Consolidation report (2009) - from testing to spread

NHSNHS Improvement

Transforming Inpatient Care Programme

Consolidation Report (2009)From testing to spread

HEART

LUNG

CANCER

DIAGNOSTICS

STROKE

Consolidation Report - From testing to spread | 3

ContentsForeword

Summary

Introduction

25 NHS acute test trusts: Progress, impact and benefits

Reported benefits and investments

Impact of the Winning Principles and Models of Care

Winning Principle 1

Winning Principle 2

Winning Principle 3

Winning Principle 4

Summary: Consolidation of testing

Beyond testing: Coverage and spread

Levers for spread

Conclusion

Acknowledgements and references

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4 | Consolidation Report - From testing to spread

Foreword

Celia Ingham Clark

The NHS has to identify ways to improve both quality and productivity in

order to continue to improve patient care in a tight economic climate.

This report provides significant encouragement that we can achieve the

joint aims of quality and productivity in the care of people with cancer.

It describes a range of ways in which cancer care can be streamlined and

become more patient-centred. The techniques all follow the four

Winning Principles. The report contains details of the spread of these

techniques accompanied by an estimate of the potential savings that

they can deliver in terms of bed-days and costs, and it demonstrates

effective implementation of the Cancer Reform Strategy.

I hope that Trust Medical Directors and Cancer Managers who have not

yet adopted the ‘Winning Principles’ will be motivated to do so on

reading this report. For those who have already delivered some quality

improvements, many of whom are mentioned in the report, the

challenge now is to implement the other improvements too!

Celia Ingham ClarkColorectal Surgeon and Medical Director, Whittington Hospital, London.National Clinical Lead Transforming Inpatient Care Programme

SummaryThe Cancer Reform Strategy (CRS 2007) highlighted the need to focus attention on inpatientcare. Too many patients were being admitted into hospital and lengths of stay were oftenunnecessarily prolonged. The CRS established the Transforming Cancer Inpatient CareProgramme to take this forward and test out ideas that would improve quality and reduceunnecessary inpatient bed days.

This report is the product of a review undertakenby NHS Improvement examining the progress andimpact of 25 Acute Trusts who took part in theTransforming Cancer Inpatient Care Programme(July 2007-2008) and the subsequent spread ofthe Winning Principles and models of care acrossEngland.

The report forms part of NHS Improvementevaluation strategy, and provides evidence ofprogress to the Department of Health CancerProgramme Board supporting the quality,innovation, productivity and prevention(QIPP) agenda.

Achievements of the 25 Acute TrustsThe 25 Acute Trusts incorporates 37 hospital siteswhich covered 16% of acute providers for cancerservices across England. In terms of improvingquality and productivity good progress was madeagainst the baseline position (see Figure 2).

• Through testing the Trusts identified four simplequality principles, published as ‘The WinningPrinciples’ (July 2008); fundamental toimproving emergency and elective pathways,clinical decision-making and enhancing patientself-management.

• Across the Trusts 108,067 potential bed daycapacity was released (Figure 2).

• Based on the lower estimate of £200 perpatient, per bed day, the potential releasedefficiency saving for the 25 trusts was £21.6m.

From testing to spreadThe learning from testing was disseminated widelythroughout the testing period (July 2007-2008) toencourage early adopters. Spreading the WinningPrinciples Strategy was launched in July 2008.Evidence from the subsequent spread survey(December 2009) identified:

• 54 NHS Trusts (covering 72 hospital sites) werespreading the quality principles and models.

• 183 improvement activities have been reported.• The main focus for spread surrounds WinningPrinciples 1 and 2; emergency and elective care,the application of communication alert systems,enhanced recovery approaches, 23 hour breastmodel and symptom specific pathways e.g.febrile neutropenia.

• Coverage increased across England from 16%to 34% of secondary acute providers(see Figure 1).

• The 2008/09 national picture shows that thetotal of bed days peaked at 5.25m in 2005/06.Since then there has been a 15% fall. The‘Spread activity’ contribution to the nationalpicture over the last two years saw a shiftedfrom 2.4% bed capacity released during testingto 34.17% as subsequent spread.

• Nationally, 264,340 bed days were releasedtowards saving a million beds days (2012).Progress is being made but the pace of spreadneeds to be accelerated.

• The four key levers identified by Trusts toaccelerate spread were planning for spread,having communication and awarenessstrategies, identify and the use of opinionleaders and sharing comparative data (seeFigure 24).



Figure 1: What contribution are the 54 Trusts making tothe national picture and the potential impact?

54 Trusts episodes ( emergency/electiveinpatients)

54 Trusts bed days

54 Trusts reduction in length of stay from2007-2008 Year

54 Trusts reduction potential savings inlength of stay from 2007-2008 Year

54 Trusts % contribution bed days towardsnational coverage 2007-2008 Year

298,595

1,750,564

0

£0

0.00%

288,527

1,660,251

90,313

£18,062,600

34.17%

309,657

1,730,149

20,415

£4,082,933

16.03%

2007-2008 2008-2009 2009-2010 Fullyear projection(provisional)

Spread strategylaunchedJuly 2008

The national picture shows that the total bed days peaked at 5.25m in 2005/2006.Since then there has been a 15% fall to around 4.5m.

