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Enhanced Recovery Masterclass Afternoon
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Enhanced Recovery Masterclass Afternoon


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  • 1. Enhanced Recovery – The managerialcomponents• How to implement• How to manage the process and use data• Sustainability• Examples and group work @officialERblog
  • 2. Implementing enhanced recovery involves changes to managerial and clinical processes, across different departments, locations, and professionsManagerial Clinicalprocesses processes @officialERblog
  • 3. Change is complex…An enhanced recovery pathway is a multi-step process No single magic step @officialERblog
  • 4. We need to focus on the clinical and process steps equally Doing the right things right for every patient Clinical Decisions Do right things (EBM) Process/System Do right changes things right Do things right (QI) Good Patient CareAdapted from Glasziou et al. BMJ Qual Saf 2011;20(Suppl 1): i13-i17 @officialERblog
  • 5. Challenges to implementing enhanced recovery - What does the literature tell us?Conclusion – Key factors for quality improvement success• Leadership• Organisational culture• Data infrastructure and information systems• Experience of quality improvement @officialERblog
  • 6. Challenges to implementing enhanced recovery - What doindustry models tell us are the ingredients for change? You need all elements to make change successful and sustainable @officialERblog
  • 7. What is your motive to change?People have different motives for change @officialERblog
  • 8. Who is creating and leading the vision?How is that vision being transferred to others and shared? @officialERblog
  • 9. What is the organisations capacity for change? Tools, techniques Personnel, time, resources @officialERblog
  • 10. Timeframe PlanMethodical, simple, uncomplicated approach @officialERblog
  • 11. Leadership @officialERblog
  • 12. Optimal Project Leadership @officialERblog
  • 13. Explaining the roles• Executive Sponsor: • Organisational commitment and alignment with strategic priorities • Ensure effective project governance • Ensure project is effectively resourced • Oversees sustainability planning • Empowerment of project team to lead improvement across the patient pathway including relationship management with other partner organisations • Participates in sector learning events with the project team • Helps the team overcome any barriers to change• Clinical / Nursing / Therapy Leads: • Clinical champion respected amongst peers and MDT • Role model who will lead change by example • Ability to challenge barriers and resistance to change • Need excellent relationship management skills and will challenge resistance to change @officialERblog
  • 14. Explaining the roles• Dedicated Project Management resource to: • Create project plan • Co-ordinate the activities of the project team, including management of team • Meetings • Manage plan against milestones • Provide communications updates to project sponsors, governance committee, project team and key stakeholders• Data management: • Support clinical teams in data collection • Provide data analysis and information reporting • Needs skills to work with clinical teams in data collection and reporting • Needs knowledge and understanding in the use of information for improvement, as well as performance reporting @officialERblog
  • 15. Pathway manager• “Responsibility without authority”• Traditionally nobody takes ownership of the whole process – we mange activities which are part of the process• Management by “persuasion and influence”• Responsibility for pathway compliance and outcome @officialERblog
  • 16. A pathway manager Bottom-Up(Development) Top-Down (Directive) General Management Expertise In-Depth Understanding of Work @officialERblog
  • 17. How do you ensure sustainability? @officialERblog
  • 18. NHS Institute for Innovation and ImprovementSustainability model - 1Developed by Maher, Gustafson, Evans 2003It is designed to • Be a simple tool • Identify and understand key barriers to sustaining change that is specific to your context • Understand what teams using the tool can do to overcome potential barriers to sustainability • Monitor progress over time @officialERblog
  • 19. NHS Institute for Innovation and ImprovementSustainability model - 2 • It was developed by a panel of experts and improvement leaders in front line positions • 250 improvement leaders working in front line positions rated the importance of the factors • Tested the model for theoretical robustness • Tested the model practically • Recommended intervention strategies • Formally evaluate ‘usefulness’ of model and intervention strategies @officialERblog
  • 20. Scores• If the overall score is above 55 it is positive• If the overall score is below 55 there will be areas that need more focused work• We recommend that the focus is on improving the two factors that have the greatest potential• If the score is below 40 we usually advise that you suspend the project and concentrate on improving the likelihood that it will sustain @officialERblog ©NHS Institute for Innovation and Im provem ent 2006
  • 21. @officialERblog©NHS Institute for Innovation and Im provem ent 2006
  • 22. Examples from a national program to improve outcomes for hip and knee replacement Rob Middleton Clinical Lead for Hip and Knee Replacement @officialERblog
  • 23. Trust 1 @officialERblog
  • 24. Trust 1 actual average total potential totalBenefits beyond helping patients 4.7 8.5Credibility of the evidence 4.7 9.1Adaptability of improved process 3.4 7Effectiveness of the system to monitor progress 2.9 6.5Staff involvement and training to sustain the process 2.5 11.4staff behaviours toward sustaining the change 5.1 11Clinical leadership engagement 6.1 15Fit with the organisations strategic aims and culture 3.4 7Infrastructure for sustainability 1.7 9.5Total 40.1 @officialERblog
