1. KSS Diabetes Medical Technology Collaborative
18 October 2017

2. Welcome
Welcome! Setting the scene for the day
Brief background of who is in the room
Fire exits and fire drill plans
Car park –enter your car registration in the lobby
Wi-fi – codes on the flip charts
Please be present in the room as much as possible – no calls, s etc.
Lunch served in the main restaurant and dessert back in the lobby
“insert joke here”
Evaluation forms
Peter Carpenter, Programme Director Quality & Safety Collaborative, KSS AHSN

3. Dr David Lipscomb, Clinical Director, SE Clinical Network
Our vision for adults with type 1 diabetes and for services across Kent, Surrey and Sussex
Dr David Lipscomb, Clinical Director, SE Clinical Network

4. What the data says Baseline Data Collection
The Current State of Play
Why collect data?
What do you want to improve, what do you NEED to improve?
How do you know this needs improvement?
How will you know what difference you have made?
“But we already know this!!”
By collecting a uniform dataset from every hospital and from every CCG we can:
Identify the gaps
Share Best Practice
Improve Together
These questionnaires were based on a template developed by Dennis Barnes and developed to try to answer the questions around Diabetes services for T1DM patients in KSS
Thank you to everyone who completed it, here are some of the highlights
Ben Williams Tom Myers Senior Analyst Information Analyst 18th October 2017

5. “Without data you’re just another person with an opinion”
- Dr W. Edwards Deming

6. 8,538 642 7.5% Diabetes Care in KSS The Numbers # T1DM patients -
recorded in the baseline data survey* -
642
# T1DM patients on NHS funded insulin pumps* -
We asked both the specialist services and CCG’s about patient volumes.
Only 2 services were able to confidently state their T1DM population
Numbers shown here are those provided by 7 commissioners who were able to articulate a number(from 21)
7.5%
% T1DM patients on NHS funded insulin pumps* -
* Some figures were omitted from the final count. Figures were omitted due to the numbers being exceptionally large, or small, compared to previous data sets.

7. 0% Commissioning of Services But, why? Summary
The percentage of CCGs who replied to the baseline survey stating that they specify skill mix and staffing levels.
Should this happen more or less?
But, why?
Specifying staffing levels would allow both CCGs and providers to assess performance
Enable clinicians to apply for further resources
Is this impossible due to the sheer number of vacancies currently available?

8. Yes 55% No 45% Commissioning of Services The issue Summary
When dealing with patients from different CCGs, is there variation in funding arrangements and applications?
The issue
Postcode lottery - patients at the same hospital receiving different care
Lengthier application process due to minute mistakes
Yes
55% No
45%
Would CCG’s like to work together either in STP footprints or across KSS to reduce variation and develop best practice commissioning models?

9. Insulin Pump Therapy Do you have discontinuation policy?
Do you have a discontinuation policy for when technology has not been successful in managing a patient’s diabetes?
Why don’t you have a discontinuation policy?
Discontinuation policies would eliminate the use of unnecessary technology, therefore reducing cost
Improve patient care
Yes
46% No
54%
Is this more resource intensive or does it save money on unnecessary resources and represent better patient care?

10. Do you specify requirement for structured patient group education?
Structured Education Is it required, and are your providing it in a timely manner?
Do you specify requirement for structured patient group education?
Do you specify requirement for when structured education must take place? No
20%
Yes
20%
Would explicit commissioning requirements help services to demand resources from management?
Yes
80% No
80%

11. Structured Education Is it required, and are you providing it in a timely manner?
What is the average time it takes from a patient starting on an insulin pump to provision of structured education?
Do you have sufficient capacity to provide structured education in a timely manner?
Yes
36%
5  hospitals provide this within 3 month
4 do not believe this is timely
1 does 
3 hospitals provide within 6-9 months
                            2 of these believe this is timely No
64%

12. Diasend Are we fully utilising the power of Diasend?
Do you share Diasend with your patients?
Do you use Diasend to prepare for patient consultation?
Do you use Diasend during consultation with a patient?
Yes
45%
Yes
55%
Yes
100% No
45% No
55%

13. Diasend Are we fully utilising the power of Diasend?
Is Diasend fully utilised?
What is preventing teams from using Diasend for all methods previously described?
Yes
27% No
73%
Could clinics run more efficiently with better planning and use of existing data?

