WHOLE SYSTEMS IMPROVEMENT<br />
CONTENT<br />Overview of NHS Tayside and the challenges facing it<br />The NHS Tayside improvement journey<br />Centre for...
Medicine for the Elderly Demonstrator
Outpatients Efficiency Demonstrator</li></ul>The Benefits<br />
THE BALANCING ACT….<br /><ul><li>NHS Tayside delivers healthcare to over 400000 patients with a budget in excess of £750m....
NHS Tayside’s principal health organisations comprise the NHS Tayside board, the single delivery unit and the Community He...
Meeting Scottish Government Efficiency & Productivity  SR10 challenge, £27.4m in 2010, £30.0m  in 2011/12following Novembe...
Continuing to deliver against the Scottish Patient Safety Programme and meeting the demands of the recently announced NHS ...
Demographic challenge around Older People’s services</li></li></ul><li>HEALTHCARE DEMAND IS GROWING<br />A new Ninewells<b...
IMPROVING QUALITY REDUCING COSTS<br />Our Choice<br />Surviving – the 5%<br />Thrive – the 95%<br />
2009-2011 – A TACTICAL JOURNEY<br />TACTICAL<br />STRATEGIC<br />PRODUCTIVITY & EFFICIENCY<br />SERVICE OPTIMISATION<br />...
2010-2012 – A BLENDED APPROACH<br />TACTICAL<br />STRATEGIC<br />PRODUCTIVITY & EFFICIENCY<br />SERVICE OPTIMISATION<br />...
2010-2012 KEY OUTCOME AREAS<br />TACTICAL<br />STRATEGIC<br />PREVENTION OF ADMISSION<br />IMPROVED DAY CARE<br />INTERMED...
Identifying the areas<br />for improvement.. <br />WHOLE SYSTEMS ANALYSIS<br />Assess the performance of the <br />whole h...
STEPS TO BETTER HEALTHCARE<br />Tayside Centre for Organisational Effectiveness    www.t-coe.org.uk<br />IMPROVEMENT ACADE...
NHS Tayside <br />–<br />first phase strategic improvement projects<br />Elective<br />Urgent & Emergency<br />Community C...
INTEGRATED CARE(VIRTUAL WARDS) - THE CHALLENGE<br /><ul><li>Emergency admissions and associated bed days not hitting HEAT ...
Challenge around Health Population Management (HPM)
Lack of effective collaboration between Health and Social Care
Alignment of e Health with key HEAT T6-T12 outcomes
Key improvement areas:</li></ul>Reduce over 65’s Emergency Beds<br />More effective HPM<br />Effective MDT working<br />Re...
INTEGRATED CARE(VIRTUAL WARDS) - THE APPROACH<br /><ul><li>Next future state workshop brought together over 70 integrated ...
Followed up by local sessions in CHP areas…
NHS Tayside worked with partners to develop new HPM toolset – PEONY2
Test  of Change Demonstrators set up in each CHP
Wider collaboration with Social Care, Voluntary Sector and Social Care
Align outcomes with LDP, HEAT and Reshaping of Older People’s services</li></li></ul><li>STEP TO BETTER HEALTHCARE – INTEG...
T6 Long Term Conditions admissions
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Whole Systems Improvement a Business Case for Quality

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NHS Tayside and the Atos Origin Alliance have developed a robust and successful culture of Continuous Improvement (CI) and change through a programme of organic development ‐ Steps to Better Healthcare ( StBH). This session will share experience from the StBH programme with particular focus on how we can learn from and accelerate positive Quality outcomes in a person‐centred and sustainable manner.