National Episodes (emergency/electiveinpatients)

National bed days

National reduction in length of stay from2007-2008 Year

National potential savings in length of stayfrom 2007-2008 Year (£200 per patient perbed day lower estimate)

National bed day saving from2007-2008 Year

775,279

4,759,067

0

£0

0.00%

757,494

4,494,727

264,340

£52,868,000

5.55%

807,621

4,631,701

127,366

£25,473,133

2.68%

2007-2008 2008-2009 2009-2010 Fullyear projection(provisional)


Where to next: A focus on spreadRetaining the focus on accelerating the pace ofspread remains a priority.

This review provides a useful baseline upon whichto build the next stage of the TransformingInpatients Spread Strategy (2010-2012). This willinclude:

• Emergency and Urgent Care Initiative led byNHS Improvement. Due to the increasingnumber of emergency admissions, the focusneeds to be retained on spreading WinningPrinciple 1 and the new models of emergencyand urgent care that include:• Triage, Treat, Transfer Pathways• Telephone triage• Crisis resolution teams and integratedcommunity working

• Improved patient signposting to urgentcare settings

• Proactive risk management by telephone toavoid unnecessary admissions

• Communication Alerts• Emergency Care Practitioner assessmentand triage

• Home tele-monitoring - Diagnostics andtesting at home

• Patient ownership of health records andemergency/urgent care plans

• 24 hour pharmacies holding emergency drugbox (for OOH GPs)

• Pain management without hospital admission• Acute Oncology Models

1. Unscheduled (emergency) patientsshould be assessed prior to the decisionto admit. Emergency admission shouldbe the exception not the norm.

The Winning Principles

• Spreading Winning Principle 2, key models:• The 23 hour breast model of ambulatory careacross cancer networks.

• Enhanced Recovery approaches• Shifting procedures from inpatient toalternative care settings.

• Repeating the spread survey during thesummer of 2010 and 2011.

3. Clinical decisions should be madeon a daily basis to promote proactivecase management.

4. Patient and carers need to knowabout their condition and symptomsto encourage self-management and toknow who to contact when needed.

2. All patients should be on a definedinpatient pathways based on theirtumour type and reasons foradmission.

IntroductionThe report draws on 180 pieces of evidence from qualitative and quantitative sources, including;learning diaries, case studies spread planners, local data and a spread survey (October 2009 -December 2009). Hospital Episode Statistics (HES) provided baseline measures (2006/7) andmeasures of progress (2009).

Review objectivesThe objectives of the review were firstly toconsolidate the progress of the 25 testtrusts by:• Examining the progress and quantifyingbenefits, investments and potential reductions inlengths of stay and bed days.

Secondly to:• Assess the coverage, spread of the WinningPrinciples and models

• Provide direction for the next stage of theTransforming Cancer Inpatient Care ProgrammeSpread Strategy.

SpreadThe definition of spread in the context of thisreport has been used as a measure not only ofincreasing numbers but also indicating whichwinning principles and models have been spreador adopted and what local levers are being usedto support this.

Since the commencement of the TransformingInpatient Care Programme 2007, the learninggained has been disseminated nationally(Transforming Care for Cancer Inpatients 2008-2009) and shared with the Department of HealthEnhanced Recovery Partnership Programme (2009)to accelerate the pace of spread; of WinningPrinciple 2 across the NHS.

Continuous ImprovementThere is a danger in a report of this nature, tojudge progress and success on ‘bottom linedeliverables’, particularly at a time whenproductivity and cost savings are high on thehealth agenda. It is therefore important torecognise that the improvements tested involvemany dimensions of change including systems,process redesign, changes in behaviour andclinical and managerial practice. This report isbased on the evidence received which may notreflect all the local variables. In most cases, thespread reported is ongoing and therefore thefindings in this report should be read within thiscontext.


25 NHS acute test trusts: Progress, impactand benefitsAchievementsContinuous incremental progress hasbeen achieved across the 25 testtrusts. The majority of sites achieved areduced length of stay from theoriginal 2006/07 Hospital EpisodeStatistics* baseline position (Figure 2).

• 80% - Reduced length of stayduring the testing period (July2007/08). Releasing 73,582potential bed day capacity

• 80% - Continued to reduce lengthof stay following the testing period

• Overall - 76% reduced length ofstay from the 2006/07 baselineposition, releasing potentially108,067 bed days, which is a 12%reduction from the 2006/07baseline position (Figure 3)

• The contextual information aroundthe trusts where length of stay wasnot reduced or sustained indicatedissues surrounding data collection,improvement work discontinuedand changes in leadership.

*All the HES data used in the review refers to:LoS = HES Length of Episode (Epiend - Epistart).If more than one episode was present in spellthen episode LoS may not equal full spelllength.

All HES data used is retrospective.

HES Baseline Data - April 2006/07 - Used as aretrospective baseline.

