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Transforming cardiac rehabilitation: celebrating achievements and sharing the learning from the national projects

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Drawing on the experience of the national Priority Projects for Cardiac Rehabilitation (CR) in 2009/10, this second and final publication outlines the next steps in transforming cardiac rehabilitation …

Drawing on the experience of the national Priority Projects for Cardiac Rehabilitation (CR) in 2009/10, this second and final publication outlines the next steps in transforming cardiac rehabilitation in England in terms of the Commissioning Pack for Cardiac Rehabilitation and the next round of National Projects aimed at testing the utility of the Pack in real life settings.

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  • 1. NHS NHS ImprovementCANCERDIAGNOSTICS NHS Improvement Heart Transforming cardiac rehabilitation: celebrating achievementsHEART and sharing the learning from the national projectsLUNGSTROKE
  • 2. Contents Foreword 3 Achievements and key learning points by site 28 Professor Patrick Doherty, National Clinical Lead for Cardiac Rehabilitation, NHS Improvement Contact information for site project managers 38 Reflections from the Clinical Leads 4 Supporting information 39 Professor Patrick Doherty, National Clinical Lead, NHS Improvement and Dr Jane Flint, National Clinical Advisor, The NHS Quality, Innovation, Productivity and 42 NHS Improvement Prevention (QIPP) challenge Introduction 6 Next steps in transforming cardiac rehabilitation 44 Chapters NHS Improvement System 46 1. UNDERSTAND YOUR SERVICE 8 2. ENGAGE WITH YOUR STAKEHOLDERS Cardiac Rehabilitation National Project Team 47 10 3. INVOLVE PATIENTS AND CARERS 12 4. ENLIST CLINICAL LEADERSHIP 14 5. COLLECT, ANALYSE AND MAKE USE OF ROBUST DATA 16 6. SPECIFY YOUR SERVICE REQUIREMENTS 18 7. COMMISSION EFFECTIVELY 20 8. USE RESOURCES WISELY 22 9. COLLABORATE AND NETWORK 24 10. SEE THE BIGGER PICTURE 26
  • 3. Transforming cardiac rehabilitation: celebrating achievements and sharing the learning from the national projectsForewordCardiac rehabilitation (CR) is a vital part of often sub-optimal. These problems are rehabilitation services across the country. I’m delighted that in 2010/11 NHScaring for patients with heart disease. It is an underpinned by the fact that funding and Launched in September 2008, the National Improvement is planning to launch a newevidence-based and cost effective commissioning arrangements for CR are Priority Project identified twelve sites across round of projects to test the utility of theintervention that reduces future mortality largely ad hoc in many areas, with CR seen the country attempting to increase access, Commissioning Packs in raising both theand morbidity and improves quality of life. as an ‘optional extra’ rather than a vital part equity and uptake to CR through quality and efficiency of CR services. of treatment. implementation of the National Institute forOver the past decade, the Coronary Heart Health and Clinical Excellence (NICE) The momentum and enthusiasm for CR hasDisease National Service Framework (CHD All in all, CR remains part of the ‘unfinished recommendations for cardiac rehabilitation been sustained over time by the CHD NSF,NSF) and related initiatives have led to a business’ of the NSF and there is a long way and the associated commissioning guidance. NICE guidance, BACR Standards and Coresignificant reduction in the rate of premature to go to meet the challenge of providing This final report celebrates some of their key Components, National Audit of CR, NHSdeath from CHD with some clear timely access to good quality cardiac achievements, as well as documenting many Improvement Priority Projects and other keyimprovements in CHD services across the rehabilitation. of the invaluable learning points that, once developments in the field that havepathway of care. But there are areas, shared, will help others to drive up standards collectively created an opportunity for largeincluding cardiac rehabilitation, that were 2010 does not mark the end of the CHD of care without reinventing the wheel. scale improvement in CR services. Thenot well positioned to benefit from the initial NSF’s implementation. Much of what is in achievements realised so far are testament tofront line investment and have developed the NSF is as relevant now as it was 10 years Evidence accrued from NHS Improvement the hard work and commitment of all thoseless quickly than others. ago, and its approach continues to stand the and the CR National Priority Projects plus who work in the field. The challenge in test of time. But there is a need to review other clinical areas implementing innovation going forward will be to maintain theDespite the collaborative and sustained and examine why we have been able to suggests that the establishment of robust impetus and sustain improvements so thatefforts of a wide range of partners, make such excellent progress in some areas commissioning arrangements for CR is likely we can build on what we have learnt in theawareness and uptake of CR remains low. but not in others - and we need to do this in to result in improved access, uptake, face of fresh challenges and continue toThe National Audit of Cardiac Rehabilitation the context of the greatest financial coverage and quality. Hidden inside the 38% drive up standards and strive for excellence(NACR 2009) identified that on average only challenge that the NHS has ever faced. Over average uptake are islands of excellence that in cardiac rehabilitation.38% of heart attack, angioplasty and bypass the next few years, at the same time as have made huge inroads to offering highpatients received cardiac rehabilitation in continuing to deliver high quality services quality CR to the majority of patients. With My thanks to all those who have contributed2007/08 and there are marked geographical and ensuring areas like cardiac rehabilitation this in mind, NHS Improvement has been to delivering these marvelous improvements.variations in access to CR services across the that have lagged behind are brought up to working alongside the Strategiccountry. Access for people with different the same high standard, the NHS will need Commissioning Development Unit (SCDU) atcardiac conditions (e.g. people with heart to focus firmly on delivering care much more the Department of Health and other keyfailure) and for various different populations efficiently. partners to develop a Commissioning Pack(e.g. women, black and minority ethnic for Cardiac Rehabilitation. In essence, the Professor Patrick Dohertygroups) is also variable. Many existing Over the life of the NSF, the Department of pack will facilitate more effective National Clinical Lead for Cardiacservices do not meet the minimum standards Health has been working with NHS commissioning of cardiac rehabilitation; Rehabilitation to NHS Improvementand core components set by the British Improvement and the cardiac networks to ensuring the shape of CR services reflectsAssociation of Cardiac Rehabilitation (BACR) spread good practice and to help increase best clinical evidence and use of CRso that the quality of care patients receive is the quantity and quality of cardiac resources are optimal. www.improvement.nhs.uk/heart 3
  • 4. Transforming cardiac rehabilitation: celebrating achievements and sharing the learning from the national projects Reflections from the Clinical Leads The NHS Improvement National Priority commissioning of new services. This has The projects have been a real success in Project for Cardiac Rehabilitation (NPP for culminated in substantial shared learning delivering a measured improvement at a CR) came out of a long standing and experience that has led to major challenging time for NHS services and commitment in the NSF for CHD to deliver innovations in redesigning clinical everyone who participated should be effective rehabilitation as part of patient pathways and specification development congratulated! care following a cardiac event or plus tangible decreases in waiting times procedure. In order to implement this and improved uptake to services. There commitment there was a clear need to have been clear lessons learnt about offer national support to local providers, implementing and measuring quality and Professor Patrick Doherty commissioners and cardiac networks to productivity initiatives many of which have National Clinical Lead for Cardiac develop, implement and evaluate led to new and innovative service models Rehabilitation to NHS Improvement innovative and productive approaches to that will withstand future service addressing national and regional issues of pressures. low uptake and inequalities of access to services. The benefits to patients are also clear in that projects have delivered greater There have been twelve projects within uptake and equity in provision, enhanced one year of inception of the NPP for CR patient risk assessment and safety and a and all have achieved major positive more flexible approach to service delivery changes to their services. The projects, underpinned by patient choice. which were supported by a combination of high quality clinical teams, perceptive commissioners and strongly committed patient representatives, have tackled varying aspects of service delivery or4 www.improvement.nhs.uk/heart
  • 5. Transforming cardiac rehabilitation: celebrating achievements and sharing the learning from the national projectsOur CHD NSF ‘unfinished business’ of The National Cardiac Conference in March The principle of conducting a thorough,Cardiac Rehabilitation (CR) has benefited 2010 allowed us to celebrate the review individualised assessment of cardiacfrom National Priority Projects tackling of the post Primary Percutaneous patents for their rehabilitation andpathways, commissioning and Coronary Intervention (PPCI) pathway secondary prevention needs remainsinequalities, working towards their two following STEMI, there being major central and will be further captured withyear achievements herein summarised. improvement in the approach to use of the Commissioning Pack. Evidence rehabilitation of these patients in leading for the value of CR for people with heartKey learning points from the journey so Networks. The example of PPCI roll-out failure is gathering momentum and thefar provide essential lessons for Networks contained within this document potential for CR to contribute to aand their cardiac rehabilitation exemplifies the need to commit to reduction in occupied bed days andprogrammes: engagement of all improving referral and uptake to CR in all readmissions will help to demonstrate thestakeholders, involvement of patients and cardiac pathways. QIPP value of investment in CR duringcarers, enlisting clinical leadership, and these challenging times.collaborating and networking so there can The encouragement and assessment ofbe effective commissioning. CR development across the English Cardiac Networks 2007-2010 has heldUnderstanding your service, specifying support of Networks and PCTs being able Jane Flint BSc MD FRCPand embedding it within the health to redesign better and sustainable National Clinical Advisor for Cardiaccommunity, collecting, analysing and improvement in patient care at its heart. Rehabilitation to NHS Improvementusing data so resources may be used The Network surveys have revealedwisely in the wider picture, are essential in Network Cardiologist Champions for CRtoday’s constrained financial environment. as well as Programme Lead Cardiologists, many appreciating a ‘Leadership Development’ Day in November 2009. www.improvement.nhs.uk/heart 5
  • 6. Transforming cardiac rehabilitation: celebrating achievements and sharing the learning from the national projects Introduction Over the past decade, NHS The National Priority Project for chairperson and National Clinical Lead, The Project was also keen to ensure Improvement and its Collaborative Cardiac Rehabilitation and Dr Jane Flint, consultant that the following core issues were predecessors have been working with cardiologist and National Clinical addressed: NHS organisations and clinical networks Launched in September 2008, the Advisor, the National Project invited to help transform services and deliver National Priority Project for Cardiac applications which focused on: • Reducing inequalities sustainable improvements across the Rehabilitation (CR) selected nine • Increasing access to and information entire pathway of care in a number of projects, comprising 12 NHS sites from • Identification and active engagement about CR services clinical specialties- most notably cancer, across the country supported by the of eligible CR participants using a • Engaging patients/carers/families in diagnostics, heart, stroke and now lung Cardiac and Stroke Networks, to drive systematic and structured approach planning services services. Working closely with the forward improvements in cardiac • Development of mixed models of • Workforce and multi-disciplinary Department of Health, NHS rehabilitation services. The overall aim provision tailored to meet the needs team approaches. Improvement’s agenda is closely aligned of the National Project was to increase of individual patients to national priorities and the access to, equity of provision for, and • Relevant rehabilitation for groups less Published twelve months after the organisation plays a key role in uptake of CR services for patients likely to access the service such as commencement of the Project in supporting the delivery and having heart attack and/ or women or ethnic minorities October 2009, the interim report on implementation of national health revascularisation, in line with the • Development of exercise components the Cardiac Rehabilitation National strategy. National Service Framework for CHD. In designed to meet the needs of older Priority Project: Lessons and Learning doing so, the Project sought to pilot people or those with significant One Year On effectively summarised Using tried and tested improvement implementation of the NICE co-morbidities the key learning from across all the methodology in addition to novel and recommendations on cardiac • Joint agreement, planning and sites and aimed to share the initial innovative approaches, NHS rehabilitation- as outlined in the NICE commissioning of services across outputs, outcomes and improvements Improvement is working with a wide Clinical Guidelines on MI: Secondary hospital trust, GP practice, PCT and with a wider audience. range of partners to test, model, prevention (NICE CG48, 2007)- utilising social/leisure services and at network implement and spread the core the subsequent NICE Commissioning wide level improvements and ‘winning principles’ Guide for CR services (2008). • Exploration of the feasibility of a which have been shown to increase generic rehabilitation model efficiency and drive up quality in Co-ordinated by Linda Binder, National encompassing other disease patient care with the aim of making Improvement Lead for NHS modalities. services better for patients and staff. Improvement, and supported by Professor Patrick Doherty, BACR6 www.improvement.nhs.uk/heart
