Transforming care for cancer patients - spreading the winning principels and good practice

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Transforming Care for Cancer Patients - Spreading the Winning Principles and Good Practice This publication, the third in a series*, supports the Cancer Reform Strategy’s (2007) Transforming Inpatient …

Transforming Care for Cancer Patients - Spreading the Winning Principles and Good Practice This publication, the third in a series*, supports the Cancer Reform Strategy’s (2007) Transforming Inpatient Care Programme. Its aim is to illustrate ‘how’ NHS Trusts are spreading tested improvements (Published July 2009).

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  • 1. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:41 Page 1 NHS NHS Improvement CANCER DIAGNOSTICS HEART STROKE Transforming Inpatient Care Programme Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice
  • 2. 65786_NHS_Improve.qxd:Moving Forward 3/7/09 13:33 Page 2 Contents Foreword 3 Acknowledgements 4 Introduction 5 Why we need to spread the Winning Principles 6 A framework for spread 7 • Understanding spread • Defining spread • Capturing the learning to support spread Winning Principle 1 8 Winning Principle 2 19 Winning Principle 3 32 Winning Principle 4 36 Further evidence supporting spread 43 Transforming Inpatient Framework for Spread: 44 Common themes and practices Spread is evident 45 Conclusions 46 References and supporting information 47 Roll of honour 48
  • 3. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:41 Page 3 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice Foreword The Cancer Reform Strategy highlighted the need to Many clinical teams have learned service focus attention on inpatient care for cancer patients. development techniques and have started to The “Transforming Inpatient Care Programme” has introduce new ideas to improve their practice. been established to take this forward. The programme Traditionally in the NHS we have been slow to is being led by NHS Improvement – Cancer in spread new ways of working both within and partnership with the National Cancer Team. Forty between organisations. NHS Trusts are now involved in piloting new approaches to care. This report provides a range of excellent examples of where teams have not only delivered The first aim of the programme is to improve the innovation in their own service but have also quality of inpatient care for cancer patients by averting spread good practice to others, thus improving unnecessary admissions and by streamlining care for the quality of care for many more patients. those who do need to be admitted. Achieving this aim also has the potential to reduce bed utilisation very considerably. In the year before the Cancer Reform Strategy over five million bed days were occupied by cancer patients. Work done during the Celia Ingham Clark development of the Cancer Reform Strategy – and now endorsed by the findings from Colorectal Surgeon, Medical Director, The pilot sites – indicates that at least a million bed days could be saved. Whittington Hospital London, National Clinical Lead and Chair Transforming Inpatients Steering The Transforming Inpatient Care Programme is an excellent example of ‘Quality, Group. Innovation and Productivity’ in practice. This programme links with the Enhanced Recovery Programme which goes beyond cancer. It also relates closely with the work being undertaken by the National Chemotherapy Advisory Group to enhance quality and safety of chemotherapy services. I would like to thank all of the pilot sites for their innovative work on developing good practice. I hope these examples will prove useful to other NHS Trusts in their quest to improve quality and productivity. Professor Mike Richards National Cancer Director 3
  • 4. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:41 Page 4 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice Acknowledgements The Department of Health Cancer Programme Board, NHS Improvement and the National Cancer Action Team would like to thank all the test sites for their continuing support and commitment to the Transforming Inpatient Care Programme. Valuable learning has emerged from this important area of work which has influenced policy, quality improvement, demonstrated innovation, efficiency and improved the patient’s experience. The learning from cancer improvement is well recognised and has been adopted across many other specialties. This is a credit to the test sites involved and their ongoing commitment to improve services and share their learning across the NHS. 4
  • 5. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 16:50 Page 5 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice Introduction Testing an idea, then realising what works that if spread could make significant If Winning Principles 1 and 2 were widely adopted by all Trusts in England the combined and how it can benefit patients is a improvements in quality, efficiency and the impact could mean releasing 25% of bed capacity in most tumour groups. By adding fantastic achievement. patient experience. Principles 3 and 4 we would see a potential further impact on bed capacity moving towards releasing a million bed days. The challenges that follow are: Over the last 12 months it has become evident that Winning Principles 1 and 2, “The Transforming Inpatient Care Programme will improve quality “We know what works. The and the following models of care have of care for patients and could save the NHS a million bed days.” spread significantly: question is - can we spread this • Communication Rapid Alert systems Mike Richards across the NHS in 2 years, or reducing unnecessary length of stay by National Cancer Director (2009) like many NHS initiatives will 25% in most tumour groups recognising the importance of valuing patient’s time. Winning Principles it take 20 years.” • Breast 23 hour model 100% coverage Previous testing identified four winning principles that can improve length of stay across Pan Birmingham for 80% of management, avert unnecessary admission, deliver care in the appropriate care settings, Mike Richards National Cancer Director (2009) patients. Reducing length of stay from improve efficiency, quality, promote value for money and importantly value the patients’ time. six days. • Acute Oncology Models being adopted and adapted across the country to ensure patient safety and reduce delays. This publication, the third in a series*, • Applying an enhanced recovery approach supports the Cancer Reform Strategy’s for elective surgery can reduce Winning Principle 1 (2007) Transforming Inpatient Care unnecessary length of stay by 50%. Unscheduled (emergency) patients should be assessed prior to the decision to Programme. Its aim is to illustrate ‘how’ admit. Emergency admission should be the exception not the norm. NHS Trusts are spreading tested Evidence from the case summaries within improvements. this publication suggests that the adoption Winning Principle 2 and adaption is due to the principles and All patients should be on defined inpatient pathways based on their tumour type During 2007- 2009, NHS Trusts (40) models: and reasons for admission. across England tested out ideas to • Being easy to apply improve the quality of the inpatient • Having a clear purpose and evident Winning Principle 3 experience by looking at valuing patient’s in practice Clinical decisions should be made on a daily basis to promote proactive case time, shifting care from an inpatient to an • Simple to understand management. ambulatory care setting, reducing • Meaningful to patients and professionals Winning Principle 4 unnecessary lengths of stay and averting • Bring together quality improvement, Patient and carers need to know about their condition and symptoms to encourage unnecessary admissions into hospital for innovation and efficiency. self-management and to know who to contact when needed. both planned and unplanned care. Testing, identified four winning principles, *www.improvement.nhs.uk/winning_principles 5
  • 6. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:41 Page 6 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice Why we need to spread the Winning Principles? At a time where the economic future is Improving quality is a journey that uncertain, David Nicholson, NHS Chief Why we need to spread what has no end point; there is always Executive has stated that: works across cancer inpatients? more that can be done. Spreading the Winning Principles will be the start • Inpatients is an area that’s had Most importantly patients have told us “Now is the time to be little attention they do not want to be in hospital. of the journey for many as the summaries in this publication innovative and adopt and • England has higher bed utilisation illustrate there is ‘not a one size diffuse the well-evidenced for cancer than any other country “Been in hospital for five fits all’ approach to spread. • Emergency admissions have risen things we should all be doing. by 47% in the past eight years days, it’s cost me over £20 to We need to look at each system and elective by 8.6% watch the TV and make calls • 40% of all cancer admissions are and process to see if it is emergency, but they use 60% of to my family, to kill the capable of taking us through bed days boredom. Why couldn’t • Inpatient care for cancer patients this big challenge” accounts for 12% of all inpatient I have taken the tablets at beds home and got them from the David Nicholson • Over half (ie over £2 billion) of the NHS Confederation (2009) total expenditure on cancer in GP, would have only cost me England goes on inpatient care something like £6 for the Quality improvement can • 60% of all cancer admissions are elective but they use 40% of beds prescription and shoe drive efficiency. days leather!” • 2007-2008: 4.7 million bed days “Quality improvements through were cancer related. Extract from a patient diary greater efficiency and redesigning services can provide the budget savings necessary to navigate this crisis" Nigel Edwards NHS Confederation Director of Policy (2009) 6