HES Testing Data – 2007/08 – Testingcommenced July 2007 to July 2008HES 2008/09 - Spread phase

Figure 2: Average Length of Stay - All Cancers(All episodes emergency and elective inpatients)25 Test Trusts Emergency and Elective Inpatient Cancer AdmissionsAverage LOS 2006/07 Baseline, 2007/08 Testing

1. Barking, Havering and RedbridgeHospitals NHS Trust

2. Barts and The London NHS Trust3. Blackpool, Fylde and Wyre Hospitals NHS

Foundation Trust4. Brighton and Sussex University Hospitals

NHS Trust5. The Christie Hospital NHS Foundation Trust6. East Sussex Hospitals NHS Trust7. Great Western Hospitals NHS Foundation Trust8. Hull and East Yorkshire Hospitals NHS Trust9. King’s College Hospital NHS Foundation Trust10. Milton Keynes Hospital NHS Foundation Trust11. North West London Hospitals NHS Trust12. Northampton General Hospital NHS Trust13. Oxford Radcliffe Hospitals NHS Trust

14. Royal Berkshire NHS Foundation Trust15. Sandwell and West Birmingham Hospitals

NHS Trust16. Scarborough and North East Yorkshire Health

Care NHS Trust17. Sherwood Forest Hospitals NHS

Foundation Trust18. South London Healthcare NHS Trust19. St Helens and Knowsley Hospitals NHS Trust20. The Hillingdon Hospital NHS Trust21. The Whittington Hospital NHS Trust22. United Lincolnshire Hospitals NHS Trust23. University Hospital Birmingham NHS

Foundation Trust24. University Hospitals of Morecambe Bay NHS Trust25.Whipps Cross University Hospital NHS Trust

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Figure 3: Inpatient episodes and bed day data

2006/07Baseline

2007/08Testing

2008/09CommenceSpread

25 Test Trusts

Episodes

Bed days

RangeAverage LOS

144,442

894,417

7.8 - 4.286.9

148,222

859,932

7.57 - 3.975.8

141,650

786,350

6.9 - 3.615.5

108,067Bed day capacityreleased

Hospital Episode Statistics


Review of the qualitative informationidentified common themes aligned tothe current Quality, Innovation,Productivity and Prevention (QIPP)agenda.

QualityKey elements for improving the qualityof patients, and carers, experiencewere identified by the sites as:• Valuing patient’s time• Setting and managing patientsexpectations

• Improving communication andinformation

• Removing duplication, and non-value adding time throughstreamlining the pathway of care.

InnovationChanges in clinical practice such asthe enhanced recovery approachesand 23 hour breast care model:• Improved the knowledge ofoutcomes

• Reduced postoperativecomplications.

This reflects the Varadhanstudy (2010) that indicated theimplementation of four or moreelements of Enhanced Recovery leadsto a reduction in length of stay bymore than two days and an almost50% reduction in complication ratesin patients undergoing major opencolonic/colorectal surgery.

These clinical models use the most upto date surgical and anaesthetictechniques, challenge traditionalpractices and promote themanagement of patientexpectations.

Alert systems have improvedcommunication, reduced length ofstay and in some cases avertedunnecessary admissions and enhancedtimely clinical decision-making.

Productivity and preventionReductions in unnecessary admissionsand reductions in prolonged lengthsof stay can reduce the risk of hospitalacquired infections, reduce demandson staff and releases bed capacity.

Capturing the benefitsHow trusts individually captured thereleased capacity and finances in realterms was a local decision and notcaptured in the review. Feedbackfrom test sites indicated someorganisations utilised the releasedcapacity to achieve the18 week waitand the cancer 62-day target.

InvestmentInvestment during testing varied fromsite to site dependent on trusts,individual starting point and localcapacity and capability. Investmentreported was predominately time,support from clinicians, managementand service improvement and changemanagement expertise. Costsidentified were minimal and oftenoffset by cost savings from reductionin use of unnecessary equipment suchas drains and by re-organisingresources.

Example: Breast 23 Hour CareModelA reduction in wound drains and theintervention of not draining seromas.Saved patients extra visits to thehospital and released clinic time whichwas utilised for breast pre-assessment.

Example: Enhanced RecoveryModelsThe current work of the EnhancedRecovery Partnership Programme hasidentified the potential costs (Figure 4)and investments required to supportimplementation, if organisations havenone of the enhanced recoveryelements in place. Dedicated time,clinical leadership and changemanagement skills are the keyinvestments required.

Figure 4: Enhanced recoverymodel estimated costs per patient(8 major surgical procedures)

Pre-referral

Pre-operative

Admission

Surgery

Post- surgery

Total net cost

£9 - 35

£20 - 82

£4 - 10

£69 -111

£30 - 73

£142 to £311

Department of Health EnhancedRecovery Partnership Programme(2009)


Reported benefits and investments

Testing identified four qualityfocused ‘winning principles’ andpractical models of care.

The Winning PrinciplesWinning Principle 1Unscheduled (emergency) patients should be assessed prior to the decisionto admit. Emergency admission should be the exception not the norm.

