delivering major breast surgery safely as a day case or one night stay (excluding reconstruction)

NHSNHS Improvement

Delivering major breast surgery safely as a day case or one night stay(excluding reconstruction)

WINNER

76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:05 Page 2

Referral(2 weekwait)

Diagnosis &Assessment

Admission

Intra-operative

Post-operative

SurgicalFollow-up

(Same day one stop/two visit system)

Pre-operative

Continuing care for cancer

patients

GeneralPractitioner

Routinescreening and

assessment

(80% of referrals)

(20% of referrals)

MDT

MDT

Primary careoptimising pre- operative health• Blood pressure • BMI, diabetes etc.• Lifestyle advice• Patient choice • Patient information

Pre-operative assessment • Overnight booking the exception not the rule• Full clinical and risk assessment eg venous thromboembolism

prophylaxis• Anaesthetic/co-morbidity management seek prompt specialist

advice• Patient education: e.g. mobility - physiotherapist/nurse/DVD• Prosthesis advice• Prescribe TTO’s• Check patient informed surgical consent• Inform patient of admission time, length of stay and discharge

date and time• Plan theatre scheduling and timing

Anaesthetics/surgery• Anaesthetics: short

acting, use local anaesthetic

• Analgesia: non steroidal/non opiate

• Minimal intra operative fluids

• Sentinel Node Biopsy*• Drains the exception not

the norm

Post surgery follow-up options• No follow up required• Patient activated e.g. telephone

call/questionnaire• Pro-active follow up call• Outpatients appointment• GP follow-up• Open access: seromas/drain

management and complications• Joint clinic: e.g. further treatment

options; chemotherapy/radiotherapy• Palliative care

Diagnosis• Full clinical assessment• Imaging: Mammogram/ultrasound/ +/-MRI +Chest X-ray • Pathology: Core/fine needle biopsy • Bloods• Discuss informed consent• Pathology reportingOutcomes• Discuss results• Involve patient in choice of treatments/trials/reconstruction• Obtain patient informed surgical consent• Confirm treatment/surgery date ** Pre-operative assessment• Provide patient information prescription, hand held

record/care plan/patient diary• Inform patient of next steps• Inform GP positive results within 24 hours/negative within

10 working days

Admission (Day Unit, Treatment Centre,Surgical Ward)• Admit day of surgery• Starvation – the ‘2 and 6’ rule fasting

time 6 hours for food and clear fluids 2 hours prior to surgery

• Consider carbohydrate drink)• No pre med• Pre-op analgesia (paracetamol/non

steroidals)

Post-operative• Analgesia: avoid PCA/opiates• Provide nutrition and mobilise• Nurse led discharge • Patient and GP discharge summary with 24

hour contacts and wound care advise• GP discharge summary• Drain management information (if required)• Fit prosthesis• Dispense TTO’s

Continuing care for cancer patients• Continuing cancer care

assessment care plan (including referral as appropriate to AHPs)

• Education – self care management programme

• Palliative care

*Intra-operative - Sentinel Node Biopsy Analysis: This is an emerging technique and needs to be evaluated.

Patient informed decision making

Day case or one night stay breast surgical pathway (excluding reconstruction)

NHSNHS ImprovementASSOCIATION OF

BREAST SURGERY

NHS Improvement would like to thank the thirteen clinical spread networks, the British Association of DaySurgery, the Association of Breast Surgery, Breakthrough Breast Cancer, clinical advisors and patients fortheir support.

Acknowledgements


Foreword

Why should major breast surgery be an inpatient procedure?

From testing to spread... the approach

Keep improvement simple

Influences, innovation and incentives for spread

Transforming Inpatients Framework for Spread application in practice:

1. Collaboration, partnerships and team working

2. Learning and unlearning

3. Continuous monitoring: Measuring spread and adoption

4. Patient centred

5. Spread simple principles and messages

6. Alignment with opportunities and levers

7. Leadership, engagement and accountability

Summary

References

Delivering major breast surgery safely as a day case or one night stay 3

www.improvement.nhs.uk/cancer

Contents

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5

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Twenty five years ago,when I was first aconsultant medicaloncologist specialising inbreast cancer, patientsundergoing breast surgery(mastectomy or breastconserving surgery) typicallystayed in hospital for 10days. Within a few yearsthis had fallen to five days,but that then became the norm.

Much more recently a second revolution in surgical carehas taken place. It is now recognised that the vastmajority of operations for breast cancer (excludingoperations for breast construction) can be safelyundertaken as a day case procedure or with a singleovernight stay.

NHS Improvement has been working with clinical teamsacross England to transform the way in which breastsurgery is delivered. This work has been supported bythe British Association of Day Surgery, the Association ofBreast Surgery and by patients. All the partners haverecognised that the transformation is good for patientsand good for the NHS. Patients do not need to beadmitted to hospital the night before surgery. Equallythey want to return to normal life as quickly as possible.

The original hypothesis underlying this work was thatstreamlining could reduce length of stay by 50% andrelease 25% of unnecessary bed days for 80% of majorbreast surgery (excluding reconstruction). This goal hasbeen exceeded. Mean length of stay has reduced form2.35 days to 1.35 days overall. The number of patientswith length of stay greater than one day has beenreduced markedly. Overall bed days have been reducedby more than 40%.

Although improvements have been observed in mostNHS Trusts, significant reductions in lengths of stay couldstill be achieved in some areas. I urge them to read thisreport and to take action. Meanwhile I would like tothank all those who have delivered both quality andproductivity – a remarkable example of ‘QIPP’ in action.

Professor Sir Mike RichardsNational Clinical Director for Cancer and End of Life Care

Delivering major breast surgery safely as a day case or one night stay4

www.improvement.nhs.uk

Foreword

I am delighted to have theopportunity to introducethis work thatdemonstrates theeffectiveness of providingmajor breast surgery as aday case or one night stayprocedure.

This programme is a verysuccessful demonstration ofdeveloping and spreading a new way of working thatmeets patients’ expectations and reduces the demand onin-patient beds at the same time in a safe and effectivemanner.

Many patients who need breast surgery areunderstandably anxious about their diagnosis, and thishas often been compounded historically by the need tospend several nights in hospital, away from their families.This NHS Improvement work has been able to changethe way in which such patients are managed, and reducethe ‘medicalisation’ of their care, so that many feel thatthey are able to retain their autonomy and get throughthe process of health care more easily.

It is a clear advantage, in the current extremely tighteconomic environment, that this change benefitspatients, is also to the benefit of those managing thehealthcare budget since it reduces the demand for in-patient beds for a large cohort of patients and thus savesmoney for trusts.

The day case and one night stay breast surgeryprogramme was started in a small area and has spread,via NHS Improvement methodology, to hospitals acrossthe country. It has now been taken up by others beyondthe programme as well, resulting in a significant shift innational figures for length of stay for patients havingbreast surgery.