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Whole Systems Improvement a Business Case for Quality

  1. 1. WHOLE SYSTEMS IMPROVEMENT<br />
  2. 2. CONTENT<br />Overview of NHS Tayside and the challenges facing it<br />The NHS Tayside improvement journey<br />Centre for Organisational Effectiveness<br />A Whole Systems Approach<br />The Improvement Programme and Projects<br /><ul><li>Virtual Ward Demonstrator
  3. 3. Medicine for the Elderly Demonstrator
  4. 4. Outpatients Efficiency Demonstrator</li></ul>The Benefits<br />
  5. 5. THE BALANCING ACT….<br /><ul><li>NHS Tayside delivers healthcare to over 400000 patients with a budget in excess of £750m. We employ over 14000 staff and provide a comprehensive range of primary, community and acute hospital services for the populations of Angus, Dundee and Perth and Kinross.
  6. 6. NHS Tayside’s principal health organisations comprise the NHS Tayside board, the single delivery unit and the Community Health Partnerships in Angus, Dundee and Perth & Kinross.
  7. 7. Meeting Scottish Government Efficiency & Productivity SR10 challenge, £27.4m in 2010, £30.0m in 2011/12following November’s budget.
  8. 8. Continuing to deliver against the Scottish Patient Safety Programme and meeting the demands of the recently announced NHS Scotland Quality Strategy
  9. 9. Demographic challenge around Older People’s services</li></li></ul><li>HEALTHCARE DEMAND IS GROWING<br />A new Ninewells<br />Hospital by 2031!<br />NHS Tayside<br />+148 beds 2016<br />+517 beds 2031 <br />
  10. 10. IMPROVING QUALITY REDUCING COSTS<br />Our Choice<br />Surviving – the 5%<br />Thrive – the 95%<br />
  11. 11. 2009-2011 – A TACTICAL JOURNEY<br />TACTICAL<br />STRATEGIC<br />PRODUCTIVITY & EFFICIENCY<br />SERVICE OPTIMISATION<br />CRES<br />TRANSFORMATION<br />DEALING WITH <br />THE 5%<br />SPENDING THE 95% BETTER<br />
  12. 12. 2010-2012 – A BLENDED APPROACH<br />TACTICAL<br />STRATEGIC<br />PRODUCTIVITY & EFFICIENCY<br />SERVICE OPTIMISATION<br />TRANSFORMATION<br />CRES<br />CRES<br />DEALING WITH <br />THE 5%<br />SPENDING THE 95% BETTER<br />
  13. 13. 2010-2012 KEY OUTCOME AREAS<br />TACTICAL<br />STRATEGIC<br />PREVENTION OF ADMISSION<br />IMPROVED DAY CARE<br />INTERMEDIATE CARE<br />CARE HOME INTERFACE<br />MEDICATION REVIEWS<br />CASE MANAGEMENT IMPROVED PATHWAYS<br />HOUSING / HOMECARE SUPPORT<br />ENABLING TECHNOLOGY<br />IMPROVED SERVICE LIASON AND DISCHARGE<br />REDUCE LENGTH OF STAY AND BED DAYS<br />INTEGRATED HEALTH AND SOCIAL CARE SERVICES<br />VIRTUAL WARDS<br />WORKFORCE REDESIGN<br />SELF CARE AND ENABLEMENT<br />COST MINIMISATION<br />WORKFORCE EFFICIENCY<br />TELEHEALTH / TELECARE<br />NEW MODELS OF CARE- DEMENTIA, FALLS AND END OF LIFE<br />WORKING WITH COMMUNITIES -<br />COPRODUCTION<br />
  14. 14. Identifying the areas<br />for improvement.. <br />WHOLE SYSTEMS ANALYSIS<br />Assess the performance of the <br />whole health system with respect to<br />local and national targets<br />Identify areas of existing & potential <br />constraints within the whole system<br />To consult with stakeholders across<br />the whole system & recommend<br />areas of priority<br />Assessing the management<br />information requirements to support <br /> better patient flow management<br />
  15. 15. STEPS TO BETTER HEALTHCARE<br />Tayside Centre for Organisational Effectiveness www.t-coe.org.uk<br />IMPROVEMENT ACADEMY<br />INNOVATION HUB & E HEALTH<br />DEVELOPMENT&SUPPORT<br />Mental Health<br />Theatre Capacity <br />Workforce Efficiency<br />Integrated Care<br />Older People<br />Mental Health<br />Optimising Facilities<br />Prescribing Medicines<br />Others Labs, Maternity<br />Finance Support<br />Scenario Planning, Financial Baselines, Benefits Tracking, Business Cases<br />Workforce Support<br />Workforce Modelling, Engagement & Communications with staff <br />Comms Support<br />Communications with public and staff <br />OE Support<br />Organisational Effectiveness support (includes eHealth)<br />
