WHOLE SYSTEMS IMPROVEMENT

CONTENT

1. Overview of NHS Tayside and the challenges facing it

2. The NHS Tayside improvement journey

3. Centre for Organisational Effectiveness

4. A Whole Systems Approach

5. The Improvement Programme and Projects• Virtual Ward Demonstrator

• Medicine for the Elderly Demonstrator

• Outpatients Efficiency Demonstrator

6. The Benefits

THE BALANCING ACT….

» NHS Tayside delivers healthcare to over 400000 patients with a budget in excess of £750m. We employ over 14000 staff and provide a comprehensive range of primary, community and acute hospital services for the populations of Angus, Dundee and Perth and Kinross.

» NHS Tayside’s principal health organisations comprise the NHS Tayside board, the single delivery unit and the Community Health Partnerships in Angus, Dundee and Perth & Kinross.

» Meeting Scottish Government Efficiency & Productivity SR10 challenge, £27.4m in 2010, £30.0m in 2011/12 following November’s budget.

» Continuing to deliver against the Scottish Patient Safety Programme and meeting the demands of the recently announced NHS Scotland Quality Strategy

» Demographic challenge around Older People’s services

HEALTHCARE DEMAND IS GROWING

Demographic change for population aged 65+ ScotlandPotential impact on emergency bed numbers 2007-2031

0

2000

4000

6000

8000

10000

12000

14000

16000

Y/E Mar 2007 Projected2011

Projected2016

Projected2021

Projected2026

Projected2031

Year

Be

ds

NHS Tayside+148 beds 2016+517 beds 2031

A new NinewellsHospital by 2031!

IMPROVING QUALITY REDUCING COSTS

Our Choice

Surviving – the 5%

Thrive – the 95%

2009-2011 – A TACTICAL JOURNEY

TACTICAL STRATEGIC

PRODUCTIVITY & EFFICIENCY

CRES

SERVICE OPTIMISATION

TRANSFORMATION

DEALING WITH THE 5%

SPENDING THE 95% BETTER

2010-2012 – A BLENDED APPROACH

TACTICAL STRATEGIC

PRODUCTIVITY & EFFICIENCY

CRES

SERVICE OPTIMISATION

TRANSFORMATION

DEALING WITH THE 5%

SPENDING THE 95% BETTER

CRES

2010-2012 KEY OUTCOME AREAS

TACTICAL STRATEGIC

PREVENTION OF ADMISSION

IMPROVED DAY CARE

IMPROVED SERVICE LIASON AND DISCHARGE

REDUCE LENGTH OF STAY AND BED DAYS

COST MINIMISATION

WORKFORCE EFFICIENCY

TELEHEALTH / TELECARE

CASE MANAGEMENT IMPROVED PATHWAYS

INTERMEDIATE CARE

CARE HOME INTERFACE

MEDICATION REVIEWS

HOUSING / HOMECARE SUPPORT

ENABLING TECHNOLOGY

INTEGRATED HEALTH AND SOCIAL CARE SERVICES

VIRTUAL WARDS

WORKFORCE REDESIGN

SELF CARE AND ENABLEMENT

NEW MODELS OF CARE- DEMENTIA, FALLS AND END OF LIFE

WORKING WITH COMMUNITIES -COPRODUCTION

WHOLE SYSTEMS ANALYSIS

Endoscopy

A&E

in-patient

out-patient

rehab

day case

acute services

acutereceiving

ward(Med/Surg)

MIU

SAS

OOH

OOH, urgent & emergency services (community)

NHS 24

GDP

GP

Community Pharmacists

family health services

Optom

refer to GP

sub-contractout-reach

Specialist acute care

tertiary services

routinedischarge

complexdischarge

LocalAuthorities

Partner & Vol organisations

refer on-going community care

1.09 million

75,979

26,077

656,466

21,089

44,242

67,032

?

104,669

242,268

3.45 LOS U/Sched

4.0 LOS Elective

Walk-In43,967

Radiology

20,670

GP referral

GP direct

access

GP referral

day patient34,659

OutpatientClinic

Community Services – partnership model with LA

Home Visit

district nursinghealth visitingspecialist nursingAHP (e.g. physio, OT)

elderly care

Care in the community

Community (day) Hospitals

mental health

Day Patient

Inpatient

other

8,725

36,929

430,000

120,000

52,300

128,685

247,703

99,006

37,273

6,697

Laboratory10,685,631

?

