Case Study Archive – General Hospital Care

The NHS South West Quality and Patient Safety Improvement Programme

Project overview: The project is a regional collaboration of South West hospital NHS trusts to improve patient outcomes by using a best practice model for improvement to implement a series of care bundles.

The project focused on five workstreams: • Critical Care • General Ward • Leadership • Medicines Management • Peri-operative.

TST Safer Care

 

Devon Access and Referral Team

Project overview: DART (Devon Access & Referral Team) was set up in April 2010 as a NHS Devon wide referral management service with the aim to support the quality and consistency of Devon referrals, ensuring the patient has a smooth pathway into the correct service.

Devon Dart Scheme

Developing the clinical service line for stroke care for Plymouth

Project overview: It was recognised that there was a need for fundamental improvements to the Stroke Pathway in the Plymouth Health Community. This was a strategic aim of NHS Plymouth, but was also a high level target initiative following the publication of the National Stroke Strategy in December 2007, and the independent review into stroke services commissioned by the SHA in July 2008.

A clinical service line for stroke was agreed as a concept in January 2009 and formally launched in April 2009, to coordinate the development of stroke services with the two healthcare providers Plymouth Hospitals NHS Trust and Plymouth Primary Care Trust provider arm.

NHS Plymouth S Care

 

Transforming the role of the Community Matron through the implementation of the Virtual Ward

Project overview: An opportunity was identified to refocus the role of the Community Matrons in NHS Swindon in order to:

  • Provide more intensive multi-disciplinary care management of specifically identified high intensity users
  • Improve the quality and consistency of care for these patients
  • Reduce readmission to hospital where appropriate
  • Develop the virtual ward concept using the community matrons as the orchestrator of care.

The very high intensive user project was launched to pilot an integrated model of care across primary care and the Community Matrons. The project was led by the Practice Based Commissioning GP across one of the three localities. The project was launched in January 2010 and the implementation was phased over three months with plans to roll out across all three integrated teams within nine months.

NHS Swindon V Wards

 

Colorectal – faster diagnosis and access to treatment for bowel cancer patients

Project overview: Bowel cancer is the third most common cause of cancer related death in the UK. Around 100 new cases of bowel cancer are diagnosed each day in the UK and the vast majority present on a symptomatic basis. The importance of symptoms or collection of symptoms can be difficult to assess and the scheme sought to deliver faster access to treatment for patients with suspected bowel cancer and to improve the speed and accuracy of bowel cancer diagnosis.

RBCHFT Colorectal

 

Enhanced Recovery Innovation Site

Project overview: Torbay Hospital – working in collaboration with its health communities and other local NHS services – has become an Innovation site for the Department of Health’s Enhanced Recovery Partnership Programme. The programme is designed to extend learning and best practice from the few hospitals which already offer enhanced recovery, or are introducing it, to other NHS hospitals. As an innovation site, Torbay Hospital is helping build evidence on how effective enhanced recovery methods can be, helping patients to get better sooner after surgery.

SDHFT Enhanced Rec

 

Reducing falls in elderly care and across the hospital – Brighton and Sussex University Hospitals NHS Trust

The project aimed to reduce inpatient falls across eight elderly care and acute medical wards. Nationally over 200,000 falls are reported each year in the NHS and are a major issue in a range of health and social care settings, both NHS and non-NHS.

The initiative has focussed on what happens to patients for the first few days in hospital. With an increasing national focus on dementia and frailty the team believes that reducing falls will become a major challenge in delivering compassionate care.  The cost of failing to address the issue in terms of cost and reputation is an additional driver.

 Outcomes:

In the eight wards covered by the initial phase, falls were reduced by 32{79f878acaa41f375dcd804cc8c058b5459a5482f20a3b9f87269b26c8734749b} in twelve months.  Following this success a trust-wide initiative replicated the activity, achieving a reduction across the trust of 17{79f878acaa41f375dcd804cc8c058b5459a5482f20a3b9f87269b26c8734749b}. The original eight wards, with minimal additional input, are still improving at a faster rate than the rest of the trust and have reduced their rate by a further 31{79f878acaa41f375dcd804cc8c058b5459a5482f20a3b9f87269b26c8734749b}.  These results indicate that a focus on the behaviour and habits of individual practitioners is the way to make change sustainable and continuous.

In 2012 the trust was shortlisted for the BMJ Safety /Improvement Award.

Information, tools and techniques used:

The first phase, which took a conventional approach to service improvement (training, action plans, guidelines, meetings etc) was abandoned after 9 months as no improvements had been made.  Phase 2 focussed on the concepts of emergent design, followership and imitation, producing outstanding results.

Over the past 3 years the team has moved from a position of thinking that safety is a product of resilient processes to thinking that safety is something that emerges out of imitating safe behaviours.

Contact details and further information:

Mark Renshaw, Deputy Chief of Safety, Brighton and Sussex University Hospitals NHS Trust: Mark.Renshaw@bsuh.nhs.uk

Paula Tucker, Head of Nursing Patient Safety, Brighton and Sussex University Hospitals NHS Trust: Paula.tucker@bsuh.nhs.uk

 

Improving hip fracture pathways – South Devon Health Services (primary and acute care) and social care.