  • 7. Transforming cardiac rehabilitation: celebrating achievements and sharing the learning from the national projectsBuilding on the ‘One Year On’ report These key learning points and the In addition to the themed chapters,this second and final publication has achievements to which they relate have Transforming CR forges links betweenbeen produced to celebrate success been distilled and grouped under a the improvements listed and theand to highlight the major series of chapter headings, themes or requirement for all NHS services toachievements across participating sites. common threads, which effectively focus on quality whilst at the same timeIn line with the raison d’être of NHS represent the main ingredients in the achieving greater efficiency. It outlinesImprovement, Transforming CR: recipe for CR improvement ‘success’ next steps in transforming CR in termsCelebrating Achievements and Sharing across the projects. of the forthcoming CardiacLearning from the National Priority Rehabilitation Commissioning Pack andProjects aims to extract the key learning As part of NHS Improvement’s the next round of National Projectspoints from the Project and share them commitment to reducing its carbon aimed at testing the utility of the Packwith a wider, national audience. In footprint, Transforming CR has been in real life settings. Last, but by nodoing so, it endeavours to demonstrate designed to be read in electronic means least, Transforming CR points tohow cardiac rehabilitation services can format with a limited print run. In other useful sources of guidance,drive up quality whilst improving keeping with this, and in order to share advice and information, including fullefficiency and achieve alignment with the learning in a more concise and contact details for each project site.the overall strategic direction of the user-friendly manner, the learningNHS. points and exemplar achievements have Generous thanks are extended to been stripped down to their everyone who has contributed toThe development of Transforming CR fundamental core and presented in list Transforming Cardiac Rehabilitation byhas been a collaborative and iterative format. A summary of achievements sharing experiences, learning,process. In May this year, project leads and key learning points can be found knowledge and guidance.for each participating site were invited on page 28. Full transcripts of theto attend a telephone ‘interview’ to interviews with individual project siteshare just three headline achievements leads are available for download atfrom their work - a difficult task in itself www.improvement.nhs.uk/heart/given the number and quality of cardiacrehabilitationimprovements in CR services across theNational Project - and to detail any keylearning points associated with eachachievement. www.improvement.nhs.uk/heart 7
  • 8. 1. UNDERSTAND YOUR SERVICE “ Understanding your existing service is an essential first step in redesigning processes to make them better for patients and staff Understand Your Service Improvement is all about continually In order to really get to grips with improvement, to find out which Full transcripts of interviews with ” working together to improve the improvements will make the biggest individual site managers are experience and outcomes for patients difference and what benefits can be available to download at: and users and looking for other ways achieved as a result, it’s really www.improvement.nhs.uk/heart/ to provide health care that important to understand where you cardiacrehabilitation continuously improves the way it are now. Examining your current meets the needs of those who depend service, exploring the environment on it and the working lives of the staff and context that it exists in, and who provide it1. gathering insight into patient and staff experience is an essential first step in getting to where you want to go and identifying what you need to do to get there. NHS Modernisation Agency (2005) Improvement Leaders’ Guide: Improvement Knowledge and Skills 18 www.improvement.nhs.uk/heart
  • 9. Key learning points Exemplar achievement:1. Know your own catchment area and analyse findings in light of this knowledge. Shropshire and Staffordshire Heart and Stroke Network Black Country Cardiovascular Network Review of current service provision with options analysis and plans to move towards a commissioned programme2. Using the same benchmarking tool across the network ensures consistency of approach across all services and helps to standardise services across the patch. Background and context Poole Hospital NHS Foundation Trust, Dorset Cardiac and Stroke Network A baseline audit in 2008 to highlight good practice and identify gaps in service indicated that a redesign of the CR service in North Staffordshire was required to increase capacity3. Be open to change and recognise that nothing is too precious to review and, if and offer rehabilitation to all eligible patients in both hospital and community settings. appropriate, change. Challenge yourself and others in the team. Encourage innovation The audit demonstrated that for the more significant gaps in regional rehabilitation, and don’t be afraid to break established ‘rules’ around service provision. Dorset County Hospital NHS Foundation Trust, Dorset Cardiac and Stroke Network service funding plays a major role. Wherever possible cost neutral changes have been implemented, yet without additional funding and engagement in primary care, any4. Assumptions or anecdotal evidence need to be substantiated when looking at for the substantial service improvement is impossible. reasons behind uptake/non-uptake of CR. Explore uptake in detail using geo-mapping and audit data and be prepared to act on the findings. The cardiac rehabilitation team were keen to begin working on redesign and took the The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, opportunity to visit other centres in the country to look at new ways of working and Dorset Cardiac and Stroke Network develop prospective plans as discussions with providers and commissioners began.5. Conducting a comprehensive and rigorous audit to establish a baseline position, help After a number of discussions with commissioners and the appointment of a cardiac understand if existing services are meeting the required standards, and provide real rehabilitation lead manager, an options analysis paper was compiled and the redesign data to back up any anecdotal evidence is an essential first step for any new project work has started. It has been agreed that this work should be supported with a view to seeking to improve the quality of patient care/ services (and win awards!). Make sure moving towards a fully commissioned service. With the development of the cardiac audits are repeated to gauge progress and reset the baseline as improvements are rehabilitation Commissioning Pack the impetus has increased and this programme will realised. be applying to become one of the new implementation sites. North West London Cardiac and Stroke Network6. Reviewing services, drawing up a broad strategy underpinned by a comprehensive service specification and obtaining universal acceptance across the health economy is not as straightforward as it may appear. Be prepared to spend a lot of time on the process and supporting documentation, consulting with and incorporating views from all key stakeholders, so that the strategy is comprehensive and meets everyone’s needs. Take every opportunity to win ‘hearts and minds’ – it will pay dividends in the long term. Peninsula Heart and Stroke Network7. Make the most of any opportunities to stand back from your service and look at what’s really going on. It takes some discipline and it’s not always easy or comfortable but understanding your existing service is an essential first step in redesigning processes to make them better for patients and staff. Northern Lincolnshire and Goole Hospitals NHS Foundation Trust, North East Yorkshire and North Lincolnshire Cardiac and Stroke Network8. It is essential to include commissioners in the initial review of services and in any plans for future service redesign. Shropshire and Staffordshire Heart and Stroke Network www.improvement.nhs.uk/heart 9
  • 10. 2. ENGAGE WITH YOUR STAKEHOLDERS “ Invest in real stakeholder engagement at every stage of the process and be prepared to adjust your ‘sales pitch’ and approach to appeal to different audiences Engage with Your Stakeholders Stakeholders are those people and groups who are affected by a project or are important to its success. The ” However, winning the hearts and minds of those with a vested interest in your project is not as simple as it sounds. Successful engagement The best approach is to analyse the level of support required from each individual or stakeholder group and then direct attention towards degree to which stakeholders are involves recognizing the different achieving it2. engaged will affect the outcome of backgrounds and cultures of the any improvement initiative. various stakeholders, understanding Stakeholder engagement may take the ‘what’s in it for them’, and using Full transcripts of interviews with many forms but is essentially a a variety of different tools and individual site managers are continuous process combining techniques to hear and listen to their available to download at: communication and involvement from experiences and needs. www.improvement.nhs.uk/heart/ the planning stages right through to cardiacrehabilitation completion. NHS Modernisation Agency (2005) Improvement Leaders’ Guide: Leading Improvement 210 www.improvement.nhs.uk/heart
  • 11. Key learning points Exemplar achievement:1. Engage service providers, individual staff groups and people at a senior level at a very Derbyshire County PCT early stage. This will lead to earlier acceptance of the need for redesign. Effective stakeholder engagement Peninsula Heart and Stroke Network Background and context2. Invest in real stakeholder engagement at every stage of the process and be prepared The CR working group made every effort to involve and consult with all key stakeholders to adjust your ‘sales pitch’ and approach to appeal to different audiences in order to from the outset. The service specification went out to public consultation, as well as encourage and sustain interest and involvement with different stakeholders. being presented to the local CHD strategic commissioning group, the Long Term Derbyshire County PCT Conditions Programme Board and clinicians from primary and secondary care. Patient representatives were involved in the development of the strategy and service3. Be prepared to manage your market. Investing resources in informing and developing specification, sat on the Procurement Project Board and were integral to the decision- potential providers reaps rewards in terms of increasing understanding of the making process. Their involvement lent credence to the process and far from being a procurement process and the service specification. tokenistic gesture; patients were fully engaged in the process and able to bring their Derbyshire County PCT varied and valuable experiences to bear on the outcome.4. Establish good relationships with the local council/ exercise providers so that you can flex the system and provide choice for patients. The recruitment of both an internal and external clinical lead was crucial to the Derbyshire County PCT development of the pathway. The internal clinical lead provided important local knowledge and clinical guidance and leadership. An external clinical lead was viewed as5. Try to engineer a broad spread of stakeholder attendance at national meetings, being essential in terms of injecting the redesign process with objectivity, enabling rotating staff/patient attendance as necessary/relevant in order to stimulate ideas, commissioners to make informed decisions and challenge current practice. encourage innovation and maintain a wider perspective. Shropshire and Staffordshire Heart and Stroke Network As the PCT intended the new CR pathway to bring care closer to home for patients, the involvement and engagement of local general practitioners and their primary care6. The provision of a focused workshop which catered specifically to the expressed colleagues was crucial. With this in mind, the PCT held a number of consultation events needs of clinicians and commissioners was essential in securing positive and sustained for primary care colleagues on a locality basis, and targeted Practice Based stakeholder engagement. Bringing clinicians and commissioners together and Commissioning clusters so that they could provide feedback to individual GPs. involving them in the process of developing outcome measures- rather than developing the measures and seeking comments retrospectively- enabled As an integral part of the procurement process, the PCT facilitated a ‘provider forum’ for involvement to be viewed as a distinct opportunity. providers interested in tendering for the new service. The PCT used this opportunity to South London Cardiac and Stroke Network present and explore key aspects of the service specification in order to answer any queries, challenge any misconceptions, and also to amend the service specification where necessary. Moreover, utilising expertise brought in from the national procurement hub, the PCT undertook to speak with all potential providers on an individual basis to stimulate interest in the tender and provide as much information on the service specification as possible. www.improvement.nhs.uk/heart 11
  • 12. 3. INVOLVE PATIENTS AND CARERS “ Listening to the patients’ voice helps to ensure service redesign is focused around the needs of patients and carers Involve Patients and Carers Meaningful and effective patient and communications between commissioners and providers and ” creating genuine, continuous and sustainable partnerships where all the carer involvement is fundamentally the communities they serve will be people involved are acknowledged as important in every aspect of improved. Overall, real patient and having a unique and important improving health care. Aside from carer involvement and engagement contribution and are respected as being a basic right, greater will lead to greater ownership and equals3. involvement of patients, carers and understanding of local health services the public in planning and delivering and why and how they need to healthcare is likely to result in better change and develop. Full transcripts of interviews with quality services that are more individual site managers are responsive to the needs of patients, Far from ‘doing to’ or even ‘doing available to download at: leading to better outcomes. Policy for’ patients, contemporary www.improvement.nhs.uk/heart/ and planning decisions are likely to approaches to involvement reach cardiacrehabilitation be more patient-focused and beyond consultation and focus on NHS Modernisation Agency (2005) Improvement Leaders’ Guide: Involving Patients and Carers 312 www.improvement.nhs.uk/heart
  • 13. Key learning points Exemplar achievement:1. Discovery Interviews should be used for other service user groups such as heart failure Poole Hospital NHS Foundation Trust, Dorset Cardiac and Stroke Network or angina patients but also has a wider application across all service provision and Utilising Discovery Interviews to review and critically analyse the service from clinical specialties. the patient perspective Poole Hospital NHS Foundation Trust, Dorset Cardiac and Stroke Network Background and context2. Regard patients and carers as equal partners in service redesign and development and Discovery Interviews, originally developed by the CHD Collaborative and utilised by provide real opportunities for them to become involved in planning and cardiac networks and other areas nationally, are a well evaluated tool for learning about a decision making. service from the patient perspective. Discovery Interviews use a semi-structured interview Dorset County Hospital NHS Foundation Trust, Dorset Cardiac and Stroke Network technique which allows the patient to speak about their experiences in their own words – a very powerful narrative that frequently leads to fundamental changes to services.3. Establish a transparent and robust system for recruiting patient and carer representatives to ensure that people are as objective as possible and do not pursue In the Dorset Cardiac Network a relevant Discovery Interview transcript is played at the their own agenda. Provide patient and carer representatives with appropriate support beginning of meetings in order to allow staff to focus on the patient perspective and to and training from a qualified and experienced Patient and Public Involvement (PPI) lead instigate discussion. to ensure that they are able to contribute in a meaningful way and allow the patient voice to be heard. One of the Discovery Interviews prompted all three CR teams across Dorset to hold a Dorset County Hospital NHS Foundation Trust, Dorset Cardiac and Stroke Network process mapping event focusing on patient letters, documentation and information booklets with patients and staff. This resulted in revision of information to meet the4. Ensure that appropriate steps are taken to safeguard patient confidentiality when needs of the patients and helped to increase uptake of CR services – for example, one of seeking to share patient data or feedback to improve care. the revisions to information was to add the phrase ‘Your consultant has recommended The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Dorset Cardiac and Stroke Network that you attend cardiac rehabilitation….’- a compelling commendation for many patients.5. Involve patients systematically in service improvement efforts, but understand and take The information review also facilitated the provision of standardised information and advantage of any opportunities to gather feedback on patient experience. greater collaboration between centres in the network – particularly between North West London Cardiac and Stroke Network Bournemouth and Poole, many of whose patients are eligible to attend the CR service at either hospital. This was particularly relevant where Poole patients attend for angiogram6. If you consider asking patients their opinion via a questionnaire or other method, there at Bournemouth and then may choose where to attend for rehabilitation. The same has to be a robust mechanism for feedback of results and then follow up to information booklet from the catheterisation suite at Bournemouth is now given to all demonstrate resulting actions. patients. This has helped prepare patients and carers for the next steps in the care Shropshire and Staffordshire Heart and Stroke Network pathway and has helped to reduce anxiety.7. It’s important to have planned in advance what you are going to do with the information and be prepared to review and alter your service as a result of the information received. Shropshire and Staffordshire Heart and Stroke Network8. Staff shouldn’t assume they always know what is best in terms of service provision - it’s the patient view that is important! Shropshire and Staffordshire Heart and Stroke Network www.improvement.nhs.uk/heart 13