14. Psychological Therapies
Psychological Therapies Are IAPT services being integrated into clinics?
Do you have clinics that integrate Psychological Therapies? (IAPT services)
Is there value in integrating IAPT services into clinics?
What are the blockages?

15. Commissioning How much are we spending?
£21.5 million
The collective sum of money 7 CCGs anticipate spending on ALL adult diabetes services
£47
per diabetic patient
£373
per diabetic patient
At best, patients are funded £1.02 per day.
This may be due to incorrect data, so how can this collaborative help both commissioners and services create more meaningful datasets to drive patient care and efficiency?
Lowest to greatest spend per diabetic patient, calculated via CCGs anticipated budget for its entire diabetes service, divided by the number of diabetic patients within its catchment area

16. Ben Williams Tom Myers Ben.williams5@nhs.net Thomas.myers@nhs.net
kssahsn.net

17. Questions 1) What commissioning arrangements do you want?
- enables CCGs to assess performance
- enables clinicians to apply for extra resources
- are there already too many vacancies?
2) Should CCGs in an STP footprint align ….commissioning?
3) Why don’t you all have a discontinuation policy?
- reduce costs of unnecessary technology
- improve patient care

18. Questions
4) What is required for you to supply structured ….education in a manner you believe is timely?
5) Is there value in integrating IAPT services into … ….clinics?
- What are the blockages?
6) What is preventing teams from fully utilising ….Diasend?
7) What do you need in order to accurately reflect the ….diabetes service you offer?

19. Discussion

20. Dr Pratik Choudhary, Kings College London & IPN-UK
Overview of technology for type 1 diabetes
Dr Pratik Choudhary, Kings College London & IPN-UK

21. Overview of technology for type 1 diabetes
Dr Pratik Choudhary
Senior Lecturer and Consultant in Diabetes

22. Disclosures
Speaker fees, advisory boards, honoraria and travel support from
- Medtronic, Abbott, Roche, Dexcom, Novo Nordisk, Lilly, Ascenscia, Sanofi, BD

23. 23 7 1 6 HbA1C (%) 9 8 2 3 4 5 Conventional treatment7 1 6
HbA1C (%) 9 8 2 3 4 5
Conventional treatment
Intensive treatment 11 12 13 14 15 16 17 10
Years
57% risk reduction* (p=0.02; 95% CI, 12 to 79%)
non-fatal MI, stroke or death from CVD
0.06
0.04
0.02
0.00
DCCT (intervention period)3 ED(observational follow-up)3
In DCCT (Diabetes Control and Complications Trial), 1441 patients with type 1 diabetes were randomised to intensive (3 daily insulin injections or insulin pump) or conventional treatment (1–2 daily insulin injections) for a mean follow-up period of 6.5 years. At the end of DCCT, participants receiving conventional treatment were offered intensive treatment. All patients returned to their own healthcare provider for diabetes care.1
In total, 1397 patients (96%) from the DCCT were followed in the observational EDIC (Epidemiology of Diabetes Interventions and Complications) study for a mean 17 years of follow-up.1
As shown in the upper graph, in DCCT the absolute difference in mean HbA1c between the intensive and conventional groups was ~2% (7.4% vs 9.1%; p<0.01) at 6.5 years, which was sustained during the intervention period. During EDIC, differences in HbA1c narrowed in these groups (8.0% vs 8.2%, respectively; p=0.03) at 11 years.1,2
As shown in the lower graph, changes in HbA1c associated with intensive treatment were accompanied by a reduction in risk of non-fatal MI, stroke or death. Differences between the conventional treatment group and the intensive treatment group started to appear from Year 9 onwards. The intensive treatment line stops at Year 17 as this was the time of the last recorded event.1
In EDIC, patients with type 1 diabetes who had received intensive treatment in DCCT had a 57% reduction in risk of non-fatal MI, stroke or death from CVD (95% CI, 12 to 79%; p=0.02). Intensive treatment also reduced the risk of any CVD event by 42% (95% CI, 9 to 63%; p=0.02).1
There are a number of potential mechanisms by which intensive glycaemic control may reduce CVD risk, including a reduction in HbA1c.1
DCCT/EDIC. N Engl J Med 2005;353:2643–2653.
DCCT/EDIC. JAMA 2002;287:2563–2569.
Dr Pratik Choudhary
Adapted from DCCT. N Engl J Med 1993;329:977–986. DCCT/EDIC. 23