This is a quality improvement that helps patients andhealthcare organisations; its very pleasing to think thatmany patients who have to have breast surgery will begoing “Home for Tea”!

Celia Ingham ClarkNational Clinical Lead for Transforming Inpatient Care


Delivering major breast surgery safely as a day case or one night stay 5


• It’s a relatively short operation• Low post operative pain• Patients can mobilise, eat and

drink early• Rare post operative events• Patients want to return to

normal life as quickly as possible.

In 2007, NHS ImprovementTransforming Inpatient CareProgramme as part of the CancerReform Strategy (2007) and recentlythe Improving Cancer OutcomesStrategy (2011) redesigned the breastcare surgical pathway (excludingreconstruction) with the workinghypothesis that:

“Streamlining of thebreast surgical pathwaycould reduce length ofstay by 50% and release25% of unnecessary beddays for 80% of majorbreast surgery (excluding

reconstruction).”

Good progress has been made • 72% of breast surgery patients

across England now benefit fromthe pathway, this number continues to increase indicating that 85% is achievable, exceeding the original hypothesis.

• There has been a gradual shift in theoverall length of stay for patients (Figure 1). The traditional inpatient pathway had a range of length of stay from 0-7 days (2007, Hospital Episode Statistics (HES)

• Currently (2011) around 42% of breast surgical procedures have length of stay (LOS) = 0 days and a ‘day case’ ranging from 6 to 12 hours

• A further 30% have LOS of one night only, (2010/11 HES provisional)

• The overall mean LOS has reduced by 56%, exceeding the original working hypothesis (Figure 2).

Why should major breast surgery be an inpatient procedure?

Figure 1: The increasing shift to day case and one night stay has been gradual

Figure 2: Breast surgery patients - Elective mean length of stay

60,000

50,000

40,000

30,000

20,000

10,000

0Year06/07

Year07/08

Year08/09

Year09/10

Year10/11 V13

Num

ber

of P

roce

dure

s

No. of inpatient admissions LoS >1No. of inpatient admissions LoS >1

No. of inpatient admissions LoS = 0,1

No. of day cases

Breast Surgery Patients - Elective Procedures

3.5

3.0

2.5

2.0

1.5

1.0

0.5

0Year06/07

Year07/08

Year08/09

Year09/10

Year10/11 V13

Mea

n Le

ngth

of

Stay

Mean LoS - Inpatients only Mean LoS - Overall

3.15

2.78 2.57

2.332.032.35 2.04

1.81 1.61

1.33

Figures 1, 2 and 3 source: TransformingInpatient Care – HES Breast Surgery Patients,a paper for the National TransformingInpatient Care Committee, Sep 2011, basedon HES extraction by NATCANSAT, andanalysis by DH. Further details on the HESextraction are provided in appendix 1.


Figure 3: Breast surgery bed days reduced by 41%, exceedingthe working hypothesis

140,000

120,000

100,000

80,000

60,000

40,000

20,000

0Year06/07

Year07/08

Year08/09

Year09/10

Year10/11 V13

Num

ber

of B

ed D

ays

Bed days for inpatient admissions LoS >1

Bed days for inpatient admissions LoS = 0,1

Breast Surgery Patients - Elective Bed Days

Delivering major breast surgery safely as a day case or one night stay6


• Bed days for breast cancer have reduced from the baseline by 50,329(41%) with most of the reduction due to shorter lengths of stay for episodes longer than a day; although the increase of short stays (zero or one day) has contributed (Figure 3)

• The proportion of patients not beingadmitted the day before surgery has increased from 69.6% (2006/7) to 94.6%

• Professional endorsement of the pathway has been achieved

• A Best Practice Tariff (BPT) is proposed for 2012/13 to incentivise day case surgery

• Patient feedback of their experience of the pathway is extremely positive

• Strong clinical engagement is evident in leading the improvements

• Variation in practice still remains with 28% of breast surgical procedures staying in hospital longerthan two days

• Lengths of stay of more than one night increases with age although variation exists across Trusts

• Variation in clinical practice surrounding the use of wounddrains, draining of, seromas, the administration of anaesthetics and pain control continues.

The continued spread, andsustainability of the breast surgicalpathway across England is animportant contribution to the wholecancer programme and as Professor SirMike Richards states:

“Over the next 15 yearsthe incidence of cancer is likely to increase byaround 24% (based oncurrent trends). Puttingpressure on inpatients’cancer services; hence inorder to keep inpatientscosts at the same level theaverage length of staymust fall by one quarter.”

Professor Sir Mike Richards (2011) National Clinical Director for Cancer and End of Life Care

If all patients with a length ofstay of more than one nightwere converted to the daycase/one night stay model,potentially 40,000 bed dayscould be saved.


7


Delivering major breast surgery safely as a day case or one night stay

Throughout the service improvement phases (Figure 4) NHS Improvement shared the learning across the NHS to encouragelocal spread, adoption and adaption.

From testing to spread... the approach

Figure 4: Service improvement stages

Phase

1

2

3

4

Year

2007

2008

2009

2010-11

Service Improvement stages

• Baseline the current situation• Review clinical procedures• Listen to all views and

perspectives• Understand the culture, context

and content of Trusts, clinical teams and pathways

• Identify best practice and challenges

• Testing out the idea: Proof of Principle – What could be achieved. The Winning Principles (2008)

• Prototype testing the transferability, confidence and competence of the improvement

• Spread, adoption and adaption

NHS coverage

7 NHS hospital sites

25 NHS hospital sites

13 clinical spreadnetworks (72 hospitalsites) 41% coverageacross England

Spreading the learning

The Winning Principles:Transforming Inpatient Care (July 2008)

Meeting the Challenge Together(October 2008)

Spreading the Winning Principlesand Good Practice (July 2009)

Consolidation Report (2009) From Testing to Spread

Spreading the Winning Principlescase studies (July 2010)

Breast day case/one night staycase studieswww.improvement.nhs.uk

Service improvement literature has, highlighted the multiplicity and complexity of service improvement, redesign thechallenges of spread and the time it takes…. it’s like a marathon not a sprint, however, it’s a race worth doing.

Pettigrew et al 1992, Senge 1999, Plesk 2000, Fraser 2002, McNulty et al 2002, Ovretveit et al 2002, Williamson 2007, Driver 2008).


8


The redesign and streamlining of the breast surgical pathway took a simple systematic approach involving a multitude ofreiterative service improvement cycles (plan do study act) and building the evidence for continuous improvement (Figure 5).


Figure 5: A consistent systematic approach was applied to capture the impact and learning

AnalysisBaseline from

different perspectives

Evaluate andcheck

sustainability

ImplementationImplement the

idea

ImplementationImplement the

idea

Clinical SpreadNetworks

Spread/AdoptionStrategy

EvaluationEvaluate the benefits

What is thedifference?

