Whole system improvement in Forth Valley

1. Whole system improvement in Forth Valley Improvement and support team meeting 15th Jan 2009

2. Context • Period of significant change and innovation • National collaborative projects • Integrated healthcare strategy includes new acute hospital 2010-2011 • Consistent bed pressures • Need for step change in results from improvement activity • Implementation • Measureable benefit • Focus and prioritisation

3. Cycle Time (CT) Resources (R) = Takt Time (TT) Lean improvement • It’s about BALANCE and FLOW

4. Improvement on the ‘shop floor’ Failure Count Failure Reason 1 Failure Reason 2 Failure Reason 3 Failure Reason 4 Failure Reason 5 Failure Reason 6 # Who When Status Action ü 1 ~~~~~~~~~~~~ ~~~~ ~~/~~/08 2 ~~~~~~~~~~~~ ~~~~ ~~/~~/08 ü 3 ~~~~~~~~~~~~ ~~~~ ~~/~~/08 4 ~~~~~~~~~~~~ ~~~~ ~~/~~/08 1. Measure actual v target for key processes 2. Assign reasons for process failure, and count … Target Process performance time 3. Routinely act on the most costly failures using: Concern Cause Countermeasure Multi-disciplinary team, according to problem

5. Process 20th Oct start 2&3 Dec 17&18 Dec 12th Nov Phase 1 Phase 2 Phase 3 Phase 4 Phase 5 Phase 6 Prioritisation Event Policy & Planning Event Analyse the Forth Valley Whole System Top Team Event Analyse Priority Areas Evaluate Options 2 - 4 weeks 1 day 1 - 2 weeks 1-2 days 1 - 2 weeks 2 days

6. Executive challenge • Transition to new models of care across system • £14.5m - £25m savings by Mar 2011 • Maximum 18 week RTT by Dec 2011 • Resilient U&E flow = 98% A&E asap • Consistent, safe care: • HAI down by 30% by 2010

7. Specialist acute care tertiary services Community Pharmacists Clinic Day Patient In Patient GP Home Visit mental health; elderly care GDP district nursing health visiting Local Authorities Optom specialist nursing AHP (e.g. physio, OT) family health services Partner & Vol organisations other community services – partnership model with LA Forth Valley System Map NHS 24 OOH SAS MIU OOH, urgent & emergency services (community) A&E amb care in-patient refer to GP CAU acute receiving unit GP referral routine discharge rehab out-patient GP referral GP feedback AHP (physio) day case diagnostics complex discharge GP direct access acute services sub-contract out-reach refer on-going community care GP referral GP direct access

8. 166,000 - NHS 24 OOH 25,100 SAS MIU 52,600 OOH, urgent & emergency A&E services (community) amb care Specialist acute care refer to GP 26,000 LOS=6.8 GP CAU tertiary services referral 12,000 acute 27,500 M 4,300 routine in - patient receiving discharge unit GP out - patient referral 41,000 LOS=3.8 196,000 9,600 GP rehab feedback AHP ( physio ) GP diagnostics day case complex direct discharge access 13,500 acute services sub - contract out - reach 50,000 refer on - going community care Community 80% occ ; Pharmacists 294 beds 1,300,000 Clinic Home Visit Day Patient In Patient GP GP mental health; elderly care referral GDP district nursing 300,000 65,000 health visiting ~130,000 Local Optom 32,000 specialist nursing GP Authorities 81,000 AHP direct (e.g. physio , OT) family health services access 962,000 Partner & Vol other organisations community services – partnership model with LA 789k OP; 135k IP 7 Forth Valley Planning Event Forth Valley System Map