24. Hvidore Study No difference in resources/ deprivation indices1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Centre Rank
7.0
7.5
8.0
8.5
9.0
9.5
95% CI A1C (%)
No difference in resources/ deprivation indices
Key predictors of outcomes were:
Tighter targets
Uniformity of message
Lower A1C  better QoL
Hvidøre Study Group et al. Diabetes Care 2001;24:

25. Levels of Care CHO Counting BD Basal CHO Counting BD Basal OR CSII
Fixed Doses
OD Basal 20
2-3 tests/day
Visual estimation
Guessed corrections
1:1 + 1:1+ 1:1
ISQ = 3
4 tests/day
Pre-meal boluses
1:1 + 1:1+ 1:1
ISQ = 3
6-8 tests/day OR CGM
Adjustments for ex
Adjust for Fat/prot
Pattern recognition
P Choudhary.

26. What does the PWD have to do?
BG - target glucose
Insulin sensitivity factor
Correction insulin
Food insulin
Carb content
Insulin: Carb
Insulin on board
65 [ 6.5] 10
12-6 3
[ 2 ]
Insulin on board
Insulin : Carb ratio 1 : 10 gms
Correction factor = 3
Current glucose = 12 mg/dl

27. Diabetic robot
If somebody says that a task is mechanical, it does not mean that people are incapable of doing the task; it implies, though, that only a machine could do it over and over, without ever complaining, or feeling bored.
Douglas R. Hofstadter, Gödel, Escher, Bach, an Eternal Golden Braid
Im very strong advocate of bolus advisors, cheap devices that have shown small benefits – but
While I dnt for a moment dobyt that we can teach someone to calcuatle an appropriate bolus dose based on insulin to cab ratios and sensitiviyt factors – only a machine would do it over and over without complainign or feeling bored – so thanks to prof Reach for that slide.
Dr Pratik Choudhary, KCL
Slide courtesy Prof Gerard Reach

28. smart meters Bolus calculators average glucose [ HbA1c ]
Data analysis - real time
Real time data upload

29. Useful apps
My sugr
Dario

30. 46 apps
Only 14 documented the calculation
27/47 allowed calculation when one or more parameters missing
Only 10 modelled IOB
67% had risk of inappropriate doses

31. Tethered Insulin pumps
Ypsopump
Roche
Medtronic Veo and 640G
Animas
Dana

32. Patch Pumps…
Omnipod
Cellnovo
Kaleido
Pay as you go… vs contracts…

33. Diaport – intra-peritoneal insulin delivery
This is the outline of the presentation - ….

34. Indications for Diaport
1. Where subcutaneous insulin is unsuitable due to:
Lipoatropthy
Lipohypertrophy
Skin reaction
Allergy
Subcutaneous insulin resistance
Co-existing skin conditions
2. for adults with type 1 diabetes with recurrent severe hypoglycaemia despite other treatments
Kings was selected by the company as 1 of 5 UK sites where this system would be availabe.

35. Freestyle Navigator II Libre
Guardian RT
640G Smart guard
DexCom G4 Platinum
Freestyle Navigator II
Libre
Sensor life
6 days
7 days
5 days
14 days
Alarms
Multiple
1 high, low and trend
High, low and projected
None
Predictive
Yes No
N/A
Trends
Rate change
Calibration
12 hrly
2h, then 12 hrly
1, 2, 10, 24, 72 h
MARD
13%
12.6%
11.8%
10%

36. Medtronic Guardian Connect

37. Dexcom G4 2 calibrations / day
Alarms, ability to share with dexcom clarity app

38. Medrum S6 sensor

39. Implantable CGM

40. DIAMOND study P<.001 P<.001 Baseline
Adjusted mean difference (95% CI)
Week 12
-0.5% (-0.7% to -0.3%)
Week 24
-0.6% (-0.8% to -0.3%)
Beck et al; JAMA Jan 2017

41. Early preterm < 34 weeks
CGM
Control
Stillbirth 1
Congenital Anomaly 2 3
Early preterm < 34 weeks 5% 7%
LGA > 90%
53%*
69%
Macrosomia > 4000g
23%*
27%
NICU > 24 hrs
27%*
43%
Presentation title
Feig et al, Lancet Sep 2017