  16. 16. NHS Tayside <br />–<br />first phase strategic improvement projects<br />Elective<br />Urgent & Emergency<br />Community Care Services<br />End to end pathway in <br />Improve Flow in Medical <br />Orthopaedics<br />Wards<br />Develop use of <br />Community Nursing <br />-<br />Community Hospitals <br />-<br />patient contact <br />Variation in referral <br />improve use/flow<br />Time /anticipatory care<br />rates<br />Reduce multiple <br />admissions in over 75's<br />AHP activity <br />-<br />Community Diagnostics <br />Referral Mgt <br />–<br />Whole<br />rebalance the activity <br />-<br />to support Community <br />System Approach<br />towards community<br />Hospital model<br />Improve efficiency<br />In Outpatients<br />Streaming access for <br />U&E patients<br />Deliver effective and<br />Efficient Theatre and<br />Surgery<br />Enhance the Ambulatory <br />i<br />Care service offered in <br />ward 15<br />Clinics<br />Information provision <br />and coding (e.g. The <br />Gap)<br />Prescribing<br />Quality Discharge <br />Communications<br />Patients still on <br />Medicines at Admission <br />medicines they no <br />Prescribing Practice<br />(ADRs)<br />longer need<br />Atos, Atos and fish symbol, Atos Origin and fish symbol, Atos Consulting, and the fish symbol itself are registered trademark<br />s o<br />f Atos Origin SA. <br />October 10<br />©<br />2006 Atos Consulting. Private for the client. This report or any part of it, may not be copied, circulated, quoted without pr<br />io<br />r written approval from Atos Consulting or the client.<br />WHOLE SYSTEM ANALYSIS –PHASE 1<br />
  17. 17. INTEGRATED CARE(VIRTUAL WARDS) - THE CHALLENGE<br /><ul><li>Emergency admissions and associated bed days not hitting HEAT T12 target..
  18. 18. Challenge around Health Population Management (HPM)
  19. 19. Lack of effective collaboration between Health and Social Care
  20. 20. Alignment of e Health with key HEAT T6-T12 outcomes
  21. 21. Key improvement areas:</li></ul>Reduce over 65’s Emergency Beds<br />More effective HPM<br />Effective MDT working<br />Reduction in Polypharmacy<br />
  22. 22. INTEGRATED CARE(VIRTUAL WARDS) - THE APPROACH<br /><ul><li>Next future state workshop brought together over 70 integrated care professionals and patient groups…
  23. 23. Followed up by local sessions in CHP areas…
  24. 24. NHS Tayside worked with partners to develop new HPM toolset – PEONY2
  25. 25. Test of Change Demonstrators set up in each CHP
  26. 26. Wider collaboration with Social Care, Voluntary Sector and Social Care
  27. 27. Align outcomes with LDP, HEAT and Reshaping of Older People’s services</li></li></ul><li>STEP TO BETTER HEALTHCARE – INTEGRATED CARE<br />Art of the probable?<br />What do you<br />See?<br />Tayside<br />Community<br />Today<br />Tayside<br />Community<br />Tomorrow<br />What now?<br />Make it real!<br />‘Test of Change’<br />Demonstrators<br />LEARN<br />DESIRE<br />ADOPT<br />What do you<br />Want?<br />We are<br /> here<br />23/08/11<br />Prioritise<br />Outcome<br /> based<br />response<br />Align<br />Benefits<br />Realisation<br />Our Future<br />Truly needs<br />Based!<br />Impact<br />Assessment<br />Initial Outcome Areas<br /><ul><li>T12 Emergency Bed Days over 65’s
  28. 28. T6 Long Term Conditions admissions
  29. 29. Patient experience
  30. 30. Releasing Time for Community Care