Case for changePlan the implementation

of the test ideaBuild the case for change

VisioningWhat are you

trying to achieve?

Testing CyclesTest out the ideas/

innovationsTest confidence and competence

Identify thereal root of the

problem

Is it theright solutionto address thereal problem

Agree theredesign and

implentation of theimprovements

NO

YES

Winning PrinciplesCapture the impact and learning

Keep improvement simple


9



Over the four years common themes and practices have emerged that supported the spread of the breast pathway. Thethemes have been collated and applied to the Transforming Inpatient Framework for Spread (Figure 6). The spreadframework identifies the common components found to influence the rate of spread.

Influences, innovation and incentives for spread

Figure 6: Transforming Inpatient Framework for Spread - Common themes and practices

SpreadMaking the Connections

A Visionfor Quality

Improvement SystematicImprovement

Approach

OrganisationalCulture and Fit

SpreadSimple

Principles andMessages

LeadershipEngagement

Accountability

Alignmentwith

Opportunitiesand LeversPatient

Centred

Learning& Unlearning

CollaborationPartnerships

and TeamWorking

ContinuousMonitoring

Progress andImpact

LinkedStrategic andOperational

Change

SpreadStrategy

Spreading new ideas and good practiceUnderstanding what good practice looks like

Prove what works and the benefitsInvolve those who need to be activelyinvolved at the start

Receptive to the improvementAdaption to the contextA degree of flexibility

CommunicationUse of opinion leadersFinding the right focusfor quality andefficiency

Clinical and managerialResponsibility for deliveryExecutive leadership

Local quality indicators and prioritiesCommissioning agreement and healthycompetitionPatients involved in testing

Accepted or rejected the improvement

Active disseminationPassive diffusion

‘One size fits no one problem’

Policies and procedures

Information Shared comparative

data

StakeholdersOwnership and a

distribution ofresponsibilities

networking

Knowledge requiredCoaching

Changing practice and behaviourTraining

The framework reflects the work of Pettigrew (1992) Receptive Contexts for Change and Rodgers (2003) Theory on the Diffusions of Innovations.


10


All the components of the framework were relevant and applied. Seven components (Figure 7) appeared to be moreinfluential in enhancing spread within clinical teams. This was evident from local interactions, case studies and reported sitefeedback involving clinical leadership, multidisciplinary teams and patients.


Figure 7: The seven influential components

SpreadMaking the Connections

SpreadSimple

Principles andMessages

LeadershipEngagement

Accountability

Alignmentwith

Opportunitiesand LeversPatient

Centred

Learning& Unlearning

CollaborationPartnerships

and TeamWorking

ContinuousMonitoring

Progress andImpact

LinkedStrategic andOperational

Change

SpreadStrategy

A Visionfor Quality

Improvement SystematicImprovement

Approach

OrganisationalCulture and Fit


Getting teamstogether was

extremelybeneficial.Rodgers(2003),highlights

theimportance of

the nature of thesocial system in which innovations arediffused. The clinical spread networkswere brought together as acommunity for spread involvingorganisations, clinical and managerialteams, patients and carers.

Their contribution to spread wasinvaluable through enhancing thedebate and sharing learning withpeers. They provided a succinctnessgaining consensus on the breastpathway. The sites shared personalexperiences, perceptions and concerns.They could be described as the “earlymajority” of adopters, forming alocalised network for spread,communication and an important linkin the spread process with theirdeliberate willingness to adopt.

11



“It's been very gratifying to have been able to share ourexperiences with so many teams from around thecountry. I have been impressed with the interest andenthusiasm of teams and the quality of the discussions,which have helped us to further examine our practiceand the perceptions around enhanced recovery afterbreast surgery.”

Hamish Brown, Consultant Breast and General Surgeon, Sandwell and West BirminghamHospitals NHS Foundation Trust

Learning from the 13 national clinical spread networks on the seven dominatecomponents - Transforming Inpatients Framework for Spread application in practice:

1. Collaboration, partnerships and team working

Figure 8: National Clinical Spread Networks

Lancashire andSouth Cumbria Humber and

Yorkshire

East Midlands

Anglia

NorthWestLondon

Merseysideand Cheshire

GreaterManchester

PanBirmingham

Arden

Three Counties

Thames Valley

South West London

Avon, Somersetand Wiltshire

Collboration,partnership and team working


12



Many lessonshave been

learned overthe fouryears.Some ofthe learning

was new,reiterative and

challenging.

It was evident across the sites that therewas variation in service improvementunderstanding and application. Also,the time required for redesign was achallenge for many organisations. Thiscan make the continuous spread ofimprovement difficult.

Supporting spread: Key learning from the clinical spread networks: The knowledge of 13

Transforming Inpatients Framework for Spread application in practice

2. Learning and unlearning

Give the right messagesin the right language tothe different audiences and tospread the knowledgefor persuasion anddecisions.

Clinicians don’t liketargets, managers do, and

patients are moreconcerned withgetting better.

Patient experience and

feedback is a key factor in

accelerating the paceof spread.

Take a systematicapproach to serviceimprovement. This takes

time but builds up agood evidencebase and gets to the realroot of the problem.

Understand the nationaland local context and

coherence with local

values and priorities.

This should not beunderestimated and isneeded to gaincommitment to deliver inchallenging times.

Engagement with keypeople leading change is

not enough, supportthem to manage,organise and mobilisethe change.

Build relationships across professions and

organisationalboundaries.

There is a need to createthe common purpose.

Learning andunlearning


13



Keep things simple,

realistic and flexible.

It’s ok to get it wrong.

Clinicians focus on

research, gatheringmore evidence and

audit.

They are oftenuncomfortable with the

service improvementapproach – but once

they understand its

value there is nostopping them.

Understand the

measurement ofimpact and success and

be clear what you wantto achieve, but remember

one persons new idea is

another person’s normalpractice.

The importance of

communication,

co-operation, and

collaboration in

working partnerships is

vital and so is

commitment.

Build the evidence basefrom the begining of the

improvement work to

strengthen, spreadand sustain and to winover the sceptics.

Identifying keyprinciples that can be

adapted to benefit allpatients develops a

common purpose.

The breast pathway is

common sense, simpleand comprehensible. Those that do notunderstand are in the

minority but can be time-consuming. Go with themajority – the others willcatch on later.

Professional boundariesand traditional roles can be

barriers to spread.

We found the doctors accepted the pathwayquicker than the nurses, butonce the nurses came onboard it flew.