42. Continuous glucose monitoring
HbA1C
Guard Control
JDRF(age 8-24)
JDRF>25 years
Battelino
GOLD
DIAMOND
IN CONTROL
JDRF<7
IMPACT
RealTrend
>70%% use
Eurythmics
STAR-3
SWITCH
ASPIRE IN HOME
Danne et al
High
Ly et al.
Choudhary et al.
HYPOCOMPASS
Hypoglycaemia 6% 7% 8% 9%
10%
Low
Dr Pratik Choudhary
Slattery et al, Diabetes Tech Ther; 2017

43. SmartGuard
Dr Pratik Choudhary

44. Predictive insulin suspension [ Minimed 640G]
693,626 PLGM suspends from carelink
Hours / day of hypoglycaemia [< 70 mg/dl ]
OO: Can we change the title to make it shorter and keep the full title in the footnote?
n = n= n=1387
Dr Pratik Choudhary
Zhong et al. et al. Diabetes Technol Ther, 2016

45. What about Libre ?
Presentation title

46. FreeStyle Libre will not be available on prescription until 1st November 2017.
The countries covered by the national formulary include England, Wales, Northern Ireland and Scotland.
The target cohort by Abbott is anyone with diabetes (any type) who uses intensive insulin management needing multiple blood sugar measurements (4 or more per day)
The next phase will involve – as with any new product which goes on tariff – agreement with local clinicians and managers regarding pathways and monitoring of use of the product
Your GP will not be able to prescribe Libre unless the local CCG has agreed to put in in their formulary.
If your CCG will not put Libre on their formulary, a letter from your clinic to your GP WILL NOT make any difference. The local system needs to agree first.
There are no NICE guidelines on the use of Libre, only a Medical Innovation Briefing, which does not make recommendations.
Just to be clear: please do not contact your clinic or GP about it yet. They will have no more information than has been shared publicly, and spending time telling individuals that they don’t know anything more than you do will take up valuable resources.

48. Suggestions Cost neutral High testers Pre-pregnancy
Pregnancy [ ? Do you need the alarms as per CONCEPTT]
Potential for cost saving
Those who meet NICE criteria for CSII  could save pump costs?
FSL should be provided as a 6-month trial to see whether individuals can demonstrate improvements in HbA1c, reducing risk of future complications:
Young adults who have not reached personalised HbA1c target despite SBGM
Those that have not reached HbA1c target as a result of infrequent testing. FSL has demonstrated effectiveness in this scenario (4)

49. Relationship Between CBG Frequency and HbA1c
11.0%
10.5%
10.0%
9.5%
9.0%
8.5%
8.0%
7.5%
7.0%
6.5%
0-2
3-4
5-6
7-8
9-10
11-12
≥13
Mean HbA1c
SMBG Per Day 11 10 9 8 7
HbA1c (%)
Frequency of Daily SMBG 1 2 3 4 5 6
≥10
MDI CT
CSII
Left chart: Adapted from Miller et al. Diabetes Care 2013; 36: Right chart: Ziegler; Ped Diabetes, 2011 Feb.

50. Dover et al; JDST 2016

51. Gazing into the future….

52. Finding it difficult to be efficient and meet demands on the service
How many patients can we squeeze into clinic????

53. E-consultations

54. Optimising / adjusting Optimising / adjusting
Face to face
Care planning
Optimising / adjusting
Optimising / adjusting
Check in for A1c
Re-adjust rates
Going travelling
Wants advice
E-consult
Virtual check in

55. Closed loop systems coming to you…

56. Basic principles Delay in insulin action Delay in glucose sensing
Algorithmic delays
Delay in insulin action

58. In closed loop for 87.2% time
124 participants
[ yrs]
Mean A1c 7.4%
In closed loop for 87.2% time
A1c 7.4 [ 0/9%] to 6.9[0.6%]
Bergenstal; JAMA, Sep 2016

59. Patients pushing the boundries
#wearenotwaiting
#OpenAPS
#nightscout

60. Driver aids vs driverless systems

61. Dr Pratik Choudhary, KCL

62. Technology is only as good as the user

63. Melissa Holloway, INPUT
Pump Services: a patient perspective
Melissa Holloway, INPUT

64. Pump services: a patient perspective
Melissa Holloway
Chief Adviser, INPUT Patient Advocacy
KSS Diabetes Med Tech Collaborative
18th October 2017

