways of from September 2011 to April local and national communication) 2012 promotes the development of new• Gained insight into team member ways of working knowledge levels and began • The importance of regularly implementing a competency evaluating clinical knowledge framework among the team in respect of more• Started weekly training sessions to complex patients (CO2 retention, improve the knowledge and skill hypercapnoea, use of oxygen in mix (e.g. maintain competences in exacerbations etc) and the value in arterial blood gas measurements) implementing ongoing training.• Successfully managed supply contract transition which was Contact initially characterised by significant Jo Riley increase in calls from patients Respiratory Service County Lead• Implemented an out of hours Tel: 01865 225472 oxygen ordering pathway Email:• Exploring the use of portable joanne.riley2@oxfordhealth.nhs.uk (capillary) blood gas analysers on home visits and acquiring Sophie Beveridge equipment through cost savings. Respiratory and Home Oxygen Service Nurse Tel: 01865 787185 Email: sophie.beveridge@oxfordhealth.nhs.uk20
  20. 20. Improving the quality and safety of home oxygen services: The case for spread3.2 NHS Southampton, Hampshire IoW Portsmouth; SHIP PCT ClusterThe Hampshire Model for the Home OxygenService - Assessment and ReviewWhat was the problem? Specific project objectives included:Considerable differences in the type • Gap analysis - to understandof service experienced by home levels of compliance with nationaloxygen patients across Hampshire standards in respect of HOS-ARwere known to exist as a result of the • Staffing review - to understandway the teams undertaking home the workforce variations across theoxygen service – assessment and countyreview (HOS-AR) had evolved in the • Care pathway review - todifferent geographical localities. understand differences in the patient journey experienced acrossIn many instances these different the county.service models reflected differences inlocal need but they were also a What did they do?reflection of differences in local Pathway analysis: A series offunding arrangements and process mapping events weredifferences in the interpretation of initiated across the county involving(and compliance with) national the home oxygen teams situated inguidance. Lymington, Fareham and Basingstoke respectively. This was supported by use of theIn addition, the impending change in data dashboard devised by the NHSoxygen supply provider and This enabled differences in clinical Improvement-Lung senior analyst andcontractual changes necessitated practice to be identified and the liaison with both the outgoing andfurther strengthening in the specific local challenges and resource incoming oxygen supply providers.arrangements for monitoring oxygen constraints documented andusage in preparation for the understood. Service planning: The team alsotransition by building upon recent reviewed NHS Improvement nationalanalyses of patient concordance. In addition, the teams in Isle of publications, the Department of Wight, Southampton and Portsmouth Health (DH) Good Practice Guide,What was the aim? provided information about local early versions of the DHThe aims of the project were to resources and the patient journey by Commissioning toolkit for COPD &1. Develop robust Pan-Hampshire completion of a mapping table Asthma and the DH Specification for service plans, specifications and a questionnaire. HOS-AR in order to develop a Pan- business (investment) case which Hampshire service specification and reflected national guidance Data management: Work on the business case framework which can2. Further improve data management analysis of patient concordance was support the development of local to achieve ongoing active intensified to gain an accurate picture investment cases by constituent monitoring of oxygen usage and of usage activity in each location and clinical commissioning groups (CCGs) ensure the successful transition of an understanding of the variations in across the county supply in March 2012. prescribing costs across the county. 21
  21. 21. Improving the quality and safety of home oxygen services: The case for spreadWhat has been achieved? What are the key learning points?A better understanding of the 1. Differences in service modelsdifferences in service models and across the county did notdelivery across the county has necessary imply differences inenhanced the ongoing discussions service quality. However,taking place between the service differences in adherence toprovider organisations and the national guidance could be acommissioners of the services. source of service inequality especially in respect of ongoingThe Pan-Hampshire service clinical review.specification has been accepted by all 2. Differences existed across theconstituent CCGs across the county county in terms of the prescribingand its recommendations in respect cost per patient and this mightof service levels will be reflected in also be attributable to differenceslocal service performance indicators. in each teams capacity to review patients changing clinical needThe various options outlined in the (and modify therapy) or differencesPan-Hampshire business case have in the use of oxygen deviceprompted a number of CCGs to modalities especially in relation toconsider investment in their local palliative care.HOS-AR to ensure compliance with 3. Significant clinical time is taken upgood practice and to also examine by routine administration as athe extent of wider respiratory service result of lack of admin. support.integration. 