A guide to commissioning cardiac surgical services

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A Guide to Commissioning Cardiac Surgical Services
Eight NHS Trusts supported by their local cardiac networks were involved as demonstration sites in the Cardiac Surgery National Priority Project. It includes practical examples of where local teams have delivered innovation in their service to improve the efficiency and experience for patients and staff ie how to reduce length of stay; ensuring patients are fit for surgery and reducing delays and discharge planning.
(Published March 2010).

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A guide to commissioning cardiac surgical services

  1. 1. NHS NHS ImprovementCANCERDIAGNOSTICSHEARTLUNGSTROKENHS Improvement HeartA guide to commissioningcardiac surgical services
  2. 2. ContentsForeword 3 Discharge planning 35Introduction 4 • Improving the patient experience for cardiac surgery pathways 36Improvement to the patient pathway -summary of recommendations 5 • Reducing length of stay of elective cardiac surgical patients to a one night stay post operatively 39Access to surgery 7 Quality - the current context 42Elective pathways 8 Supporting Information 49• Redesign of the cardiac surgery patient pathway 9 Cardiac Data Dashboard 50• Ensuring patients are fit for surgery and reducing delays in the cardiac surgical patients pathway 15 The Sustainability Toolkit 51• Process changes significantly increase 18 week performance NHS Improvement System 52 in cardiac surgery 18 Good planning can inspire change that• Tackling change - the teamwork way 20 leads to improvements 53• Cardiac surgery and 18 weeks - a pan network approach 22 References and supporting information 54Cardiac surgery trends - the national picture 24 Acknowledgements 56Non-elective pathways 29 Cardiac Surgery National Project Team 57• ‘Urgent or non urgent’, that is the question 32
  3. 3. A guide to commissioning cardiac surgical servicesForewordThere has been substantial progress in It is a clinical challenge, since it is, in thecardiac surgery over the last ten years. end, clinicians that spend the money. So,Surgeons are operating in a more timely every clinician is required to examine theirfashion on more people with higher levels practice and actively look for ways toof risk and co-morbidity, yet they are deliver care more efficiently, removingdelivering better outcomes. waste and saving money.The national audit has been a major In my last foreword (Improving the patientdriver for success and so has the work of experience: Developing solutions toNHS Improvement where a focus on delivering sustainable pathways in cardiacsystems that deliver high quality care has surgery, March 2009), I pointed out that Professor Roger Boyle CBEbeen pivotal. there are still long delays in the non- elective pathways that lead to heartNow we face an even bigger challenge. surgery. These delays have not gone awayOver the last ten years, we have benefited and still need to be addressed. Many offrom higher levels of growth in NHS the issues regarding pre-assessment andexpenditure than at any time in its history theatre scheduling are other examplesand cardiac services have been substantial where the priority projects have addressedbeneficiaries. Today, we have to recognise the key efficiency measures over the years.that it is inevitable that the wider financial Now, we cannot rest on our laurels, theresituation is going to impact on each and remains much to be done.every one of us. This challenge, to delivercontinuing high quality care while at thesame time delivering it much more Professor Roger Boyle CBEefficiently, is the biggest challenge that National Director for Heart Diseasehas faced us in the history of the NHS. and Stroke, Department of Health www.improvement.nhs.uk/heart 3
  4. 4. A guide to commissioning cardiac surgical services Introduction A superficial view would suggest that This has increased from 10% in 1999 and The focus of work undertaken by the cardiac surgery has changed little over the has brought challenges in terms of current project sites considered to be last twenty years – we still spend most of increasing co-morbidity but results constraints within the management of our time in theatre grafting coronary following surgery continue to improve. smooth patient flows includes the arteries and replacing heart valves. Mortality following CABG has fallen from following: However, closer inspection shows marked 1.9% in 2004 to 1.5% in 2008. The changes in the type of patient being seen changes in cardiac care set out in the • Pre-admission provision. by surgeons. The era of operating on National Service Framework have also had • Referral management services. patients with heart valve disease only a marked effect on the way patients are • Scheduling. when their symptoms became severe has treated we have found that we are • Discharge and post operative care passed and now many patients are operating on many more patents on an management. Steve Livesey operated on specifically to prevent urgent basis as appropriate treatments are deterioration rather than improve now available much earlier in the time This report aims to share the successes symptoms. This change means that course of patients’ disease course. with the wider NHS providing a range of patients having heart valve surgery are not excellent examples of where local teams having their operations when they have The attention focused on cardiac have delivered innovation in their service begun to slip down the slope of clinical diagnostics and 18 week pathways as part to improve the efficiency and experience deterioration when ‘risky’ surgery is the of the portfolio of work led by NHS Heart for patients and staff. only prospect of survival but when they Improvement during 2007/08 highlighted are well. a need to shift attention to cardiac surgery to develop sustainable solutions. Eight Steven Livesey This change has occurred alongside a NHS Trusts supported by their local cardiac National Clinical Lead justified increase in the expectations networks have been involved as NHS Improvement - Heart patient have of what can be done for demonstration sites during 2008/09 them and as evidence of this we are testing out new approaches to care and operating on an increasingly elderly improvement to frontline patient services. population of patients. In 2008, 25% of all patients undergoing coronary artery bypass surgery were over 75 years of age.4 www.improvement.nhs.uk/heart