65. Origins of presentation: HIN (2015)
Diabetes Improvement Collaborative
Patient Reps: Marigold Gunter, Paul Swann, Lis Warren, Claire William, Melissa Holloway
142 years of living with type 1 diabetes
30 years of pumping
‘Representative’ group?
“Pump” service vs. “diabetes” service
Context – may also apply to type 2 services
Aim – suggest quick wins to make significant differences
Overall goals
Increased access to pumps
Improved experience for patients

66. Image illustrating the relationship between the time spent self-managing diabetes (blue) and time spent with a health care provider (white).
Image illustrating the relationship between the time spent self-managing diabetes (blue) and time spent with a health care provider (white). Credit: Diabetes Hands Foundation,
David G. Marrero Diabetes Spectr 2016;29:54-57
©2016 by American Diabetes Association

67. Core values Clarity Confidence Education Continued support Reassurance
Consistency
Flexibility (one size doesn’t fit all)
Acknowledge difficulty in world of QOF
Possible no matter how small team is
Not just “what” but also “how”

68. Agenda Education & care planning Enabling peer support
Clinical support
Improving coordination with primary care, A&E

69. Education for patients
Behind every good pump service is a good diabetes service
Tech is relevant throughout the diabetes care journey
Diagnosis, transition, pre-tech, peri-tech, post-tech, even re-tech
Care plan: ongoing process of goal-setting, review and revision as appropriate
SMART goals: bespoke for and with patient, not by clinic
DAFNE Refreshers
Pump user care plan book, e.g. Animas workbook
‘No decision about me without me’

70. ‘Why do I have to educate an HCP every time I need help?’
Education for HCPs
Direct team
Consultant
DSN
Dietitian
Psychologist
Other departments
A&E
Eye clinic
Primary care staff
‘Why do I have to educate an HCP every time I need help?’

71. Patient experience
More constructive technology discussions
Transparency: proactively use NICE TA and ABCD criteria to frame discussions (rather than patients having to look them up)
MDT panel vs. one-to-one consultation
Patients can feel voiceless
Sense of conflict between DSN and consultant can arise
Tech can be perceived as a reward for diligence rather than a tool for ongoing self-management
Patient can develop a sense of “always feeling judged”
Empathy is required
‘I feel like I have to prove my worth as a person before I get treated like a patient. I never asked for T1D.’

72. “When ‘I’ is replaced with ‘we’, even illness becomes wellness”
I cannot manage my diabetes alone. You cannot support me 24/7.
Therefore I need support from my clinical team when I need it and from other people in my situation
I would welcome peer support from other like minded people and a 24/7 contact I can speak to if I have real difficulty.
I would like you as clinicians to know how I can access to support and signpost me to it.
Because we can work together to improve the support for type 1 diabetics, and we can keep more people with diabetes ‘well’

73. Social media
Out of hours and alone, people with diabetes turn to social media!
All of the following are real questions posted on social media that would ideally have been put to clinical teams
Posters’ names have been removed for privacy

74. Social media – insulin:carb ratio
Paul

75. Social media – insulin action time
Paul

76. Social media – hypo recovery time

77. Social media for good – peer groups
Social media is not all bad
Using ‘approved teams,’ it can be used as a good place to get hints and tips
It’s always there
Someone will have an answer
It may be less personal but some people like the personal disconnection from their real lives
Inappropriate posts can be removed or moderated