Winning Principle 2All patients should be on defined inpatient pathways based on theirtumour type and reasons for admission.

Winning Principle 3Clinical decisions should be made on a daily basis to promote proactivecase management.

Winning Principle 4Patient and carers need to know about their condition and symptoms toencourage self-management and to know who to contact when needed.

www.improvement.nhs.uk/cancer/inpatients

Impact of the Winning Principles and Models of Care

The Transforming Inpatient Programmehas been acknowledged as providingexcellent examples of ‘Quality, Innovationand Productivity in Practice’ (DavidNicholson CEO NHS, 2009), and theTransforming Inpatient publication (2009)Sharing the Learning, was commendedas best professional education initiativein Oncology (Excellence in Oncology2009).


Winning Principle 1

Unscheduled (emergency)patients should beassessed prior to thedecision to admit.Emergency admissionshould be the exceptionnot the norm.

Fifteen trusts tested differentmodels that included definingemergency pathways forsymptoms, palliative care andspecific conditions such asneutropenic sepsis. Trusts tested arange of communication alertsystems and approaches for rapidaccess to timely clinical decisionmaking, which supports WinningPrinciple 3.

Across the 15 test sites, thepotential of 42,147 bed daycapacity (from the baselineposition) was released(Figure 5).

WINNINGPRINCIPLE1

Figure 5: Winning Principle 1 - Baseline and potential impact

2006/07Baseline

2007/08Testing


15 Test Trusts

Episodes

Bed days

Range LOS

95,361

560,516

7.57 - 4.25

96,668

540,418

7.57 - 3.97

96,764

518,371

6.85 - 3.72


The average length of stay for cancerrelated emergency admissionsnationally by PCT is 6.5 days acrossEngland, ranging from 4.1 days to9.0 days. (HES. 2008/09).

• Emergency bed days average 11.3bed days per new cancer case,ranging from 7.1 to 17.7 bed days.

Model of Care: CommunicationAlertsThree trusts tested communicationalert systems across specific tumourgroups. Local data showed that alertsystems had an impact on reducinglength of stay by 25% in sometumour groups (Figures 6 - 9).

Communication alerts weresignificantly effective for patientspreviously diagnosed with canceradmitted as an emergency (SherwoodForest Hospitals NHS FoundationTrust case study 2008). Local dataidentified a number of admissionsaverted, this data is not captured byHES.

Emergency


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NorthamptonGeneral Hospital

NHS Trust

United LincolnshireHospitals NHS Trust

Sherwood ForestHospitals NHS

Foundation Trust

Figure 6: Average Length of Stay: Emergency Lung Inpatients

Figure 7: Communication Alert for Recurring Admissions AcrossTumour Sites - Kings Mill Hospital.

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Comparison of median length of stay for non-elective breast, gynaecological,lower GI and lung patients, pre, during and post implementation of RAPA


Based on local trust data.

HES data.

Figure 8:


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Upper GI Urology Lung

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Average length of stay by known cancer patients readmitted to hospital nonelectively with symptoms related to primary cancer or treatment -United Lincolnshire Hospitals NHS Trust

Figure 9:Average length of stay by known cancer patients readmitted to hospital asemergencies with symptoms related to primary cancer or treatment -Lung - United Lincolnshire Hospitals NHS Trust

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United Lincolnshire Hospitals NHSTrust commenced testing in urologyand upper gastrology and this hasnow spread to lung cancer patientsacross four hospital sites (Figures 8and 9).



United Lincolnshire Hospitals NHS Trust includes Lincoln County Hospital, County HospitalLouth, Grantham and District Hospital and Pilgrim Hospital Boston.

Model of Care: Emergency andSymptom Pathways13 trusts defined emergencypathways and symptom specificpathways. Models of care to improvedaily clinical decision-making(Winning Principle 3), emergencytriage approach to identify thepatients preferred place of care(Figure 10).

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& WyreHospitals

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UniversityHospitalsNHS Trust

ChristieHospital

NHSFoundation

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RoyalBerkshire

NHSFoundation

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St Helensand

KnowsleyHospitalsNHS Trust

TheHillingdonHospital

NHS Trust

TheWhittington

HospitalNHS Trust

UniversityHospitals ofMorcambeBay NHS

Trust

Figure 10: Emergency and Symptom PathwaysAverage Length of Stay All Cancers (All Episodes). Diagnosis = All Admission.Method Group = Emergency. Class of Patient = Ordinary Admission


HES data.

Winning Principle 2

Ten trusts defined electivepathways and models includingthe 23 hour for Breast CareModel, enhanced recoveryapproaches and shifting inpatientprocedures to an ambulatorysetting.

The trusts potentially released67,953 bed days (from thebaseline position) (Figure 11).

WINNINGPRINCIPLE2

Figure 11: Winning Principle 2 - Baseline and potential impact

2006/07Baseline

2007/08Testing


10 Test Trusts

Episodes

Bed days

Range LOS

52,852

358,884

7.81 - 5.08

53,149

344,064

7.36 - 4.97

48,182

290,931

7.07 - 4.79


The average length of stay for cancerrelated elective admissions nationallyby PCT is 7.2 elective bed days pernew case. The range was from 4.9days to 11.5 (HES 2008/09).