  5. 5. A guide to commissioning cardiac surgical servicesImprovement to the patient pathway - summary of recommendations one:Lessons drawn from project 1. Service prioritiesdemonstration sites suggest that 2. Models of care and idealised 1. Referral management servicesquality improvement to elective patient pathways There is often an information gap between referring provider units andcardiac surgery services requires 3. The approach to the change the tertiary centre:smarter working, a data driven initiative and the identification • Manage variation in the referral process from provider units andapproach to understanding process of root cause issues and in-house reducing multiple referral points through development ofperformance and process variation, solution development agreed referral criteria to relieve pressure on waiting times for surgery.the enhancement of staff roles and a 4. The methods/approaches to • Develop central systems for optimising referral efficiency byshared overview of the patients’ change management streamlining administrative process and referral management linkingjourney and patients experience • Strategically in gaining clinical teams across secondary and tertiary care to triage referrals andacross referring providers and the agreement to change service advise on appropriate tests/investigations.tertiary centre. models and contractual • Introduce pooled referrals across consultants as this significantly arrangements; impacts on waiting times.Cardiac networks continue to be • Operationally in the application • Use appropriate clinical staff to confirm referrals are complete anduniquely placed to assist with the of improvements including the discusses work up criteria with referrer.delivery of the quality agenda by adoption of processes that hold • Introduce a single point of contact at the tertiary centre for referrerslinking clinicians, managers and and sustain the gains. and patients. The role of the trained clinical coordinator is pivotal incommissioners together in every tracking individual patients and in ensuring the consultant team keptaspect of the patients’ journey This document identifies a range of informed of significant events.through primary, secondary and initiatives that have been successfullytertiary care. employed in meeting the challenge of 18 weeks in elective surgery whichNetworks are well positioned to inevitably required the focus toreflect local relationships between extend to systems and processes thatclinicians across organisational support the whole surgical process,boundaries to further develop safe elective or otherwise.and effective surgical pathways ofcare for patients by providing an The detailed case studies within theopportunity for clinicians and publication aim to share themanagers to work together on the knowledge and learning from theseredesign agenda and to gain pilot sites which breaks down into theagreement on: following four areas: www.improvement.nhs.uk/heart 5
  6. 6. A guide to commissioning cardiac surgical services two: three: 2. Pre admission provision 3. Scheduling • Manage variation in pre assessment services. • Move toward Day of Surgery admission as the standard of care for • Adopt investigation guidelines which state agreed timeframes from test to elective surgery as this can improve the patient experience considerably. planned date of surgery and only carry out investigations which are • Maximize theatre efficiency by reducing waste in the system for relevant, indicated and likely to alter management. example right staff in place at the right times with the right equipment. • Introduce ‘one-stops’ for outpatients to avoid wasted clinics for medical • Optimise theatre capacity by reducing slot cancellations (clinical/non staff and patients. clinical) and by scheduling procedures that assist with patient flow • Maximize opportunities for multidisciplinary team assessment and through ITU/HDU. emphasise use of technology an example would be use of video link • Where ever possible pool lists to reduce waiting times. between hospitals. • Procedure complexity scores developed to assist with scheduling • Maximize pre assessment opportunities as they help manage patient health developed as part of MDT. and reduce risk. • Maximize pre admission diagnostics particularly in referring district general hospitals by establishing agreed pre operative protocols. • Maximize patient work up prior to admission and agree the schedule for four: each clinical scenario for example surgery for coronaries, mitral valve, aortic 4. Discharge and post operative care management valve and combination. This has a beneficial effect on waiting times. • Manage variation in post operative clinical management practice. • Train and support key clinical and managerial staff to deliver some of the • Manage variation in discharge patterns reducing length of stay. work undertaken by junior doctors reconfigure services to develop • Start discharge planning at pre assessment to identify requirement for opportunities for other health care professionals to widen their skills and support and home aids to reduce requirement for delayed discharge. scope of relationship with patients. An example is the patient ‘navigator’ • Involve a range of health care professionals for example occupational role which benefits patients and families by providing information and therapists in discharge planning at pre assessment particularly where support following attendance at outpatient and pre assessment clinic. patients and in particular the elderly may have complex needs. • Maximize the scope of extended practice for nursing roles working in pre • Discharge assessment should form part of the central patient record operative assessment clinics functioning as part of the consultant led team available throughout the patient journey to all staff groups. to streamline cardiac surgery patient care. • Move toward nurse led discharge. • Maximize inclusion of different staff groupings for example anaesthetists involved in pre assessment to ensure that all patients presenting for surgery will be adequately assessed as this can reduce cancellation rates, improve operating theatre efficiency and increase patient satisfaction. Note: The resources developed by these pilot sites are available • Continue to provide information and support. through the web links and NHS Improvement system at: www.improvement.nhs.uk/heart/sustainability6 www.improvement.nhs.uk/heart
  7. 7. A guide to commissioning cardiac surgical servicesAccess to surgeryThe reductions in waiting times envisaged The need for non-medically qualified staffby the NHS Plan are now a reality and in to play an even greater role in patients’order to meet the expectations of shorter assessment and treatment is becomingwaits, the way in which patients are apparent as the effects of the reduction inmanaged and referred from one junior doctors hours are starting to bite.department to another as their treatment It is vital that training organisations workprogresses has had to improve. with trusts to ensure the workforce continues to develop to ensure timelyAs a result, the majority of units in the delivery of care in the future.country have adopted a network-agreedsystem of investigating and referringpatients on for further treatment, such ascoronary artery bypass graft (CABG).The rapid progress of patients through thesystem has been greatly facilitated by theadoption of common protocols forinvestigation and agreed timelines forreferral. Many of the steps in thepathway are now overseen by specialistnurse practitioners rather than juniordoctors and this has contributed greatly tothe efficiency of the process. www.improvement.nhs.uk/heart 7