  • 7. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 16:53 Page 7 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice A framework for spread Through evaluating the learning and looking Data analysis was undertaken using Fig 1: The Transforming Inpatient at how the test sites have spread the Winning National Hospital Episode Statistics (HES) Framework for Spread Principles, 12 common themes have emerged. (NHS Improvement 2009) A Vision and cross referenced with local data. These have been applied to a framework for for Quality Organisations completed a learning diary Improvement Systematic reference to support organisations in their Spread Improvement that provided an ongoing evaluation of Strategy quest to spread “The Transforming Inpatient Approach progress. They provided case studies and Framework for Spread” (NHS Improvement, took part in completing an electronic Linked 2009). Fig 1. Strategic & Organisational spread survey (spread planner) that Culture Operational and Fit assessed spread and coverage, this Change The framework was developed drawing provided further qualitative intelligence. upon Pettigrew’s (1993) receptive context model, Fraser’s (2002) framework for Continuous Spread Spread The spread survey was also used with accelerating spread and Rodger’s (2003) Monitoring Making the Simple non-test sites to evaluate if the Progress & Principles & diffusion of innovations. This builds upon Impact Connections Messages improvements and principles were being earlier work in cancer improvement by the more widely adopted. This was not about Cancer Services Collaborative research, but checking how far spread ‘Improvement Partnership’ where Collaboration Leadership had been achieved and how this was Partnerships Engagement Williamson’s (2007), work identified the & Team Accountability occurring. Collectively this data provided Working critical factors for whole system change the opportunity to undertake a thematic of a clinical speciality and Driver’s (2008) Alignment analysis to draw out the learning and key Learning with evaluation of the factors affecting the & Unlearning Opportunities messages. The organisations involved achievement of cancer waiting times in Patient & Levers were predominately NHS Acute Trusts and Centred the domains of leadership, performance Foundation Trusts (integrated testing is and service improvement. underway with Acute, Primary Care and Social Care, the intention is to evaluate the learning from these sites in early 2010). Understanding spread • Spread is often difficult to define rather the exception in our quest/goal to The concept of spread is often implicit • Successful spread can be active transform the inpatient experience for The selection of NHS Trusts included in within the large amount of literature (dissemination) and passive (diffusion) cancer patients across England. this publication began testing ideas in available on change and organisational • The process of spread does need an 2007. To date they have all achieved a management. Such literature contains agreed spread strategy, time, focus, Capturing the learning to different pace of spread that was contributions from many different and monitoring support spread culturally and contextually specific. All academic disciplines. • The pace of spread varies and is The NHS Trusts shared their experience of have spread the Winning Principles and influenced by many variables. spread covering three aspects: applied them to different tested From the evidence the key messages 1. What improvements/Winning improvements with a range of impact appear to be: Defining spread Principle(s) have spread? (detailed case studies are available at: • Spread has a range of meanings and Spread is the process whereby we see the 2. How has spread been achieved? www.improvement.nhs.uk/cancer). language four Winning Principles become the norm 3. What impact has been made? 7
  • 8. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:41 Page 8 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice Winning Principle 1 WINNING PRINCIPLE 1 1. Unscheduled (emergency) patients should be assessed prior to the Common themes of spread from the analysis decision to admit. Emergency admission should be the exception 6 not the norm. 5 The following five NHS Trusts spread Winning Principle 1. Four tested and 4 Number of test sites spread the same improvement (communication alerts) and approached spread in different ways. Evaluation of 3 their learning against the spread framework identified common themes 2 across these Trusts (fig 1). 1 0 Spread Simple Principles & Messages & Team Working & Operational Change Collaboration, Partnerships Continuous Monitoring, Progress & Impact Linked Strategic A Vision for Quality Improvement & Accountability Leadership, Engagement Alignment with Opportunities & Levers Patient Centred Learning & Unlearning Spread Strategy Systematic Improvement Approach Organisational Culture & Fit 8
  • 9. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:41 Page 9 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice United Lincolnshire Hospitals NHS Trust WINNING PRINCIPLE 1 Recurring Admission How was spread achieved? What has been the impact? Patient Alert (RAPA) “We used a systematic Quality improvements Coverage Efficiency benefits RAPA is a simple communication solution approach taking one tumour that ensures that everyone knows their The patient is on the right Upper GI – 3 x hospital Testing in urology and patient has arrived at the hospital. The site at a time, demonstrating pathway and seen by the sites (Lincoln County Upper GI in 1 site (Lincoln improvement benefits known cancer the evidence of why the appropriate clinical team Hospital, Louth County County Hospital) reduced patients and where admission is required Hospital and Grantham bed days by 96 = patients go to the right place, on the improvement works and Reduced number of District Hospital) within savings* £19,400 right pathway or the admission is averted measuring the benefits. We diagnostic tests/invasive United Lincoln Hospitals (October – December and redirected to the appropriate care procedures NHS Trust 2007) setting. kept the approach simple and positioned in the Upper Gastrointestinal (GI) Urology – 3 x hospital sites Impact of spread for The improvement idea was ‘pulled’ have demonstrated a (Lincoln County Hospital, Urology and Upper GI from Sherwood Forest Hospital NHS organisation. From being reduction in diagnostics Louth County Hospital and (across three hospital Foundation Trust and adopted locally. It involved with RAPA in tests/invasive procedures Grantham District General) sites) has the potential to was initially tested on one site, Lincoln from three to two tests within United Lincoln reduce bed days by 499.2 County Hospital, and is now spreading Sherwood Forest I knew the per patient Hospitals NHS Trust per annum = savings across the four hospital sites of the principle was right, but a *£99,840.00 United Lincoln Hospital NHS Trust. The clinical team that Lung – Pan United Lincoln lesson learned was that you knows the patient is Hospitals NHS Trust Invest to Save - 5 x cannot simply ‘cut and paste’ alerted; this is a familiar (Lincoln County Hospital, smart phones purchased face in time of crisis Louth County Hospital, for key workers to receive the improvement into Grantham District General alerts at a cost of £870 another organisation; it needs and Pilgrim Hospital) (£175.00 each) + £600 p.a. (£120.00 each) line to be tested and owned to rental (contract) encourage engagement and spread.” * based on cost savings of circa £200 per night per patient Julie Pipes Cancer Manager United Lincolnshire Hospitals NHS Trust 9
  • 10. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:41 Page 10 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice WINNING PRINCIPLE 1 “This is a really important Evidence from testing supporting spread reductions in length of stay for Urology and Upper GI piece of work showing genuine improvement in the Length of stay - Urology Length of stay - Upper GI quality of care that we deliver Length of stay Length of stay Length of stay Length of stay to an already vulnerable in baseline for test period in baseline for test period group of patients. It is Minimum 1 Day 0 Day 0 Day 0 Day important that all patients Maximum 55 Days 28 Days 45 Days 25 Days receive timely care provided Median 7 Days 2 Days 7 Days 7 Days by the right person in the Average 10 Days 7 Days 10 Days 8 Days right place - this is especially important for cancer patients. Early assessment is key to this and ensures that the patient and family are treated with dignity. I am pleased to see that this programme of work is being extended to cover other specialties” Dr Richard Lendon Director of Performance United Lincolnshire Hospitals NHS Trust 10
  • 11. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:41 Page 11 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice The Hillingdon Hospital NHS Trust WINNING PRINCIPLE 1 Through working across • Collaborative and close working with What has been the impact? boundaries, a palliative care site specific Clinical Nurse Specialties in three tumour groups, Upper GI, pathway was integrated into Urology and Lung and with the Quality improvements Coverage Efficiency benefits mainstream medical and Community Specialty Palliative Care Improved communication Organisation Analysis will be completed surgical care with the aim to Team amongst teams wide mid July 2009 preliminary improve the quality of care • Sharing the message and principles data has shown • Poster presentation – The Pan Alert notifications Community for end of life patients. London End of Life Care Conference regarding cancer patients A& E Specialty Palliative A&E attendances: awarded joint 2nd prize attendances and any subsequent Care Team Jan/Feb 2008 n = 117 The pathway was triggered • Ongoing monitoring and analysis hospital admissions to community Jan/Feb 2009 n = 99 by alert notifications to the • Active leadership from the Palliative specialist palliative care team and A&E attendances resulting community team and clinical Care Consultant. specific tumour clinical nurse in admission: specialists nurse specialists for acute Jan/ Feb 2008 n = 55 Productivity alone cannot ascertain the Junior doctors receive teaching Jan/Feb 2009 n = 45 cancer admissions, to optimise effectiveness of a complex intervention on the palliative care pathway the appropriateness of like palliative care input/palliative care admission, place of admission, pathway in the care of a patient (where management and length of there are so many variables that influence The Hillingdon Hospital Palliative Care Pathway stay. whether or not patients are admitted and how long they stay) in terms of directly influencing variables like length of stay How was spread achieved? (LOS) or averting admission is extremely • Increasing awareness: difficult. • Palliative Care Pathway launched at the Hospital Grand Round meeting in The key is to focus on integrating the October 2008 pathway and the quality improvements • Meetings with A&E and Emergency this will drive the efficiency gains. Assessment Unit staff • Attendance at on call handover meetings • Junior doctors teaching sessions to increase awareness and understanding. 11
