Building Capacity and Leadership to Identify Unwarranted Variation and Understanding how Technology can Support This
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Stacey McCann, Assistant Head of Commissioning, Nursing Directorate, NHS England
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Building Capacity and Leadership to Identify Unwarranted Variation and Understanding how Technology can Support This
- 1. www.england.nhs.uk Building capacity and leadership to identify unwarranted variation and how technology can support this. Stacey McCann, Assistant Head of Commissioning, NHS England 20 April 2016
- 2. www.england.nhs.uk • What is ‘unwarranted variation?’ • How can technology enable nursing, midwifery and care staff to identify unwarranted variation? • What is our leadership role? Three key questions: 2
- 3. www.england.nhs.uk ‘Variation in health care delivery that does not add value to an individual’s health care, for example: • Variation in readmission rates amongst patients discharged at weekends. • Variation in lengths of stay. • Variation in maternity care. • End of life – variation in quality of care between geographical areas and medical conditions. • ..and so on. What is unwarranted variation? 3
- 4. www.england.nhs.uk - Better experiences for individuals. - Better outcomes for individuals. - Better use of available resources. 4 Triple aim outcomes.
- 7. www.england.nhs.uk The primary objective for Right Care is to maximise value: • the value that the patient derives from their own care and treatment • the value the whole population derives from the investment in their healthcare 7 RightCare - Commissioning for Value
- 8. www.england.nhs.uk Five Key Ingredients: 1. Clinical Leadership 2. Indicative Data 3. Clinical Engagement 4. Evidential Data 5. Effective processes 1 key objective + 3 key phases + 5 key ingredients = COMMISSIONING FOR VALUE 8 OBJECTIVE - Maximise Value (individual and population)
- 9. www.england.nhs.uk What should we do? • When faced with variation data, don’t ask: How can I justify or explain away this variation? • Instead, ask: Does this variation present an opportunity to improve? • How can we utilise information technology to reduce unwarranted variation?
- 10. www.england.nhs.uk ‘Nurses, midwives and care staff need to integrate information and information technology into routine practice and embrace opportunities to manage care in new ways.’ (Cooper A, Hamer S (2012) Nursing Times) 10
- 11. www.england.nhs.uk In autumn 2012 the Nursing Technology Fund was launched, dedicated capital investment was made available to support nurses, midwives and care staff to make better use of digital technology in all care settings. The aim was; • to support staff to give safer, more efficient and more effective care, and • to empower care professionals to engage with technology in meaningful and helpful ways. 11 Nursing Technology Fund 2012
- 12. www.england.nhs.uk • Electronic observation systems that allow nurses and clinicians to record clinical data at the bedside on electronic devices in real time. • Provides real time data which can support commissioners to identify unwarranted variation in care giving. • Digital pens for community, district nurses and midwives, which allows for captured data to be integrated into back-office patient systems. • Supports timely data collection in a formalised way which enables comparison of like services. 12 Examples of new technologies:
- 13. www.england.nhs.uk • Marie Curie Cancer Care - £1m to enable mobile access to digital care records, digital capture of clinical data at the point of care, and resource- scheduling software. • Provides data to support better experience, better outcomes and better use of resources. • Devon Partnership Trust - £204K for video consultations and remote consultations in a community mental healthcare setting. • Reduces unwarranted variation in access to services by offering a universal service remotely. 13 Technology fund support:
- 14. www.england.nhs.uk ‘The innovation that telemedicine promises is not just doing the same thing remotely that used to be done face to face, but awakening us to the many things that we thought required face to face contact, but actually do not.’ David D Asch MD, Perelman School of Medicine, University of Pennsylvania 14 Airedale and partners Enhanced Health in Care Homes
- 15. www.england.nhs.uk But technology alone won't improve outcomes. For that to happen, we need nurses, midwives and care staff to lead the use of technology to support reduction in unwarranted variation. 15 Nursing Technology Fund 2012
- 16. www.england.nhs.uk • We have a central role to play in transforming NHS services; making best use of digital solutions is a key component of this. • As system leaders, how do we use technology to understand and reduce unwarranted variation? 16 What is the leadership role for nursing, midwifery and care staff?