  8. 8. A guide to commissioning cardiac surgical services Elective pathways Elective care refers to care that is Before cardiac surgery can be carried in advance of cardiac surgery, The detailed case studies included pre-arranged (planned). Managing out a range of resources have to be including clinical examination, history here demonstrate their progress, elective and emergency patient flows brought together at the right time taking, arranging radiological and outlining practical strategies for from decision to admit to discharge and the right place: surgical staff, haematological investigations in continuous improvements in the can prove challenging for nursing staff, anaesthetist, theatre accordance with Consultant or quality of care which has benefited organisations as they work to deliver time, beds. Remove any one of these departmental guidelines. The patients in reducing delays, tackling a number of national and local components and the operation has to development of new roles allows bottlenecks and enabled patients and quality and performance targets be cancelled. The sharing of staff consultant time to be effectively freed carers to access clearer information among them 18 week referral to and resources to support elective and up permitting more appropriate use alongside the achievement of targets. treatment admitted pathways, four non-elective care treatment can place of surgeons’ time. (Staffing hour A&E target and locally agreed an added stress to elective work as Cardiothoracic Units Developing a The dilemma of balancing both reduction in length of stay and urgent cases should take precedence workforce for the 21st century. elective and non elective/emergency interhospital transfer times. Yet resulting in cancellation of scheduled Livesey, S. Bartley, T. April 2007). work led some sites to adopt a whole looking at the pathway of care from elective surgery causing frustration system approach to their quality the patient’s point of view making it and delay felt by staff and patients Across the country project sites improvement work due to the smoother, more accessible, less alike. However, as there is a showed wide variation in their knock-on effects of the provision of complicated and less subject to delays permanent need to provide for non- achievement of admitted waiting non elective care to planned activity. is necessary given the volume of elective care contingencies can be times and started their journeys to patients who receive care. built into the system. improvement from differing baseline positions based on local With cardiac surgery often coming at Pre operative assessment ensures that circumstances. In understanding how the end of a lengthy diagnostic the patient is as fit as possible for the patients flowed through their service pathway the delivery of shorter surgery and anaesthetic and with a particular focus on referral waiting times completed within 18 minimises the risk of late management services, pre admission weeks is increasingly demanding. cancellations by ensuring that all provision, scheduling and post Specialty beds often occupied by essential resources and discharge operative care management these medical outliers and a lack of requirements are identified and essential facets have supported intensive care beds due to coordinated. With appropriate achievement of continuous emergencies or the clinical status of training nurses can effectively improvements in elective care patients intensify the complexity of manage the care of patients referred pathways. delivering smooth patient flows. to the pre operative assessment clinic8 www.improvement.nhs.uk/heart
  9. 9. A guide to commissioning cardiac surgical servicesSt George’s Healthcare NHS Trust and the South London Cardiac and Stroke NetworksRedesign of the cardiac surgery patient pathway reduces length of stayThe problem • Analysis of the theatre diary showed • A small number of patients treated atIn December 2008, the opportunity to cases rarely started on time and often St George’s travelled from Jersey –take part in a National Priority Project overran. due to flight restrictions imposed byprompted the St George’s cardiac • There was no policy for theatre the airline these patients were unablesurgery team to address how they scheduling. to fly home until at least ten daysmight deal with some of their • Patients were given little notice of after their surgery. This resulted inlongstanding problems to help the unit their surgery date; often less than their stay in hospital being extendedperform at an optimum level, meeting one week. to ten days post surgery as opposedboth national and internal trust to usual routine of five days.standards for issues such as length of 3.Electronic referral system,stay, cancellations, and notice period of inpatients and interhospital 4.Admission on the daysurgery date for patients. transfer patients • In Q3 2008/09, only 10% of elective • The electronic referral system, cases were admitted on the day.Both the elective and non-elective adult primarily developed for the referral of • An admission on the day project forcardiac surgical pathways had room for non-elective patients from district ‘second on the day cases’ had beenimprovement, particularly within the: The issues included: general hospitals into the tertiary successfully piloted in 2006, but had• pre-assessment service; centre (interhospital transfers) that not been sustained.• management of length of stay, 1.Pre-assessment had been implemented in 2006 was theatre cancellations and slot • During 2007/08 fewer than 60% of not being utilised. 5.Length of stay (LoS) scheduling; elective cardiac surgery patients • Paper referrals made from referring • In Q3 2008/09, the average LoS for• referral management processes attended the pre-assessment clinic. sites were frequently mislaid. elective patients was 8.8 days. internally and from referring district • Anecdotally, this was contributing to • Little and inconsistent • In Q3 2008/09, the average LoS for general hospitals. difficulties with planning patient correspondence between referring non-elective patients was 15.7 days. admission, scheduling and sites and St George’s was common • LoS needed to align with the trustAchieving and sustaining the 18 week anticipating date of discharge. place. target of elective patients beingtarget for elective surgery and the • Referring centres were unsure of the discharged on day five. Non-electiverequirement to meet the trust’s internal 2.Theatre scheduling work-up required for surgical patients LOS should also be reduced inpriority to reduce length of stay across • In Q3 2008/09, the average number resulting in patients often transferred recommendations with the NCEPODboth the cardiology and cardiac surgery of non-clinical cancellations was 10% into St George’s unprepared for guidance.care groups felt challenging. A review of all elective cases. surgery. • The cardiovascular division wasof baseline data, gathered using • These were commonly due to theatre • Length of stay was longer than required by the trust to make a savingpathway mapping, demand and overruns and lack of beds. optimum for admission to referral, of 10 beds.capacity analysis, and interviews with • Patients were often cancelled the day referral to transfer, transfer tostaff across their respective work area of before, or on the day of their surgery; treatment and treatment to dischargethe patient journey, highlighted a there was no cancellations policy to or transfer back to DGH.number of system and process issues. prevent or support the decision. www.improvement.nhs.uk/heart 9
