Unleashing D U l hi DynamismiA Case Study:The Trafford Story of Integrated Care Presented by: Samantha Nicol Integrated Care System Programme Director Dr Nigel Guest General Practitioner Nuffield Summit March 2011
Unleashing Dynamism• Intensity• Enthusiasm } qualities that enable people to get things done• Motivation• Work systems• Language } dimensions of organisational dynamism• Interpersonal style p y• Modes of thinking• Mindsets• incentives – leadership – information - policy
Let s Let’s see what you think?• For just 5 minutes discuss what you think unleashes dynamism in the programmes, strategies and projects you are currently working on• Feedback – create a list
Then there was was…… 50 years of change FHSA Community T t C it Trust Foundation Trust Hospital Trust Area District Strategic Health Authority
And so we arrive at 2008 – intolerable condition diti
What have been your intolerable conditions diti• For just a couple of minutes think what your intolerable conditions have been that have prompted you to look to unleash dynamism• Feedback – common themes?
Intermountain Healthcare Utah, Utah 1975 Perceived strengths of Intermountain Pioneering use of electronic medical records: ‘data-driven approach’ Measure, track and thereby improve clinical outcomes Evidence-based medical care guidelines Preventative medicine Risk-stratification of the patient population p p p Balance between needs of the community and available resources Non-profit health care deliveryIntermountain’s integrated system: –ffrequently cited b the Obama administration as the prime exampl of a high- tl it d by th Ob d i i t ti th i le f hi h performing organisation that reduces healthcare costs
Unleashing dynamism through VISIONARY LEADERSHIP• That is: – Vision – Environment – Relationships – Power – Performance – Self – Communication – System and processes
Unleashing Dynamism through RELATIONSHIPS• Manipulating the environment through team spirit p g g p• Removing hierarchy, value individuals in their own right• Emphasis on the team finding the solution• Focus on points of connection building trust and rapportt• Giving power to others – asking people what they think coaching conversations think,
Principles• Clinical Congress 2008• Principles• Scope of design
Trafford s Trafford’s principles of integrated care• Principle one: General Practice should be ‘locus of integration• Principle Two: Consultant opinion is an essential component of effective integrated services• Principle Three: The delivery of integrated services will primarily rest on extended role nursing and allied health professionals• Principle Four: Integrated services will be enhanced by the p g y involvement of social care• Principle Five: The voluntary sector and carers need a strong voice in the design and delivery of services• Principle Six: Future integrated services would bring together the full range of primary care• Principle Seven: Unscheduled care should be simple to access and fully integrated• Principle Eight: Where benefits can be derived from co-operation between integrated care services and conventional acute hospital services we will secure them
C eate the s o (1) Create t e Vision ( ) The present PCT THT/UHST/CMMC Community Inpatient, Inpatient Non-PbR Non PbR services daycase, services specialist Outpatients and (Independent) diagnosticsGP1 GP3 GPn … and we have persistent issues of poor GP2 GP4 integration, resilience and perhaps quality… is there a structural problem?
Systematic exploration of SPMS/ alternative extended primary care provider (2) t d d i id The future? PCT SPMS practice: GPs and THT/UHST/CMMC consultants as partners Community Inpatient, Inpatient Non-PbR Non PbR services daycase, services specialist Integrated Care Record Outpatients and (Independent) diagnosticsGP1 GP3 GPn GP2 GP4 Or FT for THT
Systematic exploration of SPMS/ alternative extended primary care provider (1) t d d i id The present
Unleashing Dynamism through FOUNDATIONS• In order to support the unleashing of dynamism you have to have rules of engagement and foundations on which you can build on• People have to know what they are getting involved in and what direction they are going in• This helps them to know what resources they can offer and what power th h d h t they have t exchange to h• The vision inspired and created passion and enthusiasm, its development involved p p from the start p people
But that is not enough… enough• Between 2008 and 2010 there was a series of business cases, submitted t th St t i b i b itt d to the Strategic Health Authority and PCT for funding to support these leaders and the relationships to develop the vision and implement the principles across Trafford to develop an integrated care system p g y and an integrated care organisation through which integrated services could be delivered.
It is probably NOT about permission and f di d funding• Two business cases, very detailed and developed with , y p the help of external consultancy did not achieve their required outcomes• Alth Although th did raise th awareness about th vision h they i the b t the i i and the potential of that vision to achieve dramatic change to the way services are provided and their cost• But their proposals were probably just too big and risky
You have done all that…..• What else is there??