  • 12. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:41 Page 12 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice Northampton General Hospital NHS Trust WINNING PRINCIPLE 1 Emergency Admission Unit How was spread achieved? (EAU) Alert “Following the initial testing in lung the results were shared Emergency Admission Unit Alert is an electronic system developed through the at the clinical nurse specialist meeting with the cancer existing patient administration system steering group and with all the cancer clinical leads in the which searches for all known cancer patients and alerts the relevant Cancer hospital. Clinical engagement was gained as well as the Nurse Specialist when the patient arrives agreement to rollout the alert principle across the other in the Emergency Admission Unit. specialties, using the electronic system. The cancer steering group reports to the hospital management team and the clinical quality effectiveness group. The progress of roll out was reported quarterly to these groups. This ensured clinical and managerial support. The service improvement facilitator (from the cancer network) became part of the Trust service improvement team and supported the spread of learning from the testing. A lesson learned which came to light when completing the spread planner survey was that we could have improved our communication internally with the wards.” Karen Spellman Cancer Lead Manager Northampton Hospital NHS Trust 12
  • 13. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 16:54 Page 13 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice WINNING PRINCIPLE 1 What has been the impact? Quality improvements Coverage Efficiency benefits Influenced length of stay Increased number of Across selected Reduction in LOS for Lung 25 patients receiving clinical teams: cancer patients by 7.4 days ‘Preferred place of care’ per patient discussion Gynaecology 20 Period of Number of Average Haematology length data admissions Yes Not Recorded No Number of Patients Proactive referral to the Head & Neck collection alerted of stay specialist palliative care Lung (days) 15 team Testicular Thyroid April-June 2006 16 12.5 Early assessment by the Upper Gastro (baseline) 10 specialist team has Intestinal July 2006- 49 9.7 ensured timely proactive (Upper GI†) December 2007 5 management of the Urology (paper fax alert patients care Skin from EAU)* April-November 12 5.1 0 Gynaecological Head & Neck Head & Neck Urological 2008 (electronic alert)** Haematological Lung Upper GI *Between Dec 2007 and April 2008 the new electronic alert system was being developed and therefore no data was captured on length of stay. **Since November 2008 the alert system has been implemented and the evaluation is currently under review. †Upper Gastrointestinal (Upper GI). 13
  • 14. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:42 Page 14 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice Sherwood Forest Hospitals NHS Foundation Trust WINNING PRINCIPLE 1 Recurring Admission The Trust won the 2007 Medical What has been the impact? Patient Alert (RAPA) Innovation Futures Award for this innovative initiative. Quality improvements Coverage Efficiency benefits RAPA is a process that supports the co- The Trust held a RAPA showcasing event ordination and timely care for patients Defined emergency Organisation wide across Lung tumour site has May 2008. Delegates came from as far as admitted as an emergency, alerting pathway nine cancer tumour sites reduced length of stay by Brighton and Gateshead. RAPA is members of the clinical teams when their 25%, releasing a potential currently being tested and implemented previously diagnosed cancer patients are Patient is assessed to Hospital Specialist 560 bed days per year at Doncaster hospitals and we have other being re-admitted to the acute hospital. admit rather than Palliative Care Team sites still coming for a demonstration on admitted to assess This equates to a potential how RAPA works! Initial testing commenced in Kings Mill Non-Cancer Specialist redistribution of £112,000 Hospital and has now been successfully Timely and appropriate areas, Cardiology, based on £200.00 per day Along with other service improvements implemented across Sherwood Forest support/interventions Respiratory, and Diabetes such as the discharge planning tool and Hospitals NHS Foundation Trust. Reduced length of stay for expansion of the Integrated Discharge Promotes ongoing Infection control alerts - all elective and non elective Team this allowed our overall average How was spread achieved? continuity of care known MRSA/CDiff cancer admissions length of stay to steadily decrease for the RAPA has now been implemented across patients are alerted to the trust as a whole despite an increasing all nine tumour sites at Sherwood Forest Early discharge supported Infection Control Team Reduced length of stay for number of service users. The graphs show Hospital NHS Foundation Trust and when they arrive in all elective and non-elective figures for length of stay in days for the Hospital Specialist Palliative Care Teams. Supports patient choice hospital admissions across financial year broken down by elective and preferred place of organisation and non-elective admissions. Showcasing at different hospital forums care Other hospital sites has enabled non-cancer specialties, outside of trust - including the Integrated Discharge Team, Doncaster Hospitals Cardiology, Respiratory, and Diabetes to benefit from RAPA. The principles have been adopted in alerting specialties/wards to patients being admitted to the hospital who are known to be MRSA or C Diff positive. This will inform staff of the need to follow trust protocols and provide most appropriate care to patients. 14
  • 15. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:42 Page 15 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice WINNING PRINCIPLE 1 A snapshot analysis in April 2009 showed Reduced length of stay for all elective & non-elective admissions across organisation sustained length of stay in the original Elective Inpatients Non-elective Admissions four test tumour sites, Breast, Lung, Average Length of Stay Average Length of Stay Upper GI and Gynaecology 5 Comparison of median LOS for the 4 4.53 4.53 4.44 original test sites, pre, during and Average Length post RAPA. of Stay (days) 3.89 3 3.43 3.3 2.77 2.76 Comparison of median LOS for non-elective Comparison of median LOS for non-elective 2 breast patients, pre, during and post gynaecological patients, pre, during and implementation of RAPA post implementation of RAPA 1 15 0 Time (days) Time (days) 2005/06 2006/07 2007/08 2008/09 2005/06 2006/07 2007/08 2008/09 Financial Year 6 6 6 4 3 Reduced length of stay for all elective and non elective cancer admissions Pre RAPA Feb 07 Apr 09 Pre RAPA Feb 07 Apr 09 RAPA Trial Post RAPA RAPA Trial Post RAPA Elective Cancer Patients Admissions Non-elective Cancer Patients Admissions Average Length of Stay Average Length of Stay 12 11.8 11.9 Comparison of median LOS for non-elective Comparison of median LOS for non-elective 10 lower GI patients, pre, during and post lung patients, pre, during and post Average Length 10 10 implementation of RAPA implementation of RAPA of Stay (days) 8 6 Time (days) Time (days) 4 5.1 4.3 9.5 4.1 4.1 8 2 6 5 4 0 3 2005/06 2006/07 2007/08 2008/09 2005/06 2006/07 2007/08 2008/09 Pre RAPA Feb 07 Apr 09 Pre RAPA Feb 07 Apr 09 Financial Year RAPA Trial Post RAPA RAPA Trial Post RAPA 15
  • 16. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:42 Page 16 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice The Christie NHS Foundation Trust WINNING PRINCIPLE 1 Preferred Priorities of Care • Raise awareness of the potential risks 260 (91.87%) of these patients have subsequently died and 211 (81.15%) (PPC) Implementation / to the organisation, staff and patients if achieved their end of life care end of life and advanced care planning Advanced Care Planning (ACP) is not implemented • Giving feedback to each ward area of Total PPC discussions Spreading the Gold Standards the results from base-lining testing Framework, Preferred Priorities of Care identifying the actual and potential 300 and the Liverpool Care Pathway in order benefits 283 to reduce length of stay and avert • Ward and medical staff are encouraged 250 260 unnecessary admissions. This is to use the surprise question amongst integrated work with the National End staff to identify potential patients in 200 211 of Life Care Strategy. their last year of life. "Would you be surprised if this patient were to die in 150 How was spread achieved? the next 6-12 months?“ Raising awareness – Poster Campaign • Working collaboratively with 100 (including on the back of toilet doors). identified medical teams to facilitate Increased staff awareness of the active decision making and improve 50 importance of identifying patients in their 49 end of life care. 23 last year of life. 0 Total PPC Deceased Still Alive Achieved PPC Not Achieved Challenges Discussions Patients PPC New learning and feedback • The biggest challenge has been • The communication department changing the mindset of health care developed a new two day enhanced professionals regarding end of life care communication skills training for • Importance of promoting the principles “The link between hospital and community services has been frontline staff (Level 2). Five training and gaining high level management sessions have been allocated for this support and awareness. invaluable and has led to a much smoother transition to shared year and will be co-facilitated by End of • Internal and external sharing of care with the community health team and oncology services. Life Project Manager and key members information through various means of the Palliative Care Team including e-mail, intranet, phone The patients and their relatives involved have expressed a great • A teaching programme has been contact, letters and updates in the deal of satisfaction with the level of care and support, both developed for all ward staff to raise hospital bulletin. awareness of recent National physical and psychological, that they have received.” developments regarding care at the end of life. The North West End of Life Care Dr Sacha Howell Honorary Consultant in Breast Medical Oncology, Model (NHS North West 2008) The Christie NHS Foundation Trust has been adapted and developed into a checklist for all ward staff to use 16
  • 17. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:42 Page 17 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice WINNING PRINCIPLE 1 What has been the impact? Raising awareness poster Quality improvements Coverage Efficiency benefits The Christie NHS NHS Foundation Trust Improved patient choice and One organisation Over 15 months released experience. 283 preferred started with ovarian capacity of 1,134 priorities for care discussions and lung cancer inpatient bed days for facilitated Manchester patients active anti-cancer only treatments. This equates 260 (91.87%) of these patients to 76 bed days per have subsequently died and 211 Known patients from month (81.15%) achieved their end of palliative care team life care wishes This equates to a Ward 1 – ovarian and redistribution of Averted inappropriate admissions breast cancer patients - £226,800 based on £200 15 consultants per day Moved care out of the hospital to involved another setting (shifting care) 59 re-admissions were Spread strategy to averted over 15 months, Facilitated rapid discharge systematically address this equates to four each tumour site and patients per month Improved clinical decision making ward (end of treatment decisions) Increased staff awareness of the importance of identifying patients in their last year of life Timely and effective communications across all sectors and disciplines Developed teaching programmes 17