  10. 10. A guide to commissioning cardiac surgical services The solution 3) Compliance with the national and Team members attended the national A project team was established and local agenda including 18 weeks, cardiac surgery priority project peer “ chaired by the unit’s general manager cancellation on the day and support meetings which inspired with clinical and managerial reduction in length of stay. members to share existing good Working together on this project membership including service 4) That the cardiovascular service is as practice within the unit and to develop managers, heads of nursing, matrons, efficient and forward thinking as any solutions to challenges shared across has brought the team together and clinical nurse specialists, clinical audit, other tertiary centre in the country. the peer group. I’m so proud of what we’ve transformation project manger, 5) That the staff within the unit are consultant cardiologist and cardiac proud to work in the unit and feel The new pathway featured: achieved. We were all sceptical surgeon. Project management support valued and part of a team. • The pre-assessment of all elective to begin with and I was was provided by the South West cardiac surgery patients by September uncomfortable admitting we had London Cardiac and Stroke Network. Highlight reports were produced for 2009. each team meeting and provided the • A theatre scheduling policy problems with our service, but Baseline data was collected to identify mechanism for monitoring each introduced in October 2009, hearing from other colleagues areas for improvement work. It was workstream against key goals, actions, including improving notice to patients clear the project had developed into a risks and progress against timeline. of their date for surgery. around the country reassured me whole pathway redesign and was Analysis of the data to show evidence • Regular monitoring of theatre that we were not any different and subdivided into five key workstreams. of the improvements was supported by cancellations to reduce the number Project team meetings were held every the trust transformation manager and non-clinical cancellations we all had the same issues. fortnight and leads were nominated for clinical audit staff members on the • Implementation of the use of Working on this project with the each work-stream to be responsible for team. electronic referrals for non-elective Network and the Heart the work. cases by January 2010. The work was also informed by the • Implementation of admission on the Improvement Team has encouraged A set of key values that reflected the analysis of qualitative data from patient day as normal practice. us to start a similar project trust’s own strategic vision were agreed and carer diaries which were used by a • The recruitment of two additional and integrated within the team’s vision number of patients and their family staff; a pre-assessment nurse and a addressing issues in cardiology – established to deliver the improvement members from the time they attended cardiothoracic nurse practitioner: we’re now looking forward to a work across the patent pathway: their pre-assessment, throughout their • Whilst these new posts required ” similar success story! stay in hospital, and for a few weeks funding overall the project was cost 1) To ensure that all patients have after their discharge. neutral – as savings were gained equal access to the service. due to the improvements made by 2) That the patient journey is safe and each work-stream, in particular, Jane Fisher free from complications. reductions in LoS and cancellations. General Manager10 www.improvement.nhs.uk/heart
  11. 11. A guide to commissioning cardiac surgical services• Implementation of new discharge • Locum theatre manager in post. • Electronic referral system used for IHT 4. Admission on the day planning for Jersey patients. • Annual/study leave booked a non-elective patients. • 2006 pilot reviewed. minimum of six weeks in advance. • All in house and IHT non-elective • Admission on the day exclusionBelow is a summary of the work and • Consultants’ rota set at six weeks referrals addressed to ‘dear surgeon’ criteria agreed.achievements in each workstream: ahead. and managed by cardiothoracic nurse • Policy agreed and signed by all • Improved theatre start and finish practitioner, rather than to a named cardiology, cardiac surgery and1. Pre-assessment times. surgeon. anaesthetic care groups.• Reviewed demand and capacity • The notice period given to patients • All referrals also processed through • Commenced 31 July 2009. within pre-assessment clinic. about their surgery date increased nurse practitioner, who then contacts• Employed second clinical nurse from one week to three. referrer to confirm receipt and discuss 5. Length of stay (LoS) specialists to increase capacity. • Outpatient referrals pooled for first work-up criteria. • Analysis of LoS compared with peers• Converted all pre-assessment clinics time CABG to ensure equity of • Nurse practitioner liaises with and national standards was used to to nurse only clinics. waiting times – this had an impact on pathway co-ordinator to arrange estimate where beds could be saved.• Worked with admissions co-ordinator general 18 week waiting times. dates for surgery, keeping referring • The transformation project manager to formalise process between • Implementation and enforcement of hospital informed. worked closely with each workstream acceptance onto waiting list and theatre scheduling policy. • The matron and nurse practitioner to measure where LoS was saved. admission to hospital. also worked with the Jersey Hospitals • Alignment of the project to the• Developed patients information sheet 3. Electronic referral system, and staff at St George’s to develop strategic direction of the trust to to explain process, now sent to all inpatients and interhospital transfer and implement a new discharge specifically save 10 beds increased patients when added to the waiting patients routine for Jerseys patients – the team engagement at senior level. list. • Cardiothoracic nurse practitioner post designed a clinically safe and practical developed and recruited to. protocol to discharge patients on day2. Theatre scheduling • Met with referring hospitals to discuss five to stay in a local hospital with• Theatre lists published weekly, ten new cardiothoracic nurse practitioner regular nurse check-ups until day ten, days in advance and with slots role, established direct contact of before flying home. This was done in available for emergency or inpatient individual who would take collaboration with the Jersey referring cases. responsibility for each referral. hospital, who were pleased with the• Set up weekly MDT meetings to • Training sessions delivered to staff (at team’s dedication to safe practice and review lists for following week and each site) on how to use referral clinical effectiveness. identify possible issues/over runs/ system. resources. • Electronic referral system used for in-• Implementation and enforcement of house in-patients between cancellation policy. cardiologists and cardiac surgeons at St George’s. www.improvement.nhs.uk/heart 11