14


Four specific aspects were commonlyhighlighted:

1. Changing clinical practice relating to the use of wound drains, drainage of seromas and pain control.

2. Assumptions that patients would not want to go home earlier.

3. Perceptions that the redesign was a cost cutting exercise.

4. Preconceptions “We do this anyway” and “this will increase re-admissions.”

”There was a misconception that the proportion ofwomen who would be suitable for early discharge inparts of the country with greatest concentration ofelderly or socially deprived patients would be difficult.The results have shown this not to be the case withachievements from Birmingham (the fourth mostdeprived area in the country outside London) and KingsCollege Hospital NHS Foundation Trust who has 20% ofpatients who are asylum seekers and a high number ofpatients with complex psychological support needs,with many from a socially deprived background. Daysurgery has been beneficial for sorting this outsmoothly.”

Jo Marsden, Consultant Breast Surgeon, Kings College Hospital NHS Foundation Trust

Some of the learning focused ondealing with uncertainties,assumptions and perceptions. Peer topeer support helped to buildconfidence levels in the new pathwayand the changes in clinical practice.


“One must learn by doingthe thing, for though youthink you know it, youhave no certainty until you try.”

Sophocles, 400BC

Many of these uncertainties had beentested by the early adopters (see Figure 4 - Spreading the Learning).

The spread networks included some ofthe early adopter sites. Bringing thesetogether helped to decrease theuncertainty and provide an evidencebase in which to build the newknowledge and challenge the old.

The spread networks could bedescribed as the early majorityadopters (Rodgers, 2003).


15


Spread survey

NHS Improvement conducted a widerspread survey (2010): This identifiedthat there was an increasing uptake ofNHS Trusts applying Winning Principle2 (NHS Improvement TransformingInpatient Winning principles 2009)particularly associated with the breastsurgery pathway.

Complexity: Local baseline ofcompliance with the elements of thebreast surgical pathway were capturedby the spread sites carrying out apathway analysis reviewing theircurrent practice.


Measuring thespread and

adoption ofthe breastpathwaycannot beover

simplified. It is ever-

changing andmany measurement indicators onlyprovide part of the story. Rodgers(2003) recommends that fourattributes should be measured, butthese rely on individual’s perceptionsas a measure of spread.

Rodgers attributes include:• Rate of adoption• Complexity• Relative advantage• Trial.

These are well researched factors andtaken into account as part of thespread stage.

Are these attributes a measure ofspread and adoption? It was found that certainly theattributes added to knowledge,learning and communication butspread and adoption is “a marathon,not a sprint”, as the breastimprovement work illustrates. It hastaken four years to reach this stage,working with the majority of earlyadopters. Although other Trustsoutside of the spread networks haveadopted the new pathway theevidence of this is based on HES length of stay data.

Application of Rodgers AttributesInfluence Spread and Adoption

Rate of adoption: National HES dataprovided the national picture andbenchmarking of progress, related tothe shift in length of stay, potentialnumber of bed days released and thetrends.


3. Continuous monitoring: Measuring spread and adoption

Figure 9: Patients who had drains required 21% more aspirations

100

90

80

70

60

50

40

30

20

10

0No Drains Drains

Perc

enta

ge

of

Pati

ents

No Aspiration Aspiration

88.8%

11.2%

32.2%

67.8%

Winning Principle 2All patients should be on definedinpatient pathways based on theirtumour type and reasons foradmission.

Relative advantage, complexityand trial: A four month national audit(November 2010 to March 2011);completed by 61% of spread sitesprovided important insights. Data wascollected on 2,087 patients, 666mastectomy patients, and 1,421 widelocal excision and other breastprocedures (cancer and non cancer).

The purpose of the audit wasthreefold; to measure progresstowards compliance against theelements of the pathway, identify thechanges in practice and to capture theviews of patients who hadexperienced the new pathway.

The audit incorporated areas identifiedin the National Mastectomy Auditreport 2010 and the nationalinpatient survey (2010).

Breast pathway audit results

Wound drainsThe audit showed there continues tobe clinical variation in the usage ofwound drains and identified thatpatient’s with wound drains required21% (Figure 9) more aspirations thanthe patients without drains.

Continuousmonitoring:

Measuring spreadand adoption


16


The audit indicated a shift in practice:• There was an increase in the number

of patients not having wound drains• Patients are now having drains

removed prior to discharge• Patients are now being discharged

home on the day of surgery with their drains in situ.

Traditionally, patients would have remained in hospital until the drain was removed. Results showed that theimpact on primary care of patientsgoing home with drains in situ hasbeen minimal.

The audit showed that only 31 patientswere reluctant to go home with drainsin situ. Sixteen patients stayed inhospital between three days to eightdays until their drains had beenremoved (Figure 10). Although thenumbers are small the impact on beddays is significant.

Clinical teams are continuing toconduct local audits associated withwound drains, particularly looking atthe cosmetic effects when using drainscompared to no drains.

Pain control• Pain control was a key feature of the

audit. Concerns had been raised by patients and clinicians that reducing length of stay relies on the patient receiving adequate pain control. The audit found the majority of patients pain was controlled with paracetamol

• 30% of patients reported that although they had only been in hospital as a day case or one night stay they had not needed to take any analgesia at home (Figure 11)

• The audit found that analgesia for mastectomy should be multimodal. Various combinations of paracetamolplus one or more local anaesthetic technique are able to provide effective analgesia.


Figure 10: Length of stay increased for sixteenpatients as a result of having a drain

Figure 11: 30% of patients said they did not require any analgesia

9

8

7

6

5

4

3

2

1

0

Number of Patients

Nu

mb

er o

f D

ays

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

450

400

350

300

250

200

150

100

50

0

Analgesia Drugs and Drug Combinations

Usa

ge

Nu

mb

er R

eco

rded

fr

om

Net

wo

rk A

nal

ysis

Paracetamol

CodeineParacetamol

Cocodamol DihydrocodeineParacetamol

Codeine,Diclofenac,

Paracetamol

IbuprofenParacetamol

DiclofenacParacetamol

Paracetamol,Tramadol

“The centres that have successfully implemented 100%day case or one night stay mastectomy have combinedeither oral or intravenous paracetamol, oftencommenced preoperatively, with one or more localanaesthetic technique i.e. local infiltration, installationof local anaesthetic into the wound and/or peripheralnerve blockade.”

Martin Kuper, Consultant in Anaesthesia and Intensive Care Medicine, The WhittingtonHospital NHS Trust and NHS Improvement Enhanced Recovery National Clinical Lead


Haematoma Mastectomy

Haematoma Other

Wound Dehiscence Mastectomy

Wound Dehiscence Other

Skin Necrosis Mastectomy

Skin Necrosis Other

Systemic Complications Mastectomy

Systemic Complications Other

0 1 2 3

Percentage of Patients

4 5 6

Co

mp

licat

ion

Typ

e

600

500

400

300

200

100

0Partial Excision

of BreastRe-excision ofBreast Margins

Wire GuidedPartial Excision

of Breast

Mastectomy

YES NO

Nu

mb

er o

f Pa

tien

ts

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Arm and shoulder exercises• The redesigned pathway introduced

arm exercises prior to surgery in contrast to traditionally post-operatively. Patients pre-operatively received information and were shown exercises. The audit found that 30% of patients reported that they did not do any arm exercises post discharge (Figure 12).

