From testing to spread: Sharing the knowledge and learning from organisations spreading the winning...

NHSNHS Improvement

Transforming Inpatient Care Programme

From testing to spread:Sharing the knowledge and learning fromorganisations spreading the WinningPrinciples - case studies

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CANCER

DIAGNOSTICS

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Contents

Introduction 3

Winning Principle 1

Electronic alerts for emergency admissions: How the learningwas spread from Sherwood Forest Hospitals NHS FoundationTrust and United Lincolnshire Hospitals NHS Trust 4

Emergency admissions, the exception rather than the norm 9

Patient Electronic Alert to Key-worker System (PEAKS) 14

Pan Birmingham Network wide spread of neutropenicsepsis pathway improvements 16

Commissioning and cost benefits of acute oncology:Supporting spread across the Anglia Cancer Network 19

Winning Principle 2

Spreading the enhanced recovery principles in patientsundergoing colorectal, liver and upper GI surgery 21

Shifting care and reducing length of stay: Ambulatorycare beds in the haematology inpatient ward 23

Adopting the 23 hour model for mastectomy patients 24

Enhanced Recovery Programme (ERP): Integratedcare pathway for elective colorectal surgery 27

Spreading Enhanced Recovery from one testproject to a network wide programme 29

Delivering care in appropriate settings 34

Enhanced Recovery: Colorectal cancer 36

Breast inpatient care: Valuing patient time 38

Winning Principle 3

Protocol for patients admitted with clinical diagnosis of malignantbowel obstruction secondary to gynaecological cancer 39

Winning Principle 4

The ‘FAB’ Programme: Fatigue, anxiety breathlessnessprogramme for patients with lung cancer and their carers 42

Acknowledgements and references 46

From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles | 3

Introduction

There has been good progress intransforming cancer inpatient care. Moreorganisations and clinical teams are adoptingthe Winning Principles and adapting the newmodels of care, but there is still more to bedone and the pace of spread needs to beaccelerated (Consolidation Report: From Testingto Spread (2009) - published July 2010).

The new levers supporting spread such as Quality,Innovation, Productivity and Prevention (QIPP),GP commissioning and a patient led NHS willcontinue to support the drive for improvementand encourage further adoption of good practice.The recent revised Operating Framework(2010/11) highlighted the importance to continueto deliver improvements in access and quality for

patients with cancer or its symptoms, and tobe seen by the right person, with appropriateexpertise. The Winning Principles underpinthese improvements.

Spread and adoption is not easy and requiresusing a multi-level of methods, levers and factorsto create, inspire and make the connections withpeople and organisations within the currentnature of the changing health landscape. Thespread case studies within this publicationillustrate many of these factors and provide anopportunity for sharing ‘working’ knowledge andlearning experiences with the intention topromote further spread, adoption and actionof good practice across the country and benefitmore patients.

1. Unscheduled (emergency) patients should be assessed prior to the decision to admit.Emergency admission should be the exception not the norm.

The Winning Principles

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

4. Patient and carers need to know about their condition and symptoms to encourageself-management and to know who to contact when needed.

2. All patients should be on a defined inpatient pathways based on their tumour typeand reasons for admission.

4 | From testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles

Electronic alerts for emergency admissions:How the learning was spread from Sherwood Forest HospitalsNHS Foundation Trust and United Lincolnshire Hospitals NHS Trust

Sandwell and West Birmingham Hospitals NHS Trust

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

WINNINGPRINCIPLE1

BackgroundThe colorectal team at Sandwell andWest Birmingham Hospitals NHS Trust(SWBH) and the Pan BirminghamCancer Network (PBCN) have beenworking to improve patientexperience, outcomes and reducelength of stay (LOS) for emergencyadmissions of colorectal cancerpatients.

Baseline data collection demonstratedthat SWBH colorectal services mirroredthe national landscape. The servicehad the largest number of emergencybed days and longest average LOSwhen compared with all other tumoursites at the trust.

For the period 2007-2008 the figureshighlighted that 64% of all bed days(3975) followed an emergencyadmittance. A simple trend indicatesthat by 2010 emergency bed days willaccount for 70% of colorectalinpatient spells. At Sandwell GeneralHospital (SGH) and City Hospital (City)almost 55% of emergency admissionsended without a specific surgicalintervention (surgery, invasivediagnostics, or an invasive procedure).

It was important to place the baselinedata into an operational context, thethree years of data was analysed andused to identify a cohort of 250patients for a review of the healthcarerecords (notes review). The review wasdesigned to record patient journeyfrom arrival at A&E through todischarge noting any interactions ordiagnostics of significance.Interactions include those by AlliedHealth Professionals (AHP) andspecialist services but exclude wardrounds and observations where nofurther actions or decisions weremade. The review also investigated ifadmitted patients were brought to theattention of the Clinical NurseSpecialist (CNS) or multidisciplinaryteam (MDT) during each stay and ifany provisional discharge dates weredecided as part of the patientsrecorded management plan. Thenotes review validated the findings ofthe Hospital Episodes Statistics (HES)data review.

The notes review covered 20% ofcolorectal cancer emergencyadmissions for a two year period andprovided context and granularity to

the benchmark data. It appeared thatpatients were not under the care ofcolorectal MDT members orinteracting with the colorectal CNSfollowing an emergency admissionand this required further investigation.

The wider MDT is used to identifyhealthcare professionals who wouldbe reasonably expected to be involvedin patients with colorectal cancer. Foran analysis of Finished ConsultantEpisodes (FCE) as well as colorectalsurgeons clinicians from thespecialities of upper GI surgery,gastroenterology, medical and clinicaloncology were also included. An FCEis only recorded when a patient ispassed into the care of a consultantand will not identify any discussionbetween colleagues concerningpatients but as the HES data has onlypatients with colorectal cancerrecorded in their diagnosis theexpectation is that the majority ofpatients have an FCE with a memberof the wider MDT.

At SGH, 224 of 380 patients admittedas colorectal emergencies did notinteract with a member of the widerMDT. If patients with a short stay ofup to four days are excluded (84) thatleaves 160 (70%) patients with a stayof five days and greater who have notseen a member of the wider MDT.

At City, 60 of the182 patientsadmitted as colorectal emergenciesdid not interact with a member of thewider MDT. Excluding short staypatients (30) leaves 30 (50%) patientswith a stay of five days and greaterwho have not seen a member of the

CFrom testing to spread: Sharing the knowledge and learning from organisations spreading the Winning Principles | 5

wider MDT. At City there were 29stays of 16 days and greater that didnot have any interaction from thewider MDT until at least day six.

The wider MDT interactions werecomparable with the interactionsabstracted from the notes reviewwere, for instance, documentedCNS attendance is 18%.

The data also demonstrated that justover 50% of patients admitted as anemergency did not have a procedureor intervention that could be codedwith OPCS4 and that half of patientsadmitted presented with symptoms ofabdominal pain, nausea and vomiting.

A report was presented to thecolorectal team, cancer services andcancer operational team, summarisingthe findings with a data appendixcontaining in depth analysis of ICD10codes, FCEs, co-morbidity etc as awhole trust and by individual site (Cityand SGH). Following discussions withthe clinical director, management, theclinical team and the CNS’s it wasagreed that the emergency pathwaywould benefit from serviceimprovement and that PBCN wouldprovide a service improvementfacilitator (SIF) to support this work.

Delays to progressThe service improvement work hadbeen authorised but the colorectalservice at SWBH were in a transitionalstate with a reconfiguration exerciseto integrate the service on a singlesite, adoption of bowel screening andtaking on the care of gynae-oncologysingle and dual stoma patients. Inaddition, the long standing ClinicalDirector was stepping down and itwas uncertain who would be hisreplacement and the SGH site wasdeveloping a fast track electivepathway whilst City wereimplementing enhanced recovery.Service improvement methodologies

were suggested and attempted onseveral occasions but it became clearthat the opening steps of anyimprovement ideas would have to besmall and local until some of thetransitional issues had resolvedthemselves.

The City CNSs had reviewed thefindings and the graphicalrepresentations of the patients timespent in hospital. They commented onthe fact that sometimes they wereonly aware of a patients admittance ifthey saw them on the ward or arelative phoned.

Patients seen Patients not seen

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Healthcare Role

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CNS Physiotherapist Dietician SocialServices

PainManagement

OutreachTeam

PalliativeCare Team

CaseManager

DischargeLiaison

US/MRI/CT/XR

Emergency Admissions - Health Record Audit - Health Care Role Interactions

1. Pain and vomiting (50%)2. Acute abdomen obstruction (4%)3. Anaemia (4%)4. Bleeding (10%)5. Constipation and diestension (1%)6. Deep vein thrombosis (3%)7. Generally unwell (9%)

8. Other (15%)9. Temperature >36C (1%)10. Temperature >38C (3%)11. Pain and vomiting 13%)12. Vomiting (10%)13. Pain (27%)

1

23

4

6

7

8109

5 1112

13

Emergency Admissions - Presenting symptoms


They also recognised that the datashowed that once they were involvedin a patient’s care that patientjourneys became more ordered andthe patient was brought to theattention of the wider MDT andreceived the appropriate clinical careand referrals to allied healthprofessionals (AHPs).

The CNSs felt that if they were madeaware of a patient being admittedthat they could visit the patient earlierand bring there skills and expertise tobear in addition to the reassurancethat having a known face (keyworker)visiting the patient would bring. TheService Improvement Facilitator (SIF)shared the learning gained fromSherwood Forest Hospitals NHSFoundation Trust and UnitedLincolnshire Hospitals NHS Trust ofhow successful their emergencycommunication alert system had beenand the CNSs agreed that if a localsolution could be found they wereprepared to test it.

On contacting the SWBH electronicpatient record development team theSIF found that a similar system wasbeing used by the infection controlteam and with a little re-designing foroperational fit e-mails and textmessages could be sent to asmartphone when a known colorectalcancer patient was admitted.

On 14 September 2009, an electronicemergency alert test cycle wascommenced at City Hospital toascertain if early CNS attendance andintervention would have an impact onpatient LOS using the model.

Using data for the period April 2007 -May 2009 and City MDT lists eachmonth there was circa 650 knowncolorectal cancer patients who wouldpotentially trigger an alert for A&Eattendance or and inpatientadmittance. Additions were alsoadded following each MDT.

The alert system utilised the existingLorenzo IPM interface and the HealthCare Professional flag on the patientPDS screen. Other than internalinterface team time there were noadditional costs associated with the ITinterface.

ImpactThe baseline data from April 2007 toMarch 2009 identified 243 emergencyadmissions with a median LOS of 13days and a mean LOS of 20 days

The team were hoping that they couldreduce median LOS from 13 days to11 and aim for CNS contact with 70%of patients.

Test cycle preliminary resultsThe results reflect the patientpopulation of City Hospital who aregenerally in a fitter state than those ofSandwell. There has been areconfiguration of the colorectalservice with the majority of surgerymoving to Sandwell.

Alerts in total 45Alerts perceived to be colorectal 19Actual colorectal related alerts 16

The median and mean LOS for the 19patients who could reasonably expectto be colorectal emergency the LOSare as follows:

Mean 3.2 and Median1 with CNSattendance 68%.

(Caveat this is a small data set and forCity only patients but the mean issuggestive in relation to the increasedCNS attendance).

As well as the overall reduction inmedian LOS there was also asignificant increase in the percentageof patients who stayed in hospital for0 to 5 days to 79%. The increase inCNS attendance may explain this shiftas there are examples of potentialadmissions to the wards being shiftedto the Surgical Admission Unit (SAU)for washouts, enemas and outpatientappointments which resulted in thepatients leaving hospital in less thanfour hours. Attendance of a knownpatient with a fractured femurhighlighted two missed follow up CTscans for which outpatient appointshave been made.

It also appears that early CNSresponse provides the junior doctorswith a colleague who has a clinicalknowledge of the patient and thismay stop diagnostics test andunnecessary treatment beingundertaken.

Mail/SMS alertsent to CNSwhen patientarrives in A&Eor ward

CNS attendspatient toresolvecolorectalissues

Speedydischarge forpatient

Patientreceivestimelytreatment

Electronic Emergency Alert Model


As the colorectal team had movedthrough their transitional phase theseindicative test cycle results helpedwith the consolidation of the projectboard and a commitment to testelectronic emergency alertsconcurrently on both sites for sixmonths with the final three monthsbeing used to test the impact of CNSfacilitated discharge.

The second stage of the test cycle wasdue to start in March 2010 when itwas intended that an additional CNSwould commence in post.

Unfortunately, the new CNS will notbe in post until after June 2010 andthat has delayed the test cycle startdate.