  12. 12. A guide to commissioning cardiac surgical services The results Increase in admission on the day The new pathway has resulted in: Theatre Scheduling - Cancellations (non clinical) from an average of 9.9% of cases per The improvements have lead to an month in Q3 2008/09, to 24.6% of 20 overall increase in productivity – theatre Cardiac Network cases per month in Q3 2009/10. project commenced scheduling, increased pre-assessment 18 Cancellation policy implemented and admission on the day, reduced This equates to 69 patients admitted on 16 cancellations and length of stay have all the day in 2009/10 to date; at £200 per Number of cancellations contributed towards an increase in 14 bed day this makes a saving of Surgical pathway activity by £103k to date. coordinator in place £13,800. 12 Rota set at Transformation six weeks team involved Reduction in non clinical 10 cancellations from an average of 8 10.1% of cases per month in Q3 2008/09, to 2.3% of cases per month 6 in Q3 2009/10. 4 Improved start/ finish times 2 AoD commenced 0 Apr08 Jun08 Aug08 Oct08 Dec08 Feb09 Apr09 Jun09 Aug09 Oct09 Dec09 May08 Jul08 Sep08 Nov08 Jan09 Mar09 May09 Jul09 Sep09 Nov09 Non-clinical (actual) Non-clinical (target) Linear (non-clinical actual) Baseline figures Percentage of non-clinical cancellations Mean Median Range April - March 2008/09 8.3% 9.0% 3-15% April 2009 - present 3.7% 4.0% 1-7% Oct - Dec 2008/09 average 10.1% 10.3% 5-15% Oct - Dec 2009/10 average 2.3% 1.9% 1-4%12 www.improvement.nhs.uk/heart
  13. 13. A guide to commissioning cardiac surgical services Reduction in length of stay for elective cardiac surgery patients, reduced from Admission on Day of Surgery an average of 8.8 days in Q3 08/09, to 7.6 days in Q3 2009/10. 60 Length of Stay - Elective Cardiac Surgery 50 11 Surgical pathway Cardiac Network coordinator in place project commenced 40 10 Percentage Transformation Surgical pathway team involved coordinator in place 30 9 Transformation Cardiac Network team involved Days project commenced 8 20 7 10 AoD commenced 6 AoD commenced 0 Apr08 Jun08 Aug08 Oct08 Dec08 Feb09 Apr09 Jun09 Aug09 Oct09 Dec09 5 May08 Jul08 Sep08 Nov08 Jan09 Mar09 May09 Jul09 Sep09 Nov09 Apr08 Jun08 Aug08 Oct08 Dec08 Feb09 Apr09 Jun09 Aug09 Oct09 Dec09 May08 Jul08 Sep08 Nov08 Jan09 Mar09 May09 Jul09 Sep09 Nov09 % CS AoD (actual) % TS AoD (target) Linear (% CS AoD) Cardiac Surgery Elective LoS Linear (Cardiac Surgery Elective LoS)Baseline figures Percentage of admitted on the day Baseline figures Length of stay for elective cardiac surgery Mean Median Range Mean Median RangeApril - March 2008/09 8.5% 8.0% 1-15% April - March 2008/09 8.8 8.8 8-11 daysApril 2009 - present 20.9% 21.1% 10-31% April 2009 - present 7.4 7.7 6-8 daysOct - Dec 2008/09 average 9.9% 7.7% 2-20% Oct - Dec 2008/09 average 8.8 8.3 8-9 daysOct - Dec 2009/10 average 24.6% 25.0% 19-30% Oct - Dec 2009/10 average 7.6 7.8 7-8 days www.improvement.nhs.uk/heart 13
  14. 14. A guide to commissioning cardiac surgical services Reduction in length of stay for non-elective cardiac surgery patients, from an Top tips b.The core team held the five points average of 15.7 days in Q3 2008/09, to 13.3 days in Q3 2009/10. 1. Engagement at senior level and outlined as a shared vision of alignment of the project to the change, and worked together to strategic direction of the trust achieve these goals. specifically saving 10 beds. c. As well as for planning purposes, Length of Stay - Non-Elective Cardiac Surgery 2. Regular reporting to senior the team meetings were important 23 management supported by robust for boosting morale for when the 21 data across a defined set of work was facing opposition or Cardiac Network project commenced measures agreed early on in the difficulties. 19 project to ensure focus. d.As a result of the project, Surgical pathway coordinator in place 17 3. Access to data. A member of the relationships and communications team with access to data was vital to throughout the team and across Days 15 measuring improvement as the the pathway boundaries have 13 network project manager struggled been improved. 11 to gain access to data, being 5. Keep in the forefront that perceived as an ‘outsider’. The improvement does not need to come 9 Transformation internal data manager was able to at a financial cost – but that by team involved AoD commenced 7 retrieve and analyse data shared working more efficiently and more Apr08 May08 Jun08 Jul08 Aug08 Sep08 Oct08 Nov08 Dec08 Jan09 Feb09 Apr09 Mar09 Jun09 May09 Jul09 Aug09 Oct09 Sep09 Dec09 Nov09 across the project team to drive the productively, patients can receive work. better care that is value for money. Cardiac Surgery Non-Elective LoS Linear (Cardiac Surgery Non-Elective LoS) 4. Interdisciplinary core project team was reflective of the key staff vital to Contact details: implementing and maintaining Jane Fisher, changes being tested. General Manager, Cardiovascular, Baseline figures Length of stay for non-elective cardiac surgery a. The core team consisted of the St George’s Healthcare NHS Trust lead for each work stream; these Jane.Fisher@stgeorges.nhs.uk Mean Median Range individuals were the people who would plan and measure the Laura Gillam, April - March 2008/09 15.5 15.4 10-21 days Senior Project Manager, South London changes – they were the people April 2009 - present 13.2 13.3 10-16 days who could really make a Cardiac and Stroke Networks. difference. Laura.Gillam@slcsn.nhs.uk Oct - Dec 2008/09 average 15.7 16.0 14-17 days Oct - Dec 2009/10 average 13.3 13.1 12-15 days14 www.improvement.nhs.uk/heart
  15. 15. A guide to commissioning cardiac surgical servicesUniversity Hospitals Birmingham NHS Foundation Trust, Heart of England NHS Foundation Trustand Birmingham, Sandwell and Solihull Cardiac and Stroke NetworkEnsuring patients are fit for surgery and reducing delays in the cardiac surgical patients pathwayThe problem clinics and with some patients attendingAchieving the national target of 90% of a further appointment at pre-admitted cardiac surgery patient assessment clinic. The pre-assessmentpathways being completed within 18 clinic workforce did not have theweeks was proving a challenge across required skills to support a fullorganisations within the Birmingham, assessment, including history taking,Sandwell and Solihull Cardiac and patient examination and assessment.Stroke Network. One of the most Therefore, an SHO was required tocommon delays in the patients’ review all patients.pathway at Good Hope Hospital wasthe time between angiography and case Attendance at pre-assessment clinic wasreview by the multidisciplinary team often more than four weeks before the(MDT). On average the wait was four date of surgery which resulted in theweeks but at it’s longest nine weeks, need to duplicate chest x-rays andparticularly if the MDTs were cancelled. blood tests on admission. This createdSurgeons from the tertiary centre were unnecessary expense to the Trust and There was also some pressure to reduce A patient progress tracker wasrequired to travel across the city to inconvenience to the patient the overall length of stay and improve appointed by the network to track theattend the MDT meetings held at the efficiencies in the patient pathway, as patients through their