78. Peer networking
Capacity for dedicated ‘pump clinics’ or ‘CGM clinics’ is limited
Normalise pumps – why?
Encourages real person-to-person support
Waiting room interactions are possible when pump patients are seen alongside MDI patients
Getting your hands on a pump with other pumpers
Reduced anxiety for people new to pumps
Gives opportunities to ask lifestyle questions
‘Intimate’ or ‘naughty’ topics may be easier to discuss with a peer than a professional
Supporting vs. ‘managing expectations’ of people interested in CGM
PAUL: My journey to the pump was an interesting one, I had completed DAFNE and was getting myself sorted but there seemed in my case to be an ongoing issue, it was discovered that I had DP, because of work patterns it became clear that a Pump was the optimum thing to progress my care. For 18 months my DSN and consultant gently worked on the benefits of the pump but nothing worked to convince me that being attached to a box 24/7 would ever be for me.
One day while waiting in clinic which was running late I bumped into a friend of mine who I had done my initial DAFNE with some 3 years prior, she revealed that she had been into see my DSN and Pump Rep to learn about advanced settings with a group of other pumpers.
In less than 20 minutes of hands on conversation with my friend my mind about pumps was changed from ‘WILL NOT PUMP’ to ‘WHEN CAN I GET ONE’?
It became clear to me that what seems to be a DARK art is actually normal. Meeting my friend in clinic helped me answer all the questions I had like
“Where do you put it”
“how do you get on in the shower”
“what about sports”
“what about sleeping?”
As good as a clinical team is, all of the above questions can really only be answered by someone who lives life with one attached.
In an ideal world I would like to see a peer network initiated so that people like myself and the ones standing next to me can help others discover pumps, understand cannula’s and infusion sets, bolus, basal’s and everything that goes along with the change in life you get.
Peer Pumpers could be done in clinic, in evening sessions, over the phone, or social media.

79. What if there were a diabetes clinical support hotline?
24/7 availability
Reliability of current support is varied
Response times vary
Evenings/weekends
Typical queries
“Having lots of hypos and not sure what to do”
“Ketones in my blood - not sure what to do”
“Pump has packed up and I’ve no in-date pens. Help!”
Could use regional ‘workbook’ and care plans
Q&A document would quickly evolve

80. Maybe one day NHS 111 will include something like this....?
What if there were a diabetes clinical support hotline? Some considerations
Staff willingness, contractual issues? Adults, parents, children? Confidentiality and record sharing Feedback to colleagues
Professional competitiveness?
Consistency of advice
Managing misuse
Establishing ‘boundaries’
Maybe one day NHS 111 will include something like this....?

81. Primary care co-ordination
Clarity about where overall responsibility sits
Regular letters to patients AND others involved
Care plan referred to throughout
Blood test results to patients PRIOR to appointments
Prescriptions: include Plan B medications
Overcoming inefficiencies/poor coordination stands to:
Reduce cost
Improve patient experience
Build confidence
Improve outcomes for all

82. Behind every good pump service is a good diabetes service
Suggestions
Introduce patient-centred care planning as a basic element of all diabetes services
Co-ordinate across diabetes clinics and primary care
Normalise pumps and CGM
In 2017/18, is there a reason not to train all diabetes clinic staff on the basics?
Intersperse patient appointments for technology users within type 1 clinics rather than segregate with a specific day/time for “pump clinic” or “CGM clinic”
Behind every good pump service is a good diabetes service

83. Q&A

86. Refreshment Break

87. …What did the teams tell us?..
Three Wishes
…What did the teams tell us?..
KSS Diabetes Medical Technology Collaborative
Workshop 1 October 18th 2017

88. Background Site Visits Good Ice Breaker
Provides wider context and purpose of project
Collaborative opportunity

89. Results – so what matters to you?
Technology
30%
More Staff
80%
Training
40%
Better Infrastructure (space for clinics, better IT support)
70%
Funding
50%
Out of the 10 Trust, 3 said that technology was what they wanted: -
With more staff although majority were wanting for more admin support to help with data collection and audit work to free up clinician time BUT also we had DSN’s, consultants and dieticians (no pharmacists though?!) BUT with the greater workforce planning issuses that trouble the NHS we are not surprised.

90. What you want for your patients
“   Patient education using technology”
BSUH
“ Commissioning of additional Education Offer for patients with Type 1 Diabetes”
SASH
“Joint preconception clinic for patients”
ASPH
Of the three questions, trusts also had to answer regarding what they would like for their patients
Better integrated Information systems for patients to see their own records and blood results to enable them to prepare for consultations. – Some of the clinicans we spoke to felt info was held up with GP or still with acute hospitals if patient is receiving care in a speciality in a locality (ie respiratory in Frimley). Wanted GP to encourage patients to have access to their own records.
Dr Caldwell mentioned better be spoke systems such as Patient view
Closing statement : not so different to all out objectives
“Better integrated Information systems for patients to see their own records and blood results to enable them to prepare for consultations.”
WSHT