Re-admission ratesThere was an assumption that reducing the length of stay would increase re-admissions. The audit showed a 2% re-admission rate, which is below thenational average 3.2% (HES 2010), The main cause for re-admissions requiringtherapeutic intervention are shown in Figure 13.


Figure 12: Patients who performed shoulder exercises

Figure 13: Main causes for re-admission


120

100

80

60

40

20

0

Length of Stay (Hours)

Nu

mb

er o

f Pa

tien

ts

0 8 15 23 30 37 46 53 60 70 77 84 101 108 124 132 149 174 195 271 529 8817

Other Breast Procedures

Total Excision of Breast - Total Mastectomy NEC

Actual Length of Stay by Procedure TypeNovember 2010 - March 2011

18


Length of stay - from days to hours

The audit established the length ofstay in hours, highlighting a shift inpractice as length of stay istraditionally recorded in days. (Figure14) Importantly, this provided the evidence that the original definition of 23 hours was not accurate.Variation in admission times andtheatre scheduling across the spreadnetworks needed to be taken intoconsideration leading to the reviseddefinition, breast day case or one night stay pathway.

Delays in dischargeThe audit highlighted that 10.5% ofpatients had a delayed discharge, thereasons recorded were:

• Patients did not want to go home with a drain in situ

• No local drain policy re discharge home with drains in situ

• No one at home and delayed social care package, not noted pre-operatively

• Changes in the initial extent of surgery: Immediate reconstruction, bilateral mastectomy

• Nausea• Awaiting medical decision• Other medical problems• Booked as an inpatient!


Figure 14: Shift from traditional inpatient to day case or one night stay


19


Patients have evaluated the newbreast pathway positivelyThe patients’ experience has beencaptured in various ways:

Patients have been recorded on filmsharing their experiences:www.improvement.nhs.uk

“I was in at 7am, sittingup with tea and biscuits at11am, home for tea by3pm and out dancing at aparty on Saturday night.”

“Just because you areolder does not mean youhave to stay in hospitallonger.”

“Highly recommended -day surgery is better.”

Patients challenged professionalassumptionsNurses and doctors at Kings CollegeHospital NHS Foundation Trust foundpatients were asking to go home.Raising the question why are wekeeping patients in? Patients alsoasked to go home at NorthamptonGeneral Hospital NHS Trust, GeorgeEliot Hospital NHS Trust and DerbyHospitals NHS Foundation Trust.

Frequently concerns were raised byprofessionals particularly nurses thatreducing the length of stay could leadto patients not receiving adequatecommunication, information andsupport. The audit of over 2,000patients (2010) who experienced thenew pathway indicated this not to bethe case (Figure 15). The results arecomparable with the National PatientSurvey (2010).


One of thestrongest

influencesfor spreadis the‘patient’svoice.’

Patientswere involved

in the redesign of the pathway andtold us:

“Being diagnosed withbreast cancer can be adifficult transition tomake, one day you are ahealthy person, the nextyou are a patient withcancer.”

Patients talked about how:

“Unnecessary waits,procedures and sittingaround in beds increasedanxiety.”

Patients stressed:

“We want to get back tonormal as soon aspossible.”

“The new pathway shouldvalue our time.”

“Treat me as a person nota cancer patient.”

Patientcentred


4. Patient centred

Figure 15: Audit of 2,000 patients who experienced the new pathway(Four questions taken from the National Patient Survey, 2010)

Q1

Q2

Q3

Q4

Patient survey question

Were you involved as much asyou wanted to be in decisionsabout your care and treatment?

How much information aboutyour condition or treatment wasgiven to you?

Did you feel you were involved indecisions about your dischargefrom hospital?

Did hospital staff tell you who to contact if you were worriedabout your condition ortreatment after you left hospital?

Response

92% Yes definitely(mastectomy and otherprocedures)

93% Right amount(mastectomy)94% Right amount (otherprocedures)

77% Yes definitely(mastectomy)

83% yes definitely (otherprocedures)94% Yes (mastectomy & otherprocedures)


Ask questions

Knowing patientexpectationsWhat is informedchoice?What ideas should wetest?

Pre and post operative focus groups

Story boards and story telling

Patient videos

Patient diaries

Patient voices

Charities

Spread the message

Get feedback

Post operative Telephone callsPatient questionnairesAudit change

20


Independent patient evaluation

Patient focus groups were held as partas an independent qualitative study ofexperiences of the pathway (HealthExperiences Research Group Universityof Oxford 2011). The 13 nationalclinical networks were invited toparticipate in the study by inviting theirpatients to take part.

Independent evaluation findings:

“Patients were often surprised that they could betreated on a day case or one night basis. Some patientsand their friends and family, were initially suspiciousabout whether the service was driven by a desire to cutcosts. Experiences in hospital (waiting for surgery,communication and information, quality of care,emotional support and discharge) were describedpositively and acted to reassure patients that their carewould not suffer, despite short stays.

This positive experience was slightly undermined ifhospital staff appeared critical of short stay.“

(Barlow et al 2011)

Different patients views are a key factor to spread Different strategies for patient engagement and involvelment were usedacross the spread networks (Figure 16).


Figure 16: Patient engagement strategies


21


Patients traditionally stayed in hospitalfor as long as six days, now themajority are home the same day orafter one night. Patient’s challengedprofessional beliefs of not wanting tobe in hospital. There was:

“Reluctance on the partof some staff to dischargepatients sooner and witha drain.”

Burton Hospital and Kings Mill Hospitalovercame the issue by holdingeducation events for ward nurses andfeeding back patients positivecomments.

Concerns were raised about thereduction in the length of stay beingdetrimental to patients psychological/physical well being. The recent auditof patients (80% response) indicatesthat there has been no adverse effect,but the foundation for this lies withgood pre-operative assessment andinforming patients that they will begoing home on the day of surgery orthe following day right from thebeginning. (Clinical Networks 2010).

“Changes in clinicalpractice have had apositive effect with otherprocedures, for examplepatients having atherapeutic mammoplasty,now also only have asingle night’s stay.”

Geraldine Mitchell, Consultant BreastSurgeon, Royal Liverpool and BroadgreenUniversity Hospitals NHS Trust

“More challenging wasconvincing some of thehospital staff that the daycase or one night stayambulatory care wasachievable for patientshaving mastectomy andaxillary node clearance.However, confidence inthe process has grownsubstantially withimplementation andsuccessful outcomes.”

Yeovil District Hospital (2011)

Across the clinical spread networks,coversations about patient experienceand satisfaction highlighted that thepathway was received positively.

“Patient feedback hasbeen extremely positive,patients reported theywere involved in theircare, treatment anddischarge and receivedsufficient information.”