journeys using areferring provider centre to review There was no anaesthetic service in the the tertiary centre is reducing its overall live database to help map the pathwayindividual cases requiring surgical pre-assessment clinic, resulting in number of beds on the cardiac surgical and identify delays in the journey.opinion. Clinical commitments often clinical problems often identified late in ward from 39 to 32. Tracking patient pathways also helpedmeant that attendance at these MDTs the patient pathway; on admission to to demonstrate that patients sometimeswas not possible. Not all patients were the tertiary centre problems had been The solution attended more than one surgical/discussed at MDT and the process of identified following assessment by the A surgical steering group was set up cardiology appointment.ensuring that patients were fully anaesthetist. This often resulted in the which included cardiologistsworked up for surgery prior to referral patient being declared unfit for surgery representing the tertiary centre and A new pathway to support theto the MDT was not supported by an and the operation cancelled. The clinic district general hospital, a cardiac achievement of 18 weeks wasagreed protocol. was not working to full capacity, flow of surgeon, an anaesthetist, management developed and agreed by all key patients through the clinic was low and representation from both trusts, a stakeholders. Baseline data wasThe system of ensuring patients were a review of the pre assessment services cardiothoracic nurse practitioner and collected to help define the problemfit for surgery was characterised by illustrated that not all slots were being tertiary centre cardiac audit clerk. The and scope of the project.inconsistency and variation across the fully utilised. Birmingham, Sandwell and Solihullsurgical teams with pre-screening not Cardiac and Stroke Network providedcarried out in all surgeons’ outpatient project management support. www.improvement.nhs.uk/heart 15
  16. 16. A guide to commissioning cardiac surgical services The project objectives were: potentially adding weeks to the • Introduction of weekly electronic pathway and unnecessary waits for Cardiac Surgery Pathway - RTT 18 Weeks MDTs using: the patient. • telemedicine to allow the transfer 2 WEEKS 5 WEEKS 2 WEEKS • An increase from 0% of patients of images between referring units Referral Received in Rapid Access Diagnostic MDT (referral previously reviewed by an anaesthetist and the tertiary centre; Rapid Access Chest Chest Pain Clinic Tests to tertiary in pre-assessment to72% over a short Pain Clinic Appointment centre) • teleconferencing between the period of time. We are working referring consultant cardiologists 9 WEEKS towards 100% of patients being and tertiary centre surgical teams assessed by an anaesthetist in pre Surgical Diagnostic Pre-Assessment Cardiac Surgery for the purpose of weekly MDT Outpatient Tests Clinic assessment clinic. case review. Use of technology was Appointment • Clinic nurses undergoing practitioner thought capable of reducing MDT training to enable implementation of Secondary care to tertiary care - 9 weeks cancellations and increasing the Tertiary care to definitive treatment - 9 weeks a cardiothoracic advanced nurse number of patients discussed at practitioner role in the pre-assessment MDT; clinic and to help address demands • introduction of a pre-referral on clinical service brought about by protocol to ensure patients are fully Progress • Development of the pre-referral EWTD. worked up prior to referral to the The tertiary centre has four core protocol to support the referring • Capacity at pre-assessment clinic has tertiary centre. purposes. Therefore, it was imperative cardiologist. This will ensure that all increased from approximately 12 to • Redesign of the pre-assessment that any project undertaken to improve the required information is available 30 available slots per week, resulting process with patients: services should be underpinned by the at the point of referral including in increased activity. This has been • attending the clinic no more than following four principles. presenting history, past medical achieved by increasing the number of four weeks before the date of history and a summary of appointments, and reducing time pre- admission for surgery at the tertiary i) Excellent patient care investigations and outstanding assessment staff spent on centre; ii) Clinical quality outcomes results. It also specifies the indications administration duties, to enable them • being assessed in pre-assessment iii) Research and innovation for undertaking core investigations to focus on clinical duties. clinic by a cardiothoracic advanced iv) Education and training. such as trans-thoracic echo, carotid • Telemedicine system is in the process nurse practitioner and an duplex scans and lung function tests. of being installed. anaesthetist to ensure they are fit These have been achieved in the Implementation of this protocol will • Development of a patient for surgery on admission to the following ways: ensure all necessary investigations are questionnaire survey to gather an tertiary centre, with a view to completed before referral to the understanding of the patients’ reducing the cancellation rate and tertiary centre, reducing the risk of experience from referral for cardiac optimising use of inpatient beds. the patient being referred back to the surgery to admission for surgery. DGH for the tests to be undertaken,16 www.improvement.nhs.uk/heart
  17. 17. A guide to commissioning cardiac surgical services Top tips Contact details: • Mapping the existing pathway is Emma Billingham essential in understanding timelines Group Manager and delays in the system.“ University Hospitals Birmingham • Strong clinical leadership (cardiology NHS Foundation Trust and cardiac surgeons). emma.billingham@uhb.nhs.ukUniversity Hospitals Birmingham is still in the process of fully rolling out • Obtain baseline data to identify if a problem exists and build in robustthe project. However, we have already seen benefits to patients with the data collection mechanisms toexpansion of pre-assessment and pre-screening clinics as well as the support improvement work. • Understanding the fundingdevelopment of anaesthetic-led pre-assessment clinics. We look forward implications and identifying who isto receiving comments from patients about their pre-operative pathway going to fund what (things like annual service costs for a piece of kitso that we can evaluate our success so far and identify any further etc) as early as possible in the projectimprovements to be made. We also welcomed the opportunity to work to avoid issues later on. • Develop a communication plan towith a local referring cardiology centre to identify bottlenecks in the facilitate the dissemination of projectpatient pathway and are currently working to resolve these. information to all admin and clerical/managerial and clinical staff involved in the pathway as this helpsI feel the project group has benefitted from networking with other to foster support and buy in to thecentres who have identified similar issues and we have learnt from improvement work making it everybody’s business.their experiences how to overcome these to ensure the overall • Bringing together key stakeholders ”success of the project. from the referring provider unit and tertiary centre together to identify issues and problems and develop joint solutions. • Understanding the patient/carerEmma Billingham, Group Manager experience is fundamental to the success of any quality improvement work. www.improvement.nhs.uk/heart 17