- 17. www.england.nhs.uk • We need better, more integrated and preventative person-centred care. • As system leaders, the role of commissioning nurses is to promote the utilisation of peer comparability linked to population outcomes and demonstrate value for money in service re-design and transformation. 17 What is the leadership role for nursing, midwifery and care staff?
- 18. www.england.nhs.uk • We need to support people in their communities and homes, reducing the need for hospital care, technology is a key enabler to make this happen. • We must use technology to generate information, that helps us compare the triple aim outcomes with peers and embark on quality improvement and optimal pathway design in collaboration with clinicians and individuals. 18 What is the leadership role for nursing, midwifery and care staff?
- 19. www.england.nhs.uk • We need to offer care in new ways that were not possible a decade ago and continue to support improved working practices with the potential to transform care. • The responsibility of system leaders is to be role models and lead partners in service transformation whilst make best use of resources, enabling better outcomes and experience for individuals. 19 What is the leadership role for nursing, midwifery and care staff?
- 20. www.england.nhs.uk • In a world where information and technology is more available than it has ever been before, we have integrated much of this technology into the way we live day to day, online banking, searching information online and planning our holidays and shopping. • But – to meet the triple aims of better outcomes, experience and better use of resources, we need to lead the use of all available technology to reduce unwarranted variation through optimal care pathway design. 20 Think!
Editor's Notes
- Welcome and introduction: Hello ….
- There are 3 key questions we need to consider in this session today – What is unwarranted variation? How can technology enable nursing, midwifery and care staff to identify unwarranted variation? What is our leadership role in identifying and working towards reducing unwarranted variation?
- Unwarranted variation may be a phrase that is new to many of you, but it is something you encounter regularly. What is unwarranted variation? We consistently aim for high standards of care for individuals – when we do, quality improves. Identification of unwarranted variation is a helpful way to focus on ensuring that consistently high standards of care are delivered for everyone. Some variations are warranted others cannot be explained and those are unwarranted variations which we need to address. ‘Unwarranted’ variation can be a sign of waste, missed opportunity and poor quality and can adversely affect outcomes, experience and resources. The result is the delivery of lower value care involving the under-use or over-use of services and treatments, either of which might be harmful. The NHS is under increasing pressure to direct all available resources to reduce harm and increase value for people and an important measure to achieve that ambition will be to identify and reduce unwarranted variation in healthcare. This means that we must have a shared understanding of the resources we have and we must work in partnership with individuals and communities, they must always be at the centre of our plans, which should be driven by choice. The call to address unwarranted variation is not a novel policy; the concept has long been a concern to both policy makers and decision makers. We know that unwarranted variation has been observed and recorded for many years, across demographic groups, geographic areas, between provider organisations and within individual care providers. Variation is also frequently observed between general medical practitioners, in areas such as the frequency of contacts, referrals, diagnostic test ordering, prescription rates, and much more. The challenge now facing the NHS is how to prepare the workforce to be capable of taking urgent and coordinated action to identify and reduce unwarranted variation.
- When we think about unwarranted variation in health care we need a measure against which we can plot our progress – this is where the triple aim outcomes can help. What are the ‘Triple Aim’ outcomes? In 2008 Berwick, Nolan, and Whittington19 first described the ‘Triple Aim’ of simultaneously improving population health, improving experience and reducing costs. We all work to achieve these aims of; - Better experiences for individual's, - Better outcomes for individuals, and - Better use of available resources. We can quantify and measure the success of our work by focusing on the ‘triple aim’ outcomes to ensure delivery and measurement of everything that we do is able to demonstrate the use of resources wisely and efficiently.