  • 14. 4. ENLIST CLINICAL LEADERSHIP “ Strong clinical leadership is imperative to obtain buy-in from key stakeholders in improvement efforts, build a shared vision and support an improvement culture… Enlist Clinical Leadership It is widely acknowledged that strong leadership at all levels in the NHS is required to achieve the ambition of ” have the skills and knowledge to lead with vision and creativity, create a culture of innovation, and help to shape and implement the strategic Although it’s not always easy to obtain, clinical leadership is crucial for the ownership and sustainability of service improvements and ongoing Full transcripts of interviews with individual site managers are available to download at: delivering gold standard health and direction of health care by clinical engagement. A significant www.improvement.nhs.uk/heart/ health services to patients and highlighting, influencing, proportion of all improvement cardiacrehabilitation communities. There is much evidence communicating with, respecting and endeavours should be focused on at a national and local level from both supporting others. They believe in the building the capacity for change and primary, secondary and tertiary care task in hand and the importance of innovation in people and that where there is effective clinical working across traditional organisations. engagement and leadership, then organisational boundaries, whilst innovation, modernisation, quality ensuring a constant focus on patient- improvement and patient-focused centred outcomes. care flourish. Effective clinical leaders14 www.improvement.nhs.uk/heart
  • 15. Key learning points Exemplar achievement:1. Engage with clinical leads from the outset and involve them in every step of the North West London Cardiac and Stroke Network project so that they can share their expertise and experience, win over other clinicians The attainment of strong clinical leadership and good clinical engagement and teams, and steer and implement change. Ensure that other stakeholders and from the outset those outside the project understand the network’s facilitative role and that the real improvements are owned and managed by the organisations and individuals that it Background and context brings together. The PPCI CR project has two clinical leads, Judith Edwards, the Senior Clinical Nurse North West London Cardiac and Stroke Network Specialist who leads the project at Imperial College Healthcare NHS Trust and Dr Amarjit Sethi, a Consultant Cardiologist from Ealing Hospital NHS Trust. Both clinical leads were2. Designate a programme leader to each individual programme and give them the highly motivated to address the problem and were comfortable with cross-sector responsibility for planning their service. working. Northern Lincolnshire and Goole Hospitals NHS Foundation Trust, North East Yorkshire and North Lincolnshire Cardiac and Stroke Network Both clinical leads are strongly committed to the development of cardiac rehabilitation across North West London and keen to facilitate uptake of CR by any means within their3. Strong clinical leadership is imperative to obtain buy-in from key stakeholders in scope. They meet regularly with the CR service improvement manager for North West improvement efforts, build a shared vision and support an improvement culture- London Cardiac and Stroke Network to review progress and discuss future plans for particularly amongst other clinicians and frontline staff. Providers find it reassuring service development, demonstrating a proactive approach in identifying new ideas or when commissioners see the need for clinical expertise in any review of service or solutions to any issues arising. plans for service redesign and feel more confident that their voice will be heard. NHS North of Tyne, North of England Cardiovascular Network The network hosts a Cardiac Rehabilitation Working Group. Judith Edwards and Dr Amarjit Sethi are actively involved in formulating and agreeing the agenda for the meetings, preparation of meeting papers, agreeing actions arising and monitoring results. Both of them attend the meetings and can be approached at any time. Without their strong commitment and motivation, working with the CR group, the service improvement manager and with staff ‘on the ground’, the project would not have achieved the level of change and the sustained achievements it has demonstrated to date. www.improvement.nhs.uk/heart 15
  • 16. 5. COLLECT, ANALYSE AND MAKE USE OF ROBUST DATA “ Use robust data to provide evidence to underpin the need for service redesign and to demonstrate achievements Collect, Analyse and Make Use of Robust Data ” problem, focus your improvement efforts, mobilise support and Most improvement projects involve a combination of qualitative and Full transcripts of interviews with Capturing, interpreting and utilising resources and demonstrate if the quantitative approaches. This allows individual site managers are good quality data is an essential resources, time and energy invested statistically reliable information available to download at: element in planning, implementing in any improvement work represents obtained from numerical www.improvement.nhs.uk/heart/ and evaluating the success of any value for money. Most importantly, measurement to be backed up by cardiacrehabilitation improvement project. Although ‘data’ when linked to the aims and and enriched by more in-depth and ‘information’ are often used objectives of a project or service, it information about the experience of interchangeably, data is effectively raw will enable you to understand, groups and individuals. materials and unorganised facts that demonstrate and measure whether when processed, organised and any change has resulted in an structured and placed in context they improvement, the scale of the become useful ‘information’. Data can improvement, and whether it’s help you diagnose and define your sustainable.16 www.improvement.nhs.uk/heart
  • 17. Key learning points Exemplar achievement:1. A pilot of audit questions is imperative in order to check whether you are asking the Black Country Cardiovascular Network right questions in the right way, otherwise you will not get comprehensive answers Pilot of a three month audit to ascertain why patients were not attending for and the answers you do receive may be misleading. rehabilitation enabled further development and refinement of questions prior to Black Country Cardiovascular Network a more comprehensive nine month audit2. It is essential to have good quality data to be able to fully understand and Background and context analyse a service. Concern had been expressed by organisations providing cardiac rehabilitation (CR) Black Country Cardiovascular Network throughout the Black Country Cardiac Network (BCCN) that the national picture for uptake of CR was not truly reflective of their experience. In addition they were aware of,3. Conducting a comprehensive and rigorous audit to establish a baseline position, help and wishing to comply with, the national emphasis to increase uptake to CR. In particular understand if existing services are meeting the required standards, and provide real they wanted to test out the difference between patients being offered, and then data to back up any anecdotal evidence is an essential first step for any new project declining CR, as opposed to CR not being offered and the reasons behind this. seeking to improve the quality of patient care/ services (and win awards!). Make sure audits are repeated to gauge progress and reset the baseline as The BCCN had already committed to the three month audit when the opportunity to join improvements are realised. the national project arose. Joining the national project gave an impetus to the audit, North West London Cardiac and Stroke Network allowing it to develop a more robust outlook, incorporating and increasing measures not4. Use robust data to provide evidence to underpin the need for service redesign and to previously considered and raising the profile of CR in the health community. They saw the demonstrate achievements. Be prepared to present these data in different ways to whole process as a means of informing commissioners about the current state of CR in meet the needs and priorities of different stakeholders. the BCCN and steps being taken to address any issues. Dorset County Hospital NHS Foundation Trust, Dorset Cardiac and Stroke Network Statistical analysis was undertaken at the end of the initial three month audit.5. Use all available data to understand where you are now, to provide evidence of the This demonstrated a huge difference between patients not being referred to the service achievement of standards, to monitor progress and to measure service improvement. in the first place as opposed to being offered the service and then declining. It became Data should cover process, payments, activity and outcomes and be able to clear during the analysis that some of the paperwork indicated a non-referral when in demonstrate return on investment and secure continued funding. Ensure that all reality, it was an agreement between the referring health care professional and the relevant indicators and measures are built into your service specification from the patient that they shouldn’t be referred for what was often the perception that physical outset and embedded in your service redesign efforts. capacity to exercise precluded referral eg severe arthritis. This bears out a general Derbyshire County PCT misconception amongst some referrers that CR is ‘just about exercise’ rather than lifestyle interventions and advice – which would also include some help with full exercise6. Build sustainability into the service by understanding demand and capacity. programmes or adapted exercise according to need. Northern Lincolnshire and Goole Hospitals NHS Foundation Trust, North East Yorkshire and North Lincolnshire Cardiac and Stroke Network Additional findings, which helped to further develop and refine the questions for the nine7. Understanding and collecting data is a vital component of service improvement and month audit, were around travel, uptake of female patients to CR and a need to clarify redesign in order to establish a baseline and benchmark services, measure progress, and add in subsequent questions to the response ‘not interested’ in returns by referrers. manage performance and avoid under-reporting. It is worth investing time and When analysing the statistical data it was apparent that this had to be done in context of resource in ensuring that everyone recognises the need for robust data and the knowledge of the local catchment area in order to make the results meaningful. systems to support data collection, analysis and submission. NHS North of Tyne, North of England Cardiovascular Network Initial findings from the nine month audit, which is due to complete in May 2010, already show improved referral and better data quality. A full and comprehensive review of the8. Consider local data requirements – you may need to establish your own dataset to use data once the audit is complete will enable the service to be reviewed and further concurrently with the NACR database depending on how you intend to use the data. developed. NHS North of Tyne, North of England Cardiovascular Network www.improvement.nhs.uk/heart 17
  • 18. 6. SPECIFY YOUR SERVICE REQUIREMENTS “ Be prepared to invest considerable time and resources into the development of a robust and comprehensive service specification which effectively captures all needs and requirements Specify Your Service Requirements A specification is a document describing a commissioner’s needs, which enables providers to propose an Experience suggests that you will get” what you ask for in the specification: Errors in writing the specification may affect end users and undermine your The preferred option for most specifications is to express requirements as outcomes, i.e. what you are aiming to achieve, rather than Before signing off the specification, it’s worth asking the question, ‘If everything we asked for was provided, would we have what we are really looking for’5? appropriately costed solution to meet strategic aims. Conversely, omitting inputs or outputs. Although some those needs. As a minimum, information may lead to assumptions outcomes may be intangible and more specifications should set out the by the providers which may or may difficult to measure, an outcomes- Full transcripts of interviews with commissioner’s requirements, provide not be correct. A specification will also based specification allows providers individual site managers are a shared understanding of each determine whether you achieve value greater flexibility to propose how they available to download at: party’s responsibilities and reflect for money: Over-specifying may result will meet the outcomes and is likely to www.improvement.nhs.uk/heart/ users’ views. in paying over the odds and runs the elicit more innovative provision cardiacrehabilitation risk of stifling innovation by restricting tailored to the needs of service users The effort and resources required to provider flexibility. On the other hand, and local communities4. develop a specification will depend on under-specifying may result in the value, complexity and risk of any expensive renegotiations of the procurement but should not be contract or delays in completion. underestimated. Institute for Innovation and Improvement: Commissioning for Patient Pathways 4 Department for Children, Schools and Families (2009): Procurement Document 7: Specification Writing 518 www.improvement.nhs.uk/heart