  • 18. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:42 Page 18 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice National overview: Spreading Winning Principle 1 towards a million bed days WINNING PRINCIPLE 1 Winning Principle 1 National Overview (HES 2006/7) Winning Principle 1 is being adopted Unscheduled (emergency) patients • Emergencies inpatient episodes and adapted into rapid alert systems, should be assessed prior to the have increased by 51% over nine defined emergency pathways and decision to admit. Emergency years acute oncology approaches. Reducing admission should be the • Emergency admissions via A&E have length of stay and averting exception not the norm. increased particularly rapidly unnecessary admissions. This has the (144%) potential to reduce emergency bed • There are nearly 200,000 days by 25%. admissions pa via A&E • The equivalent to 540 per day. This National cancer emergency equates to three patients per day, bed days total number per average size NHS Trust Releasing 25% = 740,996 bed days • Emergencies use 60% of bed days (almost three million) • Emergency bed days have increased by 14.5% over nine years • In 2006/7 there was 417,646 emergency inpatient episodes = 2,963.987 bed days • Average length of stay for emergency admissions is 7.1 days. 18
  • 19. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:42 Page 19 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice Winning Principle 2 2. All patients should be on defined inpatient pathways based on their Common themes of spread from the analysis tumour type and reasons for 6 admission. 5 WINNING PRINCIPLE 2 The following five summaries focus on 4 Number of test sites spreading Winning Principle 2. They illustrate the spread of change in clinical practice, new care pathways and shifting 3 care from an inpatient to an ambulatory setting. All five NHS Trusts have been successful in spreading the improvements 2 to the places they wanted them to go, across clinical teams, organisations and 1 cancer networks. The learning applied to the spread framework shows the common themes. 0 Spread Simple Principles & Messages & Team Working Collaboration, Partnerships Continuous Monitoring, Progress & Impact & Operational Change Linked Strategic A Vision for Quality Improvement & Accountability Leadership, Engagement Alignment with Opportunities & Levers Patient Centred Learning & Unlearning Spread Strategy Systematic Improvement Approach Organisational Culture & Fit 19
  • 20. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 15:01 Page 20 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice Pan Birmingham Network Move to 23 hour stay model We then went along the same base lining What has been the impact? and wound drains as the for all other test sites and it soon became apparent that the issues in the pathway exception for breast that were evident in the initial testing Quality improvements Coverage Efficiency benefits cancer surgery (excluding sites were also similar to those in the new Insertion of drains the All breast care excluding Reduce unnecessary LOS reconstruction) across a test sites. We were able to share the WINNING PRINCIPLE 2 exception rather than the breast reconstruction from six days to 23 hours Cancer Network. learning from the initial sites and adapt norm – aiding patient mobility surgery across the Pan the protocols that were developed for use and early discharge Birmingham Network Establishing the How was spread achieved? within the new test sites. appropriate length of stay ‘Pulling the idea’. Following the visit to Drainage of seroma the Sandwell & West for 80% of breast Kings College Hospitals NHS Foundation The way in which testing moved into exception rather than the Birmingham NHS patients including Trust, London, two consultants at each spread was: norm – less invasive Trust (City Hospital) mastectomy excluding trust were happy to test the use of drains • By the teams owning the testing idea interventions and reducing the breast reconstruction as the exception rather than the norm. from infancy. risk of infection Heart of England NHS surgery The concerns that the consultants had • Sharing the learning from other test Foundation Trust (Good prior to the visit at Kings were alleviated sites on a regular basis at the NSSG. Patients satisfaction identified Hope and Solihull) Potential to benefit 1,524 by meeting face to face with the clinicians • Testing evolved into spread within the they liked the new model patients a year (all breast at Kings. The spread of the change in organisations as well as across University Hospitals care cancer and non clinical practice had already started. organisations by regular Birmingham NHS cancer excluding breast communication and raising the profile Foundation Trust reconstruction) Following the early testing this work locally by sharing the findings. stream became a rolling agenda item at • At all Trusts there were surgeons who Walsall Hospital the Network Site Specific Group (NSSG) were not involved in testing, however, for Breast at which the surgeons and their lengths of stay have also been other clinicians came together on a bi reduced. The Pan Birmingham Network monthly basis. Within a few months it has shown that spread has been was evident that this testing was achieved and the work is being successful and when asked at the NSSG sustained. for other test sites, we got sign up from all the other Acute Trusts within the Network and at one Trust we had buy-in from both hospital sites within the Trust. 20
  • 21. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:42 Page 21 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice Baseline and potential cost savings The Pam Birmingham 23 hour model has now spread and is being sustained Potential cost savings for breast across the Pan Birmingham Cancer Network Test sites Number of Additional Number of breast consultants consultants surgeons within Test sites Total number Average Inpatient Day case Potential testing model involved in spread the Trust WINNING PRINCIPLE 2 of episodes length of cost at £200 cost at £250 savings stay per day per day Sandwell & West 2 3 5 Birmingham NHS Trust Sandwell & West 473 5.32 503,272 118,250 385,022 Heart of England NHS 2 4 6 Birmingham Foundation Trust University Hospital 394 4.04 318,352 98,500 219,852 Walsall Hospitals NHS 1 2 3 Birmingham Trust University Hospital 3 0 3 Birmingham 270 5.19 280,260 67,500 212,760 Birmingham NHS Heartlands Foundation Trust Hospital Good Hope 156 5.03 156,936 39,000 117,936 Baseline length of stay and the sustainability results for three Hospital of the organisations 2009 Walsall Hospital 231 3.95 182,490 57,750 124,740 Sustainability data Network Total 1524 4.70 1,432,560 381,000 1,051,560 Baseline Testing Consultant NonTesting Consultant 6 5 4 3 2 1 0 Hospital1 Hospital2 Hospital3 21
  • 22. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:42 Page 22 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice The National Picture - Breast Cancer Surgery Trends The national picture is showing that length of stay is decreasing: Breast Cancer Surgery Breast Cancer Surgery: Trends in Average Breast Cancer Surgery: Trends in Bed Days Breast Cancer Surgery: Trends in Procedures Length of Stay (HES 1997-2008) (HES 1997-2008) (HES 1997-2008) Average length of stay (days) Number of Procedures Mastectomy: Distribution of Inpatient Bed Days Wide Local Excision: Distribution of Inpatient Length of Stay (HES 2007-2008) Length of Stay (HES 2007-2008) Procedures Procedures 22
  • 23. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:42 Page 23 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice Sandwell and West Birmingham Hospitals NHS Trust: City Hospital Reducing length of stay for A local forum for sharing ideas across the What has been the impact? colorectal surgery patients Network and has been established ‘The Midlands Enhanced Recovery Forum’. using enhanced recovery Quality improvements Coverage Efficiency benefits techniques. The enhanced Events have been held locally and this has Patients informed of the post Sandwell & West Reduce unnecessary LOS recovery pathway sets out helped to spread Enhanced Recovery to WINNING PRINCIPLE 2 operative milestones they are Birmingham Hospital from 16 days to 5 days when patients should be three other organisations within the expected to achieve resulting Trust; City Hospital (ranging from 8 to 3) Network. expecting to eat, drink, in quicker recovery times mobilise or practice changing Heart of England NHS Enhanced Recovery is now being Patients able to drink up to Trust Potential to benefit 150 their stoma bag. discussed at the Colorectal Network Site two hours before their Walsall Hospitals NHS resections patients a year Specific Group to ensure dissemination operation Trust across the local health economy and also How was spread achieved? University Birmingham provide a means for ensuring that spread The principles of Enhanced Recovery were Strong laxative preparation not NHS Trust is continuously monitored. initially introduced by one surgeon. Some required of the key principles have been adopted The Colorectal Network by the other three surgeons in one Alternative analgesia Site Specific Group organisation so that other patients have minimising opiod side effects ensures dissemination also benefited. Early diet and across the local Health mobilisation along with effective pain Optimal use of IV fluids during economy control have been accepted more widely operation guided by although issues around bowel preparation oesophageal Doppler continue. Reestablishment of enteral nutrition from day of operation Other sites within the region, Heart of England NHS Trust, Walsall Hospitals NHS Patients are encouraged to Trust and University Birmingham NHS mobilise from day one Foundation Trust are learning about Enhanced Recovery and implementing Development of multimodal many of its principles. Two local study model of care enhanced days have been held to raise the profile recovery pathway of Enhanced Recovery principles. 23