Clinical Models of Care: Breast 23Hour Care ModelThe Breast 23 hour care model wassignificantly successful. It started inone trust with one clinician andspread across the Pan BirminghamCancer Network. Clinicians engagedwith the testing following a visit toKings College Hospital NHSFoundation Trust where clinicians hadtested not inserting wound drains.This practice was incorporated intothe 23-hour pathway and formedpart of testing with furtherimprovements in clinical decision-making, clinical practice, design ofthe pathway, pre-assessment,discharge planning and teamworking.

All patients should beon defined inpatientpathways based on theirtumour type and reasonsfor admission. Elective


Pan Birmingham local data (April -December 2009) demonstrates thespread and adoption position of the23 hour breast care model across thecancer network. Figure 12 shows theoverall delivery of wide local excisionsis 94% with 548 patientsexperiencing this pathway approach.Mastectomies are currently at 49%(348 patients) and the approachcontinues to spread.


MastectomyHOSPITAL SITE

April to December 2009 (9 months)

11+ 6 to10 2 to 5 1 0

0% 0% 15% 43% 42%

0% 6% 6% 22% 67%

0% 0% 1% 46% 53%

1% 0% 1% 16% 83%

0% 10% 10% 30% 50%

1% 0% 5% 43% 51%

0% 1% 10% 74% 14%

0% 1% 5% 39% 55%

11+ 6 to10 2 to 5 1 0

2% 5% 51% 37% 5%

0% 13% 31% 31% 25%

5% 10% 25% 56% 5%

0% 4% 16% 52% 29%

0% 27% 55% 9% 9%

9% 12% 43% 30% 6%

1% 6% 54% 36% 3%

3% 9% 39% 38% 10%

94% 49%

Breast Conserving Surgery (wide local excisions)

LENGTH OF STAY (DAYS)

City Hospital provides 94% of all breast surgery within 0 to 1 days.The network achieves a combined total of 74% in 0 to 1 days

Data taken from CBSA and relates to payments made.

Figure 12: 23 Hour Breast Care Model across the Pan Birmingham Cancer Network

Pan Birmingham Cancer Networkoverall delivered the 23 hour breastcare model (at the time of the review)to 74% of all breast surgery patients(excluding reconstructions).

The original test site at the CityHospital now delivers the 23 hourbreast care model to 94% of allbreast surgery patients (excludingreconstructions).

Figure 13: 23 Hour Breast Model - Potential Value for Money

Test sites

Sandwell & WestBirmingham

University HospitalBirmingham

BirminghamHeartlandsHospital

Good HopeHospital

Walsall Hospital

Network Total

Total numberof episodes

473

394

270

156

231

1524

Potential cost savings for breast across the Pan Birmingham Cancer Network

Averagelength ofstay

5.32

4.04

5.19

5.03

3.95

4.70

Inpatientcost at £200per day

503,272

318,352

280,260

156,936

182,490

1,432,560

Day casecost at £250per day

118,250

98,500

67,500

39,000

57,750

381,000

Potentialsavings

385,022

219,852

212,760

117,936

124,740

1,051,560

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Figure 14: Average Length of Stay: Breast Inpatient AdmissionsAcross the West Midlands 15 out of17 PCTs had the lowest averagelength of inpatient stay for breastsurgery (Figure 14).

The future potential of the 23hour Breast Care Model issignificant if spread• National average length of stay forbreast surgery is 2.8 days (HES2009)

• 34,000* new cases are registeredper annum in England.

• 34,000 x 2.8 days = 95,200 beddays. Lower estimate £200 per bedday = £560 per patient.Net cost £19.04m

• 23 Hour Breast Model - 34,000new patients = 34,000 bed days= £6.8m.

*Cancer Registrations in England 2000


Potential savings identifiedThe realisation of these efficiencybenefits across the Pan BirminghamCancer Network was a by-product ofimproving quality. It was locallydetermined how to use the releasedcapacity and capture the efficiencygains (Figure 13).

During testing the figure of £200 perday inpatient bed day is based on thelower estimate of costs used toprovide a baseline figure and toillustrate the potential.


Clinical Models of Care: Enhancedrecovery approachesEnhanced recovery approachestested in colorectal (Figure 15),gynaecology (Figure 16), and urology,reduce length of stay from thebaseline position.

The learning from this testing hasbeen shared with the Department ofHealth Enhanced Recovery Partnershipprogramme.

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Trust/Hospital Site

City HospitalSandwell and West

Birmingham HospitalsNHS Trust

Whipps CrossUniversity Hospital

Whipps Cross UniversityHospital NHS Trust

Queen Mary’s HospitalSouth London

Healthcare NHS Trust

Figure 15: Colorectal Enhanced Recovery - Winning Principle 2Average Length of Stay: Elective Inpatients Lower GI Procedures.(Lower GI Neoplasm. Procedure L1 = Colectomy, Excision of Rectum)

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Queen Elizabeth The Queen Mother HospitalEast Kent Hospitals University

Figure 16: Gynaecology Enhanced Recovery - Winning Principle 2Average Length of Stay: Elective Inpatients Gynaecological Procedures.(Gynaecological Neoplasm. Procedure L1 = Procedure on Uterus)


Model of Care: Shifting carefrom an inpatient settingShifting care to an alternative settingwas tested by Barking Havering andRedbridge Hospital NHS Trust.