91. Cheta Okonkwo Darzi Fellow
kssahsn.net

92. SWOT Analysis – Abigail Kitt, SE CN
Understanding your service
SWOT Analysis – Abigail Kitt, SE CN
KSS Diabetes Medical Technology Collaborative
Workshop 1

93. Setting the scene.. What is the purpose of a SWOT analysis?
Framework for planning
Visual tool to help with decision making
Provides analysis of impacts (internal and external)
Helps focus
A decision tool to help teams to
Build on strengths
Improve weakness
Avoid threats
Exploit the opportunities
Before starting any planning or analysis process you need to have a clear and SMART goal or objective.
What is about your service, you want to understand? Why is there a difficult for patients having access to medical technology?
What is it that you need to achieve or solve? Ensure that all key stakeholders (relevant to the issue being explored) buy into this objective or goal.

94. How to do a SWOT analysis
Determine the objective. Decide on a key project or strategy to analyse and place it at the top of the page.
Use the template provided which is divided into 4 squares in a grid
Complete each square, defining
Strength
Weaknesses
Opportunities
Threat
Review each square and draw conclusions.
The objective for this exercise has already been determined to be “Understanding your service”
Strengths – Factors that are likely to have a positive effect on (or be an enabler to) achieving the service’s objectives
Weaknesses – Factors that are likely to have a negative effect on (or be a barrier to) achieving the service’s objectives
Opportunities – External Factors that are likely to have a positive effect on achieving or exceeding the service’s objectives, or goals not previously considered
Threats – External Factors and conditions that are likely to have a negative effect on achieving the service’s objectives, or making the objective redundant or un-achievable.

95. SWOT Analysis Save copy onto A3 and on reverse of A3
Give yourself time to consider each of the four areas in depth, and try to be as realistic and rigorous as you can.
Starting with Strengths, ask yourself some key questions. What advantages do you or your service have? What do you do better than anyone else? What do your patients or commissioners see as your strengths?
Moving onto Weaknesses, ask yourself what could you improve? What should you avoid? What factors makes this difficult in your service for patients to gain access to medical technology? What do outsiders see as your weaknesses?
Next, you’ll want to consider where your best Opportunities lie. What interesting trends are you aware of? What advantages might arise from changes in technology, policy, and the like? And – this is really important – what options do your strengths open up for you?
Finally, Threats. Ask yourself what obstacles you or your service face? What are other Trusts doing that are an interest to you? Do you have funding issue? Do you have staffing issue? And what threats do your weaknesses expose you to?
When you're making your lists, be precise and prioritize, so the most important points are at the top.
You'll find that your strengths and weaknesses are often internal, while opportunities and threats often relate to external factors. This is why SWOT Analysis is often called "Internal/External Analysis."

96. Team exercise Pre-workshop exercise
SWOT analysis on understanding your service
Summarise main priority points from SWOT
Other than your Trust team was there any stakeholders you feel that should be involved?
What are your next steps?

97. Cause and Effect Analysis
Fishbone Tool
Cause and Effect Analysis
KSS Diabetes Medical Technology Collaborative
Workshop 1

98. When to use Fishbone - Cause and Effect analysis?
To analyse a serious complex problem
Can explore all causes before thinking about a solution.
Allows the problem to solved first time round
Use fishbone tool to analyse a serious problem
Explore all causes before thinking about a solution.
Best to solve the problem completely, first time round, rather than part of it and having problem continues.

99. How to do ?
Diagram based mind-map known as a fishbone analysis

100. Step 1: Identify the Problem
The problem : Why might it be difficult for patients to access technology in your service? Then, write the problem in a box on the left-hand side of a large sheet of paper, and draw a line across the paper horizontally from the box. This arrangement, looking like the head and spine of a fish, gives you space to develop ideas.
Why might it be difficult for patients to access technology in your service?
First, write down the exact problem you face. Where appropriate, identify who is involved, what the problem is, and when and where it occurs.