  • 24. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:42 Page 24 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice Sandwell and West Birmingham Hospitals NHS Trust: Enhanced Recovery Pathway The improved local Enhanced Recovery Pathway Working in partnership with patients - All patients are given a milestone Patients are informed about the benefits and requirements prior to surgery both within card to aid with early independence after surgery the outpatients setting and also at pre-assessment. This preparation is seen as key to ensuring that patients and their families are well prepared for their stay and discharge from hospital. WINNING PRINCIPLE 2 Traditional pathway Enhanced Recovery Pathway Day 0 Surgery performed Day 0 Surgery performed Drip, fluids, drain(s) Drips, fluids, drain(s), catheter Catheter/nasogastric tube Drinking tea/juice Walking short distance Day 1 Monitoring post op/sit out Pain relief via PCA/epidural Catheter in Day 2 Monitoring post op/? Short walks/sips Day 1 Eating food Walking around ward Pain relief orally Day 3 Monitoring post op/nasogastric down/flatus passed/sips Day 2 Epidural down Day 4 Oral fluids/short walk Drip down Catheter out Day 5 Drip down/drain out Day 3 Patient independent Day 6 ?Small soft diet Day 4 Discharged Day 7 Diet if tolerated/monitor bowel movements/walking “The biggest challenge to introducing enhance recovery to our team was trying to change their deeply Day 8 ?Wound clips removed held ideas about patient recovery” Day 9 Patient independent Mr Satish Bhalerao Consultant, Sandwell & West Birmingham Hospitals Day 10 ?Discharge depending on patient recovery/complications 24
  • 25. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:42 Page 25 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice The National Picture - Colorectal Cancer Surgery Trends The national picture is showing that length of stay is decreasing: Colorectal Cancer Surgery Colorectal Cancer Surgery: Trends in Average Colorectal Cancer Surgery: Trends in Bed Days Colorectal Cancer Surgery: Trends in Procedures Length of Stay (HES 1997-2008) (HES 1997-2008) (HES 1997-2008) Average length of stay (days) Number of Procedures Bed Days Colectomy: Elective - Length of Stay Excision of Rectum: Elective - Length of Stay (HES 2007-2008) (HES 2007-2008) Number of Procedures Number of Procedures 25
  • 26. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:42 Page 26 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice East Kent Gynaecological Oncology Centre Improving patient care with How was spread achieved? What has been the impact? • A systematic approach shorter hospital admissions • National publication to spread Quality improvements Coverage Efficiency benefits amongst peers Many cancer patients’ journeys include • Gynaecology NHS Leads Group avoidable prolonged hospital admissions Patients know what their Involved patients The overall length of • Network Site Specific Group (NSSG ) WINNING PRINCIPLE 2 and significant variations in length of stay. length of stay is expected to admitted for gynae stay for major • Discussions with Sheffield Teaching be prior to surgery oncology surgery in East gynaecological surgery Hospitals NHS Foundation Trust re The East Kent Gynaecological Oncology Kent gynaecological reduced from 8-7 days enhanced recovery model Centre identified and addressed obstacles Women are engaged in oncology centre; to 4-3 days • Patient and staff awareness programme in the inpatient pathway saving resources discharge planning prior to represents collaborative for expected length of stay. for redirection to areas of clinical need surgery work with MDT, 32.1% of patients and improved patient experience avoiding particularly nursing and for abdominal This work reflects many of the principles delays in investigations and treatment. Patients are happy to go medical staff hysterectomy including of enhanced recovery. home sooner without the re- ovarian, uterine and They are using a number of spread initiation of bowel function cervical malignancy strategies to ensure the messages are and take prescribed gentle were discharged within shared amongst peers both locally and laxatives in their own home four days instead of 8.1 nationally. Clinical engagement was a key days in 2006 driver in their spread strategy and Patients do not have to stay commenced right at the beginning with in with their urinary catheters Referrals to social all the key people being involved. The services, palliative care improvements were clinically led and Wound management can be team and occupational clinically focused. The major factor done in the community therapy reduced from responsible for the reduction of stay was 13 days to seven days a patient and staff awareness programme of early post-operative mobilisation and discharge, leading to an expected hospital stay. 26
  • 27. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:42 Page 27 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice The National Picture - Gynaecologial Cancer Surgery Trends The national picture is showing that length of stay is decreasing: Gynaecological Cancer Surgery Gynaecological Cancer Surgery: Trends in Average Gynaecological Cancer Surgery: Trends in Bed Days Gynaecological Cancer Surgery: Trends in Procedures Length of Stay (HES 1997-2008) (HES 1997-2008) (HES 1997-2008) Average length of stay (days) Number of Procedures Bed Days Abdominal Excision of Uterus: Elective Length of Stay Vaginal Excision of Uterus: Elective Length of Stay (HES 2007-2008) (HES 2007-2008) Number of Procedures Number of Procedures 27
  • 28. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:42 Page 28 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice Example of Enhanced Recovery Elements The three summaries; mastectomy, colorectal resection and gynaecology have all illustrated how some of the principles of Enhanced Recovery are being adopted across different tumour sites. • Optimising pre-operative Referral from haemoglobin levels Primary Care • Managing pre existing co-morbidities eg diabetes • Planned mobilisation • Rapid hydration & nourishment Pre-Operative • Appropriate IV therapy • Optimised fluid hydration • No wound drains • Reduced starvation • No NG (bowel surgery) • No/reduced bowel • Catheters removed early preparation (bowel • Regular oral analgesia surgery) • Optimising health/medical Admision • Paracetamol and NSAIDS condition • Avoidance of opiate based • Informed decision making analgesia where possible • Pre-operative health & risk or administered topically assessment • PT information & Intra-Operative expectation managed • Audit & outcome • DX planning (EDD) measures • Minimally invasive surgery • Use of transverse incisions Post-Operative • No NG tube (bowel surgery) • Use of LA with sedation • Epidural management • DX on planned day Follow-Up (inc thoracic Therapy support (stoma, • Optimised fluid physio) • 24hr telephone follow up For further information on the National Enhanced Recovery Programme visit www.18week.nhs.uk or www.improvement.nhs.uk/cancer 28
  • 29. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:43 Page 29 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice St Helens and Knowsley Hospitals NHS Trust Inpatient pathways for “Spread is through gaining The Unknown Primary Pathway is being spread throughout the Network Carcinoma of Unknown support at the cancer centre Primary: (UKP) for elective and rolling this out with and emergency patients support from commissioners” WINNING PRINCIPLE 2 How was spread achieved? The local work is now well recognised in Dr Ernie Marshall Macmillan Consultant Medical Oncologist the network with the imminent formation of a Clinical Network Group and the development of guidelines. The Unknown Primary Pathway will be a core function of the new Acute Oncology Team in each Trust. What has been the impact? Quality improvements Coverage Efficiency benefits Multidisciplinary approach Whiston Hospital Reduction in unnecessary investigations from five to Radiology alerts St Helens Hospital average of three Whiston Hospital has sustained their changes Improved clinical decision The Whittington Reduction in LOS from 22 25 making Hospital NHS Trust, days to 12 days (range 9-22) Baseline Test Cycle 1 2008 London 20 Reduce the number of Reduction from diagnosis to 15 unnecessary investigations referral five days to two days (range 1-5) 10 Patient seen within 24 hours of admission Reduction from referral to 5 team to being seen from two days to 0.5 days 0 Time to referral Time to first seen Length of stay Number of imaging /investigates per patient 29
  • 30. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:43 Page 30 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice Barking Havering and Redbridge University Hospitals NHS Trust Shifting care from “I supported this project as What has been the impact? haemato-oncology inpatients clinically it would deliver in to day case - inpatient Quality improvements Coverage Efficiency benefits terms of reducing patients’ procedures to day case and investing to save length of stay; I understood Less unnecessary time in Initially suitable Identifying the procedures that WINNING PRINCIPLE 2 hospital for patients patients were could be conducted as a day the executive teams transferred into the case improved inpatient bed How was spread achieved? Patients satisfaction Moving from testing to implementation reservations in terms of the shows they preferred day case beds utilisation by 80% took longer than expected. financial input, but knew that being treated as a day All consultants in Invest to save – four beds on the case rather than having haemato-oncology day-case unit The first business case was rejected. this would deliver both an inpatient stay - 12 in total To date 68 patients have been clinically and financially.” Improved access to transferred from inpatients to The second business case focused on the Dr Yasmin Drabu specialist nurse advice day cases savings from reducing length of stay. This Medical Director during assessments/ was due to the organisations financial 1652 hours = 68 bed days have treatments position. The involvement of the medical been saved director was a key turning point. Current procedures that have shifted from inpatient to day case Patients previously admitted for On getting the business case accepted, intravenous antibiotics to the the recruitment process took much longer haematology oncology ward Ascetic drain than expected. LOS has been reduced from 113 Blood and platelet transfusions hours five nights stay in hospital Now all 12 consultants in to four hours over five days Skin biopsy haemato-oncology use the beds but we CT guided biopsy Day case does not mean all day have learnt that shifting inpatient procedures to day case should involve all U/S guided biopsy Efficiency parties from day one including radiology. Hickman line insertion Clinical engagement is the key to its Total number of patients in admission avoidance 68 success. Bone marrow beds since February – May 2009 Consultant review Number of patients who would have had inpatient 22 IV fluids spell for this procedure Number of bed days saved to date 1652 hours = 68 bed days 30