Emergency alerts: Internalspread at SWBHUpper GIIn April 2010, when it became clearthat there were delays in the secondcolorectal test cycle it opened awindow of opportunity to offeremergency alerts to the upper GIteam. The CNS were alreadyexperiencing difficulty with knowingwhen their patients were admitted.The preliminary results meant that theupper GI CNS could test theopportunities this system offeredthem. The SIF added the flags to thesystem from ongoing MDT outcomesand on the 1 May 2010 a test cyclebegan. The upper GI CNS have readyaccess to emails throughout the dayso preferred not to use a smart phone.

What is the impact of theincremental spreadThe emergency alert flags for UpperGI have been populated using theMDT outcomes from April 2010 andeven with a small alert populationduring the period the 1 May 2010 to10 June 2006 they have receivedseven emergency alerts for patientsadmitted as an emergency.

Off those seven alerts, three patientsare still inpatients. However, theresults have been very encouragingand match those of the trial with Citycolorectal patients and the Upper GICNS confirmed the following.

Extract of Emergency Alerts - Upper GI


These are early results and theexpected LOS represents best clinicalexperience as baseline data is stillbeing validated and analysed.

As encouraging as the preliminarydata is, it is as encouraging that theCNS has found the alerts very useful.In the past they would have beenunaware of these patient admissionsand they are conscious that many oftheir patients are on palliative careplans more suited to management attheir place of choice, mostly theirhome. They have used the alerts toproactively manage the patientpathways to ensure that patientsspend the minimum time in an acutesetting receiving the most appropriatetreatment and medicines usingoutpatient services for urgent referralswhere required.

Haematology and oncologyThe haematology and oncology teamwere looking for a solution to thechallenges of identification of patientswho were admitted with potentialneutropenic sepsis and delivery of theone hour ‘door to needle’ time.Flagging the patients has beenrelatively easy but the alert has had tobe tailored to prevent false positives.For chemotherapy patients the alert isonly sent if it is an A&E or EmergencyAdmission Unit (EAU) admission.

The alert however was only part ofthe solution and it requires theemergency admissions team to receiverefresher training and to adopt theHEAT campaign. In addition juniordoctors on rotation and induction alsorequire specific training.

It is expected that in late June 2010,the Neutropenic Sepsis Alerts will golive to support the delivery ofantibiotics within one hour ofpresenting at the trust.

Incremental spread – What hasbeen learned?It was challenging to engage andkeep momentum with the colorectalservices but once the serviceimprovement project was authorisedand a clear need to alert the CNS hadbeen identified the Winning Principlescase studies provided a documentedsolution that could be shared with theteam and adapt to work locally.

It is useful to have the ColorectalProject Board structure as it hasdelivered the implementation ofelectronic emergency alerts and asword gets around the Trust otherteams are willing to accept theconcept knowing that it has beenaccepted clinically by their peers.

The teams that you work with need tobe aware of the value ofbenchmarked data and aim for a localmeasurable target that can beassessed against the benchmarkeddata.

It is important to let the various teamsfind an operational fit for their ownservice and needs and if its successfulthe message will spread and the rollout will follow.

Ownership is key to spreading thelearning. The colorectal CNS arespreading the message across thenetwork with other cancer nursesthrough presentations and by wordof mouth.

The spread still continuesThe chemotherapy unit manager fromCity Hospital has enquired how shecould set up her own alert system toensure patients on activechemotherapy who are admitted aselective inpatients for all diseasegroups don’t have their carecompromised.

Cancer services at SWBH will approvethe roll out of electronic emergencyalerts to all tumour groups if the datafrom haematology and oncology,upper GI and colorectal candemonstrate a reduction in LOS,readmissions and unnecessary testsand diagnostics.


Emergency admissions, the exceptionrather than the norm

Cambridge University Hospitals NHS Foundation Trust


BackgroundCambridge University Hospitals NHSFoundation Trust (CUHFT) is a largeteaching hospital located in SouthCambridge. The hospital has acatchment population of 500,000 butas a specialist tertiary centre serves awider patient group. Currently, CUHFThas 1,188 beds accommodating65,000 inpatient admissions eachyear. Expansion plans for the trustover the next 20 years will see thecapacity for clinical services increase insize by 50%. The hospital has anaverage length of stay of 5.4 days andcurrently runs at an average capacityof 97%, both these figures are higherthan the recommended nationalaverages and the local standards thetrust are aiming for of; 3.4 days and85% capacity respectively.

In the March 2009, the Anglia CancerNetwork (ACN) provided funding for aService Improvement Facilitator postat CUHFT. The post was established tosupport CUHFTs inclusion in theTransforming Inpatients programmebeing led by NHS Improvement.

Strategic contexts warranting CUHFTdesire to be involved with theprogramme:

National drivers• Cancer Reform Strategy - 20%reduction in cancer inpatient beddays for each SHA

• Our Health, Our Care, Our Say –Patient choice and care closer tohome

• National End of Life Care Strategy –Advanced care planning andavoidance of inappropriate inpatientadmissions

• Chemotherapy Services in England:Ensuring Quality and Safety (NCAG)– Acute Oncology Service

• The Quality and ProductivityChallenge – which asks: Howquality of care can be improvedwhilst also improving productivity.

Local drivers• Towards the best, together – East ofEngland SHA ten year strategy

• CUHFT Effective Patient Careprogramme – reducing length ofstay

• CUHFT Trust Values – Kind, Safe andExcellent

• CUHFT Releasing Capacity – strivingto reduce emergency departmentand inpatient capacity.

Problems identifiedHigh frequency of emergencyadmission of cancer patients toCUHFT and the corresponding impacton bed days meant initialinvestigations and testing was focusedaround Winning Principle 1 –assessment prior to admission. AsCUHFT has 69 inpatient beds withinits cancer division, it was felt that itwould be appropriate to look first atthe emergency pathways (seepathway diagram) into this divisionand see whether any serviceimprovements could be applied hereto make emergency admission theexception for these patients ratherthan the norm.

22,000 patients with a diagnosis of cancer attended CUHFT6,100 inpatient admissions (38,300 bed days)3,100 emergency inpatient admissions (28,000 bed days)

14,500 patients attended the cancer division2,350 inpatient admissions (15,835 bed days)1,600 emergency inpatient admissions (12,160 bed days)

Trust-widestatistics

Cancer divisionstatistics

CUHFT Cancer Patient Statistics (February 2008 – January 2009)


Baseline dataTo understand the current assessmentprocesses for emergency admissionpatients admitted to the cancerdivision, The CUHFT TransformingInpatient Cancer Care project teamconducted:• High level data analysis usingPAS data

• Retrospective clinical notes audit• Patient satisfaction/experiencequestionnaire

• Staff interviews and serviceevaluation questionnaire.

The outcome of emergencyattendance, i.e. admission ordischarge following assessment, variesdepending on what route in to thehospital the patient has taken. Thosepatients who go directly to the wardor to the Emergency Department (ED)for an assessment have a 95% chanceof admission after assessment,compared to those who wereassessed in either of the day unitswho have a 45% chance of admissionfollowing assessment. Except for asmall number of very poorly patientswho attended the ED, there was noobvious difference in the acuity of thepatients who came through thedifferent emergency routes.

Retrospective clinical notes auditA clinical notes audit was undertakenon 51/147 emergency admissions tothe Cancer division in January 2009,and showed the following:

• Documentation is poor and difficultto track route from initial referral toassessment to admission

• 25% of emergency admissionscould have been planned for orpredicted

• 33% of the patients could havebeen cared for elsewhere (i.e. in thecommunity, hospice or districtgeneral hospital)

• 30% of patients admitted were intheir last month of life.

Patient satisfaction and experiencequestionnaire274 questionnaires were sent out topatients who experienced anemergency attendance / admission tothe cancer division betweenNovember 2008 – February 2009; wereceived 103 responses, 31 of thesepatients went through the ED and 73via the other emergency routes, andshowed the following:

• Patients want more informationaround symptom management athome, what to expect and who tocontact in an emergency

• 70 patients had a specific contactnumber to ring in an emergency;within this, there were 21 differentpeople/places

• High level of reliance remains withthe GP as first point of contact in anemergency

• Patients who attended a specialistarea for assessment were moresatisfied with their experience thanthose admitted via other routes.

Staff service evaluationinterviews and surveyStaff interviews were carried out witha wide range of multi-disciplinaryprofessionals who may be involved inthe emergency admission pathway forpatients admitted in to the cancerdivision. To compliment theinterviews, two short surveys weresent out to staff working the in the EDand cancer division, and showed thefollowing:

• Slow response times of Cancerspecialists to the ED

• Lack of resources to carry outthorough assessments

• Too many emergency routes in tothe hospital for patients admitted tothe cancer division

• Professionals making decision toadmit tend to be recently qualifieddoctors with limited experience ofassessment and risk aversiveattitude to avoiding admission

• Admitting patients appears to beeasier than considering alternativesto admission.

ObjectivesFrom the information we discoveredthrough our comprehensive baselineanalysis, we set the followingobjectives:• Reduce unnecessary emergencyadmissions

• Reduce number of pathwayscurrently used by patients admittedin to the cancer division

• Improve patient experience• Have a reliable single point ofcontact to be used for advice bypatients and professionals

• Improve recording of information• Embed a culture that viewsemergency admission as a lastresort.

Accounting for % of admissions

30%

25%

15%

10%

10%

10%

Referral source

1. Self referral / Direct to ward

2. Emergency Department

3. GP referral

4. Outpatient Clinic

5. Oncology / Haematology Day Unit

6. Inter-hospital transfer

Data Analysis (February 2008 – January 2009)


Models for testingThe results from the base liningprocess were presented to amultidisciplinary steering group, whichincluded both CUHFT staff andexternal professionals. Internal staffincluded; consultants, specialistregistrars and senior nurses from theemergency department, oncologyteam, haematology team andpalliative care team and there wasinternal administrative representationfrom the associate director andoperational manager of the cancerdivision. External staff invited on tothe group included the NHSimprovement lead, lead commissionerfrom the PCT, a local GP, andrepresentatives from the cancernetwork.

The steering group considered thevarious themes identified from thebase line work and decided to testthree service improvement initiatives:i) Cancer Assessment Unit (CAU)ii) Single Point of Contact (SPC)iii) Electronic telephone triage system.

NB: During the five weeks preparationbefore the pilot it was felt that ii) andiii) would be more appropriate if theywere combined into one work stream.By time of launching the pilot theelectronic telephone triage system hadnot been developed; however a newelectronic method of recordingtelephone advice was introduced tosupport those staff managing thesingle point of contact.

Cancer Assessment UnitThe CAU was located in a fourbedded bay and staffed by anOncology Specialist Registrar, twoOncology Clinical Nurse Specialistsand one Haematology Clinical NurseSpecialist. The pilot ran for two weeksand the assessment unit was openMonday to Friday 08:00-17:00. Staffin the assessment unit also mannedthe SPC and there was one SPC forOncology and one SPC forHaematology.

All areas within CUHFT which wereidentified as taking calls from patientsor professionals seeking specialistcancer advice were given the bleepnumbers for the SPC and were told todivert all calls during the two weeks tothe professionals carrying thesebleeps. Advice given to patients wererecorded on the electronic telephonerecord form which was then faxed tothe patients GP.

Outcomes from testingThe CAU had 36 attendances, 28 ofthese were oncology patients andeight were haematology patients.

This test increased the capacity forassessment in a specialist area andmaintained the low admission ratewhich was identified in the day unitsin the base lining exercise.

Additional benefits• Assessment procedure anddevelopment of treatment planswas rapid

• Improvements reported in recordingof clinical information

• Useful having one pathway foremergency admission both for thepatient but also for the staff interms of tracking admissions anddecision making processes

• Staff reported that working withinthe unit was rewarding andinteresting.

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Percentage of patients admitted following testing in three clinical areasduring testing period


Single Point of Contact SPCThe SPC was contacted 156 times,118 of these contacts were oncologyenquiries and 38 were haematologyenquiries.

Additional benefits• Information and advice given overthe phone to patients was muchbetter recorded

• Time available for follow-up phonecalls allowed for safer practice andcontinuity of care

• Only 11 out of the 156 calls wereredirected to the patients consultingteam

• 100% of GPs who received a copyof the electronic telephone recordform said that the seeing theemergency advice given to thepatient was useful

• 73% of GPs said that having areliable SPC would help them tomanage cancer patients safely fromthe practice/community rather thansending them to the acute trust.