- The new nursing, midwifery and care staff framework, ‘Leading Change, Adding Value’ (soon to be published)includes 10 commitments, one of which is; We will champion the use of technology and informatics to improve practice, address unwarranted variations and enhance outcomes Developing a RightCare Programme for Nursing, Midwifery and Care Staff to reduce unwarranted variation The Leading Change, Adding Value framework encourages everybody to focus on unwarranted variation to reduce the three gaps and demonstrate the triple aim outcomes. By using this framework nursing, midwifery and care staff have the opportunity to step up, lead and demonstrate to the system the value that they bring by achieving the triple aim outcomes. Health and Wellbeing: - a greater focus on prevention is needed to enable health improvements to continue and to counter pressure on services Care and Quality: - Health needs will go unmet unless we reshape care, harness technology and address variations in quality and safety Funding and Efficiency: - Without efficiencies, a shortage of resources will hinder care services and progress Understanding unwarranted variation Organisations such as community hospitals can data to assess there effectiveness and care delivery, for example, one community hospital with similar demographics to another similar establishment may discover that they have a greater incidence of pressure ulcers than the other, even though they are in the same neighbourhood, have the same number of beds, the same staffing and the same client group. This suggests that there is an unwarranted variation in care, which may be due to a number of factors, including, clinical practice, a lack of training, poor leadership or even human error. Nursing, midwifery and care staff are ideally placed to investigate and identify the true reason for this unwarranted variation in care. Bringing hospital A up to the performance of hospital B will reduce harm, improve outcomes and experience, and make much more effective use of resources. To identify unwarranted variation in nursing, midwifery and care settings, the central nursing directorate is using the RightCare methodology…
- RightCare is a programme currently being rolled out across all clinical commissioning groups (CCGs) in NHS England. It originated during 2013/14 in response to requests from CCGs who asked for support to help them identify the opportunities for change with most impact. The RightCare2 programme has been developed to demonstrate, through using a range of tools, where unwarranted variation exists and how to address it. Using an evidence-based improvement methodology ensures that the change will be delivered in a planned, proven way that follows established methods. This includes the Atlas of Variation8, which demonstrates that it is possible to achieve better outcomes by looking at your local data, and asking whether the outcomes that you are achieving are as good as those achieved by the best? RightCare shares best practice by providing local examples of innovations which demonstrate the philosophy behind RightCare and are published through a series of “RightCare Casebooks9”. A collection of short online tutorials are available to introduce the work, tools and techniques; alongside an essential reading list which provides an introduction to the subject of tackling unwarranted variation and further information and knowledge on the subject. A three-stage approach to drive improvement is set out: STEP ONE: “Where to look” Because of the variety and comprehensiveness of its data, the Atlas of Variation8 represents an ideal starting point for making comparisons and identifying quickly which local services are outliers. It indicates where more detailed investigation should be focused. STEP TWO: “What to change” The second step identifies exactly which aspects of services can be improved locally. This typically involves a ‘deep dive’ into a particular care pathway to gain more detailed insight into what is working well, and what is not. This additional information informs the case for change. STEP THREE: “How to change” The final stage, “how to change”, is about proving the credibility and viability of the proposed change and then implementing it. This requires the disciplined use of reliable processes, including programme management, stakeholder engagement, analysis of the potential impact on service providers and a sound business case. The programme clearly states that the right people must work together to recognise, articulate and drive any case for change. Using this framework to address unwarranted variation does not always have to be in the form of sophisticated and complex pieces of research or audit. But can be undertaken by us all wherever we work within the system by looking carefully at the care that we deliver and comparing it to the outcomes that are achieved by our peers. We have the opportunity to drive the promotion of health and wellbeing – reaching individuals, families, communities and populations through our work. The concept of involving individuals, clinicians and care colleagues in designing end-to-end system of care pathways, will be a new and challenging process to many of us. However with national and regional support we can lead this new way of thinking, working and transforming our practice.