  • 31. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:43 Page 31 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice National overview: Spreading Winning Principle 2 towards a million bed days Winning Principle 2 National Overview (HES 2006/7) Winning Principle 2 is being adopted and All patients should be on defined • Elective inpatient bed days account for adapted into defined tumour specific inpatient pathways based on their 35% of bed days pathways, enhanced recovery approaches tumour type and reasons for • 2006/7 average length of stay for and shifting care such as procedures from elective admissions was 5.2 days inpatients to alternative delivery settings. admission. • 2006/7 there was 339,038 elective The spread of this principle and models WINNING PRINCIPLE 2 inpatient episodes = 1,750,223 bed has the potential to reduce elective bed days. days by 25% and in some tumour groups adopting the enhanced recovery approach up to 50% released bed day capacity. National cancer elective bed days total number Releasing 25% = 437.555. 31
  • 32. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:43 Page 32 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice Winning Principle 3 3. Clinical decisions should be made on a daily basis to promote Common themes of spread from the analysis proactive case management. 2.0 Winning Principle 3 is not a stand alone principle as clinical decision making is a key component across all improvements 1.5 and an integral part of all the principles. Number of test sites Regular, timely clinical decision making 1.0 can make a significant impact on quality improvement, efficiency and the inpatient experience, but often requires a change of mind set, practice, system and 0.5 behaviour in order to gain the benefits. WINNING PRINCIPLE 3 The evaluation of learning showed the following common themes. 0.0 Spread Simple Principles & Messages & Team Working Collaboration, Partnerships Continuous Monitoring, Progress & Impact & Operational Change Linked Strategic A Vision for Quality Improvement & Accountability Learning & Unlearning Leadership, Engagement Alignment with Opportunities & Levers Patient Centred Spread Strategy Systematic Improvement Approach Organisational Culture & Fit The previous summaries have highlighted the importance of clinical leadership, consultation, communication and providing evidence as an enabler for spread. The following summaries highlight some of the obstacles to spread and how they were overcome. 32
  • 33. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:43 Page 33 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice Brighton and Sussex University Hospitals NHS Trust Several strategies were How was spread achieved? What has been the impact? implemented and tested to This work has become integrated within the cancer network to support spread. try to maximize efficiency, Quality improvements Coverage Efficiency benefits optimize timely clinical The project has been promoted through Improved communication 13 whole time 75%of patients admitted decision making and hence the Cancer Network via the ‘Lead between clinical team consultants on original planned date improve both bed usage and Managers’ and ‘Chemotherapy members - weekly Improvement’ groups and interest has Elective stays have been the inpatient experience for multidisciplinary ward Part of a planned been shown in doing similar work at reduced by an average of the patients. They included discussions strategy with the other Trusts. one day per patient Cancer Network weekly multidisciplinary ward Daily clinical decision making Saving 21 bed days per discussions, daily ward paper via paper ward rounds to month rounds with the senior include outlier patients Potential to release 250 registrar, an admission Timely decision making bed days annually priorities scoring system and Admission priority scoring WINNING PRINCIPLE 3 benchmarked length of stay system “gold, silver & bronze” with appropriate triggers for Trigger point system for discharge. discharge The testing of daily clinical decision Elective patients admitted on their original planned date making seemed to demonstrate a positive outcome in that daily ward rounds by the oncology consultants did help to reduce Testing length of stay. However, this came at a Baseline Aug/Sept 07 Nov 07 Mar 08 Mar 09 significant cost of time. Without being % of all elective patients admitted 58% 62% 81% 88% 75% able to incorporate this amount of time in on original planned date workable job plans, it was not felt to be a sustainable change. The senior registrar % of priority elective patients 64% 71% 93% 85% 82% on call for the ward now undertakes a admitted on original planned date daily paper ward round instead which is How often is 100% of daily 30% 40% 71% 79% 84% fully implemented and includes all admissions achieved outliers. Average days delays for patients 2.75 days 3.5 days 1 day 1 day 1 day not admitted on original planned date 33
  • 34. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:43 Page 34 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice The Whittington Hospital NHS Trust - Acute Oncology Model Acute Oncology Model of What has been the impact? Care delivery aims to reduce length of stay for emergency Quality improvements Coverage Efficiency benefits admissions and avert Acute oncologist available to Southend to Shorter LOS for emergency unnecessary acute admissions. see new in-patient referrals Whittington covering admissions with new daily all specialities cancers This model of care had been used by the acute oncologist Rapid access clinic for new Peer to peer within Admission avoidance for when working in Southend patients presenting acutely the hospital so that some acute patients with and on moving hospital the with suspected malignancy all acute specialities suspected cancer aware of the service approach has been adopted by Fewer unnecessary tests the Whittington Hospital NHS ordered Trust supporting the spread of WINNING PRINCIPLE 3 good practice. "Most patients prefer to be at home, not in hospital. How was spread achieved? There are good examples of hospitals where effective care Peer to peer within the hospital so that all acute specialties were aware of the with high quality outcomes for patients is provided with a service. This was achieved by visiting all length of stay half that in other hospitals treating the the multidisciplinary team meetings. same sorts of patients. All should be aiming to match the achievements of the best." Celia Ingham Clark Medical Director, Whittington NHS Trust 34
  • 35. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:43 Page 35 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice National overview: Spreading Winning Principle 3 towards a million bed days is not just about numbers it’s about quality driving the numbers Winning Principle 3 Daily, timely clinical decision Clinical decisions should be making is core business in quality made on a daily basis to promote improvement. To ensure patients stay proactive case management. in hospital for the appropriate length of stay and as safe and effective as possible. Clinicians are the key characters and their timely decision making is a ‘vital episode’, but currently there remains significant variation in timely clinical decision making which adds unnecessary hours, days and delays onto a patients stay in hospital. WINNING PRINCIPLE 3 35
  • 36. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:43 Page 36 Transforming Care for Cancer Inpatients Winning Principle 4 4. Patient and carers need to know about their condition and Common themes of spread from the analysis symptoms to encourage self- management and to know who 3.0 to contact when needed. 2.5 The first summary for Winning Principle 4 illustrates clinicians and 2.0 Number of test sites patients working together for a shared cause. Theirs is a simple but strong 1.5 message to reduce deaths from neutropenic sepsis and a spread partnership – keeping the patient at the 1.0 centre was a dominate feature captured from their learning. 0.5 0.0 Spread Simple Principles & Messages & Team Working Collaboration, Partnerships Continuous Monitoring, Progress & Impact & Operational Change Linked Strategic A Vision for Quality Improvement & Accountability Learning & Unlearning Leadership, Engagement Alignment with Opportunities & Levers Patient Centred Spread Strategy Systematic Improvement Approach Organisational Culture & Fit WINNING PRINCIPLE 4 36
  • 37. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:43 Page 37 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice Blackpool, Flyde and Wyre Hospitals NHS Foundation Trust Tested multiple approaches What has been the impact? covering neutropenic sepsis management involving Quality improvements patients and clinicians with the Aim Improvement Quality Baseline Sustained Sustained aim to reduce mortality and Tested & Spread 2007 2008 2009 length of stay through Late emergency Improve patient Promote self-management Cancer Partnership 2 deaths 0 deaths 0 deaths developing an emergency presentation awareness/promote and confidence in the system Group undergoing early presentation, self audit of patient pathway for the management High risk of management and • Patient held alert card views – positive of emergency patients with mortality patient’s confidence • 24 hour help line feedback neutropenic sepsis. • Patient experience DVD Save Lives created by patients for Divisional audit on patients neutropenic sepsis How was spread achieved? to include • Patient experience captured in a DVD presentation times and distributed to over 500 patients a year, increasing patient and carer Multiple Right place first time. • One entry point • Increased patient 43% patients 60% of 75%of awareness for patients diagnosed with emergency Improve patient, • Direct admission to ward awareness direct referral patients patients cancer access points primary and secondary • Awareness campaign • When to act, to correct direct direct • Hospital wide patient group directive care awareness to GPs who to contact ward referral to referral to • Press release and where to correct correct agreed and implemented for antibiotics • Direct admission policy go ward ward given at point of entry by nurses and • Neutropenic sepsis monitored management policy • Hospital direct admissions policy implemented and monitored. This is an Delay in Improve door to • Patient group directive for Right Care 8% receive 55% receive 77% receive agreed emergency pathway. treatment treatment time for antibiotics given at point Right Place antibiotics antibiotics antibiotics WINNING PRINCIPLE 4 • Neutropenic sepsis management policy 100% of patients of entry by nurse Right Time within an within an within an implemented and monitored • Staff training hour of hour of hour of • Increased staff awareness arriving at arriving at arriving at • Winner of the 2007/8 Blackpool, Fylde e.g. protocols, presents, hospital hospital hospital and Wyre Innovation Award. laminated flow charts 37