The testing focused on shiftingprocedures traditionally carried out inhaematology and oncology inpatientbeds to a day case setting (Figure 17).

The local data in figure 18 illustratesthe potential investment and thevaluing of patients’ time.

Figure 17: Barking, Havering and Redbridge Hospital NHS Trust - Baseline & progress

(Elective Day Care and Inpatients Breast. Gynaecology, Haematology, Head & Neck,Lower GI, Thorax, Upper GI, Urology)


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Barking, Havering and Redbridge NHSTrust is continuing testing andspreading the principles makingimprovements in:

• Direct access for Sickle Cellpatients.

• Further reducing wasted patientstime for some procedures inassessment beds.

• Testing protocols for outpatientmanagement of NeutropenicSepsis.

• Further shifting care to andreducing unnecessary inpatientadmissions.

• Testing whether assessment bedscould be included in the 4-hourbed wait target?

Hickman line insertion

Blood Transfusion

Ascitic Drain

CT Guided Biopsy

US Guided Biopsy

HDR Full Insertion

IV Antibiotics

Total Cost Saving

Average no.of hoursspent asinpatient(baseline data)

Procedure

92

35

76

128

20

24

113

Average no.of hoursspent asday case(baseline data)

Average no.of hourssaved perprocedure

Average costper inpatientprocedure(baseline data basedon £8.30 per hour)

Average costper day case(audit databased on £18.75per hour)

Number ofpatientsthrough dayunit duringaudit

Releasedcost forauditperiod

4.5

7.5

9

6.5

6

7

7.5

87.5

27.5

67

121.5

14

17

105.5

£763.60

£290.50

£630.80

£1062.40

£166.00

£199.20

£937.90

£84.37

£140.62

£168.75

£121.87

£112.50

£131.25

£140.62

5

14

9

6

3

9

2

£3393.15

£2098.32

£4158.45

£5643.18

£160.50

£611.55

£1594.56

£17,659.71

Fig 18: Quantifying the impact and valuing patients time


Model of Care: Parencentesis inthe hospice settingEast Sussex NHS Trust tested avertinginpatient admissions for patients fromthe local hospice that required aparencentesis, and tested this beingundertaken at the hospice. Theconcept was tested successfully, andspread to another site, althoughnumbers of patients are small. Theoutcomes of testing has spread andintegrated into local emergencyimprovement work.

Winning Principle 3

This is not a stand-alone principleas timely clinical decision-makingis a key component integratedwithin all the principles,pathways and models of care.Two trusts, Brighton and SussexUniversity Hospitals NHS Trustand The Whittington HospitalNHS Trust tested this principleacross oncology.

WINNINGPRINCIPLE3

The Whittington HospitalNHS TrustThe local approach was to have theavailability of an acute oncologist andrapid access clinics.

Access to daily clinical decisionmaking has:

• Reduced unnecessary lengths ofstay for new unknown cancers -from 17.1 days to 12.1 days. Areduction of five days forpreviously unknown cancerpatients who were admitted asemergencies compared with theyear before adopting WinningPrinciple 3 for acute oncology.

• Made a reduction in averagelength of stay of 3.7 days forknown cancer patients.

• Significantly decreased the numberof unnecessary tests patientswould have undergone. This valuespatients’ time and improves thepatient experience.

Clinical decisions shouldbe made on a daily basisto promote proactive casemanagement.


Brighton and Sussex UniversityHospitals NHS TrustTested several strategies to maximisetimely clinical decision-making whichincluded improved communicationsbetween clinical teams, weekly MDTward discussions, Daily paper reviewof inpatients including outliers,admission priority assessment andagreed pathway trigger points toavoid discharge delays.

Evidence relating to surgical, medicaland haematology daily clinicaldecision making appears to be wellestablished and built into consultantjob plans. This does not appear to bethe case in oncology. Furtherevidence may emerge in this areafrom the National ChemotherapyImplementation Group.

Winning Principle 4

WINNINGPRINCIPLE4

Patient and carers need toknow about their conditionand symptoms to encourageself-management and toknow who to contactwhen needed.

As part of the testing, all sites wereencouraged to engage patients inpromoting self-care. Variousapproaches were used during thetesting including patient education,information, production of a DVD andtelephone help lines as central contactpoints. The view from the reviewteam was that testing had notdemonstrated or captured ‘real self-management’ and only a few siteshad been able to quantify the impactof the interventions during testing. Itappeared that once implemented orproducts produced the capture ofimpact data/audit was discontinued,although patient satisfaction auditscontinue.