  • 19. Key learning points Exemplar achievement:1. Reviewing services, drawing up a broad strategy underpinned by a comprehensive Peninsula Heart and Stroke Network service specification and obtaining universal acceptance across the health economy is The development of a new service model and detailed service specification for not as straightforward as it may appear. Be prepared to spend a lot of time on the cardiac rehabilitation, supported by all PCTs across the South West Peninsula. process and supporting documentation, consulting with and incorporating views from all key stakeholders, so that the strategy is comprehensive and meets everyone’s Background and context needs. Take every opportunity to win ‘hearts and minds’ – it will pay dividends in As with many areas across the country and despite the publication of the evidence, there the long term. has always been patchy development of CR services both nationally and across the SW Peninsula Heart and Stroke Network Peninsula. This is chiefly due to the fact that funds were subsumed by more pressing CHD priorities such as the achievement of hard targets associated with revascularisation. At2. Be prepared to invest considerable time and resources into the development of a this time there was no national tariff for CR making it difficult to understand the costing robust and comprehensive service specification which effectively captures all needs implications. Furthermore, few NHS organisations have developed tight commissioning and requirements. specifications for CR or have audit data enabling them to understand the exact cost of Peninsula Heart and Stroke Network CR and what value is being delivered for their investment.3. Establish and maintain robust systems for communication between commissioners and As a consequence, services were not given sufficient funding and appropriate resources. providers to reduce anxieties and ambiguities in service specification development. Some providers became understandably protective of their services preventing innovative NHS North of Tyne, North of England Cardiovascular Network ways of delivering menu based CR - a similar pattern to that across many areas of England. Despite considerable goodwill from CR expertise in the established CR services, it was clear that finding more creative ways of ensuring equitable access to CR was vital to secure appropriate commissioning of services. In direct response to the acknowledged inequity of CR service provision across the Strategic Health Authority area and a genuine desire to improve local CR services, commissioners asked the network to provide recommendations and a service model for commissioning future CR services. The resulting report and recommendations propose a new and innovative service model of CR with a vision to establish strong links with the broader public health prevention programmes (i.e. NHS Health Check) and the long-term conditions agenda. This will help to: 1) Ensure services are commissioned in a co-ordinated manner and relevant schemes are integrated. 2) Expand the range and choice of CR services through a comprehensive risk assessment ensuring patients receive an individual menu based service. 3) Prevent patients receiving duplication of services which overlap with the management of other diseases. A Peninsula wide service specification has been ratified by commissioners with agreed key performance indicators (KPIs) and quality markers to ensure equity of services and value for money will be achieved. www.improvement.nhs.uk/heart 19
  • 20. 7. COMMISSION EFFECTIVELY “ It is essential to include commissioners in the initial review of services and in any plans for future service redesign Commission Effectively In simple terms, commissioning is the ” interlinked activities ranging from assessing population needs and In doing so, commissioners are expected to proactively seek and build Full transcripts of interviews with process by which local organisations prioritising health outcomes and continuous and meaningful individual site managers are decide how to spend available funds investment, to developing, stimulating engagement with the public and available to download at: to ensure that the health and care and managing markets and service patients to shape services and improve www.improvement.nhs.uk/heart/ services provided effectively meet the providers. In this respect it is health and with clinicians to inform cardiacrehabilitation needs of the population and deliver incumbent on commissioners as local strategy, and drive quality, service better outcomes for patients based on leaders of the NHS to work design and intelligent resource local priorities. collaboratively with a wide range of utilisation6. partners both within and outside the Commissioning is not just about NHS to commission services that procuring products and services; it’s a optimise health gains and reductions more complex process which involves in health inequalities as well as a broader range of separate but providing value for money. www.dh.gov.uk/en/Managingyourorganisation/Commissioning/Worldclasscommissioning 620 www.improvement.nhs.uk/heart
  • 21. Key learning points Exemplar achievement:1. Explore opportunities to promote and seek innovation in commissioning and the South London Cardiac and Stroke Network provision of CR services from the full range of providers (NHS and non-NHS). The development of a set of core commissioning outcomes for cardiac Peninsula Heart and Stroke Network rehabilitation (CR) at a pan-London level2. Work very closely with Commissioners from the beginning and be sure that you are Background and context meeting their aims as well. The network identified that clinicians lacked a sound understanding of the Peninsula Heart and Stroke Network commissioning process for CR and also that commissioners did not fully understand outcomes for cardiac rehabilitation. Moreover, there was no common approach to3. Be prepared to manage your market. Investing resources in informing and developing commissioning for CR across the sector and that this was common throughout all potential providers reaps rewards in terms of increasing understanding of the London networks. procurement process and the service specification. Peninsula Heart and Stroke Network In view of this, the network organised and facilitated a pan-London event for commissioners and clinicians. The primary purpose of the workshop was to engage with4. Establish and maintain mechanisms to encourage continuous dialogue between clinical and commissioning colleagues in the development of a common set of core commissioners and providers and ensure this happens right from the outset. If this outcomes to be used when commissioning CR. process is not in place or there are delays in commencing regular meetings, anxieties may surface which then take time to resolve. The event was very well-received and generated a great deal of positive feedback from NHS North of Tyne, North of England Cardiovascular Network commissioners and clinicians alike.5. Commissioners need to understand the current service in order to develop ideas for a The core outcome measures- which are now in their third and hopefully final draft- focus new service. Transparency, an understanding of and willingness to work with providers on quality of life, patient goals and patient satisfaction. Stakeholders have agreed that CR helps to build and sustain active engagement in the change process. programmes across the patch must show evidence of benefit in all three measures. NHS North of Tyne, North of England Cardiovascular Network As part of the process, local clinicians suggested that there would be benefit from6. It is essential to include commissioners in the initial review of services and in any plans benchmarking patient satisfaction/ experience across the patch. With this in mind, a for future service redesign. patient experience questionnaire is currently being developed by and for CR patients. This Shropshire and Staffordshire Heart and Stroke Network fits in well with the quality strand of the QIPP agenda.7. Make sure that everyone is aware of what is on the horizon and be alert to how In addition to the successful identification of core pan-London outcome measures for CR, embarking on procurement might affect the involvement of stakeholders. Half way in the workshop also highlighted the lack of formal learning opportunities for CR staff to the procurement process in Derbyshire the PCT became aware of potential conflicts within the Network. In view of this, the Network is planning to hold a similar pan-London of interest with clinicians and managers from provider Trusts already engaged in the event on an annual basis, as well as regular educational sessions for CR teams at a service redesign efforts. This highlighted the importance of the need to be prepared to network level. manage relationships in a different way whilst maintaining the enthusiasm and commitment of key stakeholders in pathway redesign. The network is also hoping to incorporate the local measures into the National Audit of Derbyshire County PCT Cardiac Rehabilitation (NACR), though the current inability to produce a Network-level report is seen as a risk to delivery. www.improvement.nhs.uk/heart 21
  • 22. 8. USE RESOURCES WISELY “ Don’t duplicate systems and/or services - find out what is already available, whether public or privately provided, and forge links where appropriate Use Resources Wisely While the economic landscape around eliminating waste, more effective partnership working and the pursuit Innovation and service redesign in particular- along with prevention- are ” redesign efforts should follow a structured methodology but, more us has changed dramatically in recent of evidence-based practice. As viewed as being key enablers for importantly, should be clinically led months, the vision for an NHS with discussed later in this document, it is achieving quality and productivity and promote effective team working. quality at its heart remains the same. now more important than ever to gains and improving outcomes and Far from being an accessory ensure the use of NHS resources is efficiency in health. The key principles programme, the Quality, Innovation, geared towards providing clinically of service redesign in this respect Full transcripts of interviews with Productivity and Prevention (QIPP) effective and high quality care, comprise a focus on the patient individual site managers are agenda has created a new backdrop delivering value for money and better journey and improving patient available to download at: for the NHS and has led to a greater and sustainable outcomes for local experience and outcomes www.improvement.nhs.uk/heart/ focus on efficiency, productivity, people. NHS organisations can achieve accompanied by meaningful cardiacrehabilitation quality and value. this not only through prudent involvement and engagement of all financial management, strategic key stakeholders, including clinicians, Delivering improvements in a commissioning and good governance, managers and patients. Service resource-constrained environment but also through shrewd management requires an even bigger emphasis on of people, assets and other resources.22 www.improvement.nhs.uk/heart
  • 23. Key learning points Exemplar achievement:1. Consider using training to increase skills in marketing techniques so that patients and Northern Lincolnshire and Goole Hospitals NHS Foundation Trust, North East referrers fully understand the benefit of undertaking a rehabilitation course. Yorkshire and North Lincolnshire Cardiac and Stroke Network Black Country Cardiovascular Network Patients no longer have to wait to join the phase three CR programme in the hospital or community2. Providing sufficient time to train staff and allow them to adjust to a new system is vital, but the rewards in terms of information and patient management are almost instantaneous. Background and context Poole Hospital NHS Foundation Trust, Dorset Cardiac and Stroke Network In an effort to tackle the historical three month long waiting time, and to ensure that patients received timely and appropriate access through triage to phase three CR, the CR3. Ensure that staff are afforded sufficient time to devote to discussing and agreeing team worked alongside the local cardiac network to map the existing service and individual management plans with patients and responding to their individual needs and undertake a demand and capacity exercise. preferences. Although this can be time consuming at the outset, the amount of time spent can be reduced with experience and pays huge dividends in terms of improving patient Process mapping identified that the major bottleneck in the process was the need for experience and the quality of patient care, as well as improving overall service efficiency. patients to attend clinic appointments so that doctors could make an assessment on the The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Dorset Cardiac patient ensuring they were fit to commence the CR programme. In some cases, patients and Stroke Network were waiting several months to be seen before being deemed fit to commence phase4. Investigate interventions and services aimed at tackling health inequalities and improving three CR, and then being referred back to the CR service. The team also identified that health in deprived areas as these may help identify other potential sources of funding. clinic appointments and CR sessions were often cancelled due to Bank Holidays, study Peninsula Heart and Stroke Network days and so on.5. Don’t duplicate systems and/ or services – find out what is already available whether public In view of the findings, the team redesigned the service. Instead of waiting for a clinic or privately provided, and forge links where appropriate. appointment, patients are now given a pre-assessment appointment within two weeks of Peninsula Heart and Stroke Network being considered fit to commence phase three. At pre-assessment, patients are assessed by the nurses and the exercise instructor, and if deemed suitable are given a definitive6. As a project manager be focussed on what it is you are trying to achieve – be clear about start date for phase three - usually within a week but sometimes the next day! Any your role and the role of others you are working with to achieve redesign. patients deemed unsuitable at pre-assessment are given a clinic appointment prior to Peninsula Heart and Stroke Network commencing the exercise programme and/or CR, staff are given the opportunity to discuss the case with the consultant.7. Consider all eventualities and think about how to deal with any findings uncovered during a pilot phase. In this case, the skills competency audit identified some unexpected clinical Work is now planned to mitigate the effect Bank Holidays have on the service and there governance issues which could not be discussed further without compromising the is a strict ‘no cancellation’ policy coupled with a greater focus on forward planning. confidentiality of staff involved in the pilot. By providing each audit participant with a Patients are also encouraged to take more responsibility for their rehabilitation - sessions personal summary report/ audit feedback, the individuals concerned were able to raise missed for any reasons other than ill-health are no longer ‘tagged on’ to the end of the training and development needs in the context of personal performance reviews. programme. Patients have responded well to this and take responsibility for their own South London Cardiac and Stroke Network rehabilitation, ensuring they attend their planned sessions and exercising up to five times a week on their own according to recommended guidelines.8. Establish good relationships with the local council/ exercise providers so that you can flex the system and provide choice for patients. Partnership working with the local council and exercise instructors and conducting case Northern Lincolnshire and Goole Hospitals NHS Foundation Trust, North East Yorkshire conferences with the multi-disciplinary team on a weekly basis has enabled the service to and North Lincolnshire Cardiac and Stroke Network fast track suitable patients into phase four rehabilitation, releasing capacity for the phase three course.9. Timetable weekly communication meetings for all team members to discuss issues and propose solutions. Northern Lincolnshire and Goole Hospitals NHS Foundation Trust, North East Yorkshire and North Lincolnshire Cardiac and Stroke Network www.improvement.nhs.uk/heart 23
