Orthotic Service Re-design

1. Orthotic Service Re-design Robert Jones Head of Therapy Services East Sussex Hospitals NHS Trust Fiona Jenkins Head of Physiotherapy South Devon Healthcare Foundation Trust April 2007

2. Collaborative Working • Framework for management of change • Service improvement • Out-patient appointment systems • Stroke • Development of new posts –eg. Consultant AHPs • Publications • Presentations, workshops, lectures; nationally and internationally • INSEAD case studies for leadership and MBA programmes • Web site

3. Orthotics

4. Identify Triggers for Change • History- tendering • Waiting times • Poor throughput • Level of complaints • Contract review • Lack of partnership working • High cost • Lack of “ownership” • Clinical governance

5. Triggers for ChangeManagerial Imperatives • Finance • Clinical Governance • Cost improvement • Economical orthotic purchasing arrangements • Management (ownership) • Service Improvement

6. EastbourneOrthotics service History: • Tendered service several times between mid-1990s and 2003 • Felt there could be improvements in: patient focus, clinical effectiveness, economy of purchasing, efficiency to the organisations.

7. Essential Actions - Setting Direction • Strategic Thinking • Strategic Planning • Action

8. Essential Actions • Develop a patient centred service • Improved clinical governance • Cost effective • Better collaborative working • Improved processes • Improved partnership working • Establish multidisciplinary project group • Head of Therapies (chair) • Managers from Trust and PCT • Podiatry • Purchasing and supplies • Finance

9. Issues to be Resolved • Non competitive prices of outsourced orthotics • Process and systems design • Staffing • Finance systems • Governance arrangements • Management arrangements • Travel requirements • Storage of orthoses

10. Shared Vision • Objectives • Agree project vision - Vision of employing own orthotist with cross organisational clinics - To tender service simultaneously if unsuccessful in recruiting • Critical success factors • Patient focussed • Shared paperwork • Shared systems • Finance

11. Essential Actions - Timing • Timetable - agreed project time frame • Specification phase • Implementation • Determine evaluation parameters

12. Essential Actions - Staff Participation • All Inclusive - clinical input essential • Ownership - acute and primary care • Open - wide range of stakeholders included • Transparent - notes of meetings, project plan • Ideas - generated by clinical staff

13. Essential Actions - Negotiation with Stakeholders Identify stakeholders - patients - trusts - staff - referrers - multidisciplinary team

14. Essential Actions- Implementation • Taking the plunge • Recruitment • Transport • Locations • Induction • Communication • Training

15. Indicators for Success MANAGEMENT • Commitment, responsibility, authority and accountability • Strategic thinking • Communication • Creativity • Negotiating, Influencing • Resources • Political awareness • Inclusive style/ team working

16. Indicators for Success LEADERSHIP • Clear vision and focus • Enthusiasm and commitment • Communication • Ability to challenge ‘comfort zones’ • Empowerment of staff at all levels • Ownership – whole team involvement • Create Alignment

17. Funding arrangements Clinical governance issues Invoicing, ordering, storage, outsourcing Clinics, venues Job description, pay, funding Management arrangements Interdisciplinary working arrangements Communication Paperwork systems Information systems Referral mechanisms Liaison with consultant clinics Relationship – Consultants and their teams, AHPs and GPs Venues for clinics Financial controls Actions Agreed

18. Results • Advice from NHS supplies – they would need 3 years to change their processes! • Project completed in 4 months

19. Results – Waiting Times: weeks

20. Results – Waiting time complaints

21. Results – Cost savings: £

22. Results – Clinical Governance • Improved patient experience – less wait, more time with orthotist • Improved clinic throughput • Standardised referral/appointment systems • Standardised record keeping • Improved multidisciplinary record keeping • Improved data collection • Management arrangements established • Cost effective

23. Evaluation • Completion within time and resources - 4 months work, significant savings, improved service • Success criteria -Appointed own orthotist -Outsourcing of purchased orthotics • Training - Systems put in place • Feedback - patient feedback excellent - won Trust award for outstanding improvement in service to patients • Adjust and re-evaluate -ongoing audit

24. Sustainability • Expansion of service to Hastings Conquest and Bexhill Hospital 2004-05 • Orthotist left in 2005, able to immediately recruit and replace • Has been easy to find locum orthotist cover for holidays • CRES target met • PbR will influence interdisciplinary referrals and primary care referrals – less streamlined for patient

25. Transferability • South Devon adopted this service improvement model • Problems similar – though proportionately larger spend on orthotics that Eastbourne • Had tendered the service several times and had an orthotics service provided by an orthotics company • Potential for savings identified • Tendered service with an in-house bid employing own orthotist • In-house bid unsuccessful

26. Learning Points • Understand context • Constraints and barriers • Clear vision • Importance of people • Variety of management styles • Communication • Infrastructure • Resilience • Huge potential for national service improvement if this was rolled out.

27. Implications • Nationally orthotic services not well organised and could be improved • Improvements in patient care are realisable • Potential for much economic, efficient and effective service re-design • Improved clinical governance, accountability,responsibility, ‘ownership’

28. Contact Information robert.jones@esht.nhs.uk fc.jenkins@nhs.net Robert and Fiona Website: www.jjconsulting.org.uk