101. Step 2: Work Out the Major Factors Involved
Identify the major contributing factors that may be part of the problem.
These may be systems, equipment, materials, external forces, people involved with the problem, etc
Then draw a line off the "spine" of the diagram for each factor, and label each line
Try to draw out as many of these as possible.
people
Equipment
Why might it be difficult for patients to access technology in your service?
So can use the PESTLE analysis
environment

102. Step 3: Identify Possible Causes
For each of the factors you considered in step 2, brainstorm possible causes of the problem that may be related to the factor.
Show these possible causes as shorter lines coming off the "bones" of the diagram. Show these as lines coming off each cause line.
Can compile data
To recruit
To train
Admin Staff
people
To train
Equipment IT
Why might it be difficult for patients to access technology in your service?
DSN - Terry
With people can keep it general or more specifics
Clinic room space
environment
Hot Tip! Where a cause is large or complex, then it may be best to break it down into sub-causes
Hot Tip! To gain many perspectives involve as many stakeholders as possible to generate causes

103. Hot Tips
As an example, 5 WHYS is a tool to help brainstorm causes to problem
Asking WHY and then ask another 4 times
Why is it difficult for patients to access medical technology in our service?
why
Is the problem that we need more time ?
why
To free up demand for clinic time, who can help the nurses with audit or paperwork ?
Ask your team why the problem is occurring. (For example, "Why is team at Hospital A struggling to get more patients on pumps?")
Asking "why?" sounds simple, but answering it requires thought and intelligent application. Search for answers that are grounded in fact: they must be accounts of things that have actually happened – not guesses at what might have happened.
This prevents 5 Whys from becoming just a process of deductive reasoning, which can generate a large number of possible causes and, sometimes, create more confusion as you chase down hypothetical problems.
Working sequentially along one of the answers you generated in Step 3, ask four further "whys" in succession. Frame the question each time in response to the answer you've just recorded, and again record your responses to the right.
Others include PESTLE analysis
4 P’s
Mckinsley
why
Do we admin support? (Do we need to recruit or train?)
why
Better clinical outcomes and data collection
why
Better quality of clinical service

104. Hopefully end up with this
As an example

105. Step 4: Analyse Your Diagram
By this stage you should have a diagram showing all of the possible causes of the problem that you can think of.
Depending on the complexity and importance of the problem, you can now investigate the most likely causes further.
Hot Tip! :
A useful way to use this technique with a team is to write all of the possible causes of the problem down on sticky notes. You can then group similar ones together on the diagram.
Watch this video to discover how you can use Cause and Effect Analysis to solve problems.

106. Solution Development people Equipment environment
Can use SWOT analysis as an example of analysing the possible causes from the Fishbone
Can use select one or two causes to focus on with SWOT
Area of Focus
Can compile data
To recruit
To train
Admin Staff
people
To train
Equipment
DSN - Terry
Why might it be difficult for patients to access technology in your service? IT
Clinic room space
environment

107. Activity
Lets spend minutes on our tables to have a go and then get some feedback on your efforts!
Lets think about the possible problems identified, any similarities or differences
What are the priorities or area of focus?
What other stakeholders do you need ?
What is you next action?
Use the blank templates on your table

108. Cheta Okonkwo
kssahsn.net

109. Morning wrap up – emerging themes and thoughts for action
Dr David Lipscomb, SECN

110. Lunch
&
Visit Stands

111. 28th February 2018 13th June 2018 19th September 2018 Next events:
Further dates to hold in your diaries
28th February 2018
13th June 2018
19th September 2018

112. Dr Pratik Choudhary, Kings College London & IPN - UK
What we achieved in London and how
Dr Pratik Choudhary, Kings College London & IPN - UK

113. See PDF file

114. Frances Scott, Programme Manager, KSS AHSN
Team Exercise: A3 thinking
Frances Scott, Programme Manager, KSS AHSN

115. What is an A3 Thinking Template?
To provide a one page A3 summary of a programme, project or problem, for the project team & relevant personnel within the organisation
Visual Storyboard consists of 9 boxes with standard input requirements
Supports team problem solving and improvement work
Originated from Toyota

116. How to complete?
Based on SWOT analysis and fishbone, identify an area for improvement to tackle
Define the overall aim of the project
What data do you need and how/who will collect it?
What support do you need and from whom?
What is your plan of action?
Example……..

118. Working
Refreshment Break

119. Frances Scott, Programme Manager, KSS AHSN
Speed Dating - What is your plan of action for improvement?
Frances Scott, Programme Manager, KSS AHSN

120. Final Thoughts & Close
Dr David Lipscomb, SECN

121. 28th February 2018 13th June 2018 19th September 2018 Next events:
Further dates to hold in your diaries
28th February 2018
13th June 2018
19th September 2018