Ideas from UK modernisation: The Improvement Partnership for Hospitals

1. Ideas from UK modernisation: The Improvement Partnership for Hospitals Penny Pereira Ideas from UK modernisation

2. Ideas from the UK: Improvement Partnership for Hospitals Presentation content: • Overview of the IPH approach • Case study from an IPH site • Key learning points overview

3. Background But… • Not always having an overall impact • Not looking across the whole hospital • Some put off by too many initiatives There was already… • Lots of existing projects and activity • Work on many services / pathways • Staff with skills in each organisation The IPH approach - background IPH was set up to help hospitals create an integrated approach to improvement

4. Background • Designed to help meet demanding national targets: • 4 hour maximum wait in emergency department • Max wait for outpatients 13 weeks and falling • Max wait for inpatients 9 months and falling • Hospitals got £180k matched funding and support from a national team • c.150 hospitals participating since Jan 2003 The IPH approach - background

5. Patients who experience better care without delay High-performing patient-centred teams Clinical systems improvement The IPH approach The IPH approach - clinical systems improvement

6. Understand the variation • The root cause of delays for patients in the care system is not volume, it is variation • The greater the variation, the more capacity we need to meet demand • We create the variation through the way we organise our systems • If we reduce variation, we can make much better use of capacity The IPH approach - clinical systems improvement

7. Variation in demand for beds(admissions) The IPH approach - clinical systems improvement

8. Total Admissions Total Discharges 120 24-Dec-02 03-May-02 100 23-Aug-02 31-May-02 80 60 Number 40 20 0 04/29/2002 05/13/2002 07/08/2002 12/23/2002 01/06/2003 06/24/2002 08/19/2002 09/02/2002 10/28/2002 11/11/2002 04/15/2002 07/22/2002 09/30/2002 10/14/2002 04/01/2002 05/27/2002 06/10/2002 08/05/2002 09/16/2002 11/25/2002 12/09/2002 Date Variation in bed capacity (discharges) Number The IPH approach - clinical systems improvement

9. Average length of stay by day of medical admission 9 7.8 8 7.6 7.1 7.0 7 6.5 6.2 6.1 6 5 Average length of stay (days) 4 3 2 1 0 Monday Tuesday Wednesday Thursday Friday Saturday Sunday Variation in length of stay The IPH approach - clinical systems improvement

10. Patients who experience better care without delay Organisations that facilitate the work of patient-centred teams High-performing patient-centred teams Clinical systems improvement Organisational development The IPH approach The IPH approach - organisational development

11. OD self-assessment Resources & processes • Human resource management • Clinical systems & processes for quality improvement • Financial management Results • Patient experience & clinical outcomes • Staff experience & outcomes • Key performance targets • Value for money & productivity Strategic capacity • Leadership & direction • Policy & planning • Patient centred approaches • Partnership working The IPH approach - organisational development Intelligent information • Use of information about patient experience, outcomes, resources & processes • Staff knowledge, skills & experience • Information systems & use of technology

12. Patients who experience better care without delay Organisations that facilitate the work of patient-centred teams Environment that facilitates the work of organisations High-performing patient-centred teams Clinical systems improvement Organisational development Whole systems alignment The IPH approach The IPH approach - whole systems alignment

13. OD & whole systems alignment 1. Strong & visible leadership for improvement 2. Ambitious improvement goals agreed by all 3. Capacity in improvement skills at all levels 4. Networks to share learning across system 5. Headroom for improvement, with shared risk-taking 6. Investment based on analysis of demand & capacity 7. Approach to payment driven by clear, patient-centred principles to avoid perverse incentives 8. Working in partnership to unblock whole system constraints The IPH approach - OD & whole systems alignment

14. Case study Nottingham City NHS Trust One of four early pilots for IPH IPH case study – Nottingham City

15. Nottingham took a whole system approach… Discharge Diagnostics EMERGENCY PATHWAY Referral Assessment Treat Transfer of care CHD NSF Cancer NSF ELECTIVE PATHWAY Referral Admission Transfer of care IPH case study – Nottingham City AMBULATORY CARE Referral Treat Transfer of care Infection Control Older People NSF ‘Designed around the patient’

16. Overview of improvements to the Emergency Pathway Specific changes following months of diagnosis: • Each ward to discharge one patient before 10am • GP /A&E streaming patients in primary care • Reconfigure beds to create ESSU/EAU • Two acute physicians appointed (9am-6pm) • Changed bed co-ordinators role • No batching of bloods • Order sets instigated by Registered Nurse IPH case study – Nottingham City

17. Borders Sept 2002 – August 2004 85% reduction in daily mean, 50% reduction in variation IPH case study – Nottingham City ‘Designed around the patient’

18. Cancelled Operations April 2002 – August 2004 50% reduction in weekly mean, 50% reduction in variation IPH case study – Nottingham City ‘Designed around the patient’

19. Elective Inpatient Activity April 2002 – August 2004 Elective surgical inpatient admissions increased by 8% Feb-Jan 2004 compared to previous 12 months 30% reduction in weekly variation IPH case study – Nottingham City ‘Designed around the patient’

20. Additional benefits • The number of patients that are discharged within 24 hours has doubled from an average of 15% to 34% • Recruitment and retention of staff has improved. Sickness has reduced from 17% to less than 6% • Waits and delays in Emergency Areas are reduced. Baseline data showed that on average patients would spend 5 hours 17 minutes on the admissions unit; this has been reduced to 2 hours 59 minutes IPH case study – Nottingham City ‘Designed around the patient’

21. Staff satisfaction “It is clear that the changes you and all your colleagues have made in acute medical admissions have had a major impact of reducing last minute cancellations of surgical beds” Consultant Anaesthetist “It is a pleasure to workat the City Hospital once again, as things are running smoothly with my operating lists and I have not experienced any cancellations recently for which I am very grateful” Consultant Orthopaedic Surgeon IPH case study – Nottingham City ‘Designed around the patient’

22. What we learnt… Overall messages from our work in the UK Anything here that might be relevant for you? Key learning points

23. What we learnt… • Look across thewhole system in order to understand the real constraints • Create anintegrated approach to improvement: • Articulate a clear overall strategy • Join up improvement activities • Build improvement into mainstream business • Engage Executives, clinicians and staff at all levels and give them practical tools Key learning points

24. What we learnt… • Every organisation is different: Understand your system • Make time for in depth diagnosis • Invest in analysis and aim for real time data • Understand the small changes that will have a significant impact • Develop your organisation to have the strategy, skills and culture for really ambitious improvement Key learning points

25. This is what we learnt. Does this fit with your PFC work? www.modern.nhs.uk/iph Questions?