Financial Implications• 833 emergency inpatient admissionsAugust 2008 – July 2009; Monday -Friday 8am to 10pm

• 202 of these admissions camethrough the day units which providethe same level of specialistassessment as the CAU

• The extra 631 patients wereadmitted as inpatients via the ED orwent directly to the ward.

Assuming that the extra 631 patientshad been assessed in the CAU wherethe 41% admission rate could beapplied:• 259 patients admitted• 372 admissions averted (59%).• 2,760 bed days or £1,023,960potentially could be saved.

Benefits of these servicesThe CAU and SPC have wide reachingimplications in terms of servicedelivery and quality of care and wouldbenefit not only the trust and patientsbut also the commissioners andprimary care partners: One pathwaythrough a specialist area would reducethe rate of unnecessary admissions,take pressure off the ED and inpatientward areas and offer patientscontinuity of care during anxioustimes. By offering a specialistassessment prior to admission in aspecialist environment we have shownthat admission can become theexception and not the norm.

Patient’s thoughts on theirexperience‘The pre-admission advice and contactprior to my admission via the doctorwas second to none. I was constantlyinformed of the steps being taken toensure my safety; including knowing aCT scan was being booked for thefollowing day, so I felt more informedand involved with my own treatment.’

‘I was treated very wellas always. ButI had the same nurse look after mefrom coming in from home to beingadmitted on to the ward. Really quickand it was nice to have her follow methrough.’

Lessons learned• Engagement of all stakeholdersfrom the outset of the project andensuring that the group plays a keyrole in directing the project.Arranging short informal meetingsindividually with steering groupmembers in between formalsteering group meetings alsoensures they remain up-to-date withdevelopments and their opinions arebeing constantly reviewed anddiscussed.

• Clinical champions who bought into the idea and were able toencourage colleagues to view thepilot positively. The most effectivechampions were those cliniciansengaged on the ground floor whowere already directly involved inassessments; clinical nursespecialists and special registrars.

Single point of access: Wait tospeak to appropriate person

0 to 5 mins

11 to 15 mins Not recorded

6 to 10 mins

54%

20%

13%

13%

Current experience compared withprevious experience of telephoneaccess

Much better

Similar Not recorded

Better

49%

25%

13% 13%

Patient Experience Results


• Patients at the centre of alldevelopments and service redesignoptions engages clinicians and helpsto channel the direction of theproject.

• Alignment with national, local andorganisational priorities is key to getengagement from stakeholders.Reminding people of this alignmentas often as possible helps to embedthe necessity of change andencourage a sense of urgencywithin the project.

Challenges• The pilot was limited because wealso used staff from our existinghuman resource. This meant thatwe were unable extend the openinghours later than 5pm and as suchmissed out on applying this modelto patients who attended thehospital for emergency assessmentin the evening.

• Resources required to successfullyimplement this service were initiallyunderestimated. During the pilot,the need for increased access toboth computers and telephones

became very evident. Also, theenvironment was not ideal; the fourbeds were in close proximity to eachand separated by curtains whichraise questions regarding itscompliance with single sexaccommodation, there was not aspecified area for clinicalpreparation and only a small deskfor the staff to work on.

• Identifying a single model ofemergency assessment which meetsthe diverse needs of oncology andhaematology patients.

Emergency admissions pathway – pre testing

Emergency admissions pathway – post testing

GP

Other hospitals

Patient

Consultant

Day units

Inpatient ward

Medical secretary

On call SpR/SHO Haematology

On call SpR/SHO Oncology

Main hospital switchboard

GP liaison team

Clinical nurse specialist

On callSpR/SHOOncology

On callSpR/SHO

Haematology

Inpatientward (95%admission

rate)

Emergencydep’t (95%admission

rate)

Day unit(40%

admissionrate)

Admission

Discharge

GP

Other hospitals

Patient

GP liaison

CUH EmergencyDepartment

Admission

Discharge

CancerAssessment Unit

(41% admission rate)


Patient Electronic Alert to Key-worker System (PEAKS)Doncaster and Bassetlaw Hospitals NHS Foundation Trust


BackgroundThe PEAKS Alert for cancer patientswent live at Doncaster and BassetlawHospitals (DBH) in September 2009,initially rolled out by the lung multi-disciplinary team (MDT) andsubsequently across every tumourgroup. The alert is now live across allfour of the hospital sites in ninetumour groups and the SpecialistPalliative Care team.

The alert meets the requirements ofQIPP, showing:• Quality of care for patients andcarers is improved

• Innovation of ‘pull’ style alert• Productivity increase of thereduction in length of stay

• Prevention of inappropriateadmissions and treatments.

The idea of the cancer alert camefrom a review of similar alertsimplemented at both Sherwood ForestHospitals NHS Foundation Trust andUnited Lincolnshire Hospitals NHSTrust. Both schemes were based onthe RAPA (Recurring AdmissionPatient Alert) project work detailed inTransforming Inpatient CareProgramme for Cancer Patients – TheWinning Principles.

The alert also met requirements forDBH to meet local End of Life Strategy(2008) requirements and CancerReform Strategy (2007) initiatives.

How the PEAKS alert worksWhen a diagnosed cancer patientattends hospital as an emergency, theregistration (on PAS or eMIS) triggersthe PEAKS system, which sends analert in the form of a simultaneousSMS text message and email to the

registered key worker informing themof the patient attendance and currentlocation.

This then enables the key-worker tomake contact with the clinical staffcurrently treating the patient initiallyto understand whether theattendance is cancer related and thento ensure that the team are fullyaware of the patient’s currentdiagnosis, treatment plan andpreferred place of care.If appropriate, the key-worker can visitthe patient and carers to provideadditional support. In this way someemergency admissions have beenavoided, although it is acknowledgedthat particularly for patients on End ofLife pathways attending A&E out ofhours, hospital admission may beappropriate.

If the patient is admitted, the key-worker gets additional alerts as theyare transferred onto a ward, and soare again able to make contact withthe ward staff to ensure that they arefully aware of the patient’s currentdiagnosis, treatment plan andpreferred place of care.

FundingDBH decided to develop the ITfunctionality of the alert system afterconsidering the purchase of a bespokesystem from an external supplier, asthis was felt to provide best flexibilityand value for money. Additional costsincluded one off payments for mobilephone hardware and clinical auditsupport and regular costs for mobilephone messaging and calls and MDTadministrative support.

Patient attendsA&E/Emergency

Admission

Patientattendance input

into PAS/EMIS

Key worker callsward to check

reason foradmission

Key worker visitsreceiving areas (A&E, MAU,

ward) Staff to inform ofpatient treatment plan/

pathway/preferences

Patient/carer feelsupported by keyworker awareness

of visit

PEAKS databaseof patients linked

to specialisttreatment

Email and SMSmessage sentto key worker

Patient live onPEAKS updatedvia CNS or MDT

Informationtrigger

IT SYSTEM

OUTCOMESImproved patient experience

Reduced length of stayReduced inappropriate

admissions

Patient Electronic Alert to Key-worker System (PEAKS) How it works


BenefitsAfter the initial implementation, anevaluation demonstrated:-• Improved patient and carerexperience (through collection of‘good news’ stories)

• Reduction in LOS for these patients(via Information department data)

• Anticipated release of capacity inother areas as a result of patientsnot undergoing unnecessarydiagnostic tests, treatment andmedication.

Additionally, feedback from theClinical Nurse Specialists (CNS), whoare the key-workers receiving the alertat DBH, suggests that while the alertis an additional activity to manage, ithas brought an increase in jobsatisfaction through seeing animproved delivery of appropriate carefor their patients and an improvedpatient experience.

ChallengesThe key workers who receive thealerts work standard hours, sopatients attending out of hours (OOH)saw a delay in response time.However, part of the project alsoinvolved the circulation of detailedOOH guidance for the treatment ofcancer patients attending with variouscomplaints. Additionally the auditingof the project is currently aiming toidentify the reasons for OOHadmissions and inform work by othercommunity teams on improvingservices for these patients outside ofnormal working hours.

The auditing process itself was anadditional burden on the key workersduring the initial six months of theimplementation, but brought essentialinformation and evidence to theevaluation of the project roll outregarding number and timing ofalerts, nature of attendance andresponse times. Subsequently someteams have retained the auditpaperwork to use to support theirown systems for patient monitoring.

It is an ongoing task to ensure thatthe ‘right’ patients are on PEAKS.Initially, this means deciding how longago a patient cancer diagnosis wouldstill be relevant in impacting on theirlikelihood of emergency attendance.In addition, in order to maintain theaccuracy of the patients on PEAKS,there is a regular administrativerequirement to update PEAKS withnewly diagnosed patients for eachtumour group, which is currentlybeing undertaken by MDT staff.

In conclusion, the overall feedback fromthe cancer MDTs is that PEAKS is apositive initiative and good news storiesand initial evaluations support this.

After excellent initial success, theDoncaster locality are already lookingat the benefits of roll-out of thePEAKS alert to bring benefits to thewider health community, for example,patients undergoing chemotherapy orwith other long term conditions,known infections or those on an Endof Life Pathway.


Pan Birmingham Network wide spread ofneutropenic sepsis pathway improvements

Pan Birmingham Cancer Network


A review of the neutropenic sepsispathway identified that within hoursthe team were able to deliverantibiotics within one hour. Out ofhours (OOH) the pathway was notable to achieve the recommendation.A 50% improvement and a three-dayreduction in length of stay have beenachieved in the ‘door to needle’ OOHneutropenic sepsis pathway atBirmingham Heartlands Hospital.Learning from PDSA cycles has beenshared and spread to other trusts toimprove Network wide delivery of the‘one hour door to needle’recommendation.

Network spreadThe testing work initially commencedwith the OOH pathway at BirminghamHeartlands Hospital. This work hassubsequently spread to Good HopeHospital, and Solihull Hospital, thethree acute sites which make up Heartof England NHS Foundation Trusts(HEFT). Improvements achieved at(HEFT) have been shared and spreadthroughout trusts within the PanBirmingham Cancer Network (PBCN).

BackgroundThe PBCN guidelines for themanagement of Febrile Neutropeniastate that:• Neutropenia a neutrophil count of<1.0 x109/l

• Febrile neutropenia is any fever of38 °C or more maintained for overan hour or > 38.3°C on oneoccasion

• A raised temperature may be theonly sign of infection in aneutropenic patient. Conversely apatient may be septic and not havea raised temperature

• Neutropenic sepsis is a medicalemergency requiringcommencement of intravenousantibiotics.

The National Chemotherapy AdvisoryGroup (NCAG) report, August 2009,recommends that the delivery ofantibiotics ‘door to needle time’should occur within one hour ofpresenting with neutropenic sepsis.

In January 2009, the PBCNcommenced a three month audit tocapture ‘door to needle’ performanceof trusts. Audit results highlightedvariation in pathways and trusts abilityto deliver antibiotics within one hour.

Birmingham Heartlands Hospital auditresults highlighted that out of hourspatients would present at A&E or theAcute Medical Unit (AMU). In additionthe pathway was not delivering timelytreatment. A project team consistingof senior nurses, haematologists,matrons and a service improvementfacilitator (SIF) was convened and theyagreed a period of service review. Thefocus of the review was to gain abaseline through audit and anunderstanding of the OOH pathway.In reality this meant meeting withurgent care medical and nursingleads, a group of clinicians who areoutside the common groups ofclinicians that the Network usuallyworks with.

The review found the following:• Lack of awareness of the pathwayand the neutropenic sepsis guideline

• Difficulty in accessing the electronicguideline

• Lack of formal condition and centralline management training

• Poor symptom and conditionawareness

• Poor communication between inpatient ward and acute ward

• Poor awareness of key resourcessuch as the triage bleep holder andpatient alert cards

• Variation in place of patientpresentation

• Absence or poor availability ofintravenous antibiotics appropriatefor the treatment of neutropenicsepsis.

Despite the availability of a pathwayand tools to support delivery, thereremained barriers to staff using thesetools effectively in order to providetreatment in a timely manner. Anumber of improvements were testedand measured to determine benefit.

One point of accessPreviously, patients presented at A&Eor AMU. Multiple access pointsimpacted on the length of delayexperienced by patients. In additionpatients with neutropenic sepsis mayor may not have a temperature andthey can appear well. Without anunderstanding of the symptoms thesepatients are at risk of not beingprioritised as requiring urgentintervention.


Clinical service leads agreed andcommitted to AMU as the designatedpoint of access for patients. A periodof training for AMU staff to supportdelivery was also instigated. There wasalso agreement to educate andsignpost patients to AMU. A byproduct of the project has beenimproved communication betweenteams and a breakdown of siloworking.