86,204

77,041 3,586

Endoscopy

95,592

17,430

M 5,360

15,881

Direct access inpatients

27,352

48,627

+ 12%

+ 3%

+ 1.8%+ 8%

Endoscopy

A&E

in-patient

out-patient

rehab

day case

acute services

acutereceiving

ward(Med/Surg)

MIU

SAS

OOH

OOH, urgent & emergency services (community)

NHS 24

GDP

GP

Community Pharmacists

family health services

Optom

refer to GP

sub-contractout-reach

Specialist acute care

tertiary services

routinedischarge

complexdischarge

LocalAuthorities

Partner & Vol organisations

refer on-going community care

1.09 million

75,979

26,077

656,466

21,089

44,242

67,032

?

104,669

242,268

3.45 LOS U/Sched

4.0 LOS Elective

Walk-In43,967

Radiology

20,670

GP referral

GP direct

access

GP referral

day patient34,659

OutpatientClinic

Community Services – partnership model with LA

Home Visit

district nursinghealth visitingspecialist nursingAHP (e.g. physio, OT)

elderly care

Care in the community

Community (day) Hospitals

mental health

Day Patient

Inpatient

other

OutpatientClinic

Community Services – partnership model with LA

Home Visit

district nursinghealth visitingspecialist nursingAHP (e.g. physio, OT)

elderly care

Care in the community

Community (day) Hospitals

mental health

Day Patient

Inpatient

other

8,725

36,929

430,000

120,000

52,300

128,685

247,703

99,006

37,273

6,697

Laboratory10,685,631

?

86,204

77,041 3,586

Endoscopy

95,592

17,430

M 5,360

15,881

Direct access inpatients

27,352

48,627

+ 12%

+ 3%

+ 1.8%+ 8%

Assessing the management

information requirements to support

better patient flow management

To consult with stakeholders across

the whole system & recommend

areas of priority

Identify areas of existing & potential

constraints within the whole system

Assess the performance of the

whole health system with respect to

local and national targets

Identifying the areasfor improvement..

STEPS TO BETTER HEALTHCARE

Finance Support

Workforce Support

Scenario Planning, Financial Baselines, Benefits Tracking, Business Cases

Workforce Modelling, Engagement & Communications with staff

Comms SupportCommunications with public and staff

OE SupportOrganisational Effectiveness support (includes eHealth)

Mental Health

Theatre Capacity

Workforce Efficiency

Integrated Care

Older People

Mental Health

Optimising Facilities

Prescribing Medicines

Others Labs, Maternity

Tayside Centre for Organisational Effectiveness www.t-coe.org.uk

IMPROVEMENT ACADEMY INNOVATION HUB & E HEALTH DEVELOPMENT&SUPPORT

INTEGRATED CARE(VIRTUAL WARDS) - THE CHALLENGE

• Emergency admissions and associated bed days not hitting HEAT T12 target..

• Challenge around Health Population Management (HPM)

• Lack of effective collaboration between Health and Social Care

• Alignment of e Health with key HEAT T6-T12 outcomes

• Key improvement areas:

1. Reduce over 65’s Emergency Beds

2. More effective HPM

3. Effective MDT working

4. Reduction in Polypharmacy

• Next future state workshop brought together over 70 integrated care professionals and patient groups…

• Followed up by local sessions in CHP areas…

• NHS Tayside worked with partners to develop new HPM toolset – PEONY2

• Test of Change Demonstrators set up in each CHP

• Wider collaboration with Social Care, Voluntary Sector and Social Care

• Align outcomes with LDP, HEAT and Reshaping of Older People’s services

INTEGRATED CARE(VIRTUAL WARDS) - THE APPROACH

STEP TO BETTER HEALTHCARE – INTEGRATED CARE

DESIRE

Our Future

Prioritise Outcome based

response

TaysideCommunity

Today

TaysideCommunityTomorrow

What do youSee?

What do youWant?

What now?Make it real!

‘Test of Change’Demonstrators

Align BenefitsRealisation

Art of the probable?