  • 25. Trust 1Process Baseline CurrentAdmitted on the day of 2.9% 6.8%surgeryPatients walking to theatre 7% 24%Cancellations 2.82% 0.89%Mobilise within 12 – 18 60% 85%hours of surgeryLength of stay for hips 7.35 days 7.4 days% patients discharge 4 days 24% 46%post op @officialERblog
  • 26. Trust 2 @officialERblog
  • 27. Trust 2 actual average total potential total Benefits beyond helping patients 7.9 8.5 Credibility of the evidence 7.9 9.1 Adaptability of improved process 3.4 7 Effectiveness of the system to monitor progress 4.7 6.5 Staff involvement and training to sustain the process 7.5 11.4 staff behaviours toward sustaining the change 11.0 11 Senior leadership engagement 11.5 15 Clinical leadership engagement 8.4 15 Fit with the organisations strategic aims and culture 4.9 7 Infrastructure for sustainability 3.7 9.5 Total 70.8 @officialERblog
  • 28. Trust 2Process Baseline August 2009Admitted on the day of surgery 12% 100%Operate within 4 hours of admission 7% 75%Cancellations 11% 0%Estimated date of discharge given at 0% 100%POALength of stay for hips 11.5 days 5.75 daysLength of stay for knees 8 days 5.5 days @officialERblog
  • 29. Data @officialERblog
  • 30. ProblemThe data you have is not thedata you want, the data youwant is not the data youneed, and the data you needdoesn’t exist. . . @officialERblog 30
  • 31. Why do we need data?• Every improvement involves change but not all changes are improvements (Batalden and Davidoff 2007)• Implementing a clinical pathway (enhanced recovery) is not a goal as such, but only a way to achieve a goal (Degeling at al. 2003)Batalden PB, Davidoff F (2007) What is “quality improvement” and how can it transform healthcare? Qual Saf Health Care 16(1): 2-3.Degeling P, Maxwell S, Kennedy J, Coyle B (2003) Medicine, management, and modernisation: a “danse macabre”? BMJ 326(7390): 649-652 @officialERblog
  • 32. How do we go about using data to help do this? How do you make sure it’s good What data do you quality data? collect? Who analyses your data?How do you collect the data? How much time does it take? How do you use the data you collect?
  • 33. Firstly, differentiate between outcome and process data Outcome data Process data Internationally defined Locally defined @officialERblog
  • 34. Outcome data is not suitable for monitoring processes We need to know outcomes but outcome data doesn’t allow you to manage a process, this is because• All defects in a process do not necessarily lead to bad outcomes• Outcome data is often aggregated @officialERblog
  • 35. Aggregated data doesn’t allow us to monitor processesLength ofstay LOS remains low from one month to the next, but us the process stable? Month A Month B @officialERblog
  • 36. The average of a set of numbers can be created by many different distributionsLength ofstay Time @officialERblog
  • 37. Start using data and it’s qualitywill improve Break the cycle and start using the information
  • 38.
  • 39. Meaningful data• Quality improvement – 3 basic questions – What do you want to accomplish? – By what method will you accomplish your objective? – How will you know when you have accomplished your objective? @officialERblog
  • 40. Meaningful local process data – Example of LOS @officialERblog 40
  • 41. Example: Reduce length of stayA hospital perceives that they can reduce length of stay for a certainpatient group. What is current length of stay for these patients? What are my objectives?• Firmly establish present length of stay• Characterize patterns in, reasons for, and effects of processes on LOS• Design interventions to reduce length of stay i.e. implement enhancedrecovery @officialERblog 41
  • 42. Example: Reduce length of stayA hospital perceives that they can reduce length of stay for a certainpatient group. What is current length of stay for these patients? What information do I need to meet my objectives?• The time each patient reaches specific time points within theirhospital stay• The reasons for delays at any of these time points• Reasons for overall increased LOS @officialERblog 42
  • 43. Example: Reduce length of stayA hospital perceives that they can reduce length of stay for a certainpatient group. What is current length of stay for these patients? From where can I get this information?• Hospital Data Systems• Patient Medical Records• Departmental audits @officialERblog 43
  • 44. Example: Reduce length of stayA hospital perceives that they can reduce length of stay for a certainpatient group. What is current length of stay for these patients? Do I need to make modifications to the data collection process?• Is the data I need captured anywhere?• Is it usable?• What do I need? @officialERblog 44
  • 45. Reducing length of stay @officialERblog
  • 46. Length of stay - Control chart @officialERblog
  • 47. Source – NHS Institute @officialERblog
  • 48. Source – NHS Institute @officialERblog
  • 49. Monitoring LOS – Root cause analysis @officialERblog
  • 50. Aggregating data collection locally - Process and outcome measuresData source – Derwent database @officialERblog
  • 51. Local aggregation and warehousing of data Case mix adjusted dataData submitted nationally HES/SUS Hospital electronic record system e.g. E-camis Health professionals Local database enter audit data directly e.g. Physio, Pain, complications, post-op calls NJR OUTPUT PROMS Patient experience data, clinical outcomes, and process measures can be warehoused together Patient experience data and then combined with case-mix adjusted data
  • 52. Ongoing monitoring – make data transparent and available to all Daily, Weekly, Monthly, Annually @officialERblog