  • 24. 9. COLLABORATE AND NETWORK “ The National Priorities Project has been an opportunity to network and share information with other cardiac rehabilitation centres locally and nationally to promote best practice Collaborate and Network The vision for the NHS in England is one in which patients and the public are enabled to become active partners to step outside traditional ” commissioners they allow individuals organisational, cultural, political and geographical boundaries and work in voice in the local health economy to enable frontline staff to secure the changes they need to deliver for their patients. Full transcripts of interviews with individual site managers are available to download at: and not just passive recipients of care. a co-ordinated manner to ensure www.improvement.nhs.uk/heart/ This, in turn involves the active equitable provision of high-quality, By making both formal and informal cardiacrehabilitation engagement of staff and collaboration clinically effective services. Networks networks visible, managers can across the NHS and partner play a key role in fostering innovation systematically assess and support organisations. and bring in ideas from other areas strategically important collaboration. and initiatives to support service Networks- formal or informal- have improvement and redesign and in immense potential to improve the way doing so can help the NHS spread and that services are planned, sustain effective concepts, commissioned and delivered for both improvement ideas and processes for staff and patients. Bringing together the common good. Most importantly, clinicians, managers and networks can provide a powerful24 www.improvement.nhs.uk/heart
  • 25. Key learning points Exemplar achievement:1. Make the most of every opportunity to become involved in discussions across the PCT and Dorset County Hospital NHS Foundation Trust, Dorset Cardiac wider network. Be proactive and don’t just accept the status quo. and Stroke Network Dorset County Hospital NHS Foundation Trust, Dorset Cardiac and Stroke Network Teamwork and pan-network working, learning and sharing enabled the CR team to think ‘outside the box’ with service redesign2. Working collaboratively pays dividends in terms of cross-pollination of knowledge and skills. It may not be feasible or desirable to offer exactly the same CR service at different sites and Background and context in different localities but it is possible to work towards achieving the same high standards The population of Dorset is served by three Acute Trusts: The Royal Bournemouth NHS of care. Foundation Trust, Poole Hospital NHS Foundation Trust and Dorset County Hospital NHS The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Dorset Cardiac Foundation Trust. All three hospitals provide CR programmes, but historically these have and Stroke Network varied in length, content and place of delivery to meet local need. Dorset County Hospital in the west of the county serves a largely rural population and offers phase three3. Spend time - as a team - thinking through processes and patient pathways and establishing programmes in four community sites. cause and effect before taking action. Not all cardiac rehabilitation services are created equally and although it’s possible to work together to reach the same high standards and In an effort to ensure that the residents of Dorset are offered equitable CR services of a achieve the same improvement goals the root causes, problems and solutions may differ consistently high quality, the Network established a Dorset-wide cardiac rehabilitation from site to site. sub-group to promote joint working and encourage greater sharing and learning across North West London Cardiac and Stroke Network the patch with an initial aim to commission a service which met the BACR guidelines, and4. Plan dates for workshops well in advance - essential if you want to be as inclusive as was equitable across Dorset. possible and recognise and give consideration to the pressures that frontline services The sub-group members include clinicians, commissioners, local authority, cardiac are under. network team and patient and carer representatives. NHS North of Tyne, North of England Cardiovascular Network In order to fully understand the current state of CR services in Dorset, the team at Dorset5. Hold local meetings, or devise other ways of rapid feedback locally, while the learning and County worked with members of the network sub-group and colleagues across Dorset to discussions held at national level are still fresh and pertinent – this reduces ambiguity and provide a baseline assessment of existing services and to benchmark services against the discord and maximises the potential for shared learning, idea development and action. BACR Standards and Core Components. Shropshire and Staffordshire Heart and Stroke Network Aside from the various CR programmes across Dorset being afforded the opportunity to learn from each other, the team from West Dorset benefitted particularly from being able to come together with clinicians and commissioners and to meet and understand local decision-makers within the PCT and the wider network. This has enabled the team to see the ‘bigger picture’ and to review their service in light of future plans and priorities for the PCT and the network as a whole. www.improvement.nhs.uk/heart 25
  • 26. 10. SEE THE BIGGER PICTURE “ Create strong links to other drivers for change ” “ Make sure that everyone is aware of what is on the horizon “ Be aware of local politics See the Bigger Picture Any organisation or service needs to at the right time so that resources are used to best effect and the ” benefits (the outcome of a change that has some value for one/ some/ all ” anticipate and respond to the current organisation or service moves in of the stakeholders) and risks and future needs of all key the right direction7. (something that might happen to stakeholders, as well as paying hinder or even stop you achieving the attention to the economic, political Although not all service improvement improvements you’re aiming for) and and social environment in which it projects will come from the top of the these need to be clearly articulated exists. This means that day to day organisation where high level from the outset. operations, services and improvement objectives are set, only those initiatives projects need to be aligned with the that deliver real benefits, meet strategic vision- or the ‘where we defined business needs and are firmly Full transcripts of interviews with want to be’ of the organisation or based in organisational strategy are individual site managers are service. Strategic alignment- seeing likely to be successful and sustainable. available to download at: and responding to the bigger picture- Any improvement project, whether it www.improvement.nhs.uk/heart/ will effectively ensure that projects is mandated from the top or not- cardiacrehabilitation and services deliver the right outputs must be justifiable in terms of cost, National Diabetes Support team (2008) Diabetes Service Planning: A Project Management Guide 726 www.improvement.nhs.uk/heart
  • 27. Key learning points Exemplar achievement:1. Create strong links to other drivers for change including other local and national strategy, Peninsula Heart and Stroke Network policy and guidance, e.g. long term condition management, NHS Health Check in order to Using the Peninsula-wide service model to redesign cardiac rehabilitation increase the efficiency and financial viability of services. services in Cornwall Peninsula Heart and Stroke Network Background and context2. Make an effort to see the bigger picture. It is important to listen to the 30% who are happy A review of CR services across Cornwall highlighted that CR was not available for all with existing services but don’t forget to focus your redesign efforts on understanding and eligible groups and, indeed, that up to 50% of cardiac patients were not being offered or meeting the needs of the 70% who do not attend and this may involve doing things receiving CR. In the absence of a strategic approach a range of different services had differently and being innovative in the service you commission. evolved initially from different sources of funding. This had led to inequity of service Derbyshire County PCT provision and a lack of standardisation across the area.3. Make sure that everyone is aware of what is on the horizon and be alert to how embarking In an effort to improve CR services locally and to deliver to all eligible groups, the service on procurement might affect the involvement of stakeholders. Half way in to the improvement manager and commissioner developed and submitted a business case to procurement process in Derbyshire the PCT became aware of potential conflicts of interest the Performance and Delivery Board in the PCT outlining some options to provide with clinicians and managers from provider Trusts already engaged in the service redesign additional resources and also to redesign the community cardiology service. The first efforts. This highlighted the importance of the need to be prepared to manage submission was not approved on the basis of cost with the advice that any further relationships in a different way whilst maintaining the enthusiasm and commitment of submission would need to show that any new service would either be cost-saving or, at key stakeholders in pathway redesign. the very least, cost neutral. Derbyshire County PCT The community cardiology business case was enhanced to include elements of Chapter 84. Be aware of local politics and keep abreast of what’s going on around you so that you can NSF (management of atrial fibrillation) and to assist with Quality Marker 2 of the Stroke take advantage of any opportunities that present themselves. Strategy (the reduction of stroke risk in people with Atrial Fibrillation). The business case Shropshire and Staffordshire Heart and Stroke Network included the appointment of two additional cardiac nurses, to work with acute, community and primary care providers to ensure the appropriate management of these5. Find out about different service models by taking the time to see what’s going on outside patients and hence a potential reduction in the incidence of strokes in the county. By existing geographical (and cultural) boundaries. For example, a site visit to the CR service at incorporating these elements the business case was at the least cost neutral with the Charing Cross Hospital by the project team was a turning point in the redesign of the potential to be cost saving. Derbyshire County service and was just one method of investigating good practice The business case has now been approved. Further work with the service provider for examples from across the country. Being a part of the National Priority Project was of community services has enabled a move away from specialist roles e.g. heart failure, enormous benefit in this process as it helped to facilitate discussions with colleagues rehabilitation and arrhythmia nurses to a more generic cardiac nursing role, At present a from around the country. Derbyshire County PCT review of nursing skills and competencies is underway to ensure that the needs of all cardiac patients can be met. A full service redesign is now in progress. The aim is to ensure that all eligible patients receive a cardiac rehabilitation service and that people with atrial fibrillation are managed appropriately hence reducing the incidence of stroke. www.improvement.nhs.uk/heart 27
  • 28. Transforming cardiac rehabilitation: celebrating achievements and sharing the learning from the national projects Full transcripts of interviews with individual project site managers are available Achievements and key learning points by site for download at www.improvement.nhs.uk/heart/cardiacrehabilitation Black Country Cardiovascular Network Poole Hospital NHS Foundation Trust, Dorset Cardiac and Stroke Network Key Achievement 1: Pilot of a three month audit to ascertain why patients Key Achievement 1: Assessing and benchmarking existing CR services in were not attending for rehabilitation enabled further development and Dorset against the BACR Standards and Core Components in order to refinement of questions prior to a more comprehensive nine month audit. improve and standardise care across the network. Key Learning Points Key Learning Points 1. A pilot of audit questions is imperative in order to check whether you are 1. The assessment and benchmarking exercise allowed the team to asking the right questions in the right way, otherwise you will not get understand that they were providing a good service, but also identified comprehensive answers and the answers you do receive may be areas for improvement. misleading. 2. Using the same benchmarking tool across the Network ensured 2. It is essential to have good quality data to be able to fully understand and consistency of approach across all services in the County and helped to analyse a service. standardise services across the patch. 3. Know your own catchment area and analyse findings in light of this 3. Communicating with each individual member of the team was important knowledge. in order to help staff understand why they were undertaking the 4. Never take for granted that referrers know exactly what you offer as a benchmarking exercise and identify the direction of travel of the service. service. Develop strong communication links to update and educate health care professionals, revisiting care pathways regularly and adjusting as Key Achievement 2: Obtaining Cardiac Network funding to purchase the required. Always communicate any changes to service promptly, using the Tomcat Cardiovascular Information Management System to improve audit of widest possible circulation, and check understanding. the CR service. Key Achievement 2: Educating health care professionals to understand and Key Learning Points ‘sell’ the benefits of cardiac rehabilitation to patients, using external expertise 1. It was enormously important to identify one person from the team as a in marketing techniques, in order to increase uptake and compliance. data lead to ensure successful implementation of the Tomcat system and to train other team members in the system usage. Key Learning Point 2. Providing sufficient time to train staff and allow them to adjust to the new 1. Consider using training to increase skills in marketing techniques so that system was vital, but the rewards in terms of information and patient patients and referrers fully understand the benefit of undertaking a management were almost instantaneous. rehabilitation course.28 www.improvement.nhs.uk/heart
  • 29. Transforming cardiac rehabilitation: celebrating achievements and sharing the learning from the national projectsKey Achievement 3: Utilising Discovery Interviews to review and critically Key Achievement 2: Listening to the patient’s voice helped to ensure serviceanalyse the CR service from the patient perspective. redesign is focused around the needs of patients and carers.Key Learning Points Key Learning Points1. Plan to undertake and play Discovery Interviews on a regular basis to assist 1. Regard patients and carers as equal partners in service redesign and in review and further development of CR services. development and provide real opportunities for them to become involved2. Discovery Interviews should be used for other service user groups such as in planning and decision-making. heart failure or angina patients but we should recognise that the Discovery 2. Establish a transparent and robust system for recruiting patient and carer Interview technique has a wider application across all service provision and representatives to ensure that people are as objective as possible and do clinical specialties. not pursue their own agenda. Provide patient and carer representatives with appropriate support and training from a qualified and experienced Patient and Public Involvement (PPI) lead to ensure that patients and carersDorset County Hospital NHS Foundation Trust, are able to contribute in a meaningful way and the patient voice is heardDorset Cardiac and Stroke Network and understood.Key Achievement 1: Teamwork and pan-network working, learning and Key Achievement 3: Using baseline audit to identify and understandsharing enabled the CR team to think ‘outside the box’ with service redesign. differences in service provision and levels of uptake across a network area.Key Learning Points Key Learning Points1. Make the most of every opportunity to become involved in discussions 1. Be open to change and recognise that nothing is too precious to review across the PCT and wider network. Be proactive and don’t just accept the and, if appropriate, change. Challenge yourself and others in the team. status quo. Encourage innovation and don’t be afraid to break established ‘rules’2. Use robust data to provide evidence to underpin the need for service around service provision. redesign and to demonstrate improvements. Be prepared to present these 2. Understand that CR services may differ for legitimate reasons but that it is data in different ways to meet the needs and priorities of different possible to provide an equitable service and to strive for and achieve the stakeholders. same consistently high standards.3. Don’t get frustrated if change takes a while to engineer. Making changes can be difficult and challenging. Take the time to establish robust systems for collecting good quality audit data. www.improvement.nhs.uk/heart 29