This very successful project aimed to reduce time from A&E to theatre and improve pain control for hip fracture patients. It reviewed and revised the patient pathway through the system from paramedic through A&E, radiology, theatre, ward and discharge, including social care.

Outcomes:

There have been a number of significant improvements including extremely positive patient feedback.  The team has recorded impressive reductions in, for example, pain score on movement from severe (2.75) to mild (0.5); median time to theatre (48 hours to 19 hours) and an increase in the percentage of patients treated on the day of injury (3{79f878acaa41f375dcd804cc8c058b5459a5482f20a3b9f87269b26c8734749b} to 33{79f878acaa41f375dcd804cc8c058b5459a5482f20a3b9f87269b26c8734749b}).  Although cost reduction was not a primary aim, the programme has led to a reduction of 1,800 bed days per year, saving an estimated £326,000.  There is also some evidence of reduced post-discharge dependency and therefore a reduced social care cost.

Other intended and unintended benefits have included improvements in staff morale; theatre and ward productivity; a reduced backlog on trauma board; and the development of a screening tool for malnutrition.  However, the programme team believe that the most significant change is cultural.

Information, tools and techniques used:

A small multidisciplinary team of anaesthetists, nurses, surgeons, and a clinical systems engineer worked together, with other professionals drawn in as required to help.  The project applied Lean Thinking and Enhanced Recovery principles, involving all professional groups and patients in the redesign. The team developed an innovative technique of clinical process simulation during which the process of care was simulated by the professionals involved from injury (with a paramedic) to ward. This technique has been used for another Trust’s team and could be offered to others who are interested.

Timescale:

Approximately a year was spent defining and analysing the problem with testing of ideas for change and building the will for change. The change in process occurred in November 2010 and is sustained with regular team review of success and issues to fix; they are proud of what has been achieved and striving to improve still further.

Contact details and further information

Andrew Fordyce: andrew.fordyce@nhs.net

 

Patient Access Centre – Torbay, Devon

This programme’s purpose was to replace a hospital’s complex and inconsistent system for outpatient bookings with a call centre, using a single telephone number for all outpatient bookings.

A review found that bookings were being made by over 300 staff with over 70 phone numbers in use across the trust. In some departments, it was only possible to book an appointment between certain times and on occasion there was nobody was available to cover bookings during annual leave. The lack of consistency across the trust meant that the patient experience was confusing and navigating between specialties was difficult.

The team worked with stakeholders to interpret the review findings and to co-design a more streamlined booking system.  A new bookings process was then introduced alongside call centre technology and, after a trial period, all booking staff moved into one building.  The service has since been gradually refined to enable staff to work across specialities.

Outcomes:

Outpatient bookings are now handled by 30 full time employees.  Patient experience is much improved and savings of £1.2 million have been achieved.

Information, tools and techniques used:

The creation of a Patient Access Centre was a Process Redesign in Administrative and Managerial services project (PRAM).  The project team drew on principles from a number of change tools, using a lean systems approach and being guided by principles from the DEMAIC (Define, Enthuse, Measure, Analyse, Improve, Control) model of change.

To govern the overall project management, the team drew on principles from PRINCE 2. To embed the change, the team drew on Kurt Lewin’s ‘unfreeze, change and refreeze’ thinking.  The principles of Kubler Ross’ change curve were also instrumental in the team’s approach.  

Timescale:

The project started in January 2010 and took approximately 18 months to complete.

Contact details and further information:

Nick Debney, Torbay Hospital. Email: nick.debney@nhs.net

 

Enhanced Recovery Programme, Royal Berkshire NHS Foundation Trust

Whilst ERP is a national programme, senior leaders of NHS trusts have also been instrumental in driving forward ERP. Programme objectives have been set differently in different trusts.  In the case of Royal Berkshire NHS Foundation Trust, ERP has focused on patients as well as NHS staff, in particular giving them information to help them prepare for surgery, give them the right expectations and support them throughout their hospital stay. Information packs and patient diaries have been central to this. The trust has also developed education packages for nurses and established education sessions for staff.

Outcomes:

In Royal Berkshire hospital, length of stay has reduced from ten to six days for colorectal surgery, from five to two days for hysterectomies, from four to two days for prostatectomies and from seven to under five days for hip and knee surgery; all with no significant change in readmission rates.

Information, tools and techniques used:

Clinically led since its inception, the ERP programme at the Royal Berkshire NHS Foundation Trust uses Plan Do Study Act (PDSA) cycles to drive local implementation and improvements.

Timescale:

An enhanced recovery programme started for colorectal surgery in 2005/06 but lapsed two years later. Following the national launch of ERP, the hospital’s own programme was re-launched in 2010.  The programme is still on-going.

Contact details and further information:

Sarah Cherrill, Enhanced Recovery Nurse, Royal Berkshire Hospital.  sarah.cherrill@royalberkshire.nhs.uk

 

Reducing spend and increasing efficiency in MSK services – East Sussex

This programme aimed to improve quality, reduce spend and increase efficiency in musculoskeletal (MSK) services in East Sussex. Data on efficiency and spend in MSK services were presented to 70 participants at an event called Shaping the Future, where a number of key issues and possible solutions were identified.  These included high rates of fractures and falls admissions, high rates of arthroscopy and of elective admissions, fragmented MSK services and variation in referral rates.