Southport and Ormskirk Hospital NHS Trust (2011)


Theconcept ofspreadnetworks as

a forum ofcommunication

has been key to spread messages and makeinterpersonal links to influence others.

The success of the approach relates to its affiliation with the commonpurpose; and a

“group of knower’s.”

(Driver A, 2011)

Interestingly, it was found thatalthough the spread networks weregeographically located, the informalnetworks across geographical areaswere often stronger, particularly withclinicians.

Through using simple messages whichrelayed information, principles andsharing practices on the groundknowledge was enhanced anddiscussions and conversations were stimulated.

“First of all we had toovercome our ownpreconceptions ofpatient’s opinion about ashorter stay in hospital.We thought patientswould find the shorter stayunacceptable and patientanxiety levels wouldincrease; but, we did notfind this to be the case.”

Royal Bolton NHS Foundation Trust (2011)

Spread simpleprinciples and

messages


5. Spread simple principles and messages


22


Wider conversations Breast charities and patient groupsplayed an important contribution inhelping to spread the messages aboutthe new pathway. It has been reallyencouraging to see patient’s reviewswww.independent.cancerpatientsvoice.org.uk

“We showed that notonly is this pathwayacceptable to the greatmajority of patients butthat it is genuinelypreferred by them, andthat this can be achievedwithout any compromisein the quality of care withpatients feelingempowered to makedecisions and choices.”

National Clinical Spread Networks(2011)

Simple messages... hints and tips

To access the recent success storiesfrom across England on deliveringmajor breast surgery as a day case or a one night stay (excludingreconstruction) case studies and forfurther information please visit:www.improvement.nhs.uk/cancer


“It’s do-able, safe andpatients want to go home.”

National Clinical Spread Networks(2011)

For the health community• Increase dialogue across the

health community improves working relationships with primary care and provider colleagues

• Spread sites arranged training events for community staff and some planned GP site visits to inform colleagues of the improvements

• Review and share patient information with community colleagues as early as possible

• Reassure GPs the new pathway does not increase their workload

• Communicate to GPs, practice nurses and district nurses thatpatients will be discharged home earlier and safely because they arebetter sooner

• The new pathway focuses on quality and safety not pushing patients through faster to save money

• The changes in anaesthetics have allowed patients to recover more quickly following surgery

• The breast pathways aim is to ‘getback to normal as soon as possible’….”Home in time for tea.”

For pre-assessment• Managing patient’s expectations

from the beginning has been key. Patients need to be advised at theoutset of their likely length of staywhich is reinforced by the whole team throughout the pathway

• Physiotherapists and breast care nurses see patients at pre-operative clinic providing earlier support and risk management

• Pre-assessment is a vital part to the success of the pathway.

For admission and discharge• Staggered admission times are

possible and reduced unnecessarywaits for patients

• Nurses like nurse led discharge. They have reported this increases job satisfaction, skills base and knowledge allowing them to manage their work load more effectively

• Pre-prescribed discharge medication (TTOs) on admission and pre-packed TTO on the day unit/ward prevents discharge delays

• Consultants have said that the ward rounds are now able to focus on patients requiring more medical input and they have achieved a reduction in length of stay without detriment to the patient

• Patients are not left without support: 24/7 cover and telephone advice/support lines and follow-up support calls are available to patients.


Alingmentwith

differentopportunities,

levers anddrivers contributed

to the pace of spread and sustainabilityof the pathway (Figure 17). The rangeof levers included:

• Policy• Professional• Patients• Performance• Payment• Purchasing• Practice.

The levers were useful as they highlightthe connectiveness involved and showthat spread is not a one dimensionalapproach.

The breast pathway has been wellreceived.

23


Support from charities

“We welcome the introduction of the day case or onenight stay breast surgical pathway as this should meanincreased choice and the option of a shorter stay forpatients where this is clinically appropriate. As thismodel is rolled out across the NHS, we hope that therewill be a strong focus on providing patients with clearinformation about their options for surgery, includingexpected length of stay, risks and benefits to enablethem to make an informed choice about their care.”

Maggie Alexander, Policy and Campaigns Director, Breakthrough Breast Cancer


Professional endorsement

“We have pleasure inendorsing this; it looks likea fabulous piece of workthat ticks every box withour own promulgatedethos of a plannedpathway and evidencebased care that not onlyimproves quality, but alsoefficiency of care.”

Dr Mark Skues, President Elect, BritishAssociation of Day Surgery


6. Alignment with opportunities and levers

Figure 17: Alignment with opportunities and levers

Best PracticeTariffER

ToolkitLocal

CQUINS

BreastSurgery

Patients

Clinical Linesof Enquiry

Improving CancerOutcomesStrategy

NHS Evidence

CommissioningRoyal Colleges& Associations

QIPP‘Right Care’

InformedDecision Making

OutcomesFrameworkDomain 3

Alignment withopportunities

and levers


24


Recommended best practice...NHS EvidenceThe day case or one night stay breastsurgical pathway has beenrecommended as best practicesupporting the spread of knowledge inthe NHS www.evidence.nhs.uk

Incentives... Commissioning forQuality and Innovation PaymentFramework (CQUINS) It has been important to continuouslyalign this work to support spread andadoption. Incentives such as CQUINScan be useful (Department of Health, (CQuins)Payment Framework 2010).

Local quality indicators CQUINSprovide a higher priority for deliverylocally increasing the rate of spread,providing positive benefits for clinicalteams but whilst not a primary driver ishelpful to start getting teams on boardFigure 18).

Breast surgery has been included in the set of exemplar CQUIN goalsProvider Sector: Acute

Commissioning“Patient experience should be important tocommissioners and GPs inparticular. Commissioningservices that provide a highquality patient experiencewill be a Key PerformanceIndicator (KPI) for the newconsortia.”

Dr Alan Nye, Principal in General Practice,Oldham and NHS Improvement EnhancedRecovery National Clinical Lead


Description of goal

Description of indicator

Numerator

Denominator

Rationale for inclusion

To improve the quality, safety, outcomes andproductivity of breast surgery

Number of patients having breast surgery as a daycase or one night stay

Number of patients having breast surgery as daycase or one night stay in the Trust

Total number of patients having breast surgery inthe Trust

The day case or one night stay breast surgicalpathway has been developed as a good practicemodel by clinicians and endorsed by the BritishAssociation for Day Surgery. The new pathwayhas been widely welcomed by cancer and non-cancer patients

Figure 18:

Breast Surgery Best Practice Tariff (BPT)BPTs are prices set as part of thenational tariff list to financiallyincentivise providers to adhere toevidence based best practice. Thebreast surgery BPTs proposed for2012/13 are designed to encouragebreast surgery to be carried out as aday case where clinically appropriate.Performing these procedures as a daycase offers advantages to both thepatient and the provider; the BritishAssociation of Day Surgery (BADS),advise that patients prefer torecuperate in their familiar homeenvironment, while providers benefitfrom reduced pressure on inpatientbeds. The breast surgery BPTsproposed for 2012/13 represent anexpansion to the scope of theprocedures covered by the 2011/12BPTs, with some changes to the daycase rates where appropriate(Appendix 1).