We know that patients are receivinginformation and that for example,Blackpool, Fylde and Wyre NHSFoundation Trust has distributed aDVD to over 500 patients across thecancer network. The DVD is given topatients on chemotherapy, helpingthem to identify the signs andsymptoms of neutropenic sepsis. TheDVD has been acknowledged as goodpractice and has been adopted byother areas.

There will be the opportunity tocapture more information from theNational Patient Survey regardinginpatient care and with the newemergency initiative this will providethe opportunity to focus on somespecific areas of self-caremanagement.


The patient’s stories in theDVD are very powerful andmake much more impact onother patients and carersabout the importance ofpresenting early.Lead cancer nurse

“”

This DVD is a good idea.Verbal information andleaflets don’t really sink inbecause it’s such a difficulttime. You can’t take it all in,it’s a bit too much, but I thinkthe DVD will stick in people’sminds.

“

”Husband of a patient

Summary: Consolidation of testingThe 25 test sites provided evidence ofprogress, potential impact and theongoing implementation of thewinning principles and models of carethat improve quality of the patientexperience and productivity. Theprogress reported here demonstratesthat test trusts have moved frominitial testing and that improvementcontinues. The quantitative figureshowever should not be judged inisolation of the organisational contextand complexities of change involved.


4 10 26

2 6 16

1 9 17

4 6 9

1 18

8 12 26

3 6 8

1 2 13

2 2 14

8

*Does not include Children, Mental Health, Eyes, Orthopaedics, Heart/Chest, and Rheumatic Diseases.

Beyond testing: Coverage and spreadSince the commencement of theTransforming Inpatient CareProgramme 2007, the learning hasbeen widely shared and disseminatednationally as part of the spreadstrategy (Transforming Care for CancerInpatient Publications, 2008, 2009.Annual Conference 2008, 2009).


Figure 19: Beyond testing - coverage and spread map

155 Potential Acute SecondaryCare Provider Trusts*

25 Test Trusts (covering 37hospital sites)

December 2009 - 54 Trusts(covering 72 hospital sites)

Expansion and coverage beyond the 25 test sitesSpread is evident across England, going beyond the 25 test trusts (Figure 19), with34% of the potential acute secondary providers indicating they are involved inspreading the quality Winning Principles and Models of Care. This provides auseful baseline position of coverage.

EmergencyPathways

SHA NeutropenicSepsis

EnhancedRecovery

23 HourBreast

ShiftingProcedures

Figure 20: Spread and adoption activity by SHA

East Midlands

East of England

London

North West

South Central

South East Coast

South West

West Midlands

Yorkshire & the Humber

North East

CommunicationAlerts

Clinical DecisionMaking

SelfManagement

Spread activityIn some areas, to accelerate the paceof spread, the tested models of carehave been identified as a healthcommunity priority and brought in aspart of local commissioning for qualityand innovation framework qualityaccounts (CQuINS).


Spread SurveyDecember 2009 - January 2010

Number of Hospital Sites

0 5 10 15 20 25 30

Communications Alert Systems - Winning Principle 1

Emergency Pathways - Winning Principle 1

Palliative Care Pathways - Winning Principle 1

23 Hour Breast Care Surgical Model - Winning Principle 2

Enhanced Recovery Pathway - Winning Principle 2

Patient Transfers/Repatriation - Winning Principle 2

Shifting Procedures from Inpatients to Day Care - Winning Principle 2

Carcinoma of Unknown Primary - Winning Principle 2

Clinical Decision Making - Winning Principle 3

Neutropenic Sepsis - Winning Principle 1 & 4

23 Hour Helpline - Winning Principle 4

Acute Oncology Model - Winning Principle 1 & 3

Figure 21: Extent of spread


Figure 21 highlights which quality Winning Principle is being adopted and spread.

• 72 hospital sites are activelyspreading the improvements. Somesites are embarking on more thanone improvement activity.

• From the evidence reviewed(December 2009) - there arecurrently 183 improvement activitiessupporting spread across England.

Good ideas and innovations arespreading and being adopted byorganisations, clinicians and managersacross England with quality as thekey driver.

35

30

25

20

15

10

5

0

Nu

mb

ero

fPa

tien

ts

ImplementationPlan

Use of OpinionLeaders

Benchmarking PatientGroups

CommissioningAgreements

NoneCommunications& Awareness

SharedComparative Data

Figure 24: Reported levers for spreadDecember 2009

When comparing the reported leversof spread (Figure 24) against theTransforming Inpatient Framework,seven of the elements have beenidentified. Figure 23 highlights theseelements.


Levers for spread

Fig 22: The Transforming InpatientFramework for Spread

SpreadMaking theConnections

A Visionfor QualityImprovement Systematic

ImprovementApproach

OrganisationalCultureand Fit

SpreadSimple

Principles &Messages

LeadershipEngagementAccountability

Alignmentwith

Opportunities& LeversPatient

Centred

Learning& Unlearning

CollaborationPartnerships& TeamWorking

ContinuousMonitoringProgress &Impact

LinkedStrategic &OperationalChange

SpreadStrategy

The learning from the TransformingCancer Inpatient Care Programmeremains practically based as it drawson real experiences and the challengesof taking a good idea and spreading itfurther to benefit more patients. Thelearning from the test sites has beenused to develop a TransformingInpatient Framework for Spread(2009); Driver (2008); Williamson(2007); (Figure 22). The framework isa tool to help support otherorganisations and teams in their questto spread good quality innovations.