- Commissioning for Value is about identifying priority programmes which offer the best opportunities to improve healthcare for populations; Improving the value that patients receive from their healthcare and Improving the value that populations receive from investment in their local health system. By providing the commissioning system with: Data, Evidence, Tools and Practical support around spend, outcomes and quality, The Commissioning for Value programme can help clinicians and commissioners transform the way care is delivered for their patients and populations. Commissioning for Value is Not intended to be a prescriptive approach for commissioners, rather a source of insight which supports local discussions about prioritisation and utilisation of resources. It is a starting point for CCGs and partners, providing suggestions on where to look to help them deliver improvement and the best value to their populations. EXAMPLE OF VARIATION: An individual Stroke - If he’s from E Surrey and he has a stroke he will have far more unplanned care than if he’s from S Glouc, he’ll be far less likely to return home afterwards and he’ll die sooner. Heart Disease - Central Mcr – far more likely to die of heart disease than Central Birmingham (SAME Nottm City Vs Portsmouth) Stroke - S Worc far more likely to die of Stroke than N Somerset, & S Worc spend 25% more on non-elective Stroke care Diabetes - Bradford Vs Luton Currently, there is little coordination, shared knowledge or sharing of expertise between organisations and no systematic approach to addressing the problem unwarranted variation presents, what we do know is that many individuals working in the NHS consider that they should be taking more action to identify and reduce unwarranted variation.
- NHS RightCare offers a standard means of prioritised and transformational commissioning. It teaches CCGs and CSUs where the fish are and how to get at them. It brings clinicians from across the system together on the same agenda. It gets Local Health Economies to design optimal in the systems they most need to fix and then challenge themselves to deliver the optimal they have just designed. One objective 3 key phases 5 key ingredients
- RightCare is a national initiative which to work effectively demands technological support and solutions in terms of reducing unwarranted variation in care.
- The value of collecting data electronically where possible at the point of care using modern technologies is paramount to identifying unwarranted variation in care giving. Nursing, midwifery and care staff are centrally placed to use new technologies to support optimal pathways for individuals which deliver better, outcomes, experiences and better use of resources.
- When the nursing technology fund was launched in 2012 it was to support staff to give safer, more efficient and more effective care. It was aimed at empowering care givers to engage with technology in meaningful and helpful ways. There have been many good examples of new innovative technologies across health care which have genuinely made a difference to individuals and communities and have started to reduce unwarranted variation. Some examples include the use of telehealth and telemedicine in rural areas where access to health care settings is very varied due to geography, use of mobile data collection in community to reduce time resource of staff and increase the quality of shared records which improve outcomes and experience for individuals.
- Some examples include..
- And specific funded projects are looking to support more personalised care for people in a variety of settings, ie hospice, at home, in the community, in acute settings and remotely in more rural areas.
- We recognise that advances in technology have helped to transform care and our roles. As frequent early adopters, we can continue to be at the forefront of innovation and systematic change, enabling individuals to access information, use diagnostic tests, record their own health data and to live more independently and safely in their own homes. Our clinical decision-making can be enhanced by having access to the relevant information at the point of care and sharing it with our service users and across other professional groups and settings. We can reach out to communities in sparsely populated areas by using technology to plan and deliver care closer to their homes and develop effective treatments. We must recognise the work on ‘Big Data34’ which uses the analysis of large structured datasets and unstructured data to aid clinical decision making, personalised care and research. We need to prepare for the future for routine tasks that we currently undertake being replaced by technology. We need to exploit the vast array of opportunities presented by technology to address unwarranted variation, improve outcomes and experience, promote self-management and independent living, deliver a step change in public health awareness, and improve efficiency and productivity. We will meet this commitment by: Developing the skills needed in a technology-literate workforce. Advocating technologies that may assist in reducing unwarranted variations in care. Leading as early adopters of technology to improve health and enhance efficiency. Empowering and supporting individuals to improve health or self-managed care. Using technology to manage workflow more effectively such as mobile working. KEY MESSAGES Ensuring that relevant nursing, midwifery and care ambitions in local digital roadmaps, help build a national picture of IT capability. Developing a digital nursing roadmap to support implementation of this framework. Ensuring that the user experience is as seamless as possible between primary care and specialist services, and across health and social care.