Truly needsBased! Impact

Assessment

We are here

23/08/11

ADOPT

LEARN

Initial Outcome Areas• T12 Emergency Bed Days over 65’s• T6 Long Term Conditions admissions• Patient experience• Releasing Time for Community Care• Medication Concurrence

IHI CARE CO-ORDINATION MODEL

Goals(G) Co-ordination(C)

ValueProposition

Family, associated assets

PATIENTIDENTIFICATION

OUTCOMES

Feedback Feedback

For people with multiple

needsFamily Social CarePeer GroupsCarer/s Voluntary

Supporting with

enabling technology

Predictive RiskTools

GP SystemsCommunity Information

Systems

TelehealthTelecare

Performance Management

Business Analytics

Personalised Multi-channel interfacePerson Centred

CARE CO-ORDINATOR

ServiceDesign

ServiceDelivery

ANGUS CHP – PATIENT PROFILE

Macro IntegratorNHS Tayside and Angus Council

724

10148

25372

72487LTC’sAsthma

6101COPD2056

Diabetes4698

HBP16423

CHD5318

LEVEL 1HEALTHY

COMMUNITIES

2%LTC

Population

MICRO INTEGRATORS

LEVEL 2SUPPORTED SELF CARE

LEVELS OF CAREVIRTUAL

WARD

ANTICIPATORYCARE PLANS

PATIENT PASSPORTS

CASEMANAGEMENT

LEVEL 4INTENSE

CASE MANAGEMENT

LEVEL 3CASE

MANAGEMENT

PRO-ACTIVECONTACT

SUPPORTINGSELF CARE

PREDICTED RISK PROFILE

70%LTC

Population

28%LTC

Population

66%Overall

Population

Obesity11854

PRO-ACTIVECONTACT

SUPPORTINGSELF CARE

North West

187

North West

2631

North West

6577

North West

18790

North East

191

North East

2673

North East

6684

North East

19096

South

346

South

4844

South

12111

South

34601

Virtual Wards focusing on Tier 4 , Innovative Step Down Services are key to success!

Project DefinitionStatement

Benefits Statement

Project Status Report

ENSURE OUTCOMES ARE DELIVERED….

Is used for:

1. Stating your case for change

2. Current state analysis

3. Evidence / Data4. Envisaged Change5. Summarise

benefits

Is used for:

1. Define benefits in detail

2. Define appropriate measures

3. Summarise enabling changes ( PP&T)

4. Summarise milestone tracking

Is used for:

1. Report on delivery progress.

2. Report on Benefits Realisation against plan.

3. Escalate to Project Board or EMT for decision, support etc

Multi- disciplinary Project Board, Clinical and Finance essential

RESHAPING CARE FOR OLDER PEOPLE – OUTCOMES 1

Programme No Outcome 1

Outcome 2

Outcome 3

Outcome 4

Outcome 5

Outcome 6

Outcome 7

Outcome 8

Outcome 9

Outcome 10

Maintain people at home

Avoid Social Admission

Reduction in hospital admission

Avoid re-admission

Avoid DelayedDischarge

Reduced Bed Days

Reduction in Acute Beds

Reduction in Care Home placement

Reduction in Care Home admissions

Reduction in acute psychiatric beds

W1 Housing with care P1

W1 Effective assessment in community

P2

W1 Continuing Care in Care Home

P3

W1 Telehealthcare P4

W1 At risk assessment and support

P5

W1 Integration P6

W2 Improve service for people living with Dementia

P7

W2 Enhance OT & Equipment Service

P8

W2 Carer Support P9

W2 Capacity Building & Co-production

P10

W2 Improved models of public information

P11

Programme No Outcome 11

Outcome 12

Outcome 13

Outcome 14

Outcome 15

Outcome 16

Outcome 17

Outcome 18

Outcome 19

Outcome 20

Reduction in emergency respite placements

Improved quality of life for patient and carers

Improve service user and carers health

Improved Efficiency

Sustainable joint workforce with right skills mix

Reduction in building costs

Integrated assessment framework

Build community resilience

Develop social enterprise

Increased choice

W1 Housing with care P1

W1 Effective assessment in community

P2

W1 Continuing Care in Care Home

P3

W1 Telehealthcare P4

W1 At risk assessment and support

P5

W1 Integration P6

W2 Improve service for people living with Dementia

P7

W2 Enhance OT & Equipment Service

P8

W2 Carer Support P9

W2 Capacity Building & Co-production

P10

W2 Improved models of public information

P11

RESHAPING CARE FOR OLDER PEOPLE – OUTCOMES 2

TECHNOLOGY ENABLING INTEGRATED CARE

Glu

e

Integration Platform

Acc

ess

De

vice

Use

r

Se

curit

y

Ap

plic

atio

ns

Clinical Portal

PMS GPCommunity

Health&Social

Virt

ual

Dat

abas

e

Se

rvic

e

Sta

ff ID

RB

AC

TELEHEALTH

TELECARE

PREDICTIVE RISK

BUSINESS ANALYTICS

Complex Case

Management

CaseManagement

Pro-activeContact

Prevention

Collaboration Tools

Clinician Manager Administrator Patient

• Test of change demonstrators commenced March 2011 following introduction of PEONY2…

• Enabling technology being fully utilised

• Aligning with local improvement initiatives eg CMR in Angus, Case Management and ACP’s across Tayside..

