1. Understanding and Demonstrating the benefits of improvement A work in progress!

2. Where do you begin? Quality improvement for the service user Increase percentage of patients receiving this surgery as a day case from 22% to 50% by April 2010 What difference does this make for patients?

3. GP referral Outpt apt No test results Adm Adm night pre- surg surgery No surgery Cancelled theatre Ward stay home LOS TTO variation GP (sick note) Sick note Discharge info Pain meds Lap chole pathway for 97.9% Ninewells’ patients as inpatients Waste to be removed: Repeat outpatient apt Admission pre-surgery Cancelled operations Post-surgery stay Variation in TTOs Variation in sick note/discharge info Understanding and quantifying the waste in the current system

4. Lap chole pathway for 50% post change for Ninewells’ patients as daycase surgery GP referral Outpt apt surgery home Apt for surgery made Arrive on day TTOs Sicknote Discharge letter Waste removed: Repeat outpatient apt Admission pre-surgery Cancelled operations Post-surgery stay Variation in TTOs Variation in sick note/discharge info Map the future state

5. Collecting information from a patient’s notes to understand the waste Number of GP apts When tests were done Number of outpatient apts (grade of Dr they saw) Surgery cancelled or not Length of stay Any complications whilst in hospital Discharge letter or not TTOs – what drugs, length of time Did they have any complications/re-admissions

6. Understanding Cost Cost of GP apt Cost of outpatient apt Cost of medics time Cost of time in ward (overnight stay) Cost of drugs ?Admin costs

7. Summarising the data into cost Is it possible to produce an estimated range of the cost of the waste in the current process? Clear time frame that you are quantifying this waste for: is it over 6months? Things to think about: –range in waste per patient –Variation in waste = variation in cost

8. Understanding the cost of change Time for redesign –Cost of staffing time – how many people will be involved in the redesign work? Parallel processes –Frequently, changing to a new model of service delivery involves running parallel processes for a short period of time New technology implementation?

9. Summary– the start of a framework: Understand the waste in the current pathway Map out pathway Determine how much by when – what are you aiming to achieve? By when? Map out future state Identify waste that you plan to remove from the pathway from comparing the two pathways

10. Summary– the start of a framework: Undertake an audit of a sample of patient notes to collect information about the frequency and variation of waste along the pathway Use this information to determine some ranges of cost in terms of: –Staff time –Financial Cost –Patient time/experience –Extrapolate your costs based on a specific time period and level of activity, including taking into consideration the impact of the change; will it impact on all patients or a % of them?

11. Summary– the start of a framework: Quantify the cost of undertaking the improvement work Build a project plan From the plan, estimate the time commitment for all staff involved Consider any possible costs of running the old and new pathways at the same time: will this happen? How many patients will be going through the old process, how many through the new? For how long? Quantify the cost of any new equipment/IT developments/staff etc Compare the cost of undertaking the work with the cost of the waste in the current system

12. What will be the impact? Quality improvement? Direct cash releasing saving? Increased productivity? Cost avoidance? Resource release, e.g staff time? – what will you do with it? Putting timelines around the savings made through removing the waste, e.g. £x will be saved in y months, £z over £a years.