The programme has since focussed on pursuing solutions to these issues, including peer-review by GPs of referrals, agreeing surgical policies for arthroscopy and eight further orthopaedic procedures and introducing physiotherapy triage as an alternative to orthopaedic referral.  To achieve change in systems and results, it has been necessary to influence culture and behaviour and seek consensus across a number of systems. Alongside this, an integrated MSK service has been procured in Hastings and Rother and commissioning of a similar service is being considered for the remainder of East Sussex in conjunction with other local commissioners.

Outcomes:

Savings achieved in arthroscopy totalled £1.8million in 2010/11 and a further £600K in 2011/12 Interim outcomes for physiotherapy triage are encouraging, and there is increased interest in MSK from a primary care perspective.  A service specification and business case has been agreed for a Falls and Fracture Liaison service for East Sussex and work is underway to implement Shared Decision Making – critical to ensuring that patients are fully aware and have the option to participate in decisions about their care, particularly where more than one treatment option may be available.

Information, tools and techniques used:

The programme has used a range of national and regional best practice tweaked for local use. The project drew on a number of sources: the Framework for Musculoskeletal Services, National Institute of Clinical Excellence, surgical policies from other PCT areas, data from the NHS Atlas of Variation and the South East Public Health observatory.

Contact details and further information:

Fiona Streeter, Service Development Team Leader, East Sussex: fiona.streeter@nhs.net

Rapid Assessment & Consultant Evaluation (RACE)

This programme established a new admissions unit, the Rapid Assessment & Consultant Evaluation (RACE) ward.  Here medical patients with geriatric needs (frailty, multiple co-morbidities, advanced age dementia) referred to hospital as emergencies, are assessed and cared for by a consultant-led multidisciplinary (MDT) team, including doctors, nurses, physiotherapists, occupational therapists and community support staff.

All patients receive comprehensive geriatric assessment (CGA) within 24 hours of admission and there is a daily multidisciplinary meeting attended by the ward team and representatives from Poole Intermediate Care Service, Poole Social Services and Dorset Social Services to facilitate discharge planning.

GPs can also refer patients to the daily emergency clinic held on the ward to access rapid diagnostics and CGA without admission to hospital.

The aim of the unit is rapid comprehensive assessment of older patients with complex needs. This facilitates early supported discharge and avoids unnecessary hospital stays which can be detrimental to older patients. The trust benefits from a reduced length of stay for older patients with concomitant savings.

Outcomes:

Within 3 months of the establishment of the RACE ward marked improvements were recorded. Patient discharge within 48 hours increased from 20{79f878acaa41f375dcd804cc8c058b5459a5482f20a3b9f87269b26c8734749b} to 40{79f878acaa41f375dcd804cc8c058b5459a5482f20a3b9f87269b26c8734749b}, and average length of stay decreased from 19 to 13 days. The quality of patient care also improved as a result of comprehensive geriatric assessment at the front door.

Information, tools and techniques used:

The original impetus for the change was managerial, but the change was driven bottom up: planned, led and implemented by clinicians.

Contact details and further information:

Prem Fade, Department Director: Prem.Fade@poole.nhs.uk

Enhancing Quality and Recovery Programme – Kent, Surrey and Sussex

Enhancing Quality and Recovery is a clinically-led rapid quality improvement programme which triangulates clinically robust data to drive quality improvements in clinical interventions, patient reported outcomes and patient experience.  The programme uses accurate benchmarking of clinical practice to identify variation and then supports clinicians to innovate and improve patient outcomes. It recognises best practice and promotes a collaborative approach whereby learning is shared within and between different Trusts.

The EQ programme aims to streamline care and improve accountability through reliable and directly comparable information on clinical quality; and to rapidly spread and adopt evidence-based improvements to multiple settings.

Outcomes:

In the first year over 25,000 patients were tracked by the programme. Quality improvement scores show a 15 per cent improvement for heart failure and pneumonia patients, eight per cent for hip & knee and five per cent for heart attack. More granular improvements were demonstrated such as a 20 per cent increase in the number of patients with pneumonia receiving their antibiotics within six hours of arriving in the hospital.

Individual Trusts are able to compare their quality performance within their Trust (at ward and clinician level), against other Trusts across this region, with trusts in the North West and with hospitals in the United States in order to improve their quality of care.

Information, tools and techniques used:

The EQ programme uses the PDSA (Plan Do Study Act) rapid quality improvement methodology, recommended by the IHI (Institute for Healthcare Improvement) and the NHS Institute for Innovation and Improvement.  The team has also used some of the principles of the MSP and Prince 2 programme management tools, adapted to suit their own purposes.

Contact details and further information:

Kay MacKay, Director, Enhancing Quality and Recovery Programme: kay.mackay1@nhs.net

Further information at: http://www.enhancingqualitycollaborative.nhs.uk

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