4. Clinical teams lacked consistent and concise information andGood lines of communication were central management supportestablished with the incoming oxygen concerning home oxygen patients.supply provider and home oxygenpatients who were concordance Contactoutliers were identified and flagged Chris Sladeup with clinical staff for review and Clinical Networks Manager Tel. 02380 627672 / 07833293074 Email: chris.slade@hampshire.nhs.uk or chris.slade@nhs.net22
  22. 22. Improving the quality and safety of home oxygen services: The case for spread3.3 Derby Hospitals NHS Foundation Trust,Derbyshire County PCT, Derby City PCTService improvement review to ensuresustainability and consistency of the DerbyshireHome Oxygen ServiceWhat was the problem? What was the aim?The introduction of home oxygen The project aimed to address theseservice-assessment and review (HOS- problems by developing andAR), with blood gas monitoring implementing plans to:available both within clinic and home 1. Improve data coordination, analysissettings, and the establishment of and reporting by reducingclinical and oxygen supply usage data administrative duplication,review and management had enabled inconsistent recording and gettinggreat strides to taken in addressing greater clarity around lines ofhistoric problems of inappropriate reporting.oxygen prescribing and sub-optimal 2. Achieve greater consistency ofmanagement together with message among healthcareinequalities of care associated with professionals in terms of thepatients varying ability to travel to message to patients and in termshospital for assessment or review. of the goals of therapy. 3. Identify clearly who, where andThis had enabled the newly why home oxygen was prescribedestablished service to meet all its through improved.initial quality and financial measures 4. Improve ambulatory oxygen • The team worked with the NHSduring its first two years of existence. assessment and monitoring Improvement - Lung senior analyst procedures. to develop data dashboards whichHowever, problems still remained 5. Improve the removal pathway for would more easily enable thewith many local healthcare patients without a clinical tracking and monitoring of oxygenprofessionals still not familiar with the requirement for home oxygen. usage and prescribing.principal goals of oxygen therapy • An initial demand and capacity(addressing hypoxia) resulting in What did they do? exercise was undertaken to identifyinappropriate therapy initiation. • The team undertook a process ways of increasing service capacity. mapping event and involved • Patient information literature wasMany patients understanding about patients, community and hospital- revised in order to strengthenboth their condition and their therapy based respiratory staff together messages about the goals ofwas still variable and the with colleagues from palliative care, oxygen therapy and also the safeadministrative and governance IT and the Trust transformation and effective use of equipment.processes for the local HOS-AR department.needed to both keep pace with the • Patient referral forms and datachanging primary care landscape and entry processes were reviewed toenable greater analysis and reporting. capture redundancy and identify areas for improvement. • Ongoing dialogue and training was undertaken with the (new) in- coming oxygen supplier in order to manage the transition to a new supply contract. 23
  23. 23. Improving the quality and safety of home oxygen services: The case for spreadWhat has been achieved? What are the key learning points? Contact• Inappropriate prescribing has been • Changes in respect of the new Sue Smith reduced by establishing a local HOOF were initially a source of Specialist Practitioner for consensus among healthcare frustration for GPs and Consultants Home Oxygen professionals about the use of the but these changes have now been Tel. 01332 787825 new part a/b Home Oxygen Order agreed. Email. sue.smith31@nhs.net Form (HOOF). • Access to data, and critical review,• Prescribing guidance for all has been particularly valuable in modalities of oxygen is now more identifying the priorities and closely aligned to national objectives for the service. standards and best practice and as Previously, the team believed that