  31. 31. Medication Concurrence</li></li></ul><li>IHI CARE CO-ORDINATION MODEL<br />Person Centred<br />For people with multiple needs<br />Personalised Multi-channel interface<br />Family, associated assets<br />Family<br />Social Care<br />Peer Groups<br />Carer/s<br />Voluntary<br />Goals(G)<br />Co-ordination(C)<br />PATIENT<br />IDENTIFICATION<br />OUTCOMES<br />Value<br />Proposition<br />Service<br />Design<br />Service<br />Delivery<br />Supporting with enabling technology<br />CARE CO-ORDINATOR<br />Feedback<br />Feedback<br />Predictive Risk<br />Tools<br />GP Systems<br />Community Information Systems<br />Telehealth<br />Telecare<br />Performance Management<br />Business Analytics<br />
  32. 32. ANGUS CHP – PATIENT PROFILE<br /> Virtual Wards focusing on <br />Tier 4 , Innovative Step Down <br />Services are key to success! <br />Macro Integrator<br />NHS Tayside and Angus Council<br />LEVELS OF CARE<br /> 724<br />2%<br />LTC<br />Population<br />North West<br />187<br />North East<br />191<br />South<br />346<br />LEVEL 4<br />INTENSE <br />CASE <br />MANAGEMENT<br />VIRTUAL<br />WARD<br />ANTICIPATORY<br />CARE PLANS<br />PATIENT <br />PASSPORTS<br />CASE<br />MANAGEMENT<br /> 10148<br />28%<br />LTC<br />Population<br />LEVEL 3<br />CASE<br />MANAGEMENT<br />North West<br />2631<br />North East<br />2673<br />South<br />4844<br />PRO-ACTIVE<br />CONTACT<br />SUPPORTING<br />SELF CARE <br />70%<br />LTC <br />Population<br />LEVEL 2<br />SUPPORTED <br />SELF CARE<br /> 25372<br />North West<br />6577<br />North East<br />6684<br />South<br />12111<br />PRO-ACTIVE<br />CONTACT<br />SUPPORTING<br />SELF CARE <br />LEVEL 1<br />HEALTHY<br />COMMUNITIES<br /> 72487<br />66%<br />Overall<br />Population<br />North West<br />18790<br />North East<br />19096<br />South<br />34601<br />LTC’s<br />Asthma<br />6101<br />COPD<br />2056<br />Diabetes<br />4698<br />HBP<br />16423<br />CHD<br />5318<br />Obesity<br />11854<br />PREDICTED RISK PROFILE<br />MICRO INTEGRATORS<br />
  33. 33. ENSURE OUTCOMES ARE DELIVERED….<br />Project <br />Definition<br />Statement<br />Benefits <br /> Statement<br />Project <br /> Status<br /> Report<br />Is used for:<br />Stating your case for change<br />Current state analysis<br />Evidence / Data<br />Envisaged Change<br />Summarise benefits<br />Is used for:<br />Define benefits in detail<br />Define appropriate measures<br />Summarise enabling changes ( PP&T)<br />Summarise milestone tracking<br />Is used for:<br />Report on delivery progress.<br />Report on Benefits Realisation against plan.<br />Escalate to Project Board or EMT for decision, support etc<br />Multi- disciplinary Project <br />Board, Clinical and <br />Finance essential <br />
  34. 34. RESHAPING CARE FOR OLDER PEOPLE – OUTCOMES 1<br />
  35. 35. RESHAPING CARE FOR OLDER PEOPLE – OUTCOMES 2<br />
  36. 36. User<br />Device<br />Access<br />TECHNOLOGY ENABLING INTEGRATED CARE<br />Applications<br />Security<br />Service<br />Complex <br />Case<br />Management<br />Collaboration Tools<br />Glue<br />Staff ID<br />Virtual<br />Database<br />Case<br />Management<br />Clinical Portal<br />RBAC<br />Pro-active<br />Contact<br />PMS<br />GP<br />Community<br />Health&<br />Social<br />TELEHEALTH<br />PREDICTIVE RISK<br />TELECARE<br />BUSINESS ANALYTICS<br />Prevention<br />Integration Platform<br />
  37. 37. INTEGRATED CARE(VIRTUAL WARDS) - THE BENEFITS<br /><ul><li>Test of change demonstrators commenced March 2011 following introduction of PEONY2…
  38. 38. Enabling technology being fully utilised
  39. 39. Aligning with local improvement initiatives eg CMR in Angus, Case Management and ACP’s across Tayside..