Patient alert card redesignedThe original patient alert cardprovided patients with a 24 hourtelephone contact number to accessthe haematology/oncology triagebleep holder. The role of the triagebleep holder is to provide the patientwith advice and support. Beforetesting if urgent treatment wasrequired, patients were advised topresent with their card at theemergency department.

A survey identified 71% (28/44) ofacute staff had not seen aneutropenic sepsis alert card,potentially due to patients notshowing the card to staff. Additionallythe card did not promote urgentmedical treatment.

The alert card was redesigned and isnow visually alerting as it is red asopposed to the original white. Ithighlights the life threatening natureof the condition and provides patientsand staff with a checklist ofsymptoms. Staff members have readilyavailable guidance on how to treatthe patient and also directions on howto access the electronic guideline onthe trust intranet.

The alert card is now used for allhaematology and some oncologypatients on all three HEFT sites.

The improvements in the HEFT alertcard have been shared with othertrusts within the network that areadopting or adapting the alert card tosuit the needs of their patients.

Development of electronicpatient alertsAn electronic flag is now attached tothe patient electronic record and ithighlights the need for urgenttreatment. The electronic flag wasproduced through partnershipworking between nursing and IT staff.It uses existing capabilities ofelectronic patient record system, andso did not incur any additionalfinancial outlay. It also includes thealert card and guideline information.

Future developments are plannedwhich will enable the system to bemore proactive. It will be able tocommunicate with a bleep or pager toinform a nominated staff member ofthe patient’s presentation to hospital.This would enable the individual toprovide timely support or administerantibiotics. The benefit of utilising analert system has been shared withvarious trusts within the Network.

Delivery of competencybased trainingThe staff survey identified 68%(30/44) of staff surveyed had not readthe guideline. In addition, 75%(33/44) of staff had not had anyformal training in the management ofneutropenia.

The Haematology CNS now providescompetency based training to acutestaff which is aligned with policy. Shealso provides nursing staff withpractical skills to identify thecondition, manage central lines andfacilitate the delivery of timely care.

The impact of training has beenshared with other trusts with in thenetwork.

For example at University HospitalsBirmingham Foundation Trust (UHBFT)the project team updated oncologynursing staff on how to managepatients with suspected neutropenicsepsis. UHBFT report the impact of

Benefits of training staff

• Improved knowledge andskills of nursing

• Increased likelihood of staffrecognising the symptomsof neutropenic sepsis

• Supporting ‘right person,right time’ thinking

• Increasing the liklihood ofthe delivery of timely care

• Terms such as ‘neutropenicsepsis suspected’ orantibiotics given as perpolicy’ are documentedmore frequently

• Training providescoordinated way of raisingcondition awareness andmanagement which is inline with trust policy.

this update is 51% of patientsreceiving antibiotics with an hour anda 72% within 1½ hours.

Improving condition awarenessand management based on trustpolicy and guidanceA survey of acute staff identified that32% (14/44), do not know where tofind the guideline and moresignificantly 45% (20/44) did notknow there was a guideline.

Before testing electronic access to theguideline was not intuitive, it took tensteps and several minutes to access it,as it was not located in the trustintranet policy section. Improvementshave been made so that access to thepolicy takes three steps, it takes lessthan a minute and it is also linked toan electronic alert. Finally it is locatedin the policy section of the intranet.

Ensuring that trusts have an accessiblepolicy or guideline in place whichsupports staff in the delivery oftreatment is the main principle beingspread throughout the network.


Reducing delays through PatientGroup Directives (PGD)The longest pathway delay exists fromthe point of medic assessment to thetime the antibiotic is prescribed.Baseline data showed 36% (5/11) ofpatients experienced an average delayof 134 minutes at this point. A PGD isbeing developed which will enablespecific nursing staff to prescribe andadminister a stat dose of antibiotics.Once ratified the PGD will eliminateduplication, reduce hand offs and leadto a decrease in delay to treatment.

Development of the PGD has beenchallenging, primarily due to thenumber of teams involved in itsdevelopment. Additional support forthe PGD was gained by sharingpathway data on the OOH pathwayperformance and the impact of thePGD at Blackpool, Fylde and WyreHospitals NHS Foundation Trust whereit provided a 69% improvement indoor to antibiotics time.

Development of an antibiotics boxto improve access to treatmentAccess to the right antibiotics hasbeen achieved through thedevelopment of an antibiotics drugbox. The box is secure and lockable.It contains appropriate antibiotics,medical supplies required for thetreatment of neutropenic sepsis and apaper version of the guideline.

Once used the box is swopped with afully stocked replacement box situatedon the haematology/ oncology ward.In conjunction with the PGD the boxwill reduce the barriers faced bynursing staff to deliver the one hourdoor to needle target.

Improving communicationbetween teams to support coproductionA survey highlighted that 61% (27/44)of acute staff did not know that therewas a triage bleep holder on Ward 19.In addition 66% (29/44) acute staffhad not been contacted by the triagebleep holder. This indicated that thecommunication between teams wasnot supporting co production.

Improvements and benefitsachievedAMU staff receive a verbal hand overfrom the triage bleep holder prior tothe patient presenting at their unit.The verbal handover enables AMU toprepare for the patient’s arrival.

The double sided triage form has beenreplaced by the single sided UKONSform. Staff find this easier to completeand understand. The completed formis faxed to AMU providing timelyinformation supported by the verbalhand over.

Reducing barriers to effectivecommunication between teams hasimproved the flow of information andpatients in the pathway. Improvedcommunication has also promoted coproduction as teams now supporteach other in care delivery.

ConclusionUnderlying the improvements andlearning achieved is a clearunderstanding of the pathway inconjunction with hard work and driveof staff members at all levels of theorganisation to improving theprovision of care for patients withneutropenic sepsis.

The OOH process from presentation to hospital

STEP 1Patienttriaged

by a nurse

STEP 2Patient

is assessedby a medic

STEP 3Medic

prescribesantibiotics

STEP 4Nurse

administersantibiotics

STEP 5Patientadmittedto hospital


Commissioning and cost benefits of acute oncology:Supporting spread across the Anglia Cancer Network

Anglia Cancer Network


Commissioners and trusts now haveaccess to comparative informationabout costs of treating cancer patientsin the network, enabling rates ofemergency and planned admissions,lengths of stay and Payments byResults (PbR) costs to be identified andcompared for different tumour sites,providers and PCTs. This will help inbuilding business cases forimplementing nationallyrecommended improvements, as wellas identifying inefficiencies intreatment practice within thenetwork.

Published Programme Budgeting (PB)data suggests the cost of treatingcancer in the Network is c£250m pa,and Cancer Reform Strategy (CRS)data suggests that about 50% of thisis Inpatient cost. Variations in PB costrelative to incidence suggest grosssavings of £30m pa across thenetwork are possible if the cost percase of the three lowest cost PCTswere applied to the three highest costPCTs. Specialist resources wereconsequently commissioned to studydetailed Payment by Results inpatientdata for cancer spells in the network,at a cost of c£40k.

PCTs have already reported savings ofover £1m pa as a result of thisanalysis. These and future consequentproductivity savings will enableprojects to be implemented in theareas of acute oncology, 23 hourbreast, enhanced recovery and daycase chemotherapy, providing all ofthe benefits identified by the CRS and

NHS Improvement as being associatedwith these projects. Gross savings of£5.5m per annum in inpatients costshave been identified as realisable as aresult of implementing CRSrecommendations for these fourprojects, most of which occurs inacute oncology.

Programme Budgeting gives a goodindicator of total cancer care costs perPCT, but does not provideopportunities to analyse cost at levelslower than PCT.

PbR data readily available in all PCTs,covering all surgical admissions andmany non-surgical treatments, can becombined across the Network givingimportant comparative data. Thiswork requires financial and IT skills tobe shared across the network and ashared commitment to informationexchange.

Interest in using the tool which hasbeen developed, and interest inincreasing awareness of costs, is veryhigh throughout the network.

Existing contractual and financialarrangements for cancer treatmentare not widely understood by cancercommissioners, especially in the non-PbR areas of chemotherapy andradiotherapy, where availability ofactivity and cost information differpotentially for each provider. There isno consistent standard for whether totreat chemotherapy treatment asinpatient activity or not, or on how toreport it.

There is a good case for establishingnetwork wide cost reporting on aregular basis, harnessing the PbR datawhich is already being collectedcontinuously by PCTs, and in somecases by the SHA or its contractors, inorder to monitor benefits realisation.This approach is being adopted acrossthe network to support the spread ofthe Winning Principles.


Anglia Cancer Network - Potential savings per project


Spreading the enhanced recovery principles in patientsundergoing colorectal, liver and upper GI surgery

Aintree University Hospitals NHS Foundation Trust

Winning Principle 2All patients should be on defined inpatient pathways basedon their tumour type and reasons for admission.

WINNINGPRINCIPLE2

The t rust is part of the EnhancedRecovery Partnership Programme.Enhanced Recovery pathways havebeen introduced for patientsundergoing colorectal and liversurgery. A pathway will also beintroduced for patients undergoingupper GI surgery. The two aims of thework are to improve the quality ofcare for patients and to reduce lengthof stay.

The project aimed to reduce length ofstay by the following:

• Liver pathway – reduce LOS for50% of patients to ≤ five days

• Colorectal pathway – reduce LOSfor 80% of patients ≤ five days

• Upper GI pathway – reduce LOS for80% of patients ≤ nine days.

The impact is being measured throughmonitoring length of stay, readmissionrates and patient satisfaction surveys.

LOS data collected through the DHdatabase for each patient is beingused in Statistical Control Charts tofeedback improvement data to theteams. The mean LOS has gone from12.64 days to eight days following thelaunch of ERP (Source: Data submittedto the DH database for each patientadmitted to ward 10 from 12/12/2009to 13/04/2010).

Patients

ERP Commenced

50

40

30

20

10

0

-10

-20

Length of Stay The Mean (average)

Lower Control LimitUpper Control Limit

Len

gth

of

Stay

Reduction in length of stay has supported the closure offive beds on the enhanced recovery ward


Achievements and impact• Developed multidisciplinaryIntegrated Care Pathways for majorcolorectal surgery and liver surgerythat are initiated during the preoperative stage

• Set up a ‘patient school’ to provideopportunity for patients to becomefamiliar with the Enhanced Recoveryprogramme prior to admission

• Developed patient informationbooklets/diary that set out theexpected care trajectory and whatpatients can do to help themselves

• Introduced a rolling programme ofstaff education to train all staff inthe department on the principles ofEnhanced Recovery

• Hosted a ‘stakeholder event’ withcolleagues from primary and socialcare to raise awareness of the ERPwork at Aintree and to explore howto improve the referral anddischarge processes betweenprimary and secondary care

• Launched ward 10 as the EnhancedRecovery ward on 8 March 2010

• Improved team working andcommunication between nurses andmedics

• Patients are better informed abouttheir care and dischargearrangements

• Positive feedback from patients• Patients are more proactive in theircare and spend less time in bed

• More effective use of physiotherapyteam’s time (patients are dressedand sitting by the side of the bedwhen the physiotherapist arrives)

• Stoma nurses providing Saturdaymorning service to facilitateweekend discharges which hasimpacted on LOS

• Ward day room is being convertedback into a dining area for patientsto eat away from the bedside andencourages mobility

• A dedicated area for patienteducation/counselling has beenestablished

• Some patients have beendischarged significantly earlier thanthey would have been traditionally.

Lessons learned• Process mapping the patientpathway with the MDT allows theteam to understand what happensnow, helps define scope, and formsthe basis of the pathway

• Involving the whole team in theprocess of pathway developmenthelped develop team working, andensured that everyone was aware ofwhat was happening; bringingeveryone along at the same time

• The pathway work enabled personaldevelopment opportunities for thenursing and AHP staff on the wardwho undertook responsibilities forspecific aspects of the project toprogress improvements to theorganisation of care

• Bringing the team together to talkabout the patient pathway, out ofthe normal ward routine, allowedfor productive discussions andprovided a supportive environmentin which to challenge anyassumptions raised relating to thedelivery of care

• Identifying the matron as projectlead was key; it brought the benefitof pre- established positive workingrelationships with the doctors,nurses and AHPs; an in-depthknowledge of local systems,including specific cultural traitswithin each department; andknowledge of who to contact toproblem solve issues relating topathway development and estatesissues. This knowledge wasinvaluable in progressing the project

• Being involved in the nationalprogramme set the pace for change,and support from the ADO ofsurgery ensured that pace was keptup

• The consultant colorectal surgeonand liver surgeon were visible interms of support for the project andarticulating the evidence base forchanges in clinical practice tocolleagues, and the rest of theteam

• Dedicated time from a member ofthe service transformation teamprovided support for the projectlead who had a day job, allowed fordevelopment of governancestructures for reporting andmonitoring of the project, andpractical help in terms of theapplication of service improvementtools and techniques

• Key challenges remain ongoingengagement of the three primaryand three social care organisationsthat are linked to Aintree. A pilotreferral from pre op to social workwith one of the social careorganisations is being tested, andtwo of the PCTs have agreed inprinciple to test systems from GPsurgeries to improve optimisation ofpatients prior to admission

• Core leadership for each of thepathways, have dedicated time forproject management and a predefined timeline for the project, andcommitted executive level support.