such is both tighter and clearer. It they had issues with GP has also been made widely commenced HOOFs, however the available and is being incorporated data suggested that this was no into the Trust website. longer the case. This indicates that• Data harmonisation work has made both the original work has been a progress and all (clinical and supply success, but also that resources usage) data will be entered onto could now be focused elsewhere in System1 to enable it to be accessed order to achieve improvements in across the multi-disciplinary team. areas of a greater need – the team• The new patient information leaflet are considering supporting in- has been well received and the hospital prescribing. quality of prescribing has improved • Service Improvement has become a with a shift from 60% of patients key part of the team’s thinking, having an optimal oxygen and ensuring that they have prescription to 90%. evidence has been helpful for the• A thorough review of the team, but also in supporting governance arrangements in discussions with commissioners. respect of oxygen therapy and • The team could have continued persistent smokers has been being ‘good enough’ – the service undertaken inclusive of liaison with improvement work has encouraged expert legal counsel. them to think critically and aim for better.24
  24. 24. Improving the quality and safety of home oxygen services: The case for spread3.4 Salford Royal NHS Foundation TrustMaintaining a safe, cost effective and accessibleHome Oxygen Therapy Service (HOTS)What was the problem?Home oxygen service – assessmentand review (HOS-AR) had beensuccessfully introduced in Salford in2008 with the establishment of theHome Oxygen Therapy Service(HOTS). Robust referral processeshad been implemented and the HOTSteam were part of an integratedrespiratory service. They also hadvery strong links with other non-respiratory disciplines.The team had access to supplierinvoices and reports which they usedto monitor oxygen usage, the sourcesof prescribing and also the range ofclinical conditions existing amongpatients in receipt of home oxygen What was the aim? What did they do?therapy. A safe, cost effective and accessible The team undertook a number of home oxygen service was a local project activities in support of theThe use of an electronic referral priority and so the primary aim was above objectives:proforma (incorporated within local that 95% of all HOOFs originate fromGP computer systems) together with the HOTS team (5% allowance for Multidisciplinary engagement: Asystematic changes to clinic venue paediatric and end-of-life patients). process mapping event involvinglocations and the establishment of Continuous service improvement numerous staff types, assortedhome visit clinics improved access to would be achieved by: medical specialties and stakeholders.HOTS significantly. This highlighted areas for • Reviewing HOTS referral processes improvement both in respect ofHowever, each month there remained and documentation clinical and administrative processes.a small number of new Home Oxygen • Continued integration of HOTS It also illustrated the evolving role ofOrder Forms (HOOFs) originating with wider respiratory team to the HOTS team and raised awarenessfrom outside of the HOTS team and support delivery of a high quality of issues across the wider respiratoryinitiating home oxygen in un-assessed COPD care bundle care pathway.patients. This was of great concern • Greater links with end-of–life carersas the HOTS team were uncovering and staff to ensure appropriate, Change in clinical practice: Further(un-assessed) home oxygen therapy beneficial and cost-effective home low-level mapping of the actualpatients with chronic type 2 oxygen prescribing, therapy oxygen assessment process promptedrespiratory failure for which oxygen alteration and follow-up the team to continue taking bloodtherapy could be potentially harmful. • Continued monitoring of home gas measurements on air in both the oxygen usage data to support first and subsequent (three week) transition to a new oxygen supply clinic visit but to undertake titration provider, maintain clinical on oxygen (to target oxygen governance and ensure cost- saturations) in the three week clinic effectiveness assessment visit only. 25