  40. 40. Envisaged benefits across Patient Access, Service Redesign and Patient Experience:</li></ul>Drive effective attendance at A&E<br />Reduction in unscheduled bed days<br />Effective discharge models<br />Focus on the right patients<br />Increase value multi-disciplinary team time<br />Net CRES of £1.5-2.0m per annum.<br />
  41. 41. MEDICINE FOR THE ELDERLY-BUSINESS CHALLENGE<br /><ul><li>No standardised operating procedures, resulting in unwarranted variation at each stage of the patient journey..
  42. 42. Over 40% of all patient admissions are elderly, and will GROW!
  43. 43. Variation in LoS across MfE wards..
  44. 44. Average LoS higher that ‘best of breed’, around 28 days..
  45. 45. Discharge planning not always linked to EDD..
  46. 46. Issues around capability and capacity of downstream services..</li></li></ul><li>MEDICINE FOR THE ELDERLY- OUR APPROACH<br /><ul><li>NHS Tayside Service Improvement team and Atos supported an MDT through a pathway redesign process…
  47. 47. A collaboration of extensive healthcare experience and application of LEAN thinking…
  48. 48. Initial review highlighted large amounts of waste and variation
  49. 49. 7 key improvement areas identified:</li></ul>Admission Criteria <br />Inpatient management <br />Discharge planning<br />Social work redesign<br />Staffing profile <br />Co-located wards <br />Step up / Step down <br />
  50. 50. MEDICINE FOR THE ELDERLY- BENEFITS<br /><ul><li>Wide variety of Service Improvements achieved, qualitative and financial…
  51. 51. Patient focus and removing waste has delivered a higher quality more cost effective service…
  52. 52. Key outcomes/benefits achieved:</li></ul>Reduced inappropriate admissions<br />Reduced Length of Stay (28-18 days)<br />Lower re-admissions<br />Closure of 2 wards<br />CRES in excess of £1.4m per annum.<br />
  53. 53. OUTPATIENTTHE CHALLENGE<br /><ul><li>10% DNA’s across Tayside in 2009..
  54. 54. 3990 clinics were cancelled across Tayside in Tayside in 2009…
  55. 55. 189 clinics were cancelled within 6 weeks notice in 2009…
  56. 56. 85,922 patient appointments were moved in Tayside in 2009, 50% by the hospital..