We currently have a 14 bed inpatienthaematology ward with eight singlebedded rooms.

Baseline evidence showed that up tothree haematology inpatient beds aday are utilised by non specialtypatients and a number of patientstreated on the haematology pathwaywere often well enough to go homein the evening, returning thefollowing day and some patients haveweekend leave, such as patientsundergoing blood product supportand diagnostic work up.

• The predominant use by thehaematologist of the inpatient bedsis for remission, induction andconsolidation chemotherapy foracute leukemia, usually acutemyloid leukaemia (AMC) althoughacute lymphoblastic leukemia (ALL)is also treated

• It was agreed that these patientswould ideally support anambulatory care pathway

• The consultant champion helped toinfluence this change.

The first phase recently commenced inJune 2010, six inpatient beds wereclosed and in place three ambulatorycare chairs were opened. This is in theearly days of implementation and theimpact of this change on patients andcapacity is being monitored. If thisphase is successful the intention is tomove to six ambulatory chairs furtherreleasing haematology day patientsfrom the Chemotherapy Day Units fornon-cancer related patients e.g.rheumatology patients requiringmonocional drug treatment.

Shifting care and reducing length of stay: Ambulatorycare beds in the haematology inpatient ward

East Kent Hospitals NHS Foundation TrustsKent and Canterbury Hospital



IntroductionThe Derby Hospitals NHS FoundationTrust consists of two sites, the LondonRoad Community Hospital and theRoyal Derby Hospital, which is aCancer Centre. The trust has acatchment population of around600,000 patients in SouthernDerbyshire.

The breast team at the Royal DerbyHospital consists of four consultantswho undertake around 230mastectomies per annum. The teamdecided to look specifically at themastectomy patient pathway with aview to improving the patient’sexperience and valuing patients’ timeby giving suitable patients the chanceto be discharged from hospital earlierfollowing their surgery. The team wasinterested in looking at the 23 hourmodel that had been adopted by thePan Birmingham Cancer Network(PBCN) very successfully. Contact wasmade with Birmingham so that wecould learn first hand from themabout their experience.

The length of stay for mastectomypatients compared favourably withthe rest of the country, but we felt wecould still improve this. The data fromthe first six months of 2008 showedthat 95 patients had been treated andapproximately 8.6% of these patientswere discharged the day after theiroperation. The length of stay rangedfrom one day to 21 days, with 76% ofthese patients being dischargedbetween days two to four.

What we did• Reviewed existing pathway• Identified variance in length of stay• Created new mastectomy inpatientpathway for testing

• Inclusion criteria proformadeveloped for 23 hour breastmodel

• Suitable patients were identifiedfrom October 2008

• Questionnaire – adapted fromPBCN

• One consultant agreed to use a lowvacuum drain

• Discharge information reviewed andinformation sheets created for thedifferent types of drains used

• Engagement – Breast 23 hourmodel standing agenda item atBreast Network Site SpecificGroup (NSSG)

• Engagement - Training events forcommunity nurses - enhancedworking relationships withPCT/provider colleagues

• Patient’s expectations - patientswere advised at the outset that ifthey were medically fit and thepatient was in agreement dischargewould take place around 24 hoursafter their operation

• Pre-operative assessment breastcare nurses (BCN) were inattendance at the pre assessmentand were able to further identifypatients who would be suitable

• Patient satisfaction questionnairescompleted.

Adopting the 23 hour model for mastectomy patientsDerby City Hospital NHS Foundation Trust


Length of Stay - Days

40

35

30

25

20

15

10

5

01 2 3 4 5 Plus

Nu

mb

ero

fp

atie

nts

Inpatient stay - January to June 2008


Pathway July 2008 Pathway since early 2009

Patients seen in clinicwith results (Date givenfor surgery and preassessment clinic)

Nurse led preassessment clinicPatients will also see physioand breast care nurse,ocassionally surgeon

KTC admission clinicConfirm consent/patientinformation and meetanaesthetist

Patients dischargeddays 2-4 (some nurseled discharge butpredominantly consultantled)

Patients discharged intocare of district nurseteam - referrrals faxedSome visits take place24-48 hours post discharge- not all patients visited

Attend nuclear medicinefor Sentinel Node Biopsy

On occasion visit ward 311

Surgery

Admit post op to ward 311

Patients seen in clinic with resultsBreast care nurse also present(Date give for surgery and preassessment clinic)

Nurse led pre assessment clinicPatients will also see physio andbreast care nurse, ocassionally surgeon

AdmissionConfirm consent/patient informationand meet anaesthetist

Patients discharged following day

Day case admission loungeKings Treatment Centre

All patients discharged into careof district nurse team - referrralsfaxed

Nuclear medicine for SentinelNode Biopsy

Surgery

Admit post op to ward 311

23 hour lengthof stay discussed

Length of stayre-iterated

Day of surgery

Consultant identifiesthose patients suitablefor nurse led discharge

Verbal and writteninformation leafletgiven to patients abouttheir drains

Community teamcontact all patients dayafter discharge andvisits for wound check,support and drainremoval

Breast Care Nurse visitsall patients on wardbefore discharge

Breast Pathway - Pre and Post Testing


Early Progress - Spread to otherconsultantsThe testing ran from October 2008 toFebruary 2009. It was agreed toinclude the first 25 patients in thetesting of the new pathway that weretreated by one consultant but it wassoon realised that this would take tolong to recruit this number ofpatients, so the other threeconsultants agreed to identifysuitable patients.

ResultsDuring testing we have reduced ourLOS, and we have also continued toimprove on this since implementationand the improvement in LOS is beingsustained. This is demonstrating aquality driven service that is valuingpatient’s time.

Patient experience

‘They were very good at thehospital, before and after theoperation. Also the districtnurses were very caring too.’

‘No criticisms – felt consultedyet advised professionally.’

Conclusions• The 23 hour stay model is nowfirmly embedded in the trust

• The results of the patientsatisfaction questionnaires showthat patients are very happy withthe new service.

• Communication and relationshipsbetween the hospital trust and thecommunity teams has improvedsignificantly

• Continued reduction in length ofstay

• The percentage of patients whowere discharged after 23 hours hadincreased to 61% for the monthsJuly to December 2009.

Challenge

Patient expectation - patientsenquired why other patients werebeing discharged sooner than themwhen they had had their operationon the same day

Applying a standardised pathway –nurses raised concerns if patientswere not aware they could gohome after 23 hours

A low number of questionnairesreturned, so unable to measure howthe patients felt about 23 hourdischarge - it was felt that this maybe because patients are given somuch information at pre-operativeassessment

Breast care nurses unable to attendpatient on the ward beforedischarge

Solution

If patients were medically fit andagreed they were also dischargedafter 23 hours.

The option of the 23 hour dischargewas mentioned to ALL patients atdiagnosis and pre-operativeassessment clinic

Once a patient had been identifiedas suitable, SIF sent thequestionnaire out

Robust follow up procedure forpatients introduced – BCN timefreed up by the introduction on anadministrator

3

2.5

2

1.5

1

0.5

0Pre test - up to

Sept 08Testing phase

Oct 08 - Feb 09Post test

Mar 09 - May 10

2.85

2.53

1.98

Comparison of mean length of stay - pre, during andpost implementation of the 23 hour Breast Model


What is ERP?The programme is based on the workof Professor Henrik Kehlet. It is oftenreferred to as rapid or acceleratedrecovery.

This is a multimodal and evidencebased approach to patient’s pathwayof care.

It is comprehensive multistep andmultidisciplinary which optimisespatient organ function and recovery.

Aim of ERPThe implementation of the ERPthrough Integrated Care Pathway(ICP) is to provide pre, intra and post-operative patient’s care with the aimto:• Reduce mortality• Reduce morbidity• Reducing length of hospital stay.• Reducing physiological andpsychological stress.

Benefits of ERPFor the patient:• Improve patient experience• Empowered as a partner in his/hercare

• Planned earlier rehabilitation / returnto work

• Reduce exposure to hospitalinfection

• Fewer complications.

Quality:• Improve clinical outcome withdecreased mortality and morbidity

• Quality Standards met e.g. CQC,cancer standards, NICE guidelines

• Operational standards met e.g. 18weeks, cancer pathway.

Staff:• Improve multidisciplinary experience• Team building opportunities• Educating and training• Recognition for achievingimprovements in quality andpatient.

Current practice at Whipps CrossUniversity HospitalCurrent trend of care follows thetraditional pre-operative and post-operative model of care wherepatients undergoing major colorectalsurgery were experiencing long andvariable length of stay (LOS).• Lack of shared vision on patient’spathway

• Lack of communication betweenthe multidisciplinary team

• Fragmentation of care• No established audit and evaluationof care experience (DOH 2010).

Whipps Cross University Hospitalapproach to ERP• The steering group was establishedin February 2009. The core groupcomprised of:• Surgeon (lead for ERP)• Anaesthetist• Pain team• Physiotherapist/occupationaltherapist

• Pre-admission team• Ward nurses• Dietician• Specialist nurses• Discharge coordinator and socialworker

• Attendance of ERP course by StMarks and other training events e.g.National Awareness Events

• Develop shared vision between themultidisciplinary team

• Creation of a steering group• Evidence explored througheducation literature review andbaseline study

• Developed a dedicated pathway ofcare by each lead discipline and thedevelopment of approvedintegrated pathway of care

• Developed process map of patientsjourney

• Case analysis• Collaborative problem solving• Delivering of an in-house rollingtraining programme for staff andjunior doctors

• On going monthly meetings toupdate and monitor

• Auditing results of first phase of ERPand comparison with previousstudies

• Submission to clinical governanceand approved

• External bodies: NHS improvementteam, NHS for London

• Audit and pilot on LOS and patientsatisfaction survey.

Enhanced Recovery Programme (ERP): Integratedcare pathway for elective colorectal surgery

Whipps Cross University Hospital NHS Trust



ResultsThe tables show that length of stayhas been reduced from an average of11.6 days to 6.1 days.

The future for ERP at Whipps CrossUniversity Hospital• Confirming decrease mortality andmorbidity through audit

• Focusing on other teams e.g.urology, gynaecology to embracethe Enhanced Recovery programme

• Dedicated bay on the surgical wardfor patients on ERP

• Closer working partnerships withlocal health community and helpdeveloping ERP in other trusts.

Sustaining change• Patient prospective auditperformance and patientsatisfaction

• Case base discussion• Study compliance• Continued in-house training forstaff and junior doctors.

14

13

12

11

10

9

8

7

6

5

4

3

2

1

10

Patient Reference

2 3 4 5 6 7 8 9 10 11 12 13 14 15

Len

gth

of

Stay

(po

sto

p)

Day

s

Expected length of stay (days) Actual length of stay (days)

Whipps Cross University Hospital ERP colorectal audit 2010

14

12

10

8

6

4

2

0Whipps Cross

Inpatient Audit 2008/09National Database HES

2008/09ERP Implemented

20009/10

Nu

mb

ero

fp

atie

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Whipps Cross University Hospital ERP colorectal audit 2010


SummaryThe Colorectal Surgery Team at CityHospital agreed to test the use of anEnhanced Recovery approach as partof the National TransformingInpatients Programme. After initialtesting showed positive results theywent on to adopt the processpermanently. Learning from theirexperiences the Pan BirminghamCancer Network has supported thespread of Enhanced Recovery, first tothe other colorectal services in thenetwork and then to other specialties.Work to complete adoption into allrelevant specialties is ongoing but thenetwork is already seeing substantialreductions in average length ofpatient stay, with positive patientexperiences and no increase inreadmission rates.

Testing Enhanced Recoveryat City HospitalColorectal surgery patients havehistorically had long and variablelengths of stay in hospital. Researchinto a number of different practiceshas shown that it is possible todramatically reduce length of stay andimprove outcomes by adopting adefined patient pathway following theprinciples of Enhanced Recovery.These principles focus on optimisingthe patients’ physical condition beforesurgery, minimising the impact of thesurgery and then returning the patientto their pre-surgical state as quickly aspossible. Patients are also given clearinformation about what to expect andthe part they need to play in theirown recovery.