Unleashing Dynamism through TESTING - ‘P f of Concept’ ‘Proof f C t’• What they did do however, was achieve a £2m investment and a year to develop the infrastructure necessary to deliver the vision• It came back to – Leadership – Relationships – Framework
In Action• The following slides set out a series of case g studies taken from Trafford’s Integrated Care System Programme that has now been running for nearly one year• Highlighting the elements of unleashed dynamism across multi professional groups groups, multi organisations and during one of the most turbulent times in the NHS in 60 years
Unleashing Dynamism through PROGRAMME MANAGEMENT OG G• As a vehicle for implementing strategy and for bringing about corporate renewal as alternative organising structure• Programme as an emergent phenomenon, conscious of and responsive to external change and shifting strategic goals• Framework/structure therefore atemporal or with indeterminate time horizons• Vehicle for enhancing corporate vitality concerned with nurturing of individual and organisation-wide capabilities as well as the efficient deployment of resources d l t f• Intimately bound up with and determined by context rather than governed by a common set of transferable principles and processes.• Not a scaled up version of project management• Adaptive not prescriptive
Unleashing Dynamism through PROGRAMME MANAGEMENT• Leadership at all levels, skilled individuals with clearly defined authority, accountability and responsibility and programme governance aligned to sources of influence• Benefits management – identification, quantification, owners and tracking• Stakeholder management and communications – understanding stakeholders interests and impact of the programme, engagement of them g g g• Risk management and issue resolution – managing risk at an acceptable level• Planning and control – prioritisation of projects and grouping of projects linked to benefits realisation• Business case management – value management of benefits, costs, timescales and risks• Quality management – configuration management, change control on documentation, quality assurance and review of outputs to ensure they are ‘fit for purpose’
Unleashing Dynamism through PROGRAMME MANAGEMENT• Engaging people as change agents• Realistic about the effort of change• Link between behaviour and outcomes• Priority to systems that provide touch points with individuals and teams• Used to provide space for the conversations• Seeing culture as embedded in actions
Clinical Panel Project Manager’s• Louise Rogerson – End of Life• Andrew Giles – Respiratory p y• Brooks Kenny – Diabetes• Guy Hamilton – Data Sharing / Information• Ric Taylor – Mental Health• Tim Weedall – ENT• Jason Hughes – Unscheduled Care
Andrew GilesRespiratory Project Manager Gail Mann ICS Programme Manager
Diabetes Clinical Panel• Put in picture of Panel
Unleashing Dynamism through CLINICAL PANELS• A safe shared space to build relationships that are about clinical care not about organisations li i l t b t i ti• Chaired by a primary and secondary care clinician• A good mix of opinions, but essentially commonly shared g p y y and owned values• Patients and carers• Clear strategic outcomes – focussing on quality of clinical care and clinical outcomes measuring improvement• Time
Unleashing Dynamism through CLINICAL PANELS• Management support g pp• Information/data – about their current patients and clinical practice• Shared aims• Small steps• [Any chance we could do this like a jigsaw coming together with previous slide and make it one slide?]
Unleashing Dynamism through SHARED INFORMATION Illustration 1 – risk stratification (diabetes) Band1 Band2 Band3 Band4 Band5 Biochemical HbA1c <7 7‐9 >9 dont know HbA1c date HbA1c date <13 months <13 months >13months don t know dont know Systolic Blood pressure <120 120‐140 >140 dont know Diastolic Blod pressure <70 70‐90 >90 dont know Serum Cholesterol <5 >5 dont know serum Creatinine (kidney) <120 120‐200 >200 dont know Microalbinuria <3 >3 dont know Microvascular comorbities Chronic Kidney Disease 1 2 3 4 5 Diabetic Neuropathy Diabetic Neuropathy yes No don t know dont know Retinopathy yes No dont know Macrovascular comorbidities MI (ACS/NSTEMI/STEMI/ANGINA) yes no CVA (TIA/RIND/CVA) yes no PVD yes no Other Age 18 44 18‐44 45 64 45‐64 65+ Hospital admissions in last 12m 1 2 or more
Unleashing Dynamism through SHARED INFORMATION Illustration 2 – i k t tifi ti (di b t ) Ill t ti 2 risk stratification (diabetes) Band1 Band2 Band3 Band4 Band5BiochemicalHbA1c <7 7‐9 >9 dont knowHbA1c date <13 months >13months dont knowSystolic Blood pressure <120 120‐140 >140 dont knowDiastolic Blod pressure <70 70‐90 >90 dont knowSerum Cholesterol <5 >5 dont knowserum Creatinine (kidney) <120 120‐200 >200 dont knowMicroalbinuria <3 3 >3 3 don t know dont knowMicrovascular comorbitiesChronic Kidney DiseaseDiabetic Neuropathy 1 yes 2 No 3 dont know 4 5 RiskRetinopathy yes No dont know CategoryMacrovascular comorbiditiesMI (ACS/NSTEMI/STEMI/ANGINA)CVA (TIA/RIND/CVA) yes yes no no 1PVD yes noOtherAge 18‐44 45‐64 65+Hospital admissions in last 12m 1 2 or more Note: For illustration only y
In Summary It is all about… It is not all about…..A burning platform or an intolerable conditionVisionary Leadership at all levels Seeking permissionRelationships – cross organisational and professional boundaries FundingFoundations – vision, values OrganisationsProgramme Management – providing a framework to support creativity and Bricks and Mortarinnovation while ensuring shared learning, transparency of benefits andaccountability Command and control
I leave you with this thought thought….• Matthew chapter 4 verses 12 -23 p – A fisher of men a leader calling to his followers caught through teaching and persuasion – Together grasp the sense of what is needed to be done – Build on what has been done well in the past – Called to serve • Vision, energy, enthusiasm – Hearts turned by • Hands willing to get dirty • Working together to deliver a vision.