9. Specialist acute care tertiary services Community Pharmacists Clinic Day Patient In Patient GP Home Visit mental health; elderly care GDP district nursing health visiting Local Authorities Optom specialist nursing AHP (e.g. physio, OT) family health services Partner & Vol organisations other community services – partnership model with LA 166,000 Forth Valley System Map NHS 24 OOH 25,100 SAS MIU +1.1% 52,600 OOH, urgent & emergency services (community) A&E amb care in-patient +2% refer to GP CAU 26,000 LOS=6.8 acute receiving unit GP referral 38,000 12,000 routine discharge rehab 27,500 M 4,300 out-patient GP referral 41,000 LOS=3.8 196,000 9,600 GP feedback -26% +24% (new) AHP (physio) diagnostics day case complex discharge GP direct access 13,500 3,000 acute services +3% sub-contract out-reach 50,000 refer on-going community care +12% 330k AHP 32k Nr 28k DP; 17k OP 80% occ; 294 beds +5% 1,300,000 GP referral 300,000 65,000 ~130,000 32,000 GP direct access 81,000 963,000

10. Specialist acute care tertiary services Solutions to imbalance lie in whole system … NHS 24 OOH T SAS MIU T OOH, urgent & emergency services (community) A&E amb care in-patient refer to GP CAU acute receiving unit GP referral routine discharge rehab Q out-patient GP referral GP feedback Q Q Q AHP (physio) diagnostics day case complex discharge GP direct access acute services sub-contract out-reach refer on-going community care Community Pharmacists Clinic Day Patient In Patient GP Home Visit GP referral mental health; elderly care Q GDP district nursing health visiting Local Authorities Optom specialist nursing GP direct access AHP (e.g. physio, OT) family health services Partner & Vol organisations other community services – partnership model with LA

11. 1st OP Appt Outcome Discharged 24.8%DNA 4%Failed Discharge 1.7%Awaiting Results 8.8%Waiting List DC 4%Ref other Clinics 2.7%IP wtg list 7%Blank/Other 8.8%Further Appt 38.4% Losses = 29% of capacity Outpatients Scheduled capacity 80% of demand Demand 1000Capacity 793 23.4 wks 45 wks (83% > 18 wks) Quality Losses 17-42% 3.2 Planned Orthopaedics Outpatients OP – Lost Capacity Hips – Sept 08Capacity 363Pts seen 255(overtime 69)DNA 13Unfilled Appt 44Canc Clinic 50 home Pre-Op Theatre in-patient Discharge out-patient out-patient GP referral refer on-going community care day case diagnostics 9.5 wks 16.5 wks

12. Discharges by day of the week Approx 60 bed days a week (£1.6M p.a.) 19% Sunday shortfall

13. Opportunity to release bed capacity 30%

14. Distribution of acute LOS Avoid admission and ambulatory care … Are there 3 themes here ? Reduce LOS by improved inpatient and discharge processes Generally elderly patients. Avoid admission …

15. District nurse diary study:conclusions • Opportunities to increase productivity • Reducing lost time (eg. admin, meetings etc) • Scheduling domiciliary time more efficiently • Using lower grade staff for routine work • Shifting routine treatment room work to GP practices and phlebotomist • Improving predictive planning with acute services • Balancing nursing resource effectively to meet 7 day a week demand • Opportunities for released capacity • Increased capacity in treatment rooms to support acute discharge • Increased capacity for anticipatory care • Understanding return on investment of different options

16. NHS Forth Valley Priority Improvement Work-Streams Elective Work-stream Urgent & Emergency Work-stream Primary & Community Work-stream Reduce variation in referral management Redesign whole system U&E pathway Releasing/developing capacity in primary care and community services Mainstream advanced care planning to reduce inappropriate hospital admissions Systematic improvement in LA supported discharge Improve ‘home-to-home’ visibility of patient pathway Improve quality of Urgent and Emergency “front door” services Diagnostics Work-stream Systematic improvement of Labs Increase CT (MRI) productivity / capacity Reduce avoidable unplanned admissions Articulate the productivity benefits from 18 week programme Systematic improvement in acute in-patient management Enabling Work-streams : Leadership & Communication; Information & Metrics; Training; Programme Mgt;

19. Conclusions • Whole system perspective was revealing • Increased focus on primary and community care • Process highlighted the need for good information • Real focus on evidence • Challenged us about how we prioritise resource use • Produced plans with clarity and shared understanding