As part of the National TransformingInpatients Programme, the teamagreed to test a pathway involving thefollowing:• Reduced fasting for six hours pre-opwith fluids allowed up to two hoursbeforehand

• No bowel preparation• Avoiding opiate based analgesia• Limited IV fluids post operatively• Early oral fluids and food• Early mobilisation from the day ofsurgery.

Spreading Enhanced Recovery from one testproject to a network wide programme

Pan Birmingham Cancer Network


Colorectal Service, City Hospital, Sandwell and WestBirmingham NHS Trust

Colorectal Service, Walsall Hospitals NHS TrustColorectal Service, Sandwell Hospital, Sandwelland West Birmingham NHS TrustColorectal Service, Heart of England NHSFoundation TrustColorectal Service, University Hospital BirminghamNHS Foundation Trust

Gynaecology Service, Sandwell Hospital, Sandwell andWest Birmingham NHS TrustGynaecology Service, City Hospital, Sandwell and WestBirmingham NHS TrustUrology Service, University Hospital BirminghamNHS Foundation Trust

All patients should be on a defined inpatient pathwaybased on their tumour type and reasons for admission

Main Test Site

Spread SitesPhase 1

Spread SitesPhase 2

WinningPrinciple 2


Results of testingThe pathway was tested on a smallnumber of patients to represent eachtype of procedure with the followingresults (figure 1).

These positive initial results wereenough to increase the confidence ofthe staff to implement these changeson a wider scale and as a resultpatients at City Hospital nowexperience a very different pathway tothat of only a couple of years ago(figure 2).

Lessons learnedPatient’s expectation of their recoveryis a key factor in the success of theprogramme. They need clearinformation leaflets and to have themessage consistently reinforced by allthe staff they come into contact with.This was a big cultural change formany staff and they need time to fullyunderstand the process and becomeconfident applying the principles.Formal training is particularly usefulfor this but staff have also benefitedfrom hearing about the experiences ofcolleagues.

A particular aspect of the programmemay not be suitable for a patient butthis should not preclude them fromparticipating in the rest of thepathway. Each aspect makes its owncontribution to their recovery and weshould aim to apply as many as areappropriate for each patient.

Changes are made to the patient’spathway at every step sointerdisciplinary working is required tomake sure these changes are practicalfor each affected staff group. Keymembers of the team are surgeonsand ward nurses but many otherpeople should be involved includinganaesthetics, pain management,discharge liaison, physiotherapy,dietetics and pre-assessment.

Procedure Current Predicted Test Patient Potentialaverage length of stay actual length difference inlength of stay on test of stay length of stay

pathway per patient

Colectomy 12 Days 4 Days 5 Days 7 Days

Colectomywith stoma 16 Days 6 Days 6 Days 10 Daysformation

Colostomyreversal

12 Days 4 Days 2 Days 10 Days

Day Traditional Pathway Enhanced Recovery Pathway

0 Surgery Performed Surgery PerformedDrip, Fluids, Drain, NG Tube Drip, Fluids, Drain and Catheterand Catheter in in NG Tube removed after surgery

Epidural for pain reliefDrinking in recoverySitting out in chair

1 Nil by mouth Eating normallySit out in chair if able Catheter out

Regular walks around wardBegin oral pain relief

2 Sips Epidural downShort walk Drip down

3 Sips Patient independentNG tube down if flatus passed Showered and dressed

4 Oral Fluids DischargeShort walks

5 Drip downDrain out

6 Soft diet

7 Diet if toleratedWalking more

8 Wound clips removed

9 Patient Independent

10 Discharge at discretion of consultant

Figure 1

Figure 2


Spread Phase 1 – Colorectalservices across the NetworkAfter the success of the City Hospitalpilot it was agreed that EnhancedRecovery Programmes would bedeveloped for all the colorectalservices with in the Pan BirminghamCancer Network. This would focusinitially on City Hospital’s sister site,Sandwell General Hospital and WalsallHospital as these two teams wereparticularly keen to proceed. Workwould then commence at Heart ofEngland NHS Foundation Trust andUniversity Hospital Birmingham NHSFoundation Trust.

From the beginning the aim was tosupport each team progressingindividually while sharing resources toavoid duplication of work. Thenetwork developed a set ofstandardised ‘work packages’ toensure each of the projects wereaddressing the key issues and alsoproduced resources to be used acrossthe network including educationposters and patient information cards.The network has also taken on therole of gathering and analysing lengthof stay data.

Development of standardisedwork packagesAfter reviewing the relevant literatureand in consultation with the clinicalteams the following list of workpackages was agreed. It was felt thatthis covered all the essential aspects ofEnhanced Recovery and encouragedthe teams to embark on discretepieces of work rather than trying tochange everything at once. Each trustnominates a lead for each workpackage ensuring that the work isshared our amongst the team ratherthan always falling to the EnhancedRecovery lead, who was then freed upto act as a coordinator of all the workpackages.

Development of network wideresourcesPart of the networks strategy tosupport spread was to monitor whatresources the individual trusts neededand to produce some of thesecentrally to avoid duplication of workand ensure consistency across theregion. As a result the network hasworked with representatives from thetrusts to produce a number ofresources including:• A patient information card – abusiness card sized list of themilestones for each day of apatients recovery, encouraging themto play an active role in meetingthose goals on the road to recovery

• A staff education poster – a posteraimed at ward staff and juniordoctors which explains the nine key

things staff can do to help theirpatients recover quicker

• A patient held record andinformation leaflet – a bookletwhich combined all the informationthe patient should be receiving atthe pre-assessment appointmentwith a daily journal sectionreiterating the milestones for thatday and allowing them to record theactions they have taken

• Training sessions – different types oftraining sessions were developed tomake them accessible to all staff.These could be for small groups onthe ward, one to one for key staff ormore formal study days withspeakers from leading organisationsand the national partnershipprogramme.


Work Area Objective

Pre-assessment Train pre-assessment staff to manage patient expectation and hand out ‘pre-op’drinks and information leaflets.

Patient Information Manage patient expectation and support their recovery by producing acomprehensive patient information booklet and an interim leaflet.

Pre-op Drinks Provide patients with a set number of carbohydrate loading drinks to reduce theimpact of fasting and the consequent insulin resistance.

Pathway Notes Produce pathway paperwork to support staff in delivering the components of theprogramme.

Admission to Ward Patients to be admitted on day of surgery except where there is a clinical reason forearlier admission.

Anaesthetics Ensure that anaesthetic practice is in line with the principles of Enhanced Recovery,including short acting anaesthetics, no pre-med and restricted fluids.

Surgery Ensure that clinical practice is in line with the principles of Enhanced Recovery,including transverse incisions and reduced bowel prep.

Recovery Ensure that recovery procedures are in line with the principles of Enhanced Recovery,including removing NG tubes, allowing oral fluids and restricting IV fluids

Mobilising on Ward Patients to be out of bed after surgery and walking regularly from the following day.

Eating on Ward Patients to be eating and drinking after surgery and returning to a normal dietquickly.

Pain Management Development of a protocol that manages the patient’s pain with out compromisingtheir recovery.

Discharge Processes Develop discharge criteria and consider nurse led discharge. Plan discharge processessuch as arranging TTOs to prevent delays.

Follow Up Calls Senior nurse to contact patients 24 hours after discharge to troubleshoot and preventreadmission.

Primary Care Info Ensure GPs are aware of the new processes. GPs to manage patient’s comorbiditiespreoperatively and set expectations.

Pre-assessment

Peri-operative

OntheWard

AtDischarge

Standardised work packages


Results so farThree of the four trusts have beenable to provide robust length of staydata which covers all electivecolorectal surgery patients showingeach achieving a substantial reductionover the course of the year. Provisionaldata for the first quarter of 2010/11indicates this trend is continuing, withall trusts moving towards their aim ofa 6.5 day average (figure 3).

The aim of 6.5 days has been agreedas while it was felt that ‘straightforward’ enhanced recovery casesshould have a four or five day stay,the teams felt strongly that no patientshould be considered ‘off thepathway’ and that all patients shouldbe included regardless ofcomorbidities or social problems. The6.5 day average was therefore arrivedat to make an allowance for a smallnumber of patients who couldreasonably expect a longer lengthof stay.

Spread Phase 2 – Other specialtiesAs interest in Enhanced Recovery hasspread and other teams have heardabout the success achieved by therecolorectal colleagues, the Network hashad contact with a number of otherteams wanting to embark on similarprojects. As a result work is nowbeginning with two gynaecologyteams and a urology team. Theseteams will really benefit from all the

work that has gone on already. Thisspread process will not only apply theknowledge we have gained with theearly adopters but can also easilyadapt the resources that weredeveloped for the colorectal teams tosuit the other specialties. Due to thisbig advantage we anticipate thatthese new projects should be able todemonstrate results within a muchshorter time frame.

16

15

14

13

12

11

10

9

8

7

6Q1 Q2 Q3 Q4

Quarter

Day

s

Trust 1 Trust 2 Trust 3 Aim

Figure 3: Average length of stay 2009/10

Sandwell & WestBirmingham NHSTrust - City Site

Colorectal

Sandwell & WestBirmingham NHS

Trust - Sandwell SiteColorectal

Walsall HospitalsNHS TrustColorectal

University HospitalsBirmingham NHSFoundation Trust

Urology

Sandwell & WestBirmingham NHS

Trust - Sandwell SiteGynaecology

Sandwell & WestBirmingham NHSTrust - City SiteGynaecology

Heart ofEngland NHS

Foundation TrustColorectal

University HospitalsBirmingham NHSFoundation Trust

Colorectal

Work completed Work nearing completion Work ongoing Work in early stages

How Enhanced Recovery is spreading across Birmingham


Hull and East Yorkshire Hospitals NHSTrust has recently seen a significantdevelopment in its cancer servicesfollowing relocation into the newQueens Centre for Oncology andHaematology. This developmentprovided an facility to deliversignificant changes in workingpractice and released capacity. Onechange was the transfer of delivery ofsome chemotherapy regimens fromthe inpatient to outpatient setting.Transferring the delivery of Cisplatinregimens (where clinically appropriate)to the day unit has made a significantreduction in inpatient length of stay(LoS). This change supports theNCAG guidelines (2009) and theTransforming Inpatients Programmedrive to improve quality and ‘save amillion bed days’ (NHS Improvement2009).

A new network protocol for deliveryof Cisplatin in the outpatient settingwas agreed by the Humber andYorkshire Cancer NetworkChemobiological Group. Whenreviewing the delivery of the Cisplatininpatient regimes it was necessary toremove from calculations the top10% of long stays as this assumes agroup of patients that are in clinicalneed of an inpatient stay. Looking atthe delivery of the Cisplatin regimenin October 2009 there were 45patients identified as a sample ofinpatient stay LoS to set a base line forimprovement (after removing the10%). This in turn showed that 101bed days were used in delivery of theCisplatin regime showing an averageof 2.2 days LoS per regimen delivery.

LoS is being used as a key metric formeasuring improvement, however, itmust also be stated that there hasbeen a significant improvement inpatient experience and valuing thepatients time, as they spend less timein an acute hospital setting.This improvement has been achievedwithin existing staffing resource anddelivered with a change of workingpractice.

By moving the Cisplatin regimen toout patient delivery there has been asignificant reduction in the number ofinpatient bed days used for thispathway.

Looking at the four month period ofNovember, December, January andFebruary (2009-10) there were 404regimes of Cisplatin delivered. Againremoving the top ten percent of longstays to account for patients thatwould have needed inpatient careregardless has shown that on average0.9 in patient bed days are used perpatient as represented below with70% of patients having no inpatientstay displayed below.

This has had a significant impact uponpatient experience and bedmanagement within the cancercentre.

Delivering care in appropriate settings

Queens Centre for Oncology and HaematologyHull and East Yorkshire Hospitals NHS Trust


350

300

250

200

150

100

50

00 1 2 3 5 6 14 22 264 7 8 10 16 18 19 369

Total

Number of Days

Nu

mb

ero

fPa

tien

ts

70% of patients have no inpatient stay


Delivery of the service as anoutpatient led appointment hasallowed reduction of average LoSfrom 2.2 to 0.9 days; providing asaving in the region of 1500 beddays per year within the centre.This has allowed for an improvementin access to the centres wards and byreleasing bed capacity for patientsthat would have previously beentreated within other specialities in thetrust.