• Envisaged benefits across Patient Access, Service Redesign and Patient Experience:

1. Drive effective attendance at A&E

2. Reduction in unscheduled bed days

3. Effective discharge models

4. Focus on the right patients

5. Increase value multi-disciplinary team time

6. Net CRES of £1.5-2.0m per annum.

NHS Tayside BSU Dashboard Test of Change

Safe Effective Timely

Efficient Equitable Patient Centred

INTEGRATED CARE(VIRTUAL WARDS) - THE BENEFITS

MEDICINE FOR THE ELDERLY-BUSINESS CHALLENGE

• No standardised operating procedures, resulting in unwarranted variation at each stage of the patient journey..

• Over 40% of all patient admissions are elderly, and will GROW!

• Variation in LoS across MfE wards..

• Average LoS higher that ‘best of breed’, around 28 days..

• Discharge planning not always linked to EDD..

• Issues around capability and capacity of downstream services..

• NHS Tayside Service Improvement team and Atos supported an MDT through a pathway redesign process…

• A collaboration of extensive healthcare experience and application of LEAN thinking…

• Initial review highlighted large amounts of waste and variation

• 7 key improvement areas identified:

1. Admission Criteria

2. Inpatient management

3. Discharge planning

4. Social work redesign

5. Staffing profile

6. Co-located wards

7. Step up / Step down

MEDICINE FOR THE ELDERLY- OUR APPROACH

• Wide variety of Service Improvements achieved, qualitative and financial…

• Patient focus and removing waste has delivered a higher quality more cost effective service…

• Key outcomes/benefits achieved:

1. Reduced inappropriate admissions

2. Reduced Length of Stay (28-18 days)

3. Lower re-admissions

4. Closure of 2 wards

5. CRES in excess of £1.4m per annum.

NHS Tayside BSU Dashboard Test of Change

Safe Effective Timely

Efficient Equitable Patient Centred

MEDICINE FOR THE ELDERLY- BENEFITS

CAPACITY BUILDING IS…

An approach to the development of sustainable skills,

organisational structures, resources and commitment for

healthcare improvement

Hawe et al: 1999

CHARACTERISTICS REQUIRED TO DELIVER IMPROVED OUTCOMES

Build Infrastructure

& Capacity

Quality improvement education programme

Evidence based learningLeadership development

Technology & Innovation• Real time

measurement and information systems

Priorities maintained during crises Stability of general management and

program management Supporting and enabling staff in their “day

job” of improvementAdaptive internally and externally

Alignment:• Will and commitment• Vision• Strategy• Culture• Measurement• Learning organisation

Ref: Staines 2009

TAYSIDE CENTRE FOR ORGANISATIONAL EFFECTIVENESSwww.t-coe.org.uk

Develop an innovative education and training resource to build further out capacity and capability in improvement science.

Real time information and measurement resources to support quality improvement of clinical services.

Enhance spread and share of good practice through use of technology e.g. Clinical Portal, Clinical Dashboards.

Mobilisation of trained experts in quality improvement organisational development and leadership to support improvement work.The focus of this expertise will be mobilised to support front line staff and clinicians to build capability in improvement methodology and support key improvement programmes

A dynamic approach to knowledge transfer which supports our “All teach: All learn” philosophy in support of quality improvement.

Technology Enabling

Health

Knowledge Management

Improvement Academy

Improvement &

DevelopmentSupport

MAKING BETTER PLACES,MAKING PLACES BETTER

Our Stretch Challenge 2011-2015

“ those who are less able to coproduce and use public services as a resource in their

lives, experience much more negative outcomes”

This accounts for 40% of public sector expenditure in Scotland

SUMMARY

• A whole system approach is key..

• Identify high impact projects and prioritise resource..

• Leadership aligned with core personal objectives key..

• Skills transfer critical to accelerate Continuous Improvement across whole system..

• Quality improvement with associated CRES can be achieved..

• Early engagement of whole system stakeholders essential..

• Pro-active internal/external communication policy..

• Build on best practice evidence and focus on reducing unwarranted variation…