  57. 57. High percentage of patient appointment moves DNA on new appointment(50%)…
  58. 58. 23% on new capacity and 17% of review capacity are lost against the planned templates…</li></li></ul><li>OUTPATIENTS – THE CHALLENGE<br /><ul><li>Analysis, diagnostic and redesign work resulted in four major workstream areas:</li></ul>Detailed clinic redesign methodology skills transferred to line management teams…<br />Identify variation and waste with OP clinics then remodel service..<br />Implement an NHS Tayside wide access policy <br />Test of change around patient booking process and implement a central booking function..<br />Review workforce plans to evaluate the current and future staffing models..<br />
  59. 59. OUTPATIENTS – THE BENEFITS<br /><ul><li>It is envisaged that the project will deliver a number of quality improvements:</li></ul>Reduction in number of cancelled clinics, reduced DNA’s and number of moved patients..<br />Improve OP clinic effectiveness by matching capacity and demand to ensure LDP and national targets are achieved..<br />Improve clinic utilisation rates..<br />Workforce- improve nursing skills mix profile through implementing a skills register and flexible resource bank thus reducing banks staff and OT..<br />Envisaged savings of £2m by March 2012..<br />
  60. 60. CAPACITY BUILDING IS…<br />An approach to the development of sustainable skills, organisational structures, resources and commitment for healthcare improvement <br />Hawe et al: 1999<br />
  61. 61. CHARACTERISTICS REQUIRED TO DELIVER IMPROVED OUTCOMES<br />Quality improvement education programme <br />Evidence based learning<br />Leadership development<br />Build<br /> Infrastructure<br /> & Capacity<br />Alignment:<br /><ul><li>Will and commitment
  62. 62. Vision
  63. 63. Strategy
  64. 64. Culture
  65. 65. Measurement
  66. 66. Learning organisation</li></ul>Technology & Innovation<br /><ul><li>Real time measurement and information systems</li></ul>Priorities maintained during crises <br />Stability of general management and <br />program management <br />Supporting and enabling staff in their “day job” of improvement<br />Adaptive internally and externally<br />Ref: Staines 2009<br />
  67. 67. TAYSIDE CENTRE FOR ORGANISATIONAL EFFECTIVENESSwww.t-coe.org.uk<br />Mobilisation of trained experts in quality improvement organisational development and leadership to support improvement work.<br />The focus of this expertise will be mobilised to support front line staff and clinicians to build capability in improvement methodology and support key improvement programmes<br />Real time information and measurement resources to support quality improvement of clinical services.<br />Enhance spread and share of good practice through use of technology e.g. Clinical Portal, Clinical Dashboards.<br />Improvement <br />& <br />Development<br />Support<br />Technology <br />Enabling <br />Health<br />Develop an innovative education and training resource to build further out capacity and capability in improvement science.<br />A dynamic approach to knowledge transfer which supports our “All teach: All learn” philosophy in support of quality improvement.<br />Knowledge <br />Management<br />Improvement <br />Academy<br />
  68. 68. MAKING BETTER PLACES,MAKING PLACES BETTER<br />Our Stretch Challenge 2011-2015<br />“ those who are less able to coproduce and use public services as a resource in their lives, experience much more negative outcomes”<br />This accounts for 40% of public sector expenditure in Scotland<br />
  69. 69. Transformation<br />Transformation<br />Division<br />Improvement<br />Improvement<br />>25%<br />>25%<br />Redesign<br />Redesign<br />Improvement<br />Improvement<br />Organisational scope<br />5<br />-<br />25%<br />5<br />-<br />25%<br />Streamlining<br />Streamlining<br />Improvement<br />Improvement<br />~5%<br />~5%<br />Department<br />Work processes<br />Business processes<br />Business objectives<br />Work processes<br />Business processes<br />Business objectives<br />Content scope<br />Content scope<br />THE TRANSFORMATION JOURNEY TO 2015…<br />Whole<br />System<br />Analysis<br />Improvement Action Weeks<br />
  70. 70. SUMMARY<br /><ul><li>A whole system approach is key..
  71. 71. Identify high impact projects and prioritise resource..
  72. 72. Leadership aligned with core personal objectives key..
  73. 73. Skills transfer critical to accelerate Continuous Improvement across whole system..
  74. 74. Quality improvement with associated CRES can be achieved..
  75. 75. Early engagement of whole system stakeholders essential..
  76. 76. Pro-active internal/external communication policy..
  77. 77. Build on best practice evidence and focus on reducing unwarranted variation…</li>
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