  • 30. Transforming cardiac rehabilitation: celebrating achievements and sharing the learning from the national projects The Royal Bournemouth and Christchurch Hospitals NHS Foundation Key Achievement 3: Following up patients at 12 months and sharing the Trust, Dorset Cardiac and Stroke Network outcomes with practice nurses has helped to improve long term patient care. Key Achievement 1: A mutually agreed management plan is now given to Key Learning Points Myocardial Infarction (MI) and Percutaneous Coronary Intervention (PCI) 1. Use data and seek hard evidence to assess ongoing patient needs. People patients. may need different amounts of support and for a much longer period of time than professionals assume. Key Learning Point 2. Ensure that appropriate steps are taken to safeguard patient 1. Ensure that staff are afforded sufficient time to devote to discussing and confidentiality when seeking to share patient data or provide feedback to agreeing individual management plans with patients and responding to improve care. their individual needs and preferences. Although this can be time consuming at the outset, the amount of time spent can be reduced with experience and pays huge dividends in terms of improving patient experience and the quality of patient care, as well as improving overall service efficiency. Key Achievement 2: Local geo-mapping and survey data helped the CR team in Bournemouth to plan service expansion more effectively. Key Learning Points 1. Assumptions or anecdotal evidence need to be substantiated when looking at for the reasons behind uptake/non-uptake of CR. Explore uptake in detail using geo-mapping and audit data and be prepared to act on the findings. 2. Be prepared to pilot different approaches to providing CR in order to ensure services are equitable and respond to patient choice. 3. Working collaboratively pays dividends in terms of cross-pollination of knowledge and skills. It may not be feasible or desirable to offer exactly the same CR service at different sites and in different localities but it is possible to work towards achieving the same high standards of care.30 www.improvement.nhs.uk/heart
  • 31. Transforming cardiac rehabilitation: celebrating achievements and sharing the learning from the national projectsNorth West London Cardiac and Stroke Network Key Achievement 2: The attainment of strong clinical leadership and good clinical engagement from the outset.Key Achievement 1: Achieving an award-winning increase in the uptake of CRamong patients receiving Primary Percutaneous Coronary Intervention (PPCI). Key Learning Points 1. Engage with clinical leads from the outset and involve them in every stepKey Learning Points of the project so that they can share their expertise and experience, win1. Conducting a comprehensive and rigorous audit to establish a baseline over other clinicians and teams, and steer and implement change. Ensure position, help understand if existing services are meeting the required that other stakeholders and those outside the project understand the standards, and to provide real data to back up any anecdotal evidence is network’s facilitative role and that the real improvements are owned and an essential first step for any new project seeking to improve the quality of managed by the organisations and individuals that the Network brings patient care/ services (and win awards!). Make sure audits are repeated to together. gauge progress and reset the baseline as improvements are realised. 2. Best practise and lessons learned from the project will be shared with2. Set specific, measurable, attainable, realistic and timely goals so the whole other CR programmes across North West London. team can establish what needs to be done to get to where it wants to go, how long it will take to get there, and can ensure that each member of Key Achievement 3: Involving patients in order to improve patient experience. the team is moving in the same direction.3. Spend time- as a team- thinking through processes and patient pathways Key Learning Point and establishing cause and effect before taking action. Not all cardiac 1. Involve patients systematically in service improvement efforts, but rehabilitation services are created equally and although it’s possible to understand and take advantage of any opportunities to gather feedback work together to reach the same high standards and achieve the same on patient experience. improvement goals the root causes, problems and solutions may differ from site to site. www.improvement.nhs.uk/heart 31
  • 32. Transforming cardiac rehabilitation: celebrating achievements and sharing the learning from the national projects Peninsula Heart and Stroke Network Key Achievement 2: Implementation of the new CR service model is being incorporated into the Commissioning for Quality and Innovation (CQUIN) Key Achievement 1: The development of a new service model and detailed payment framework (Plymouth PCT) with the possibility of linking to the service specification for cardiac rehabilitation supported by all PCTs across the South delivery of NHS Health Check in the future. West Peninsula. Key Learning Points 1. Be prepared for a thorough exploration of the complete range of services Key Learning Points available to support CR to take longer than anticipated. 1. Reviewing services, drawing up a broad strategy underpinned by a 2. Don’t duplicate systems and/ or services – find out what is already comprehensive service specification and obtaining universal acceptance available whether public or privately provided, and forge links where across the health economy is not as straightforward as it may appear. Be appropriate. prepared to spend a lot of time on the process and supporting 3. Explore opportunities to promote and seek innovation in commissioning documentation, consulting with and incorporating views from all key and the provision of CR services from the full range of providers (NHS stakeholders, so that the strategy is comprehensive and meets everyone’s and non-NHS). needs. Take every opportunity to win ‘hearts and minds’ – it will pay dividends in the long term. 2. Create strong links to other drivers for change including other local and Key Achievement 3: Using the Peninsula-wide service model to redesign national strategy, policy and guidance, e.g. long term condition cardiac rehabilitation services in Cornwall. management, NHS Health Check, in order to increase the efficiency and financial viability of services. Key Learning Points 3. Investigate interventions and services aimed at tackling health inequalities/ 1. Engage service providers, individual staff groups and people at a senior improving health in deprived areas as this may help identify other potential level in redesign plans at a very early stage. This will lead to earlier sources of funding. acceptance of the need for redesign. 2. As a project manager, focus on what it is you are trying to achieve – be clear about your role and the role of others you are working with to achieve redesign. 3. Be innovative in pulling together a business case, especially in a time of economic down turn. 4. Work very closely with commissioners from the beginning and be sure that you are meeting their needs.32 www.improvement.nhs.uk/heart
  • 33. Transforming cardiac rehabilitation: celebrating achievements and sharing the learning from the national projectsSouth London Cardiac and Stroke Network Key Achievement 2: The development of a Skills Competency Audit for CR.Key Achievement 1: The development of a set of core commissioning Key Learning Pointsoutcomes for CR at a pan-London level. 1. Consider all eventualities and think about how to deal with any findings uncovered during the pilot phase. In this case, the skills competency auditKey Learning Points identified some unexpected clinical governance issues which could not be1. The national projects Cardiac Rehabilitation workshop on health related discussed further without compromising the confidentiality of staff outcome measures, facilitated by Steve Callaghan from Liverpool PCT, was involved in the pilot. pivotal for the network team in gaining an understanding of how 2. By providing each participant in the skills competency audit with a outcome measures for the project could be formulated, shared and refined personal summary report/ audit feedback, the individuals concerned were using a sector wide approach. able to raise training and development needs in the context of personal2. The provision of a focused workshop which catered specifically for the performance reviews. expressed needs of clinicians and commissioners was essential in securing positive and sustained stakeholder engagement. Bringing clinicians and Key Achievement 3: Improving access and outcomes with specific commissioners together and involving them in the process of developing target groups. outcome measures- rather than developing the measures and seeking comments retrospectively- enabled involvement to be viewed as a distinct Key Learning Points opportunity. 1. The implementation of three new services has identified the need to3. Difficulties obtaining robust data on CR have made benchmarking, incorporate effective referral pathways into CR from the respective patient establishing a baseline and setting realistic improvement goals for CR pathways for angina, Implantable Cardioverter Defibrillator (ICD) and heart across the area a significant challenge. failure. 2. The term ‘PDSA’ may have gone out of fashion, but the Plan, Do, Study, Act - pilot then spread approach to improvement really does pay dividends in terms of improving CR services for people with CHD. www.improvement.nhs.uk/heart 33
  • 34. Transforming cardiac rehabilitation: celebrating achievements and sharing the learning from the national projects Derbyshire County PCT Key Achievement 2: Aligning the new CR service with World Class Commissioning competencies in order to procure a best value, quality service. Key Achievement 1: Remodelling the CR pathway in order to commission an effective, consistent and equitable CR service across Derbyshire PCT. Key Learning Points 1. Be prepared to invest considerable time and resources into the Key Learning Points development of a robust and comprehensive service specification which 1. Find out about different service models by taking the time to see what’s effectively captures all needs and requirements. going on outside existing geographical (and cultural) boundaries. For 2. Make an effort to see the bigger picture. It is important to listen to the example, a site visit to the CR service at Charing Cross Hospital by the 30% who are happy with existing services but don’t forget to focus your project team was a turning point in the redesign of the Derbyshire County redesign efforts on understanding and meeting the needs of the 70% service and was just one method of investigating good practice examples who do not attend. This may involve doing things differently and being from across the country. Being a part of the National Priority Project was of innovative in the service you commission. enormous benefit in this process as it helped to facilitate discussions with colleagues from around the country. Key Achievement 3: Effective stakeholder engagement. 2. Allow key stakeholders, including clinicians and commissioners, to become really involved and engaged from the outset. Key Learning Points 3. Make sure that everyone is aware of what is on the horizon and be alert 1. Invest in real stakeholder engagement at every stage of the process and be to how embarking on procurement might affect the involvement of prepared to adjust your ‘sales pitch’ and approach to appeal to different stakeholders. Half way in to the procurement process in Derbyshire the audiences in order to encourage and sustain interest and involvement with PCT became aware of potential conflicts of interest with clinicians and different stakeholders. managers from provider Trusts already engaged in the service redesign 2. Be prepared to manage your market. Investing resources in informing and efforts. This highlighted the importance of the need to be prepared to developing potential providers reaps rewards in terms of increasing manage relationships in a different way whilst maintaining the enthusiasm understanding of the procurement process and the service specification. and commitment of key stakeholders in pathway redesign. 4. Use all available data to understand where you are now, to provide evidence of the achievement of standards, to monitor progress and to measure service improvement. Data should cover process, payments, activity and outcomes and be able to demonstrate return on investment and secure continued funding. Ensure that all relevant indicators and measures are built into your service specification from the outset and embedded in your service redesign efforts.34 www.improvement.nhs.uk/heart
  • 35. Transforming cardiac rehabilitation: celebrating achievements and sharing the learning from the national projectsNorthern Lincolnshire and Goole Hospitals NHS Foundation Trust,North East Yorkshire and North Lincolnshire Cardiac and StrokeNetworkKey Achievement 1: Patients no longer have to wait to join the phase threeCR programme in the hospital or community.Key Learning Points1. Make the most of any opportunities to stand back from your service and look at what’s really going on. It takes some discipline and it’s not always easy or comfortable but understanding your existing service is an essential first step in redesigning processes to make them better for patients and staff.2. Build sustainability into the service by understanding demand and capacity.3. Establish good relationships with the local council/ exercise providers so that you can flex the system and provide choice for patients.Key Achievement 2: Assigning an individual programme manager to eachprogramme improved co-ordination and planning.Key Learning Points1. Designate a programme leader to each individual programme and give them the responsibility for planning their service.2. Timetable weekly communication meetings for all team members to discuss issues and propose solutions. www.improvement.nhs.uk/heart 35
  • 36. Transforming cardiac rehabilitation: celebrating achievements and sharing the learning from the national projects North of Tyne, North of England Cardiovascular Network 2. Commissioners need to understand the current service in order to develop ideas for a new service. Transparency, an understanding of and willingness Key Achievement 1: Meaningful engagement between commissioners and all to work with providers helps to build and sustain active engagement in cardiac rehabilitation providers across NHS North of Tyne. the change process. 3. Establish and maintain robust systems for communication between Key Learning Points commissioners and providers to reduce anxieties and ambiguities in service 1. Establish and maintain mechanisms to encourage continuous dialogue specification development. between commissioners and providers and ensure this happens right from 4. Plan dates for workshops well in advance - essential if you want to be as the outset. If this process is not in place or there are delays in commencing inclusive as possible and recognise and give consideration to the pressures regular meetings, anxieties may surface which then take time to resolve. that frontline services are under. 2. Strong clinical leadership is imperative to obtain buy-in from key stakeholders in improvement efforts, build a shared vision and support an Key Achievement 3: Agreeing a standard data set for all of our CR providers. improvement culture- particularly amongst other clinicians and frontline staff. Providers find it reassuring when commissioners see the need for Key Learning Points clinical expertise in any review of service or plans for service redesign and 1. Understanding and collecting data is a vital component of service feel more confident that their voice will be heard. improvement and redesign in order to establish a baseline and benchmark services, measure progress, manage performance and avoid under- Key Achievement 2: Development of a draft standard pathway service reporting. It is worth investing time and resource in ensuring that everyone specification. recognises the need for robust data and the systems to support data collection, analysis and submission. Key Learning Points 2. Consider local data requirements – you may need to establish your own 1. Include administrative staff and consider operational processes in any dataset to use concurrently with the NACR database depending on how discussions between commissioners and providers around service you intend to use the data. development and redesign as these may impact on the change process. A team approach to considering all the processes underpinning a patient pathway fosters a collaborative approach to problem-solving and overcoming challenges and helps to break down cultural and organisational barriers.36 www.improvement.nhs.uk/heart