  18. 18. A guide to commissioning cardiac surgical services Royal Brompton & Harefield NHS Foundation Trust in collaboration with North West London Cardiac and Stroke Network Process changes significantly increase 18 week performance in cardiac surgery Overall there was a considerable amount These meetings also highlighted of incomplete data on the inpatient concerns around how the IPTMDS forms waiting list (KH07). The position of were being completed. These patients along their 18 week pathway discussions resulted in a revised surgical was not known due to clock starts being patient pathway and process changes found/given/used too late. Data flow of featuring: patients after going on KH07 was not recorded accurately. These • Patients seen at the pre-operative inconsistencies meant that Royal assessment clinic (POAC) being Brompton & Harefield NHS Foundation declared ‘fit for surgery’ before being Trust had little chance of achieving the added to the surgical waiting list. 18 week admitted referral to treatment • Agreed and standardised use of the pathway target. 18 week suite of rules across referring The problem • Clinic outcomes were often not providers and the tertiary centre. The trust performance for referral to documented following the patients The solution • Inter-trust contacts for administrative, treatment pathways for cardiothoracic attendance at the pre operative The trust employed 18 week clerical and nursing staff were surgery, within 18 weeks between assessment clinic (POAC), a crib sheet co-ordinators to assist the 18 week exchanged so that in future clock April - August 2008 had remained was developed for the clinic staff to project manager and received project start requests were sent to the right consistently below the 90% national show what rules can/cannot be management support from the North people. target, sitting in the low 30-50%. A applied in different situations. West London Cardiac and Stroke • Support and training on application review of the elective surgical pathway • 18 week clock stops were not always Network to focus on the cardiac surgery of the 18 week rules for key admin for planned care illustrated the following used appropriately, for example pathway. personnel and nursing leads of the issues: patients requiring referral for pre-assessment service to help reduce conditions on a new clinical pathway The surgical pathways were mapped variation and ambiguity in their • Patients were typically added to the such as haematology often resulted in from the point of referral made by the application. surgical waiting list before they had an inappropriate continuation of the secondary care provider through receipt • Patients at other trusts who were been assessed and declared ‘fit for 18 week clock. of referral to treatment by tertiary care under investigation were recorded on surgery’ which resulted in extended • These patients were not recorded on centre which helped to identify RBHfT PAS as ‘active monitoring’, wait times for definitive treatment a central list and were at risk of bottlenecks in the surgical pathway. effectively stopping the clock on their well beyond 18 weeks. getting lost ‘in the system’. cardiac surgery pathway. The cardiac • The understanding and application of • A number of patients had already A series of meetings with the referring nurse practitioners would follow the the 18 week suite of rules varied breached their 18 week pathway by trusts and the tertiary centre helped gain progress of the patient through their among staff within administrative, the time the referral was received by a common understanding of how to appointments and tests ensuring that clinical and managerial roles at the the tertiary centre, this was partly due apply the 18 week rules suite and there were no unnecessary delays, tertiary centre and referring providers. to the accompanying Inter Provider develop a shared agreement for applying once declared fit for surgery they Transfer Minimum Data Set (IPTMDS) clock-starts and stops across providers. would be added to the waiting list. form being incomplete or incorrect.18 www.improvement.nhs.uk/heart
  19. 19. A guide to commissioning cardiac surgical services• Redesign of the clinic outcome form week rules and how to apply them Comparative data of performance for a four month period year on year with fields developed to show a range effectively. of scenarios and how the clock rules • There has been an improvement in apply. both the number of IPTMDS forms April - August 2008 Performance• The integrity of data on KH07 was sent through and their data closely monitored. Appropriate and completeness. Apr May Jun Jul Aug Average effective data management and • Improved communication between communication significantly improved staff has also helped reduce delays in Wexham Park 71% 80% 79% 44% 50% 64.8% the accuracy of the data used to referrals, transferring and sharing of Lister 60% 66% 41% 46% 12% 45% monitor performance. information and the booking of• Where possible clock starts were appointments. Luton and Dunstable 0% 16% 20% 25% 21% 16.4% found prior to booking POAC. The 18 week database was used by pre- Top tips operative administrative staff to plan April - August 2009 Performance • Communication between providers the patients clinic attendance date in and across staff groups including line with trust targets and appropriate Apr May Jun Jul Aug Average administrative and clerical, clinical and to breach date.• Through discussion over the 18 managerial is key to ensuring full Wexham Park 86% 100% 97% 100% 96% 95.8% week rules and the use of medical understanding of the 18 week rules management it transpired that and effectively applying them. Lister 70% 88% 74% 70% 86% 77.6% referring trusts treat the majority of • Developing and strengthening Luton and Dunstable 100% 92% 86% 84% 96% 91.6% their patients before referring working relationships between the them on. cardiac nurse practitioners and the surgical medical teams helped poolResults the expertise to support a full • A thorough understanding between Contact details• By December 2008, the trusts 18 pre-operative assessment clinic. how the information systems and Gemma Snell week admitted performance met the • Access to the 18 week co-ordinator operational processes correlated by Service Improvement Project Manager minimum 90% which continues to be contactable by bleep increases their the 18 week co-ordinator had a huge North West London Cardiac and sustained, often peaking above the accessibility for staff to flag queries impact on improving data quality and Stroke Network 95% target. Pro-active tracking of and problems regarding interpretation hence performance issues. Email: gemma.snell@nhs.net patients along their pathway has of the rules. • Building relationships and improving ensured there have been no • Meeting regularly with teams along communication channels with unwarranted delays. the surgical pathway for example the referring trusts had a considerable• There has been a far greater theatre scheduler who booked impact on improving performance as understanding within the hospital staff elective and non-elective cases, there was a sense of shared and between referring trusts of the 18 helped reduce avoidable delays. responsibility. www.improvement.nhs.uk/heart 19