  • 38. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:43 Page 38 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice Efficiency Coverage Efficiency benefits Organisation wide Reduction in mortality Length of stay 30 All entry points 75% of patients direct referral to correct ward Baseline Test (2008) Implemented (2009) where patients may 25 attend know what 77% receive antibiotics within an hour of arriving at 20 care is required hospital Days 15 3 patients a week are admitted with neutropenic sepsis. LOS has reduced from 6 days to 4 days over the test 10 period, which equates to 312 bed days saved per year 5 Cost of standard ward stay = £200 per day 0 Number of Length of stay Length of stay This has the potential to save £62,400 per year Patients (days): Maximum (days): Average In addition, fewer patients present to A&E. In 2007 33% of patients presented to A&E; in the 2009 audit 5% of Quality Improvement patients presented to A&E % Receive antibiotics within 1 hour Average A&E cost is £24 per person Baseline Test (2008) Implemented (2009) This equates to 43 less A&E attendances per year which 90 equates to £1032 per year 80 WINNING PRINCIPLE 4 70 Overall potential saving is £63,400 per year 60 50 40 30 20 10 0 Presentation - Administration: % within 1 hour 38
  • 39. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:43 Page 39 Transforming Care for Cancer Inpatients Great Western Hospitals NHS Foundation Trust Neutropenic Sepsis Pathway What has been the impact? Febrile neutropenia is a common Quality improvements Coverage Efficiency benefits potentially life threatening complication of chemotherapy. Prompt diagnosis and Improved patient education All chemotherapy patients Earlier presentation of post chemotherapy complications treatment are important. The Great and satisfaction Western Hospitals NHS Foundation Trust in Swindon are further improving 24 hour contact – Inpatient Haemato-Oncology A faster and specialised system for providing advice for patients emergency care of adult haematology Triage help line Ward (Dove) and Day Therapy following chemotherapy treatment with the potential to reduce and oncology patients admitted with Treatment Centre (DTC), Acute unnecessary GP appointments and hospital admissions suspected neutropenic sepsis by Assessment Unit (AAU) and encouraging earlier presentation and Emergency Department (ED) working towards achieving a ‘door to Nurse to nurse referral & Dove and DTC, AAU and ED More timely referral for assessment and treatment antibiotic’ time of one hour or less. improved communication In addition, a scoring system; between AAU and the Multinational Association of Supportive Haemato-Oncology Team Care in Cancer (MASCC score 2009) to identify low and high risk patients has Suspected Neutropenic AAU, Dove, DTC and ED. More timely and complete package for assessment and been introduced to ensure that the most Sepsis pathway pack treatment appropriate antibiotics are administered. All patients have an AAU, Dove, DTC and ED. An increase from 36% to an average of 69% of patients The overall aim is to improve patient assessment of MASCC risk receiving intravenous antibiotics within one hour of arrival at satisfaction, reduce the length of stay index score on admission hospital prior to the introduction of MASCC scoring* (LOS) and target the use of intravenous antibiotic therapy. Introduction of a’ low risk’ antibiotic policy to reduce length of stay where appropriate, but, * the need for medical assessment How was spread achieved? of the scoring prior to treatment has extended the ‘door to WINNING PRINCIPLE 4 Trust wide by active dissemination antibiotic time’ (43%) and requires further work but over 86% through education and training of staff received antibiotics within one hour of assessment and availability of the pathway in appropriate clinic areas. Continuous Direct telephone number to AAU & Dove to Ambulance Improved timeliness of transport to hospital audit and education are important to ambulance service for staff Service raise the profile but challenging because to arrange transport of the large number of staff involved. A (previously arranged by GP) full time Lead Chemotherapy Nurse has been appointed to support this important function. 39
  • 40. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 15:07 Page 40 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice Great Western Hospitals NHS Foundation Trust: Continuous Audit Audit results May-Jun Mar-Apr Jun-Aug Mar-May 2007 2008 2008 2009 Antibiotics <1h 36% 78% 60% 86% Gent <2h 67% 60% 28% 0% Mean LOS 24 days 11 days 10 days 2.25 days In hospital mortality 30% 0% 0% 0% WINNING PRINCIPLE 4 40
  • 41. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:43 Page 41 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice Hull and East Yorkshire Hospitals NHS Trust 24 Hour Palliative Care What has been the impact? Telephone Advice Line Quality improvement Coverage Efficiency benefits Palliative care patients often presented either at clinic or A&E with common Enhanced patient choice, awareness and self-management Each locality will maintain Reduced emergency admission symptoms such as pain, nausea, vomiting, their own model of care and length of stay Increase patient confidence in own decision making increased respiratory tract secretions and • Hull and East Yorkshire Hull & East Yorkshire Hospitals breathlessness. The Humber and Right pathway, right person, first time Hospitals from 119 calls 11% (13 patients) Yorkshire Coast Cancer Network explored Identified symptom pathways enhancing proactive • Scarborough admitted to hospital 2 patients models of service that would support prevention and care • Whitby attended day case unit saving 72 patients and their families in their own • Ryedale Primary unnecessary bed days and an home by providing a 24 hour helpline. Cross boundary working, helping patients and their families in Care Trust estimated 47 hospital admissions This work has been spread using different avoiding the need for hospital admission at times of distress were prevented models across the Network. How was spread achieved? A wide range of information and advice Lessons learnt St Andrew’s Hospice 24 Hour The Palliative Care Steering Group, was has been given to the callers, which We know that the service is working, Hotline - Reason for Call initially formed to implement the varied from simple advice on although there is a need to ensure there Syringe Driver Advice Symptom Control Advice guidelines as recommended by NICE. management of the patient at home, is continuous monitoring to be able to Drug Dosage Medication Advice The Palliative Care Steering Group was pain relief and radiotherapy side effects. quantify the impact to ensure that the Support Advice re Hospice Facilities responsible for dealing with any issues or All GPs, district nurses and Macmillan patients following the calls are not 10 concerns that arise, supporting the nurses have been advised appropriately ending up in hospital via another route. localities and ensuring that the correct and have received follow up calls the next 8 locality measures and peer review working day from the service lead. measures are adhered to where palliative 6 WINNING PRINCIPLE 4 care is appropriate. Spread was further supported by having agreed protocols, locality measures and 4 Excellent cross boundary working adherence to peer review measures. including communication and advice to help patients and their families avoid the 2 need for hospital admission at times of distress. 0 7 months 41
  • 42. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:43 Page 42 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice National overview: Spreading Winning Principle 4 - Patients and quality improvement driving the numbers towards saving a million bed days Winning Principle 4 The main aim of Winning Principle 4 Winning Principle 4 is being adopted Patient and carers need to know is to encourage self-management and adapted into support models about their condition and through: such as telephone helplines, symptoms to encourage self- information advice and key contacts. management and to know who • Putting patients first ensuring they to contact when needed. have a choice and control in their Further work is needed to fully life develop patient self-management • Promoting better support for the models. patient and carers • Making sure that patients get the right help at the right time before reaching a crisis point • Ensuring easy access to information, advice, support and advocacy • Offering support that is tailor made to meet the patients/carers needs. WINNING PRINCIPLE 4 42
  • 43. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:43 Page 43 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice Further evidence supporting spread The spread planner survey was sent to Emerging key messages cancer networks for completion and this The initial findings from the survey have provided a snap shot of ‘how’ the the potential to inform planning for Winning Principles and improvements spread, regardless if the intention is to were being spread, moving beyond initial spread with/across organisations, across testing. networks, health communities or Strategic Health Authorities. One of the issues we are facing is to ensure that good ideas and improvements The survey provided a useful baseline do not get ‘trapped in location’ but travel position and further evidence of the (horizontally and vertically) to improve the themes for spread. There are some quality of care. The cancer networks important messages, but no new mind- were considered to be well placed in this blowing messages or solutions for spread, context and would capture information but for many sites the spread planner from sites who had not been involved survey has been used as a checklist to in the initial testing. support local spread and their plans for ‘scaling up’ improvement. The survey was not simply focused on numbers about take up, but also It is the intention to repeat the survey 3-6 captured the different elements of ‘how’ monthly and share this learning across the spread was being achieved. Spread is the NHS. a measure not only of increasing numbers but also about the principles and processes that support this. 43
  • 44. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:43 Page 44 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice Transforming Inpatient Framework for Spread: Common themes and practices Spreading new ideas and good practice Understanding what good practice looks like Active dissemination Prove what works and the benefits Passive diffusion Involve those who need to be actively ‘One size fits no one problem’ involved at the start A Vision for Quality Improvement Systematic Spread Receptive to the improvement Improvement Strategy Adaption to the context Approach Policies and procedures A degree of flexibility Linked Organisational Strategic and Culture Operational and Fit Change Continuous Spread Spread Communication Information Monitoring Simple Shared comparative data Progress and Making the Principles and Use of opinion leaders Connections Finding the right focus for quality and efficiency Impact Messages Collaboration Leadership Partnerships Engagement and Team Accountability Working Clinical and managerial Stakeholders Alignment Responsibility for delivery Ownership and a distribution of responsibilities Learning with Executive leadership Networking & Unlearning Opportunities Patient and Levers Centred Knowledge required Local quality indicators and priorities Coaching Commissioning agreement and healthy competition Changing practice and behaviour Patients involved in testing Training Accepted or rejected the improvement 44