  • 37. Transforming cardiac rehabilitation: celebrating achievements and sharing the learning from the national projectsShropshire and Staffordshire Heart and Stroke Network Key Achievement 3: Using attendance at national peer support meetings, and the information provided, to invigorate and stimulate discussion at localKey Achievement 1: Meaningful analysis of patient questionnaires producing meetings to progress change.relevant outcomes for patients and staff in service provision. Key Learning PointsKey Learning Points 1. Try to engineer a broad spread of stakeholder attendance at national1. If you consider asking patients their opinion via a questionnaire or other meetings, rotating staff/ patient attendance as necessary/ relevant in order method, there has to be a robust mechanism for feedback of results and to stimulate ideas, encourage innovation and maintain a wider then follow up to demonstrate resulting actions. perspective.2. It’s important to have planned in advance what you are going to do with 2. Hold local meetings, or devise other ways of rapid feedback locally while survey information and be prepared to review and alter your service as a the learning and discussions held at national level are still fresh and result of the information received. pertinent. This reduces ambiguity and discord and maximises the potential3. Staff shouldn’t assume they always know what is best in terms of service for shared learning, idea development and action. provision – it’s the patient view that is important!Key Achievement 2: Review of current service provision with optionsanalysis and plans to move towards a commissioned programme.Key Learning Points1. It is essential to include commissioners in the initial review of services and in any plans for future service redesign.2. Utilise staff enthusiasm for change to maintain momentum, ensuring that you explore all methods to overcome any seemingly impossible obstacles.3. Be aware of local politics and keep abreast of what’s going on around you so that you can take advantage of any opportunities that present themselves.4. When planning service redesign, visit beacons of good practice. www.improvement.nhs.uk/heart 37
  • 38. Transforming cardiac rehabilitation: celebrating achievements and sharing the learning from the national projects Contact information for site project managers Listed below are the leads for each of the Vicky Sievey South London Cardiac and Stroke NHS North of Tyne, North of England projects cited within this document. Clinical Lead, Cardiac Rehabilitation Network Cardiovascular Network Should you require further information on The Royal Bournemouth and Christchurch any of the projects, please contact them Hospitals NHS Foundation Trust Alice Jenner Tara Twigg directly via the e-mail addresses supplied. Victoria.Sievey@rbch.nhs.uk Senior Project Manager Service Improvement Officer alice.jenner@stgeorges.nhs.uk tara.twigg@newcastle-pct.nhs.uk Black Country Cardiovascular North West London Cardiac and Michelle Bull Network Stroke Network Shropshire and Staffordshire Heart Senior Project Manager and Stroke Network Ruba Miah Farah Irfan-Khan Michelle.Bull@slcsn.nhs.uk Service Improvement Manager Service Improvement Project Manager Jane Barnes Ruba.miah@nhs.net farah.irfan-khan@nhs.net Derbyshire County PCT Service Improvement Manager j.barnes@nhs.net Russell Tipson Antoinette Scott Janet Whitehead Network Lead for CR Assistant Director Public Health Specialist Director Action Heart Antoinette.Scott@nhs.net janet.whitehead@derbyshirecountypct.nhs.uk russtipson@actionheart.com Peninsula Heart and Stroke Network North East Yorkshire and North Dorset Cardiac and Stroke Network Lincolnshire Cardiac and Stroke Chrissie Bennett Network Linda Everett Service Improvement Manager Clinical Lead Cardiac Rehabilitation christine.bennett@phnt.swest.nhs.uk Louise Bevington Poole Hospital NHS Foundation Trust Lead Cardiac Specialist Nurse, Linda.Everett@poole.nhs.uk Lorna Geach Northern Lincolnshire and Goole Service Improvement Manager Hospitals NHS Foundation Trust Elaine Tovell Cardiology and Stroke, Scunthorpe General Hospital Cardiac Rehabilitation Team Leader NHS Cornwall & Isles of Scilly Louise.Bevington@nlg.nhs.uk Dorset County Hospital NHS Lorna.Geach@CIOSPCT.cornwall.nhs.uk Foundation Trust elaine.tovell@dchft.nhs.uk Michelle Roe Network Manager Peninsula Heart and Stroke Network Michelle.Roe@plymouth.nhs.uk38 www.improvement.nhs.uk/heart
  • 39. Transforming cardiac rehabilitation: celebrating achievements and sharing the learning from the national projectsSupporting informationPlease note that the following section body mainly comprising of standards relate to the infrastructure to questions about the effectiveness ofcontains references to organisations physiotherapists and other support cardiac rehabilitation and the treatments and are intended to helpand/or documents that had currency professionals who are working in or contents of a programme are defined providers, practitioners and patientsover the life of the National Priority interested in the exercise/physical by the recommended core components. make informed decisions about healthProject. Many of these references will activity components of cardiac www.bcs.com/documents/affiliates/bacr care.continue to be of value to cardiac rehabilitation. The ACPICR provides, in /BACR%20Standards%202007.pdfrehabilitation services in moving association with the British Association The Cochrane Library houses a numberforward, but it is in no way intended to of Cardiac Rehabilitation (BACR), Two supplements to the Standards and of relevant reviews investigating thebe a definitive or exhaustive list. education via post graduate courses in Core Components on Staffing of effects of cardiac rehabilitation. addition to publishing standards, Cardiac Rehabilitation programmes and www.cochrane.org/2010 Evidence Update on Cardiac competency and peer review Automated External Defibrillators information-practitionersRehabilitation documents to promote and facilitate (AEDs) and Exercise were published inThis Annual Evidence Update from NHS clinical excellence within its field of 2009. It is anticipated that the Department of Health (2000)Evidence draws together the evidence expertise. Standards will be updated in 2010. Coronary heart disease: nationalfrom systematic reviews and other high www.acpicr.com www.bcs.com/pages/page_box_conten service framework for coronaryquality research and guidance ts.asp?navcatID=49&PageID=625 heart disease - modern standardspublished in the past year, building on British Association for Cardiac and service modelsprevious updates. This evidence has Rehabilitation (BACR) Standards The Cochrane Collaboration The National Service Framework forbeen greatly assisted by the NHS and Core Components for Cardiac The Cochrane Collaboration is an Coronary Heart Disease (NSF CHD),Improvement-Heart CR team and Rehabilitation (2007) international, independent, not-for- published in March 2000, set out aexpert reviewers from the British Developed in affiliation with the British profit organisation which provides up- strategy to modernise CHD servicesAssociation for Cardiac Rehabilitation. Cardiac Society and cited in the to-date, accurate information about the over ten years. It details 12 standardswww.library.nhs.uk/CARDIOVASCULAR/ Implementation Advice accompanying effects of health care. Contributors for improved prevention, diagnosis,ViewResource.aspx?resID=346140 the NICE clinical guideline 48, this work together to produce systematic treatment and rehabilitation and goals document defines minimum standards assessments of healthcare to secure fair access to high qualityAssociation of Chartered and core components for cardiac interventions, known as Cochrane services. The chapter on cardiacPhysiotherapists in Cardiac rehabilitation services and will help Reviews (www.cochrane.org/cochrane- rehabilitation, one of seven clinicalRehabilitation (ACPICR) commissioners, providers, patients and reviews), which are published online chapters, sets out how the NHS andFormed in 1995, the Association of the public to understand what a good in The Cochrane Library others can best help people who haveChartered Physiotherapists in Cardiac service looks like and to raise standards (www.thecochranelibrary.com). had a heart attack, revascularisation orRehabilitation (ACPICR) is a national across the country. The minimum Cochrane Reviews answer clinical other cardiac event maximise their www.improvement.nhs.uk/heart 39
  • 40. Transforming cardiac rehabilitation: celebrating achievements and sharing the learning from the national projects chances of leading a full life and angioplasty for the majority of England “The Department recognises that there Department of Health (2010) The resuming their place in their community within acceptable treatment times. The may be unacceptable variation in the NHS Quality, Innovation, (Standard 12). At the time of Report includes guidance which availability of cardiac rehabilitation. We Productivity and Prevention publication it was anticipated that full updates previous guidance on shall look to develop a set of indicators Challenge: an introduction for implementation would take 10 years or treatment of heart attack in the to improve general access to cardiac clinicians more. National Service Framework for rehabilitation because it can lead to This booklet has been published to Coronary Heart Disease. This guidance improved outcomes and reduce support clinical teams and NHS In 2010, the Department of Health is intended to encourage best practice demands for acute hospital beds.” organisations to meet the quality, indicated that the focus is now on and to inform commissioners, cardiac www.dh.gov.uk/prod_consum_dh/grou innovation, productivity and prevention those areas that have developed more networks and service providers in their ps/dh_digitalassets/@dh/@en/@ps/@sta/ (QIPP) challenge and provides ways in slowly than others, including cardiac discussions on the configuration of @perf/documents/digitalasset/dh_1101 which NHS clinicians can all get rehabilitation. acute services, including the provision 59.pdf involved in shaping the response locally. www.dh.gov.uk/en/Healthcare/Longterm of discharge planning, aftercare services conditions/Vascular/Coronaryheartdisease and access to cardiac rehabilitation Department of Health: Revision to The National Cardiac Rehabilitation /Nationalserviceframework/index.htm programmes the NHS Operating Framework for Audit Project (NACR) www.dh.gov.uk/prod_consum_dh/grou England for 2010/11 The National Audit of Cardiac www.dh.gov.uk/en/Publicationsandstati ps/dh_digitalassets/@dh/@en/document The revised Operating Framework, Rehabilitation (NACR) is a collaboration stics/Publications/PublicationsPolicyAnd s/digitalasset/dh_089454.pdf published in June 2010, makes specific between the British Heart Foundation, Guidance/DH_4094275 reference to the forthcoming the British Association of Cardiac Department of Health: The NHS Commissioning Pack on CR (p.11). “To Rehabilitation, the Coronary Heart Department of Health Vascular Operating Framework for England support the development of pathway Disease networks, the Department of Programme Team (2008) Treatment for 2010/11 tariffs, a number of ‘commissioning Health and the Healthcare Commission, of Heart Attack National Guidance, The operating framework for the NHS packs’ are in production, starting with designed to improve cardiac Final Report of the National Infarct for 2010/11 sets out the priorities for cardiac rehabilitation, which is to be rehabilitation services at the local and Angioplasty Project (NIAP) the NHS for the year ahead to assist published shortly.” national levels. The Audit is part of the The National Infarct Angioplasty Project with planning. Although the national www.dh.gov.uk/en/Publicationsandstati Central Cardiac Audit Dataset (CCAD) (NIAP) is a feasibility study looking at focus for the past three years has stics/Publications/PublicationsPolicyand programme run by the NHS how far primary angioplasty can be remained broadly the same, the Guidance/DH_110107 Information Centre. The NICE rolled out as the main treatment for priorities in 2010 touch on other issues Implementation Advice published to heart attack in place of clot-busting that PCTs and their providers will want support Clinical Guideline 48 drugs. This is the final report concluding to be mindful of and include specific recommends participation in and use of that it is feasible to roll out primary reference to cardiac rehabilitation:40 www.improvement.nhs.uk/heart
  • 41. Transforming cardiac rehabilitation: celebrating achievements and sharing the learning from the national projects National Institute for Health and National Institute for Health and Scottish Intercollegiate Guidelines Clinical Excellence (NICE) Clinical Clinical Excellence (NICE) Clinical Network (SIGN) Guideline No. 57 Guideline 48 (2007) Secondary Guideline 5 (2003) Chronic heart (2002) Cardiac Rehabilitation prevention in primary and failure: Management of chronic The Scottish Intercollegiate Guidelines secondary care for patients heart failure in adults in primary Network (SIGN) develops evidence following a myocardial infarction and secondary care based clinical practice guidelines for the This national guideline for the NHS The NICE chronic heart failure guideline National Health Service (NHS) in offers best practice advice and makes recommendations about: Scotland. Guideline No. 57, supported recommendations on secondary • the care provided by GPs and hospital and endorsed by the BACR, provides prevention for patients in primary and healthcare professionals who have evidence-based recommendations for secondary care after a myocardial direct contact with patients with best practice in cardiac rehabilitation. infarction (MI). It includes specific heart failure guidance on cardiac rehabilitation after • all the key areas of managing heart It is primarily concerned with an acute MI (see Section 1.2). As with failure including diagnosis, drug and rehabilitation following myocardial all NICE guidance, this nationally non-drug treatments and the infarction (MI) or coronary agreed guideline should be taken into management of depression and revascularisation, but also addresses the account by commissioners when anxiety. rehabilitation needs of patients with planning and delivering care. angina or heart failure.the NACR to collect baseline data and http://guidance.nice.org.uk/CG48/NICE Section 1.2 on treating Heart Failure www.sign.ac.uk/pdf/sign57.pdfmonitor implementation of the NICE Guidance/pdf/English recommends that, “Patients with heartguideline. The Audit produces an failure should be encouraged to adoptAnnual Statistical Report on cardiac NICE has also published regular aerobic and/or resistive exercise.rehabilitation in the UK and is the only Implementation Advice for this Clinical This may be more effective when partnational source of information on Guideline: of an exercise programme or auptake, activity and outcomes of www.nice.org.uk/nicemedia/pdf/word/I programme of rehabilitation”.cardiac rehabilitation. AFINAL.doc http://guidance.nice.org.uk/CG5/NICEGwww.cardiacrehabilitation.org.uk/datas uidance/pdf/Englishet.htm www.improvement.nhs.uk/heart 41