The NCAG recommendations (2009),and the increasing demands oninpatient capacity acted as the majordrivers for change. The ability to utiliseday unit facilities that were availablefrom moving to a new unit providedthe catalyst for change.

The clinicians were champions of thenew network protocol as they couldsee benefits for both patients and theservice. The key challenge was theredesign of pathways so that longeroutpatient regimens could bedelivered. Staffing levels wereadjusted to enable 8am to 6pm coverfor the day unit. Staff were consultedand involved in the redesigning of theservice.


Although good average length of staywas identified at Hinchingbrookehospital, there was considerablevariation.

• Average LoS = 8 days for patientshaving an elective anterior resection.

• Average LoS = 12 days for patientshave an elective hemicolectomy.

With the advances in surgicaltechniques and feedback from othersites, we decided to look at ourpathways and attempt to standardiseour length of stay. We also wanted tooffer the best care for patients, reducewaiting times and achieve clinicallyand financially sustainable services.The primary resource and investmentwe used was staff time. Initially, wediscussed ideas at a clinicalgovernance meeting. We had thebacking of colleagues, managementand the SHA. Meetings were heldwith key stakeholders to discuss andidentify key players including theinvolvement of colleagues inCommunity Care Service (Providers)and NHS Cambridgeshire(Commissioners). This gave us theopportunity for a joined up andseamless care pathway. A half dayevent was held involvingthe following stakeholders inidentifying the issues and actionplanning.

Consultants Out-patientstaff

Patients and carers Dietitians

Pre-op assessment PALS

Cancer management Ward nurses

Pharmacy Physio

GPs OOH GPservices

Colorectal NurseSpecialist Stoma Nurse

Theatres Recovery

Anaesthetists

Setting patient expectationsfor surgeryWe provide patient information toassist with managing patientexpectations of surgery and recoveryand this empowers patients aspartners in the process and aids theirunderstanding of what is expected ofthem.

Information is provided at differentpoints in the pathway, both writtenand verbal, during clinic, pre-opassessment, ward and at discharge.The feedback that patients provide tous, for example, on writteninformation is used to help re-draftand ensure we meet the needs of thepatients. This is an iterative process.

Changing practicePre-op optimisation of the patient isdone, especially nutrition. Earlynutritional assessment is conducted,which must be scored in the clinic(supplements are given if required).We are reducing the fasting periodand glucose loading prior to surgery.

A collaborative care plan (CCP) wasdeveloped which all disciplines havesigned up to. This is a multi-disciplinary document that identifiesthe key nursing, physiotherapy,medical and other interventionsneeded each day.

OutcomesQuality and productivityWe have successfully; improvedquality and productivity:• Reduced length of stay (LoS). Pleasenote: LoS did not immediatelyreduce and there was a ‘chaotic’period initially after the change wasfirst introduced. This soon settledand LoS was reduced as follows:• Average LoS = was 8 days forpatients having an electiveanterior resection. Now 4-5days

• Average LoS = was 12 days forpatients have an electivehemicolectomy. Now 8-9 days

• Risks involved with hepatic arterialinfusion (HAI) have been reduced

• Multi-disciplinary notes haveimproved

• There is an agreed plan of carebetween disciplines. This can beused as an educational tool forstudents and newly qualified staff

• The amount of nursing paperworkto be written has been reduced sothis allows increased time for directpatient care.

With the standardisation of care, bestpractice is adopted and variation(depending on experience/knowledge)is reduced or eliminated.


Enhanced Recovery: Colorectal cancerHinchingbrooke Healthcare NHS Trust


Challenges in changing theservice included:• Differing opinions on the bestdietary management in the peri-opphase between different sites anddifferent disciplines still exist

• Managing patient expectations fromthe outset

• Managing staff expectations andthe change process

• Managing changes indocumentation (CCP)

• Pain management, which needs tobe effective but should not hamperearly mobility.

Next stepsThis is an iterative process and we arealways looking to improve. We arecontinually looking for furtherrefinements of the CCP as newevidence comes to light.

Further investigation is being doneinto new pain managementtechniques to promote earliermobilisation and removal of lines,catheters etc. which can hampermobility.

Tighter fluid management peri-operatively is also being looked into.


The West Suffolk Hospital (WSH),wanted to improve the breast service.Changes in the breast service were notimplemented as a specific project buthave evolved over time since 2004. Theprimary investment has been staff timeand commitment. The most importantand challenging issue was changing andmanaging expectations of both staffand patients.

The team regularly look at continuouslyimproving the service they provide via:• Weekly breast care nurse meetings• Breast cancer patient experiencequestionnaires to every patient threemonths after diagnosis date

• Bi-monthly breast unit businessmeetings

• Annual breast cancer audit day andservice improvement day.

Managing patient expectationsPatient expectations and understandinghas evolved through easier access toinformation on the internet etc. Patientsare now informed at the very beginningof the service what is provided and theexpected length of stay. Pre assessmentis conducted one week beforeadmission.

Key changes in practice• Admission on day of surgery• Surgical technique – flap suturing –which reduces the need for drains

• Glue is used to seal incisions so nodressings are required

• No Patient Controlled Analgesia (PCA)is used

• Nurse-led discharge is in place.

Drains are not used routinely, whichsupports early discharge. There are twoconsultants at WSH, one who does notuse drains at all and one who does usedrains for axillary node clearances butthese patients are discharged with theirdrains if necessary and possible.

Post-op information is given to thepatient, including follow upinformation, and the patient isdischarged with all the informationwhich includes:• Discharge letter (including follow upappointment details)

• Details of support services• Post-operative information, includinga care plan from the ward.

The patient is asked to contact thepractice nurse three days after theoperation for a wound check.

For patients who are discharged withdrains:• On the day of discharge the districtnurse is contacted to confirm thedischarge arrangements and patientscondition.

• Patients are discharged with a districtnurse letter, dressings andmedications.

• If they need additional drainageequipment, the patient is seen at theWSH. This is very rare.

• The district nurse then contacts thepatient, on the day they aredischarged, to confirm a visit to thepatient at home the next day.

• The district nurse then visits thepatient daily whilst the drain is inplace. The district nurse removes thedrain on the fifth day after surgery orwhen drainage <50 mls per day.

The majority of the patients are nowdischarged between one to two days.Some patients are discharged on thesame day and some lists are done in theday surgery unit. If patients are notdischarged on the same day, patientsare normally discharged the nextmorning. It is all done on an individualpatient basis.

A three month audit was recentlyconducted which covered the periodfrom January – March 2010. Out of 100breast operations performed:• Nine in day surgery unit (DSU)• One was plastics• 74 were cancers• 91 patients were discharged within 24hours

• Seven discharged within two days• Two discharged within three days.

Therefore, 91% of patients weredischarged within 24 hours, 98% weredischarged within two days and 100%of patients were discharged within threedays.

The key to the success of thischange has been:• Changing and managing expectations- patients, surgeons, nurses and allother involved staff.

• Dynamics of the team - team workingand a collaborative approach, with thebreast care nurses being essential tothe smooth running of the service.

The team now regularly review theservice to consider ways of improving itand it has become part of the cultureand mindset of the whole team.


Breast inpatient care: Valuing patient timeWest Suffolk Hospital, Bury St Edmunds

WINNINGPRINCIPLE3


Protocol for patients admitted with clinical diagnosisof malignant bowel obstruction secondary togynaecological cancer

Royal Cornwall Hospital NHS Trust

Winning Principle 3Clinical decisions should be made on a daily basis topromote proactive case management.

We have centralised the care ofwomen suspected of intestinalobstruction due to gynaecologicalcancer to the gynaecology ward. Thepatients are seen daily by thegynaecological oncology and palliativecare teams and managed according tothe protocol. This provides astructured approach to their care,assessing the role of surgery and ifinappropriate, attempts to managethe symptoms medically. Medicationis adjusted daily as required and ajoint review is made on the sixth dayto formulate ongoing care.

The prognosis for these women isoften poor and their management isusually haphazard resulting in longstays in hospital. The protocol aims toprovide a definitive plan ofmanagement within a week reducingthe stay in an acute hospitalenvironment.

We estimate that up to 30% ofwomen with ovarian cancer willpresent with intestinal obstruction aspart of recurrent disease.Management is audited against theprotocol using forms produced by thehospital audit department. Laminatedcopies of the protocol are kept in theward and placed temporarily in thepatients being managed. Thedevelopment of the protocol involvedthe gynaecological oncology andpalliative care teams as well as a leadnurse form the ward and the Trustaudit team.

Achievements and impactThe protocol commenced on the1 March 2010, with five patientsmanaged to date. Two have gone onto surgery and further chemotherapy,two have resolved with medicalmanagement and one has beenmanaged palliatively. Structuredquality of life has not been assessedbut we are intending to use theEORTC QOL questionnaires. Themanagement has been more proactiveand decisions made earlier than in thepast.

The results of the audit andmanagement will be evaluated aftersix months.

Lessons learnedDevelopment of the protocol was acollaboration between thegynaecological oncological andpalliative care team. It was presentedat the surgical directorate clinicalgovernance meeting as many of thesewomen are admitted under thesurgeons. The current problem ismaintaining a multidisciplinaryapproach over the weekends. Theevidence base involved an extensivereview of the medical literature relatedto the management of intestinalobstruction in gynaecological cancers.

Spread and adoptionAlthough in its infancy, the protocolhas centralised the management ofthese patients across the hospital andhas been supported by the generalsurgeons who are now transferringthese patients early in theirmanagement. They are alsoconsidering the use of the protocol innon gynaecological cancer cases.There have been requests fromclinicians in Leeds and London forcopies of the protocol.

(Haloperidol used if pain presentas cyclizine may precipitate withhyoscine butylbromide)

If opioid naïve, start at 10-15mg over24 hours, or 5-10mg over 24 hours iffrail / low body weight (10mgDiamorphine = 30mg oral morphine).

If already on opioids,Diamorphine/opioid dose to bediscussed with hospital palliative careteam – Monday – Friday 0900 – 1630or Specialist Palliative Care AdviceLine, 01736 757707 to accessdiscussion with Consultant on-call.

If considering use of oxycodone asinjectable opioid, bewareprecipitation with cyclizine insyringe driver.

Protocol for Patients Admitted with Clinical Diagnosis of Malignant Bowel Obstruction Secondary toGynaecological Cancer

Initial Audit Protocol – prospective from (01.03.2010)

Clinical diagnosis = abdominal distension, pain, nausea and vomiting +/- constipation or absenceof PR flatus, which may occur later.

Admission: Refer to Gynaecology Oncology, and Hospital Palliative Care TeamsTreatment Algorithm (Medical)

IV fluids. Nil by mouth.NG tube placement, IF ACCEPTABLE TO PATIENT

Colicky pain present Pain present but not colicky

Hyoscine butylbromide 60 – 80 mgs via Cyclizine 150 mgs+ syring

Haloperidol 3 mgs driver over Diamorphine/other opioid+/- 24 hrs

Diamorphine/other opioid

In addition: Transfer patient toWheal Agar Ward ASAPInvestigations:Abdominal x-rayAbdominal CT with contrast ASAP.

UNLESS:• Clearly unfit for any surgical orprocedural intervention

• Patient refuses to consider anysurgery or procedure

• Senior gynaecological surgicaldecision NOT for surgery (exclusioncriteria may include: previouslaparotomy precluding success,abdominal carcinomatosis evidencedby diffuse palpable tumours,massive ascites with rapid re-accumulation after drainage).

Specialist palliative care andgynaecology review• Face to face review within 24 hoursideally (or telephone review ifunavailable).

• Daily review both teams after.

A decision to proceed to surgerymay be taken at any point ifdeemed appropriate by seniorreview.Criteria may include:• Radiology suggesting highprobability of single-site obstruction(e.g. post-op adhesion or singlediscrete neoplastic mass)

• Low tumour bulk on imaging• Patient fit for surgery.


Day 2: Treatment algorithm(medical)If NG tube in place:Consider removal of NG tube if

• Nausea and vomitingcontrolled/significantly improved,and volume of NG drainage<500mls previous 24 hours

• Patient would prefer no NG tube.

Parenteral fluidReview need for intravenous fluid :

• May be appropriate to change tosubcut fluids

• May be appropriate to stop allparenteral fluids if patient clearlydeteriorating rapidly

• If symptoms well controlled, allowclear fluids by mouth and reviewneed for iv/sc fluids after 24 hours.