Incentives such as CQUINSand BPT can be useful butthere needs to be carefulconsideration about theplans in place to ensuresustainability post incentive.


25


Clinical lines of enquiryThe day case or one night stay breastsurgical model is being piloted in theclinical lines of enquiry with key clinicalindicators for peer review (NationalCancer Action Team, 2010).

NHS Outcomes FrameworkThe redesigned breast surgical pathwayaligns to the NHS OutcomesFramework (DH 2010) particularlydomains 3, 4 and 5.

Quality, Productivity, Innovationand Prevention (QIPP)The changes to the patient pathwayfrom a resource perspective havemostly been managed throughstreamlining and re-allocation of skillmix and time. This supports previousfindings that the day case or one nightstay breast surgical model is costneutral.

Lancashire Teaching Hospital NHSFoundation Trust changed theirpractice:

“Routine chest x-rayshave ceased pre-operatively, only patientswith pre-existingconditions are now x-rayed. Under service linereporting this hascreated a saving of£24.41 per patient.”


Sharing the outcomes withcommissioners has promoted re-investment to ensure patients areprovided with comprehensive pre-operative assessments and followup services e.g. post operative phonecalls. It is paramount that local codingissues are resolved and any moneysaved should be reinvested back intothe pathway.

DOMAIN 5:Treating and caring for people in a safeenvironment andprotecting them from avoidable

harm

DOMAIN 3:Helping people to

recover from episodes of ill

health or following injury

DOMAIN 4:Ensuring thatpeople have a

positive experience

of care

Improving Cancer OutcomesStrategy (2011) is about improving thequality of services and improvingefficiency and breast services make animportant contribution.

“We know that offeringappropriate patients theopportunity to have theirbreast cancer treated as a daycase or a one night stay ratherthan as an inpatient improvestheir experience and reducestheir length of stay savingcommissioners money.”

Improving Cancer Outcome Strategy(Department of Health, 2010)

The Anglia Cancer Networkanalysed payment by resultscomparative data that wasreadily available for all PrimaryCare Trust’s (PCTs). Bycomparing the current cost andpotential savings of the breastday case or one night staymodel they concurred that themodel was cost neutral. Clinicalengagement has been thedriving force for the change.

“This pathway did notrequire additionalresources or investment,only a change in practiceand culture.”

Northwick Park Hospital

This service improvement work hasdemonstrated that by improvingquality a by product is efficiencysavings:

“The average stay forwomen undergoingmastectomies and otherbreast cancer surgery hasfallen from five days toless than one, and theTrust has saved anestimated £300,000 ayear."

Hamish Brown, BMA Quality Time:November 2010, 8 9)

National cancer action team


26


principles to other surgical procedures. Some clinicians have taken the lead toexplore breast reconstructive surgery asmore patients may opt forreconstruction at the time of theirmastectomy operation. These clinicalleads are testing how the principlescould be applied.


Leadershipand

engagementfrom clinicians

and managersthroughout the four

years of the service improvementphases has been crucial. Clinicians’attitude and belief in the pathway wasa key driver, once they acknowledgedthe patients views and challenged theirown thinking.

There has been a variety of leaders,opinion makers and championsinvolved. Some have led from thefront, whilst others have pushed frombehind, some have been participativeand others directive. We utilised all thedifferent styles to encourageengagement and commitment forspread.

Future ambitionWhat has become apparent is thatclinicians want to take the breastsurgical pathway further and apply the

Leadership,engagement and

accountability


7. Leadership, engagement and accountability

Figure 19: Applying the principles further

Proposed procedure

Wide local excision

Wide local excision and axillary node clearance

Mastectomy and sentinel lymph node biopsy

Mastectomy and axillary node clearance

Reconstruction impact/expanders

Latissimus dorsi flap LD

Abdominal DIEP

Abdomen (Transverse rectus abdominis muscle) TRAM

Length of stay

Day case

Day case

Day case

Day case or one night stay

One night stay

Reduce length of stay

Reduced length of stay

Reduced length of stay

Changes in clinical practice

No wound drains

No wound drains

No drains

No drains or home with drains

Enhanced recoveryAccelerated discharge



The opportunities for breast surgeryare shown in Figure19, these fit wellwith the enhanced recovery principlesas shown by the evidence basedreview of enhanced post operativerecovery after breast surgery (Arsalani-Zandeh et al 2010). www.improvement.nhs.uk/enhancedrecovery

Chief Executive

“A really good idea”

“A lot easier to introduce than I thought”

Clinical Lead

“Not as much objection fromthe patients as I thought”

General Manager

“Patients seemedkeen to return to normal as quickly as possible”

Breast Unit Nurse, Royal Bolton Hospital NHS Foundation Trust

“Patients were happy that they could sleep in their own bed”

Breast Unit Nurse, Royal Bolton Hospital NHS Foundation Trust


27


The last four years of serviceimprovement in breast surgery hasshown that major breast surgery canbe delivered safely as a day case or onenight stay. Patient quality, experienceoutcomes and re-admission rates arenot compromised and importantly“patients prefer not to stay inhospital.”

The evidence is clear that unnecessarylengths of stay are reduced andchanges in clinical practice supportpatients “getting better sooner.”

The original working hypothesis of:“The streamlining of the breastsurgical pathway could reduce lengthof stay by 50% and release 25% ofunnecessary bed days for 80% ofmajor breast surgery (excludingreconstruction).” This has beenexceeded and demonstrates thefurther potential of achieving 85%with continued spread and adoption.

The success of the pathway lies inclinical and patient engagement:Managing the patient’s expectations atthe beginning of the pathway byhaving a good pre-operativeassessment and anaesthetic techniquecombined with clear communicationacross the multidisciplinary team andhealth community. Variation in themanagement of wound drainsremains, but the evidence basecontinues to be developed.

The efforts for the continuing spreadand adoption of the day case or onenight stay breast surgical pathwaycontinues locally and nationally. It isenvisaged that with the advancingclinical evidence, the day case or onenight stay pathway will become thenorm and more patients are:“Home in time for tea”.


Summary


28



Arsalani-Zadeh. R., Elfadl. D., Yassin N.,MacFie. J (2010). Evidence-based review ofenhancing post-operative recovery afterbreast surgery. British Medical JournalNovember 2010, published online in WileyOnline library.

Barlow F., Ziebland S. (2011) Qualitativestudy of experiences of the day case and23 hour breast cancer surgery service: Areport for the Transforming InpatientProgramme, commissioned by NationalCancer Action. Health ExperiencesResearch Group University of Oxford(August 2011)

Brown H. (2010) Quality Time, BritishMedical Association November 2010 p8-9.

