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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 …

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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  • 1. WHOLE SYSTEMS IMPROVEMENT
  • 2. CONTENT
    Overview of NHS Tayside and the challenges facing it
    The NHS Tayside improvement journey
    Centre for Organisational Effectiveness
    A Whole Systems Approach
    The Improvement Programme and Projects
    • Virtual Ward Demonstrator
    • 3. Medicine for the Elderly Demonstrator
    • 4. Outpatients Efficiency Demonstrator
    The Benefits
  • 5. THE BALANCING ACT….
    • 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. 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. Meeting Scottish Government Efficiency & Productivity SR10 challenge, £27.4m in 2010, £30.0m in 2011/12following November’s budget.
    • 8. Continuing to deliver against the Scottish Patient Safety Programme and meeting the demands of the recently announced NHS Scotland Quality Strategy
    • 9. Demographic challenge around Older People’s services
  • HEALTHCARE DEMAND IS GROWING
    A new Ninewells
    Hospital by 2031!
    NHS Tayside
    +148 beds 2016
    +517 beds 2031
  • 10. IMPROVING QUALITY REDUCING COSTS
    Our Choice
    Surviving – the 5%
    Thrive – the 95%
  • 11. 2009-2011 – A TACTICAL JOURNEY
    TACTICAL
    STRATEGIC
    PRODUCTIVITY & EFFICIENCY
    SERVICE OPTIMISATION
    CRES
    TRANSFORMATION
    DEALING WITH
    THE 5%
    SPENDING THE 95% BETTER
  • 12. 2010-2012 – A BLENDED APPROACH
    TACTICAL
    STRATEGIC
    PRODUCTIVITY & EFFICIENCY
    SERVICE OPTIMISATION
    TRANSFORMATION
    CRES
    CRES
    DEALING WITH
    THE 5%
    SPENDING THE 95% BETTER
  • 13. 2010-2012 KEY OUTCOME AREAS
    TACTICAL
    STRATEGIC
    PREVENTION OF ADMISSION
    IMPROVED DAY CARE
    INTERMEDIATE CARE
    CARE HOME INTERFACE
    MEDICATION REVIEWS
    CASE MANAGEMENT IMPROVED PATHWAYS
    HOUSING / HOMECARE SUPPORT
    ENABLING TECHNOLOGY
    IMPROVED SERVICE LIASON AND DISCHARGE
    REDUCE LENGTH OF STAY AND BED DAYS
    INTEGRATED HEALTH AND SOCIAL CARE SERVICES
    VIRTUAL WARDS
    WORKFORCE REDESIGN
    SELF CARE AND ENABLEMENT
    COST MINIMISATION
    WORKFORCE EFFICIENCY
    TELEHEALTH / TELECARE
    NEW MODELS OF CARE- DEMENTIA, FALLS AND END OF LIFE
    WORKING WITH COMMUNITIES -
    COPRODUCTION
  • 14. Identifying the areas
    for improvement..
    WHOLE SYSTEMS ANALYSIS
    Assess the performance of the
    whole health system with respect to
    local and national targets
    Identify areas of existing & potential
    constraints within the whole system
    To consult with stakeholders across
    the whole system & recommend
    areas of priority
    Assessing the management
    information requirements to support
    better patient flow management
  • 15. STEPS TO BETTER HEALTHCARE
    Tayside Centre for Organisational Effectiveness www.t-coe.org.uk
    IMPROVEMENT ACADEMY
    INNOVATION HUB & E HEALTH
    DEVELOPMENT&SUPPORT
    Mental Health
    Theatre Capacity
    Workforce Efficiency
    Integrated Care
    Older People
    Mental Health
    Optimising Facilities
    Prescribing Medicines
    Others Labs, Maternity
    Finance Support
    Scenario Planning, Financial Baselines, Benefits Tracking, Business Cases
    Workforce Support
    Workforce Modelling, Engagement & Communications with staff
    Comms Support
    Communications with public and staff
    OE Support
    Organisational Effectiveness support (includes eHealth)
  • 16. NHS Tayside

    first phase strategic improvement projects
    Elective
    Urgent & Emergency
    Community Care Services
    End to end pathway in
    Improve Flow in Medical
    Orthopaedics
    Wards
    Develop use of
    Community Nursing
    -
    Community Hospitals
    -
    patient contact
    Variation in referral
    improve use/flow
    Time /anticipatory care
    rates
    Reduce multiple
    admissions in over 75's
    AHP activity
    -
    Community Diagnostics
    Referral Mgt

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