- The Five Year Forward View sets out why change is needed. The key leadership contribution of nursing, midwifery and care staff is crucial to maintaining the highest standards and delivering effective change. Where can we use our leadership to have the most impact? Today, nursing, midwifery and care staff are expected to be competent in delivering high quality care, and skilled at managing resources and leading change; skills that add value. We have a fundamental role to play in identifying and identifying and reducing unwarranted variation. By identifying and addressing it, we can help to narrow the three gaps. It is important that everyone recognises, no matter where we work, we are in different ways a leader who can make a difference to the individuals or populations whom we care for. We can identify and address unwarranted variation in many ways and efforts can range from being quite small in size – right up to leading large scale transformational change. As nursing, midwifery and care staff, we have a key leadership role in driving this search for clinical excellence by engaging with staff, and working in partnership at a local and national level with staff, trade unions and professional organisations. By working in partnership we develop sustainable solutions.
- The Five Year Forward View sets out why change is needed. The key leadership contribution of nursing, midwifery and care staff is crucial to maintaining the highest standards and delivering effective change. Where can we use our leadership to have the most impact? Today, nursing, midwifery and care staff are expected to be competent in delivering high quality care, and skilled at managing resources and leading change; skills that add value. We have a fundamental role to play in identifying and identifying and reducing unwarranted variation. By identifying and addressing it, we can help to narrow the three gaps. It is important that everyone recognises, no matter where we work, we are in different ways a leader who can make a difference to the individuals or populations whom we care for. We can identify and address unwarranted variation in many ways and efforts can range from being quite small in size – right up to leading large scale transformational change. As nursing, midwifery and care staff, we have a key leadership role in driving this search for clinical excellence by engaging with staff, and working in partnership at a local and national level with staff, trade unions and professional organisations. By working in partnership we develop sustainable solutions.
- The Five Year Forward View sets out why change is needed. The key leadership contribution of nursing, midwifery and care staff is crucial to maintaining the highest standards and delivering effective change. Where can we use our leadership to have the most impact? Today, nursing, midwifery and care staff are expected to be competent in delivering high quality care, and skilled at managing resources and leading change; skills that add value. We have a fundamental role to play in identifying and identifying and reducing unwarranted variation. By identifying and addressing it, we can help to narrow the three gaps. It is important that everyone recognises, no matter where we work, we are in different ways a leader who can make a difference to the individuals or populations whom we care for. We can identify and address unwarranted variation in many ways and efforts can range from being quite small in size – right up to leading large scale transformational change. As nursing, midwifery and care staff, we have a key leadership role in driving this search for clinical excellence by engaging with staff, and working in partnership at a local and national level with staff, trade unions and professional organisations. By working in partnership we develop sustainable solutions. We need to be able to generate information through the use of technology, that helps us compare the triple aim outcomes with peers and then embark on quality improvement. - that's the USP of the right care approach.
- The Five Year Forward View sets out why change is needed. The key leadership contribution of nursing, midwifery and care staff is crucial to maintaining the highest standards and delivering effective change. Where can we use our leadership to have the most impact? Today, nursing, midwifery and care staff are expected to be competent in delivering high quality care, and skilled at managing resources and leading change; skills that add value. We have a fundamental role to play in identifying and identifying and reducing unwarranted variation. By identifying and addressing it, we can help to narrow the three gaps. It is important that everyone recognises, no matter where we work, we are in different ways a leader who can make a difference to the individuals or populations whom we care for. We can identify and address unwarranted variation in many ways and efforts can range from being quite small in size – right up to leading large scale transformational change. As nursing, midwifery and care staff, we have a key leadership role in driving this search for clinical excellence by engaging with staff, and working in partnership at a local and national level with staff, trade unions and professional organisations. By working in partnership we develop sustainable solutions.