Symptom control review:• If nausea and vomiting remainuncontrolled consider change ofanti-emetic to Levomepromazine6.25 to 12.5 mgs per 24 hours insyringe driver

• If high volume vomiting/NG tubedrainage more than 1000 mls in 24hours despite nil by mouth and anti-emetics:• Add or increase Hyoscinebutylbromide to 120-160 mgs/24hours (do not mix with Cyclizine,if patient previously on Cyclizine,anti-emetics should be changed toLevomepromazine as above)

• Adjust opioid for pain relief asappropriate

• If high small bowel obstruction plusgastric dilation confirmed, consideradding proton pump inhibitor.

Gynaecological review re surgicalintervention using exclusion /suitability criteria as end page 1,initial section page 2Consider appropriate place of care –discussion with patient and family ifappropriate.

Day 3: Repeat assessments as perday 2 PLUSParenteral fluid:• If symptoms have become wellcontrolled in last 24 hours, allowclear fluids by mouth and reviewneed for iv/sc fluids after further 24hours

• Stop parenteral fluids if toleratingoral fluids.

Symptom Control Review• If high volume vomiting/NG tubedrainage greater than 1000 mls in24 hours despite previous measures:• Stop Hyoscine butylbromide andadd Octreotide 300 microgramsper 24 hours in syringe driver

• Adjust opioid and anti-emetic dosesas needed.

Day 4: Repeat assessments as perday 2 and 3 PLUSSymptom Control Review• If high volume vomiting/NGdrainage tube drainage greater than1000 mls in 24 hours despiteprevious measures :

• Increase Octreotide to 600microgms/24 hours in syringe driver

• Adjust opioid and anti-emetic dosesas needed.

Day 5: Repeat assessments as perday 2, 3 and 4 PLUSSymptom Control Review• If high volume vomiting/NGdrainage tube drainage greater than1000 mls in 24 hours despiteprevious measures:• Increase Octreotide to 900microgms/24 hours in syringedriver.

Consider appropriate place of care –discussion with patient and family ifappropriate.

Day 6:Joint or same day gynae/oncologysurgical and specialist palliative carereview:• Final decision regarding any surgicalor interventional options of care

• Definitive decision regardingongoing place of care if not madeearlier and no possible surgicaloptions

• If NOT for surgery, ongoingresponsibility of care betweengynaecology and specialist palliativecare until moved out of acute trust,or death of patient if unfit to bemoved.

• Consider PEG.



WINNINGPRINCIPLE4

The ‘FAB’ Programme:Fatigue, anxiety and breathlessness programme forpatients with lung cancer and their carers

Burton Hospitals NHS Foundation Trust, Queens Hospital

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

The trust tested a multidisciplinarycare approach to Fatigue, Anxiety andBreathlessness (FAB) for patients withlung cancer and their carers. Themultidisciplinary team included aRespiratory Physician, Physiotherapist,two Occupational Therapists, LungClinical Nurse Specialist (CNS),Dietician, Clinical Aroma therapist anda Fixed Term Therapy Assistant.

The FAB programmes aim supportsthe spread of Winning Principle 4 to:• Empower patients and carers totake control of their symptoms andmanage their own health needs.

• Reduce emergency admissions forpatients with lung cancer due toproblems related to the symptomsof fatigue, anxiety andbreathlessness, where appropriate.

• To provide patients and carers withthe knowledge and skills toeffectively manage symptoms athome, to avoid inappropriateemergency visits and/or admissionsto hospital.

• Provide access to high quality carefrom a wide range of health careprofessionals

• Increase the patient and carers’ability to effectively self-managesymptoms associated with a lungcancer diagnosis in the patient’sown home.

BaselineAn audit of 25 randomly selectedpatients with lung cancer accessingBurton Cancer Services wascompleted to look at non-electiveadmissions and to explore the reasonsfor emergency visits and hospitaladmissions. The results showed that,• 13 (20%) of the 64 non-electiveadmissions were due tobreathlessness.

• Average length of stay eight days.

Measuring improvementThe following evaluation methodswere used to measure the impact ofthe FAB programme:• An Assessment Toolkit completed bythe patient pre and post programmewhich includes:• Hospital Anxiety & Depression(HAD) Scales

• Fatigue Severity Scales• Breathlessness Scales• Goal Planning

• Patient and carer experience surveys• Review of the patient pathways forpatients to compare the number ofnon-elective admissions and lengthof stay for patients who do and donot attend a FAB programme.

Resource and investmentA bid for £10K was submitted to theEast Midlands Cancer Network inFebruary 2009, for non-recurrentService Improvement funding tosupport the initial local testing and theimplementation of 4 x 6 weekBreathlessness ManagementProgrammes for patients with lungcancer and their carers. The fundingsupported:• Sessional staff costs for twooccupational therapists and aphysiotherapist

• The fixed term appointment of atherapy assistant

• External venue hire to run theprogramme away the hospital site,in order to reduce feelings ofanxiety associated with attendingthe hospital for appointments andtreatment

• Patient transport.


ResultsTo date, three ‘FAB’ programmes havebeen run. The first two have beenevaluated from a patient’s perspective.

• The final FAB programme is due tobegin in September 2010 and aimsto include targeted chemotherapyawareness and inform carers aboutthe signs and symptoms ofchemotherapy related problems.

• Efficiency savings have been madethrough the provision of patienteducation around self managementtechniques in a group setting.Compared to providing support topatients and their carers/relatives ona one to one basis, group sessionsensure that both the patients, carersand staff time is valued.

‘The support and knowledgeof other patients and theirpartners was invaluable.’

• Patient/carer experience surveysevaluated the programme positively.Questions are asked to discover theusefulness of the programme, whattheir expectations of theprogramme were and if they wererealised, and how they intend to usethe information and techniques thatare covered within the programmeto help the patients and carers feelbetter equip to manage their owncare at home.

Patient responses

Have you found the FAB clinic useful?• “Yes - Useful to hear other people'sattitudes towards their condition.”

• “Yes - Joining in a group and beingable to talk to other people. Alsotalking to therapist involved.”

Did the FAB clinic meet yourexpectations?• “Yes - Opportunity to share viewsand learn basic techniques.”

• “Yes - Informative & helpful.”

Do you feel that the FAB clinic hashelped you to cope better with anysymptoms/problems you have beenexperiencing?• “I do feel I will cope much betterwith my problems. Relaxing andbreathing control especially.”

• “Yes - both for information &practical support.”

Do you feel that the FAB Clinic hashelped you to feel better able to copein a crisis?• “Yes - Anxiety being my mainproblem.”

• “Yes - Relaxation techniquespractised.”

Is there anything that you will dodifferently as a result of attending theFAB clinic?• “Not so inclined to panic.”

Carer responses

Do you feel that the FAB clinic hashelped you to cope better with anysymptoms/problems you have beenexperiencing?• “Helped me not to be overprotective.”

Do you feel that the FAB clinic hashelped you to feel better able to copein a crisis?• “To know the crisis is recognisedand how to cope with it emotionallyand physically.”

Is there anything that you will dodifferently as a result of attending theFAB clinic?• How to help my partner as she facesthe problems of FAB.

General comments• “As the partner of a patient, I feelbetter able to support my husbandthrough his experiences of acutebreathlessness, anxiety and generalfatigue.”


Outline of the FAB Programme

Goal planningDuring week one, patients are askedto consider specific problems, identifypersonal goals and to formulate anaction plan. This allows each patientto identify what is important to them.In addition it means that the staff areable to identify what support eachindividual needs to improve theirquality of life.

Figure 1 opposite, illustrates the typeof goals patients who attended thefirst FAB programme (FAB Programme1) set themselves.

Outlined below (figure 2) are some ofthe examples which illustrate each ofthe themes opposite.

FAB related• “To learn how to remain calm andused controlled breathing.”

• “To have more energy to do things.”• “To learn to relax and to talk toothers to relieve stress.”

Emotions• “To find ways to deal withaggression by talking andaddressing worries.”

• “To learn to accept help from othersand to recognise good friends.”

Lifestyle and independence• “To manage the train journey orflight to Lyon.”

• “To be to play football etc. withgrandsons.”

• “To be able to attend hospital andmedical centres independently.”

Preparation for others• “To prepare the relevant paperworkand to ensure family understandsmy wishes.”

• “To find a residential placement formy mother.”

Body image• “To stabilise weight.”

The goal planning element has beenproven to demonstrate improvementsin patient experience and selfmanagement from the end ofprogramme review. During week six

of the FAB programme, the patientsare asked to review their personalgoals and action plan and thencomment on any progress they havemade towards achieving them.

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10

8

6

4

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0FAB related Emotions Lifestyle &

IndependencePreparations

for othersBody Image

Goal Theme

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Figure 1: Planned goals for patients attending FAB Programme 1

12

10

8

6

4

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0FAB related Emotions Lifestyle &

IndependencePreparations

for othersBody Image

Goal Theme

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Figure 2: Goal planning actions achievedthrough the FAB Programme


Comments and outcomes stated bythe patients which illustrate each ofthe themes identified:

Follow advice given on course• “Easier to plan ahead appropriately,use relaxation techniques.”

• “Have benefited from taking toothers in the same situation, userelaxation techniques.”

• “Feel much calmer, breathingsettling into a routine, coping betterwith walking and managing thestairs.”

• “More controlled eating plan.”

To use techniques learnedat the group• “Have learned to pace myself and toconserve energy, I now setachievable tasks for myself.”

• “The write up in the FAB handoutwas good and it has helped but alsotalking as a group and practicingbreathing exercises.”

• “I now set two to three jobs a dayand do them in the morning takingshort breaks in between with coffeeand biscuits.”

Signposting and referral toother services• “To address blue badge parkingwith the authorities.”

Advanced care planning• “To source instructions, contacts,required forms etc.”

• “To liaise with Social Services.”

Advise to othersFollowing service improvementtechniques were useful in planning,implementation and development ofthe FAB programme, around:• Effective clinical engagement• Risk assessment• Action planning• Options appraisal• Experience surveys• Patient pathways.

Top tips• Ensure all key stakeholders areinvolved and kept up to date withthe progress

• Plan to use PDSA cycles to test eachprogramme

• Be flexible to develop programmeaccordingly.

Key challenges• Identifying performance measuresto assess the impact of the FABprogramme.

• Reduced attendance in the secondprogramme.

• Poor experience survey andassessment toolkit return for thesecond FAB programme.

Discussions have taken place with theFAB multidisciplinary team membersto explore the reasons for the lattertwo challenges. An options appraisalwas put together to outline strategiesthat could be explored to address thechallenges.

Evidence baseResearchers (Corner et al, 1996;Bredin et al, 1999; Syrett & Taylor,2003) have found that lung cancerpatients can benefit from amultidisciplinary, non-pharmacologicalbreathlessness intervention throughan increased functional level andability to perform activities of dailyliving. In addition patients reported areduction in feelings of anxiety andlevels of perceived breathlessness.

The next stage of the FAB programmeis to evaluate from a productivityperspective and to quantify the impacton reducing emergency admissionsthrough empowering patients.


Acknowledgements and referencesWith thanks to the staff andpatients at:

• Anglia Cancer Network• Aintree University Hospitals NHSFoundation Trust

• Burton Hospitals NHS FoundationTrust

• Cambridge University HospitalsNHS Foundation Trust

• Derby City Hospital NHSFoundation Trust

• Doncaster & Bassetlaw HospitalsNHS Foundation Trust

• East Kent and Canterbury Hospital• Hinchingbrooke Healthcare NHSTrust

• Hull & East Yorkshire HospitalsNHS Trust

• Pan Birmingham Cancer Network• Royal Cornwall Hospital NHS Trust• Sandwell & West BirminghamHospital NHS Trust

• West Suffolk Hospital• Whipps Cross University HospitalNHS Trust.

SHARING AND SPREADING YOUR SUCCESSTO IMPROVE PATIENT CAREwww.improvement.nhs.uk

Further details relating to the information and case studies in this publicationare available on our website at www.improvement.nhs.uk/cancer/inpatients

Further reading

NHS Improvement - TransformingInpatient Care Programme AnIntegrated Approach: TheTransferability of the WinningPrinciples - Sharing the Learning(July 2010).

NHS Improvement - TransformingInpatient Care ProgrammeConsolidation Report (2009): FromTesting to Spread (July 2010).

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

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

NHS Improvement - The WinningPrinciples – Transforming InpatientCare Programme for Cancer Patients(July 2008).

NHS Improvement TransformingInpatient Care Programme Team

Celia Ingham ClarkNational Clinical Lead TransformingInpatient Care Programme

Ann DriverDirector,NHS [email protected]

Angie RobinsonNational Improvement Lead,NHS [email protected]

Marie TarpleeNational Improvement Lead,NHS [email protected]

Catherine StrongPA Transforming Inpatient CareProgramme, NHS [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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