  • 45. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:43 Page 45 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice Spread is evident Initial findings and messages • There were mixed views surrounding Spread is evident • The main focus for spread is commissioning. Some viewed 80 surrounding Winning Principle 1 and 2 commissioning as the lever to ensure - the emergency and elective pathways. the improvement was sustained, whilst 70 Many sites commented that Winning others viewed commissioning as a lever Principles 3 and 4 were integral to all to make improvement happen No. of hospital sites 60 the principles • Responses indicated that spread from 50 • The following models of delivery initial testing in an organisation takes are being adopted: at least one year. 40 • Communication alert (RAPA) model 30 • 23 Hour Breast Model of Delivery • Enhanced Recovery Approach 20 • Developing Neutropenic Sepsis Pathways 10 • A number of sites do not have an active 0 spread strategy. Many stated that where 2007 2008 2009 testing was successful spread Year automatically followed across tumour sites if the baseline evidence and measure of benefits from testing was robust • Network Site Specific Groups were viewed as important to spread improvement • Clinical nurse specialists and middle managers were seen as the hardest to engage 45
  • 46. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:44 Page 46 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice Conclusions Over the last two years, innovative ways sepsis pathways from one clinical team to The tools, techniques and approaches of delivering services for inpatients with another, from community to community are available for use and do not need cancer have been tested with over 40 and widespread across England will to be reinvented, coupled with clinical pilot sites across England. The case always be a challenge. support. studies presented in this document come highly commended, as practical examples This work demonstrates how innovations Our evidence is compelling, the case of what can be achieved. have been adapted and are spreading; studies in practice making a difference for just look at the concept of ‘rapid alerts’ the service and patients. 1 million bed The result is a number of credible, originated in Sherwood Forest Hospitals days – is it achievable? From this observable innovations which NHS Foundation Trust, on one site (Kings evidence, definitely. demonstrate real improvements in the Mill) in one specialty - lung, and now way services are provided and delivered. spreading to Lincolnshire, London, From now on, our goal is to make these Importantly, for patients they have valued Brighton, Doncaster and other sites. The innovations the norm rather than the time, ensure patients receive quicker 23 hour model is now becoming the exception and see all potential inpatients treatment, minimise time in hospital and standard across all of Birmingham with cancer benefit from this good ensure a more responsive service for the hospitals with a potential saving of over practice. patients and their carers. £1 million per annum. Let us ask ourselves why would a patient Our challenge to you is, if you were to want to stay six days in hospital when 23 take just one of these innovations and hours is an option? By spending £175 on adapt to your local situation, just think a smart phone, we could avert unecessary of the impact you could make. Our Janet Williamson emergency admissions and reduce a recommendation is that you start with National Director, NHS Improvement hospital stay for one patient by days! Winning Principle 1 ‘emergency patients Should a patient stay 15 days or five days assessed prior to admission’ or Winning by adopting an enhanced recovery Principle 2 ‘all patients should be on a pathway? How easy could it be to adopt defined inpatient pathway’ and that Blackpool’s DVD to avert emergency you contact Ann Driver or a member admissions for neutropaenic sepsis? of her team who can help you to turn this into a local reality Spreading innovations such as Rapid (ann.driver@improvement.nhs.uk). Alerts, 23 hour models, enhanced recovery approaches and neutropaenic 46
  • 47. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:44 Page 47 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice References and supporting information Biddy J., Bevan H, Carter E., Bate P., McNulty T., Ferlie E (2002) Nordin AJ. (2007) Enhanced Recovery Robert G. (2009) The power of one, Reengineering Health Care: The for Gynaecological Patients. Cancer The power of many. Bringing social complexities of organisational Inpatient Case Studies: 4 Winning movement thinking to Health and Transformation. Oxford. Principles, NHS Improvement, viewed 11 healthcare improvement; NHS Institute November 2008 for Innovation and Improvement National Cancer Intelligence Network www.improvement.nhs.uk/winning_princi www.ncin.org.uk ples/principles_2/queen_elizabeth.pdf Cancer Commissioning Toolkit www.cancertoolkit.co.uk National Cancer Services Analysis Pettigrew A. Whipp R (1993) Managing Team www.canceruk.net/natcansat Change for Competitive Success. Department of Health; High Quality Blackwell Care for All: NHS Next Stage Review National End of Life Care Programme (2008) www.dh.gov.uk www.endoflifecareforadults.nhs.uk Plesk. P.E. (2000) Spreading good ideas for Better Health Care. VHA Inc Department of Health NHS Cancer NHS Improvement (2008) Transforming Reform Strategy (2007) www.dh.gov.uk Inpatient Care: The Winning Principles Rodgers E. M. (2003) Diffusion of www.improvement.nhs.uk Innovations Free Press 5th Edition Driver A. (2008) Factors affecting the achievement of cancer waiting times NHS Improvement (2008) Transforming The Gold Standards Framework targets in NHS Trusts: an exploratory Inpatients Care: Meeting the Challenge www.goldstandardsframework.nhs.uk study. Unpublished thesis Doctorate together….delivering care in the most Professional Studies in health; Middlesex appropriate setting, supporting Williamson J. (2007). The critical factors University, London delivery. www.improvement.nhs.uk for whole system change of a clinical specialty identified through the Fraser S. (2002) Accelerating the NHS Modernisation Agency (2004) Cancer services Collaborative Spread of Good Practice: A workbook Manage variation in patient discharge ‘Improvement Partnership’, for Health Care. Kingsham Press thereby reducing length of stay; 10 Unpublished thesis Doctorate Professional High Impact Changes for Service and Studies in Health, Middlesex University, Liverpool Care Pathway Improvement and Delivery: A guide for London www.endoflifecare.nhs.uk/eolc/lcp.htm NHS leaders, p32 47
  • 48. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:44 Page 48 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice Roll of honour Barts and The London NHS Trust Heart of England NHS Foundation Queen Mary’s Sidcup NHS Trust University Hospital Birmingham Trust; Good Hope Hospital, Heartlands NHS Foundation Trust Barking, Havering and Redbridge Hospital, and Solihull Hospital Royal Berkshire NHS University Hospitals NHS Trust Foundation Trust University Hospitals Bristol NHS Trust Hull and East Yorkshire Hospitals Blackpool, Flyde and Wyre Hospitals NHS Trust Royal Devon and Exeter NHS University Hospitals of Morecambe NHS Foundation Trust: Blackpool Foundation Trust Bay NHS Trust; Lancaster GPs Hospital & Preston Hospital King’s College Hospital NHS Foundation Trust Sandwell and West Birmingham University College London Hospitals Brighton and Sussex University Hospitals NHS Trust; City Hospital NHS Foundation Trust; The National Hospitals NHS Trust Lancashire Care NHS Hospital for Neurology and Neurosurgery Foundation Trust Scarborough and North East Yorkshire Cambridge University Hospitals NHS Healthcare NHS Trust University Hospitals of North Foundation Trust; Addenbrookes Leicester County and Rutland PCT Staffordshire; Stoke PCT & North Hospital & Cambridgeshire PCT Sheffield Teaching Hospitals NHS Staffordshire PCT Manchester PCT Foundation Trust Coventry PCT; University Hospital Walsall Hospitals NHS Trust Coventry Milton Keynes NHS Sherwood Forest Hospital NHS Foundation Trust Foundation Trust Whipps Cross University Hospital Derby Hospitals NHS NHS Trust Foundation Trust Nottingham County Teaching PCT St Helens and Knowsley Hospitals NHS Trust; Whiston Hospital East Kent Hospitals University NHS Norfolk and Norwich Hospitals Foundation Trust; Queen Elizabeth, the NHS Trust The Christie Hospital NHS Trust Queen Mother Hospital Northampton General Hospital The Hillingdon Hospital NHS Trust East Midlands Cancer Network NHS Trust The North West London Hospitals George Eliot Hospital NHS Trust Oxford Radcliffe Hospitals NHS Trust NHS Trust; St Marks Hospital Great Western Hospitals NHS Oxfordshire PCT The Whittington Hospital NHS Trust Foundation Trust Pan Birmingham Cancer Network United Lincolnshire Hospitals Guys and St Thomas’ NHS NHS Trust; Grantham and District Foundation Trust Poole Hospital NHS Hospitals, Pilgrim Hospitals Boston, Foundation Trust Lincoln County Hospital, County Hospital Louth and Lincolnshire PCT 48
  • 49. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 16:54 Page 49 Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice Transforming Inpatient Team: for further information Ann Driver Director ann.driver@improvement.nhs.uk Angie Robinson National Improvement Lead angie.robinson@improvement.nhs.uk Marie Tarplee National Improvement Lead marie.tarplee@improvement.nhs.uk Catherine Strong PA catherine.strong@improvement.nhs.uk 49
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  • 52. 65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:41 Page 52 NHS NHS Improvement CANCER DIAGNOSTICS HEART STROKE NHS Improvement With nearly ten years practical service improvement experience in cancer, diagnostics and heart, NHS Improvement aims to achieve sustainable effective pathways and systems, share improvement resources and learning, increase impact and ensure value for money to improve the efficiency and quality of NHS services. Working with clinical networks and NHS organisations across England, NHS Improvement helps to transform, deliver and build sustainable improvements across the entire pathway of care in cancer, diagnostics, heart and stroke services. Delivering tomorrow’s NHS Improvement 3rd Floor | St John’s House | East Street | Leicester | LE1 6NB improvement agenda ©NHS Improvement 2009 | All Rights Reserved | Telephone: 0116 222 5184 | Fax: 0116 222 5101 for the NHS www.improvement.nhs.uk