  20. 20. A guide to commissioning cardiac surgical services Essex Cardiothoracic Centre, Basildon and Thurrock University Hospitals NHS Foundation Trust in collaboration with Essex Cardiac and Stroke Network Tackling change - the teamwork way The problem 1.Collegiate system for review of The Essex Cardiothoracic Centre (CTC) is patient referrals. a relatively new unit which opened in 2.Process for allocation of ‘pooled’ July 2007, with many of its clinical patients to consultant surgeons pathways and their supporting systems resulting in longer waiting lists for and processes having been developed certain procedures. early in the organisations history. The 3.Pre-assessment clinic not working to trust faced challenges with meeting its full potential due to the skills of the national target of 90% admitted staff carrying out the clinic. pathways completed within 18 weeks of referral to treatment with performance Baseline audit of the current service was often running between 30-40%. carried out in relation to theatre Review of the surgical pathway was cancellations and theatre day/time. An seen as paramount to the continued audit tool was developed which allowed success and growth of the unit, all sections of the theatre to be evidenced by internal audits that had measured, for example time taken to identified areas for development and call for patient, time in anaesthetic improvement. room, knife to skin time. This audit • Patients often needed to make more The solution helped to identify timing delays and The elective cardiac surgery pathway than one visit in the pre operative A Surgical User Group (SUG) was identified sections of the theatre day was seen as a key area of focus to part of the surgical pathway as a established with members drawn from where improvements to efficiency could review systems and processes in the result of surgical outpatients and across the multidisciplinary team to be made in order to optimize theatre following areas of the pathway: pre-operative assessment clinics spearhead the development of the usage and reduce surgical cancellations (POAC) being held separately. surgical service. An action plan with as a result of clinical and non clinical • Surgical collegiate system, a process clear timescales was produced, the matters. The picture of theatre of clinical review to ensure correct ECTC were able to focus on problems current service was discussed and ideas cancellations was broken down into the procedure and surgeon determined several audits were carried out which generated for future developments and following: for all cardiac surgery referrals, carried identified areas where improvements improvements planned. All changes to out by surgeons prior to the patient were required in order to streamline the the service were approved by the SUG. • Interhospital transfer patients attending an outpatients’ appointment. service, improve patient experience and Additional project support was provided received at the unit were often not Challenges in sustaining the collegiate improve efficiency and effectiveness. by the Essex Cardiac and Stroke fully optimised. system, based on two surgeons The unit were keen to maintain high Network. • Unfit elective patients. reviewing each referral on a bi weekly patient satisfaction levels whilst • Anaesthetic cove.r basis, were related to ‘buy in’ and maximizing the use of in patient beds Mapping of the current pathway • Availability of intensive care beds. agreement from the surgical teams. and theatre utilisation. highlighted issues with: • Theatre over-runs.20 www.improvement.nhs.uk/heart
  21. 21. A guide to commissioning cardiac surgical servicesA retrospective audit of 40 case notes • Improve 18 week referral to treatment • Reduction in unnecessary duplication Contact details:was carried out across six consultant times for admitted pathways. of tests. Tests performed at POAC, Jenni Brownsurgeons during a three month period – • Improve efficiency within theatre day. CXR, blood tests and ECGs now Matron, Essex Cardiothoracic Centre -this illustrated the problem of delay remain valid from time performed Basildon and Thurrock Universitypatients experienced between being The new service now provides: until admission into ECTC. Hospital NHS Foundation Trustseen in pre operative assessment clinic • Same day outpatient clinic and pre- • Reduced waiting times for cardiac Jenni.brown@btuh.nhs.uk(POAC) and their admission for surgery assessment. surgery from nine weeks to six weeks.which often resulted in tests being • Dedicated lead pre-assessment nurse. • Timely POAC to admission hasrepeated, an unnecessary expense to • Forum for monitoring and auditing reduced length of stay by one day forthe Trust. The case note audit measurables to improve service. some groups of cardiac surgicalhighlighted in some cases the time • Same day admission for cardiac patients with same day admission.interval was 10 weeks between POAC surgery.and admission for surgery which • Super multidisciplinary team (MDT) for Top tipsinvalidated the tests necessitating them review of complex cardiac surgery • Working together in ato be repeated on admission. cases with joint cardiology and surgical multidisciplinary team and assessment of the patient presented. collaborating with key stakeholdersUnderstanding our cardiac surgical within ECTC and with referringpathway by using service improvement Results District General Hospitals (DGHs)techniques and data helped us to 18 week admitted pathways are now meant everyone understood eachidentify service improvements and areas performing consistently at 90% as a others perspectives.where patient experience could be result of: • Engagement with staff across a rangeimproved. • Improved working relationships and of disciplines and at all levels MDT working have developed as a including consultant surgeons,Our overarching aim was to: result of the involvement of all anaesthetists, nurses, perfusionists• Reduce the time frame between disciplines within ECTC as a result of and management team. attendance at pre operative the development of Surgical User • Strong leadership and senior assessment clinic and admission for Group. management support. surgery by four weeks. • Reduction of in -hospital theatre • Schedule meetings to meet the needs• Reduce theatre cancellations to cancellations from 20% to 10%. of all disciplines to ensure attendance. below 10%. • Reduction in wait from pre operative • Production of robust data collection• Reduce waiting times from nine assessment clinic (POAC to admission and analysis to support the project, weeks to six weeks for cardiac for elective cardiac surgery from nine drive key changes and ensure the surgery. weeks to six weeks. work remained focused. www.improvement.nhs.uk/heart 21

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