Ideas from UK modernisation: The Improvement Partnership for Hospitals Penny Pereira Ideas from UK modernisation

Ideas from the UK: Improvement Partnership for Hospitals Presentation content: Overview of the IPH approach Case study from an IPH site Key learning points overview

Background There was already… Lots of existing projects and activity Work on many services / pathways Staff with skills in each organisation The IPH approach - background But… Not always having an overall impact Not looking across the whole hospital Some put off by too many initiatives IPH was set up to help hospitals create an integrated approach to improvement

Background Designed to help meet demanding national targets: –4 hour maximum wait in emergency department –Max wait for outpatients 13 weeks and falling –Max wait for inpatients 9 months and falling Hospitals got £180k matched funding and support from a national team c.150 hospitals participating since Jan 2003 The IPH approach - background

Clinical systems improvement Patients who experience better care without delay High-performing patient-centred teams The IPH approach - clinical systems improvement The IPH approach

Understand the variation The root cause of delays for patients in the care system is not volume, it is variation The greater the variation, the more capacity we need to meet demand We create the variation through the way we organise our systems If we reduce variation, we can make much better use of capacity The IPH approach - clinical systems improvement

Variation in demand for beds (admissions) The IPH approach - clinical systems improvement

Number Variation in bed capacity (discharges) The IPH approach - clinical systems improvement

Variation in length of stay Average length of stay by day of medical admission MondayTuesdayWednesdayThursdayFridaySaturdaySunday Average length of stay (days) The IPH approach - clinical systems improvement

Organisational development The IPH approach Clinical systems improvement Patients who experience better care without delay High-performing patient-centred teams Organisations that facilitate the work of patient-centred teams The IPH approach - organisational development

OD self-assessment Strategic capacity Leadership & direction Policy & planning Patient centred approaches Partnership working Resources & processes Human resource management Clinical systems & processes for quality improvement Financial management Results Patient experience & clinical outcomes Staff experience & outcomes Key performance targets Value for money & productivity Intelligent information Use of information about patient experience, outcomes, resources & processes Staff knowledge, skills & experience Information systems & use of technology The IPH approach - organisational development

Whole systems alignment Organisational development Clinical systems improvement Patients who experience better care without delay High-performing patient-centred teams Organisations that facilitate the work of patient-centred teams Environment that facilitates the work of organisations The IPH approach - whole systems alignment The IPH approach

OD & whole systems alignment 1.Strong & visible leadership for improvement 2.Ambitious improvement goals agreed by all 3.Capacity in improvement skills at all levels 4.Networks to share learning across system 5.Headroom for improvement, with shared risk-taking 6.Investment based on analysis of demand & capacity 7.Approach to payment driven by clear, patient-centred principles to avoid perverse incentives 8.Working in partnership to unblock whole system constraints The IPH approach - OD & whole systems alignment

Case study Nottingham City NHS Trust One of four early pilots for IPH IPH case study – Nottingham City

EMERGENCY PATHWAY Referral Assessment Treat Transfer of care ELECTIVE PATHWAY Referral Admission Transfer of care AMBULATORY CARE Referral Treat Transfer of care ‘Designed around the patient’ Cancer NSF CHD NSF Discharge Diagnostics Older People NSF Infection Control Nottingham took a whole system approach… IPH case study – Nottingham City

Overview of improvements to the Emergency Pathway Specific changes following months of diagnosis: Each ward to discharge one patient before 10am GP /A&E streaming patients in primary care Reconfigure beds to create ESSU/EAU Two acute physicians appointed (9am-6pm) Changed bed co-ordinators role No batching of bloods Order sets instigated by Registered Nurse IPH case study – Nottingham City

Borders Sept 2002 – August 2004 ‘Designed around the patient’ 85% reduction in daily mean, 50% reduction in variation IPH case study – Nottingham City

Cancelled Operations April 2002 – August 2004 ‘Designed around the patient’ 50% reduction in weekly mean, 50% reduction in variation IPH case study – Nottingham City

Elective Inpatient Activity April 2002 – August 2004 ‘Designed around the patient’ Elective surgical inpatient admissions increased by 8% Feb-Jan 2004 compared to previous 12 months 30% reduction in weekly variation IPH case study – Nottingham City

The number of patients that are discharged within 24 hours has doubled from an average of 15% to 34% Recruitment and retention of staff has improved. Sickness has reduced from 17% to less than 6% Waits and delays in Emergency Areas are reduced. Baseline data showed that on average patients would spend 5 hours 17 minutes on the admissions unit; this has been reduced to 2 hours 59 minutes Additional benefits ‘Designed around the patient’ IPH case study – Nottingham City

Staff satisfaction “ It is clear that the changes you and all your colleagues have made in acute medical admissions have had a major impact of reducing last minute cancellations of surgical beds” Consultant Anaesthetist “It is a pleasure to work at the City Hospital once again, as things are running smoothly with my operating lists and I have not experienced any cancellations recently for which I am very grateful” Consultant Orthopaedic Surgeon ‘Designed around the patient’ IPH case study – Nottingham City

What we learnt… Overall messages from our work in the UK Anything here that might be relevant for you? Key learning points

What we learnt… 1.Look across the whole system in order to understand the real constraints 2.Create an integrated approach to improvement: Articulate a clear overall strategy Join up improvement activities Build improvement into mainstream business 3.Engage Executives, clinicians and staff at all levels and give them practical tools Key learning points

What we learnt… 4.Every organisation is different: Understand your system 5.Make time for in depth diagnosis 6.Invest in analysis and aim for real time data 7.Understand the small changes that will have a significant impact 8.Develop your organisation to have the strategy, skills and culture for really ambitious improvement Key learning points

This is what we learnt. Does this fit with your PFC work? Questions?