  • 42. Transforming cardiac rehabilitation: celebrating achievements and sharing the learning from the national projects The NHS Quality, Innovation, Productivity and Prevention (QIPP) challenge Arguably, the greatest challenge for the The challenge for cardiac rehabilitation QUALITY Experience NHS over the next decade and beyond in moving forwards is no different. But • Increased patient choice is to continue to deliver a commitment it is now more important than ever that Safety • Care provided closer to home to a service with quality as its each pound spent on cardiac • Centralised referral and patient • Relevant patient information organising principle through a period of rehabilitation is focussed on providing tracking • Discovery Interviews, patient forums significant financial challenge by clinically effective and high quality care, • Standardised protocols and and patient questionnaires to inform concentrating on improving as well as improving patient safety and procedures assessed against development of services which meet productivity and eliminating waste. experience. evidence base patient needs. • Risk stratification form In order to achieve the vision, the NHS The Priority Projects have highlighted • Criteria for shuttle testing patients INNOVATION must continue to deliver a commitment that sometimes simple changes can • Governance standards developed to a service with quality as its result in improvements in efficiency, with metrics system • Rehabilitation led follow up organising principle through a period of safety and patient care which could, if • Skills competency assessment. • Looking at ways to include NHS significant financial challenge by implemented across the NHS, result in Health Check Effectiveness • Drug therapy reviews concentrating on improving significant savings. In short, the • New community and home based productivity and eliminating waste. programme has shown that innovation • Task group acting to coordinate all programme for Ischaemic Heart quality initiatives. can be a major driver of quality and Disease (IHD) Since the launch of the CHD in NSF in productivity improvements. • Cardiac rehabilitation outcome 2000, a considerable amount of PRODUCTIVITY measures identified momentum has been applied to driving In October last year, the interim report • Clear management plans • Increased number of patients up standards of care in cardiac for the National Priority Projects8 • Effective use of staff and programmes accessing rehabilitation services rehabilitation, on improving quality and identified the following quality, – no shutdown of services • Reduced hand offs – integrated team tackling inequalities, often with limited innovation, productivity and prevention • Implantable Cardioverter Defibrillator with fewer referral steps funding. (QIPP) benefits after just 12 months of (ICD) rehabilitation (rolled out) • Using and scheduling staff more the programme: • Rehabilitation led follow up. effectively • Rehabilitation led follow up – reduces the need for outpatient attendance • Ensuring availability of multidisciplinary team (MDT) staff to increase flow. 8NHS Improvement (2009) Cardiac Rehabilitation National Priority Projects: lessons and learning one year on42 www.improvement.nhs.uk/heart
  • 43. Transforming cardiac rehabilitation: celebrating achievements and sharing the learning from the national projects The example on the right illustrates how one of the priority project sites has Quality: the new model will improve patient safety as the single point of referral and patient tracking will ensure that sought to align new community cardiac all eligible patients are recruited to the programme. Standardised protocol and procedures will operate across the area rehabilitation services with the QIPP and can be assessed against the evidence base for cardiac rehabilitation. The commissioned service will be able to agenda. demonstrate its effectiveness by close monitoring of the health outcomes of patients attending cardiac rehabilitation as well as the referral and waiting times experienced by patients. Commissioners will also be ensuring value for money by agreeing activity based contracts with the provider which will reward high uptake levels. Patients will experience a As indicated in its introduction to better service as they will be provided with increased patient choice, care closer to home and a more flexible service clinicians9 on QIPP, the Department of that can provide a service for people with limited mobility and co-morbidities. Health has established that: Innovation: the service model uses an ‘opt out’ system rather than the current model which is ‘opt in’. By referring“innovation (especially the patients directly into an assessment clinic where they can be fully informed of the choices available to them, patients widespread adoption of best will be able to make informed decisions about whether they want to participate in the programme. This innovative model aims to be more inclusive and attract a higher degree of participation from groups traditionally less likely to practice) and prevention (in attend (women, people with co morbidities, black and ethnic minorities). the medium term through secondary prevention, and, Productivity: the commissioning of a cardiac rehabilitation service will increase productivity in the following ways: • Attainment of offer and uptake rates as defined in the NSF for CHD over the longer term, through • Increase referral to cardiac rehabilitation and therefore referral on to other lifestyle support services such as smoking primary prevention) will be key cessation and weight management enablers for achieving quality • Ensure the PCT is achieving value for money by moving towards an activity based contract and standardising costs and productivity gains.” • Closer working between cardiac rehabilitation service and primary care ensuring that patients with CHD and heart failure benefit from sustained management and follow up after they complete rehabilitation. It is clear from the interim benefits and Prevention: cardiac rehabilitation is a secondary prevention service; therefore one of its primary goals is to prevent many of the major achievements and patients from suffering another cardiac event in the future. There is evidence to show that cardiac rehabilitation helps key learning points outlined in this people fight back against chronic illness by developing healthy lifestyle behaviours, it can prevent anxiety and document that cardiac rehabilitation depression and also help people deal with social issues such as re-entering employment and understanding and will continue to have a central role in obtaining benefits. helping the NHS to achieve its vision of becoming more productive, people- centred and preventative. Department of Health (2010) The NHS Quality, Innovation, Productivity and Prevention Challenge: an introduction for clinicians 9 www.improvement.nhs.uk/heart 43
  • 44. Transforming cardiac rehabilitation: celebrating achievements and sharing the learning from the national projects Next steps in transforming cardiac rehabilitation Taking Stock At the time of publication, the Experience from the field suggests that Published in March 2000, the CHD NSF Department of Health indicated that the establishment of robust set out a strategy to modernise CHD ‘For the whole NHS and other bodies to commissioning arrangements for CR is services. It details standards for implement the NSF in its entirety could likely to result in improved access, improved prevention, diagnosis, take 10 years or more’. 2010 does not uptake, coverage and quality. In view of treatment and rehabilitation and mark the end of the CHD NSF’s this, and in parallel with the includes goals for securing fair access implementation. Much of what is in Department’s comprehensive review of to high quality services. the NSF is as relevant now as it was ten the NSF, NHS Improvement has been years ago, and much of it will still be working alongside the Strategic Over the course of the last ten years, relevant in the future. But, ten years on Commissioning Development Unit excellent progress has been made and from publication, the Department is (SCDU) at the Department of Health the Public Service Agreement target to taking stock – looking at why such and other interested parties to develop reduce the death rate from CHD, stroke excellent progress has been made in a Commissioning Pack for Cardiac and related diseases in people under 75 some areas while others, like cardiac Rehabilitation. by at least 40 percent was met five rehabilitation, have remained years early. ‘unfinished business’. The resulting The Pack is designed to: review of the impact of the NSF aims to However, although the death rate from distill key success factors as well as • Provide materials to help CHD is falling, advances in the exploring barriers to implementation. commissioners stimulate interest and • Be capable of being adapted to treatment and management of heart contract effectively with both encourage innovative delivery models attacks and improved survival in people Commissioning for Improvement incumbent and new providers; and reflect local circumstances; with impaired cardiac function, Many of the problems associated with • Include service specifications and • Minimise unwarranted variations in combined with an aging population, undesirable variations in service delivery procurement templates which will the delivery of care: early diagnosis mean that the burden of disease is and access to high quality cardiac focus on ensuring the delivery of and managing conditions better growing and becoming more rehabilitation are underpinned by the high-quality responsive care, while prevents expensive exacerbations, concentrated in older age groups. fact that in spite of the impetus allowing providers flexibility to with benefits throughout the health generated by the NSF, NICE, BACR and develop innovative delivery models; system. the National Audit, among other levers, • Include advice to commissioners on funding and commissioning procurement, contractual matters arrangements for CR remain largely ad and issues such as pricing and risk hoc with CR seen as an ‘optional extra’ management; rather than a vital part of treatment.44 www.improvement.nhs.uk/heart
  • 45. Transforming cardiac rehabilitation: celebrating achievements and sharing the learning from the national projects Building on the firm The projects are due to commence in Linda Binder foundations set by the during 2010 following the publication National Improvement Lead, National Priority Projects in of the CR Commissioning Pack and will NHS Improvement 2009/10, the primary aim run until March 2011 initially, in line linda.binder@improvement.nhs.uk of this exciting with national priorities. Mob: 07747 603978 programme of project work will be to increase In keeping with the ethos of NHS Mel Varvel access to and uptake of Improvement, key learning and National Improvement Lead, cardiac rehabilitation and achievements will be shared nationally NHS Improvement to improve the quality of through a variety of different media, mel.varvel@improvement.nhs.uk CR services through including workshops, conferences, Mob: 07917 504894 effective implementation of the new publications and the website atIn essence, the Pack will enable the Cardiac Rehabilitation Commissioning www.improvement.nhs.uk/heart/cardiac Sarah Armstrong-Kleineffective commissioning of CR services; Pack. rehabilitation. National Improvement Lead,ensuring the shape of CR services NHS Improvementreflects best clinical evidence and use of It is envisaged that the pack will prove If you would like to know more sarah.armstrong-klein@improvement.nhs.ukCR resources are optimal. This will raise to be a practical guide to help NHS about the Cardiac Rehabilitation Mob: 07917 505265both quality and productivity of CR organisations commission CR services Commissioning Pack or the Nationalservices and will help to meet the more efficiently, encourage greater Heart Projects for 2010/11, please Lesley Manningchallenge of providing timely access to innovation and productivity in the way contact the workstream Director or Programme Support Team,good quality CR. in which services are provided and National Improvement Leads below: NHS Improvement ultimately improve services and quality lesley.manning@improvement.nhs.ukNational Heart Projects 2010/11 outcomes for NHS patients and their Julie Harries Tel: 0116 222 5244To support the development, carers and families. In doing so, Director, NHS Improvementimplementation and roll out of the implementation will support julie.harries@improvement.nhs.ukCommissioning Pack for CR, NHS organisations to deliver the Quality, Mob: 07810 836305Improvement is planning to recruit a Innovation, Productivity and Preventionnumber of project sites to help test the (QIPP) agenda.utility of the pack in real life settings. www.improvement.nhs.uk/heart 45
  • 46. Transforming cardiac rehabilitation: celebrating achievements and sharing the learning from the national projects NHS Improvement System What is it? Which specialties are included? The NHS Improvement System is a The system can be used to support comprehensive, online tool to sustainable service improvement support sharing of quality service in any specialty. improvement resources in NHS services. Giving you direct access to What does it contain? useful information and stories from • Service improvement tools around the country, it will assist you and resources in your own service improvement • Practical guidance work. • Case studies • Useful contacts Why use it? • Signposting and links. The NHS Improvement System actively helps organisations to Where can I see a effectively achieve their objectives in demonstration of the system? line with national and local policy and Demonstrations of some of the key strategy. It enables users to be more modules are available on the strategic and align long-term goals improvement system home page at: Who can use the system? that can help to deliver high quality, www.improvement.nhs.uk/ The system is free of charge and can patient focussed health outcomes. improvementsystem be used by all staff working for NHS organisations in England. How can I register to use the system? Access to the system is controlled by user ID and password. To request an ID contact support@improvement.nhs.uk46 www.improvement.nhs.uk/heart
  • 47. Cardiac Rehabilitation National Project TeamNHS Improvement National Clinical LeadsJulie Harries Professor Patrick DohertyDirector - NHS Improvement National Clinical Leadjulie.harries@improvement.nhs.uk P.Doherty@yorksj.ac.ukLinda Binder Dr Jane FlintNational Improvement Lead National Clinical AdvisorNHS Improvement Jane.Flint@dgoh.nhs.uklinda.binder@improvement.nhs.ukMel VarvelNational Improvement LeadNHS Improvementmel.varvel@improvement.nhs.ukSarah Armstrong-KleinNational Improvement LeadNHS Improvementsarah.armstrong-klein@improvement.nhs.ukLesley ManningProgramme Support Teamlesley.manning@improvement.nhs.uk
  • 48. NHS NHS ImprovementCANCER DIAGNOSTICS HEART LUNG STROKENHS ImprovementWith over ten years practical service improvement experience in cancer, diagnosticsand heart, NHS Improvement aims to achieve sustainable effective pathways andsystems, share improvement resources and learning, increase impact and ensure valuefor money to improve the efficiency and quality of NHS services.Working with clinical networks and NHS organisations across England, NHSImprovement helps to transform, deliver and build sustainable improvements acrossthe entire pathway of care in cancer, diagnostics, heart, lung and stroke services. ©NHS Improvement 2010 | All Rights Reserved | August 2010Delivering tomorrow’s NHS Improvement 3rd Floor | St John’s House | East Street | Leicester | LE1 6NBimprovement agenda Telephone: 0116 222 5184 | Fax: 0116 222 5101for the NHS www.improvement.nhs.uk