(NHS Improvement 2009)

Figure 23: Sites identifying seven elements of theTransforming Inpatient Framework for Spread

SpreadMaking theConnections

A Visionfor QualityImprovement Systematic

ImprovementApproach

OrganisationalCultureand Fit

SpreadSimple

Principles &Messages

LeadershipEngagementAccountability

Alignmentwith

Opportunities& LeversPatient

Centred

Learning& Unlearning

CollaborationPartnerships& TeamWorking

ContinuousMonitoringProgress &Impact

LinkedStrategic &OperationalChange

SpreadStrategy


ConclusionFrom testing to spreadThe review has shown that theTransforming Inpatient CareProgramme continues to makeprogress. Spreading and encouragingadoption and adaption of the winningprinciples and new models of careacross England, but there is still moreto be done and the pace needs to beaccelerated.

The new levers supporting spreadsuch as QIPP, GP commissioning and apatient led NHS will support the drivefor change and further adoption ofgood practice.

Spread and adoption is not easy andrequires a multi-level of methods,levers and factors to create, inspireand connect to people, organisationsand within the nature of the currenthealth landscape. The programme willcontinue to support spread anddisseminate the practical learningacross the NHS to benefit all patients.


Acknowledgements and referencesAcknowledgements

Transforming Inpatient CareProgramme Test Sites

Professor Sir Mike RichardsNational Director for Cancer andEnd of Life Care, National CancerAction Team

Celia Ingham ClarkNational Clinical Lead and Chair ofTransforming Inpatient CareProgramme

NATCANSAT (National CancerServices Analysis Team) with aspecial thanks to Neal Jones

Thank you to the organisationswho responded to the spreadsurvey.

Enhanced Recovery PartnershipProgramme

References

NHS Improvement - TransformingInpatient Care ProgrammeAn integrated approach - Thetransferability of the WinningPrinciples - Sharing the learning(July 2010)

NHS Improvement - TransformingInpatient Care ProgrammeFrom Testing to Spread - Sharing theknowledge and learning fromorganisations spreading the WinningPrinciples (July 2010)

NHS Improvement - TransformingCare for Cancer Patients: Spreadingthe Winning Principles and GoodPractice (July 2009)

NHS Improvement – TransformingInpatient Case Studies (July 2009)

NHS Cancer Reform Strategy (2009) -Achieving Local Implementation -second annual report

NHS Improvement - Meeting thechallenge together... delivering care inthe most appropriate setting (October2008)

NHS Improvement - The WinningPrinciples: Transforming Inpatient CareProgramme for Cancer Patients (July2008)

Letter from David Nicholson CBE ,NHS Chief Executive. Implementingthe Next Stage Review visions: thequality and productivity challenge(Gateway ref: 12396)

Department of Health, EnhancedRecovery Partnership Programme:Delivering Enhanced Recovery:Helping patients to get better soonerafter surgery (2010)

National Chemotherapy AdvisoryGroup Guidance (August 2009).National Cancer Action Team.

Driver A. (2008). Factors effectingachievement of cancer waiting timetargets in NHS Trusts; an exploratorystudy. Unpublished thesis, DoctorateProfessional Studies in Health;Middlesex University, London

Williamson J. (2007). The criticalfactors for whole system change of aclinical specialty identified through theCancer Services Collaborative‘Improvement Partnership’.Unpublished thesis, DoctorateProfessional Studies in Health;

Middlesex University, London

Cancer Reform Strategy 2007

Excellence in Oncology Awards 2009 -British Oncology Association

NHS Improvement websitewww.improvement.nhs.uk

Krishna K Varadhana, Keith R. Nealb,Cornelius H.C. Dejongc, Kenneth C.H.Fearond, Olle Ljungqviste, Dileep N.Loboa.

The enhanced recovery after surgery(ERAS) pathway for patientsundergoing major elective opencolorectal surgery. A meta-analysis ofrandomised controlled trials.

Key contacts

Ann [email protected]

Angie RobinsonNational Improvement [email protected]

Marie TarpleeNational Improvement [email protected]

Catherine [email protected]

3rd Floor | St John’s House | East Street | Leicester | LE1 6NB

Telephone: 0116 222 5184 | Fax: 0116 222 5101

www.improvement.nhs.uk

NHS Improvement

With over ten years practical service improvement experience in cancer,diagnostics and heart, NHS Improvement aims to achieve sustainableeffective pathways and systems, share improvement resources andlearning, increase impact and ensure value for money to improve theefficiency and quality of NHS services.

Working with clinical networks and NHS organisations across England,NHS Improvement helps to transform, deliver and build sustainableimprovements across the entire pathway of care in cancer, diagnostics,heart, lung and stroke services.

Delivering tomorrow’simprovement agendafor the NHS

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Consolidation report (2009) - from testing to spread

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