  25. 25. Improving the quality and safety of home oxygen services: The case for spreadMany patients present with markedly What has been achieved? What are the key learning points?improved blood gas levels at the Home oxygen prescribing – The aim • Process mapping supports thethree week assessment and so the of ensuring safe quality assured identification of opportunities tooriginal titration exercise was prescribing of home oxygen though quickly change both clinicalunnecessary. In addition, patients the 95% HOOF target has been met. practice and also the organisation(with no known heart failure This was accompanied by continued of care processes.diagnosis) who have a PaO2 > 8.3kPa month-on-month reductions in • Multidisciplinary involvement inat the first initial assessment are prescribing costs in the months service re-design enablesreferred back to their GP with advice preceding the transition of oxygen consideration of the wholefor subsequent re-referral to HOTS if supply (which is likely to introduce pathway of care and identificationthe patient deteriorates. Previously further cost efficiencies). of areas for improvement outsidepatients were kept under review if the immediate project scope.their PaO2 < 9kPa Increased assessment clinic capacity – • Quality assured prescribing and cost Initial assessment clinic duration times efficiency will only be maintainedAdministrative and data have been reduced through the by continual monitoring of oxygenmanagement changes: The referral change in practice, reducing waiting usage by the HOTS team and tightform was altered to include times for new referrals and enabling control of HOOF prescribing.additional information to establish an additional clinic slot for urgentthat patients are medically stable assessment for palliative oxygen. Contactprior to assessment. The involvement Melissa Collingeof the commissioner in the mapping Further safeguards against acute Respiratory Nurse Specialistevents supported the team’s efforts oxygen toxicity - the multi-disciplinary Tel. 0161 206 0865in acquiring administrative support to whole pathway discussions prompted Email. melissa.collinge@srft.nhs.ukhelp improve data management in the routine issuing of oxygen alertadvance of oxygen supply transition cards to all patients in need of nonand oversee the introduction of invasive ventilation (NIV).additional data recording and audittools.The team have also established ageneric email address which allowsfor prompt processing of referrals anda shortened appointment bookingprocess.26
  26. 26. Improving the quality and safety of home oxygen services: The case for spread3.5 Stockport NHS Foundation TrustFit for purpose – clinical quality, costeffectiveness and patient satisfactionWhat was the problem?The Oxygen Assessment Service inStockport (Oasis) and localcommissioners jointly identified theneed to expand the community-based service to enable GPs to referpatients for specialist home oxygenservice - assessment and review(HOS-AR) and also to appropriatelyrepatriate home oxygen patients(whose condition did not requireacute hospital / tertiary centre care)back to the community.The service also needed to preparefor the transition to a new oxygensupply contract, which washappening in parallel with the teamtransferring from the Primary Care • Maximise the cost effectiveness of • Patient reconciliation: PatientsTrust (PCT) to the local Foundation the HOS-AR service whilst prescribed oxygen but not knownTrust, by identifying and minimising the cost of prescribed to the service were identified byimplementing improvements in oxygen reconciling to the oxygen providerservice efficiency, data management • Ensure that oxygen is prescribed (Air Products) concordance reportand prescribing safely, (without causing increased to their patient care records carbon dioxide retention), and only • Audit of GP oxygen prescribing:What was the aim? when clinically beneficial (hypoxic) This enabled the team to estimateThe project was established to • Build close working relationships the numbers of expected GPachieve the following objectives: with other local clinical teams referrals upon commencement of• Review the current service in order managing patients prescribed GP direct access to Oasis to identify both good practice and oxygen and ensure care is • Patient categorisation: Patients areas for improvement consistent across the health were stratified according to disease• Identify gaps in consistency of care economy. complexity, age and prescribing to patients prescribed home oxygen modality short burst/long-term• develop clinical and prescribing What did they do? oxygen therapy in order to support data management systems in order The project team undertook a discussions between clinicians to meet the requirements and number of specific project activities about which patients should be timescale for implementation of a namely: provided full HOS-AR by Oasis new national Home Oxygen supply • Care pathway mapping: The those patients who should be contract (2 July 2012) team process mapped the journey known to the service but managed• Expand the service to ensure that for patients currently cared for by by other specialist services all patients who would benefit from Oasis in order to identify oxygen therapy are offered timely inefficiencies, highlight patients high quality assessment and care who fell outside of the pathways of appropriate to their needs care and reveal inequalities in service provision. This was used to generate improvement ideas 27

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