Department of Health (2007) The CancerReform Strategy (December 2007)

Department of Health (2010) Liberatingthe NHS: Transparency in Outcomes – AFramework for the NHS; Department ofHealth (July 2010)

Department of Health (2010) National Patient Survey

Department of Health (2010) Using theCommissioning for Quality and Innovation(CQUIN) payment framework

Improving Cancer Outcomes – A Strategyfor Cancer (January 2011)

Driver A. (2008) Factors affecting theachievement of cancer waiting timestargets in NHS Trusts: an exploratory study.Unpublished thesis. Doctorate ProfessionalStudies in Health. Middlesex University.

Driver A. (2011) Network DevelopmentProgramme, Presentation, London(October 2011)

Fraser S.W. (2002). Accelerating the spreadof good practice: A workbook forHealthcare, Kingsham Press

National Cancer Action Team (2010)National Cancer Peer Review Programme.Delivery Specification Guide 2010-2011Clinical Lines of Enquiry

NHS Improvement (2008) The WinningPrinciples: Transforming InpatientProgramme. (July 2008)

NHS Improvement (2008) Meeting theChallenge together….delivering care in themost appropriate setting NHS Improvement (2009)

Transforming Care for Cancer Patients -Spreading the Winning Principles andGood practice: A Framework for Spread;NHS Improvement: Transforming InpatientCare Programme (2009) (p44)

NHS Improvement (2009) ConsolidationReport: from Testing to Spread.

NHS Improvement (2010) TransformingInpatient Care Programme Spread Survey(October 2010)

NHS Improvement (2010) Spreading theWinning Principles Case Studies (July 2010)

NHS Information Center (2011) NationalMastectomy and Breast ReconstructionAudit, Annual Reports 2010 and March2011.

Ovretveit J, Gustafason D (2002) QualityImprovement Research: Evaluation ofquality improvement programmes. Qualityand Safety in Health Care, Vol 11, Issue 3September 2002.

Pettigrew A, Ferlie E., McKnee L. (1992)Shaping Strategic Change. BlackwellOxford.

Plesk P.E (2000) Spreading Good Ideas forBetter health Care. VHA Inc.

Rogers E (2003) Diffusions of Innovations.Free Press 5th Edition

Senge (1999) The Fifth Discipline. RandonHouse London.

Williamson J (2007) The critical factors forwhole system change of a clinical specialtyidentified through the Cancer ServicesCollaborative ‘Improvement Partnership’,unpublished thesis. Doctorate ProfessionalStudies in Health. Middlesex University.

Case studies

Detailed case studies from the 13 ClinicalSpread Networks are available on the NHSImprovement website:www.improvement.nhs.uk/cancer/inpatients

Websites

Association of Breast Surgery (ABS):www.associationofbreastsurgery.org.uk

BASO:www.baso.org.uk

Breakthrough Breast Cancer:www.breakthrough.org.uk

British Association of Day Surgery (BADS):www.bads.co.uk

Department of Healthwww.dh.gov.uk

Department of Health: Quality, Innovation,Productivity and Prevention (QIPP)www.dh.gov.uk/en/Healthcare/Qualityandproductivity/QIPP

Independent Cancer Patients’ Voice:www.independent.cancerpatientsvoice.org.uk

National Inpatient Survey 2010www.cqc.org.uk/node/1667

National Mastectomy Audit Reportswww.ic.nhs.uk/services/national-clinical-audit-support-programme-ncasp/audit-reports/mastectomy-andbreast-reconstruction

NHS Evidencewww.evidence.nhs.uk

NHS Improvement Enhanced Recoverywww.improvement.nhs.uk/enhancedrecovery

References and resources


29


Explanatory notes on the Datasetunderlying Figures 2, 3 and 4.This is based on a Procedure Based Cutof Relevant Breast Procedures extractedfrom HES Inpatient or Day Case EpisodesBetween 1st April 2006 and 31st May2011 (inclusive).

• Episode data has been converted to a Procedure based cut, for one record per relevant breast procedure. Therefore if an episode contains more than one 'relevant' procedure, each procedure will be counted separately

• 2010/2011 Version 13 and 2011/2012 v2 are provisional data only.

• Elective admission method group, includes both elective admissions and transfers

• For a list of breast procedure codes included in this cut, see below

• Procedures have been identified as having a reconstruction if the relevant reconstruction code appears in the same episode.

Filters applied in this analysis (on allsheets)• Admission Method Group = Elective• Reconstruction = False (procedures are

excluded where a reconstruction occurs in the same episode as the procedure)

• Diagnosis = All (cancer and non-cancer).

Note: Most of this analysis also onlyincludes mastectomy and other excisionsof breast (and excludes diagnosticprocedures and other operations) exceptsheet "National-Proc1 0607 1112"which clearly shows numbers for eachprocedure group.


Appendix 1

Breast Procedure Codes relevant to this extract

Included:

Mastectomy

Other Excision of Breast

Excluded

Diagnostic Procedure

Other Operations

Reconstruction

B271-B276, B278, B279

B281-B289

B321, B322, B323, B328, B329

B31, B311, B318, B319, B341-344, B35, B352-B355, B374, B401, B408, B409

B291-B294, B298, B299, B301, B308, B309,B361-B363, B368, B369,B381, B382, B388, B389,B391, B392,B393, B398, B399

The BADS Directory of Procedures (3rd edition) suggests day case rates whichshould be achievable in most cases, but also set certain caveats which mean thatthese rates may not be achievable. The BADS directory of procedures is availableat:https://www.daysurgeryuk.net/bads/shop/shopdisplayproducts.asp?id=9&cat=BADS+Publications


30

www.improvement.nhs.uk/cancer


Further information

Transforming Inpatient Team:

Ann DriverNHS Improvement [email protected]

Angie RobinsonNational Improvement [email protected]

Sue CottleNational Improvement [email protected]

Marie TarpleeNational Improvement [email protected]

Catherine StrongPersonal [email protected]


NHSNHS Improvement

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NHS Improvement3rd Floor | St John’s House | East Street | Leicester | LE1 6NB

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NHS Improvement

NHS Improvement’s strength and expertise lies in practical service improvement. It has over adecade of experience in clinical patient pathway redesign in cancer, diagnostics, heart, lung andstroke and demonstrates some of the most leading edge improvement work in England whichsupports improved patient experience and outcomes.

Working closely with the Department of Health, trusts, clinical networks, other health sector

partners, professional bodies and charities, over the past year it has tested, implemented, sustained

and spread quantifiable improvements with over 250 sites across the country as well as providing

an improvement tool to over 1,000 GP practices.

Delivering tomorrow’simprovement agenda for the NHS


delivering major breast surgery safely as a day case or one night stay (excluding reconstruction)

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