transforming care for cancer patients - spreading the winning principels and good practice

NHSNHS Improvement

Transforming Inpatient Care Programme

Transforming Care for Cancer InpatientsSpreading the Winning Principles and Good Practice

HEART STROKECANCER DIAGNOSTICS

65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:41

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Contents

Foreword

Acknowledgements

Introduction

Why we need to spread the Winning Principles

A framework for spread • Understanding spread• Defining spread• Capturing the learning to support spread

Winning Principle 1

Winning Principle 2

Winning Principle 3

Winning Principle 4

Further evidence supporting spread

Transforming Inpatient Framework for Spread:Common themes and practices

Spread is evident

Conclusions

References and supporting information

Roll of honour

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Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice

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Foreword

Many clinical teams have learned servicedevelopment techniques and have started tointroduce new ideas to improve their practice.Traditionally in the NHS we have been slow tospread new ways of working both within andbetween organisations.

This report provides a range of excellent examplesof where teams have not only deliveredinnovation in their own service but have alsospread good practice to others, thus improvingthe quality of care for many more patients.

Celia Ingham ClarkColorectal Surgeon, Medical Director, TheWhittington Hospital London, National ClinicalLead and Chair Transforming Inpatients SteeringGroup.

The Cancer Reform Strategy highlighted the need tofocus attention on inpatient care for cancer patients.The “Transforming Inpatient Care Programme” hasbeen established to take this forward. The programmeis being led by NHS Improvement – Cancer inpartnership with the National Cancer Team. Forty NHS Trusts are now involved in piloting newapproaches to care.

The first aim of the programme is to improve thequality of inpatient care for cancer patients by avertingunnecessary admissions and by streamlining care for

those who do need to be admitted. Achieving this aim also has the potential to reducebed utilisation very considerably. In the year before the Cancer Reform Strategy overfive million bed days were occupied by cancer patients. Work done during thedevelopment of the Cancer Reform Strategy – and now endorsed by the findings frompilot sites – indicates that at least a million bed days could be saved.

The Transforming Inpatient Care Programme is an excellent example of ‘Quality,Innovation and Productivity’ in practice. This programme links with the EnhancedRecovery Programme which goes beyond cancer. It also relates closely with the workbeing undertaken by the National Chemotherapy Advisory Group to enhance qualityand safety of chemotherapy services.

I would like to thank all of the pilot sites for their innovative work on developing goodpractice. I hope these examples will prove useful to other NHS Trusts in their quest toimprove quality and productivity.

Professor Mike RichardsNational Cancer Director


Acknowledgements


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The Department of Health CancerProgramme Board, NHS Improvementand the National Cancer Action Teamwould like to thank all the test sitesfor their continuing support andcommitment to the TransformingInpatient Care Programme. Valuablelearning has emerged from thisimportant area of work which hasinfluenced policy, qualityimprovement, demonstratedinnovation, efficiency and improvedthe patient’s experience.

The learning from cancerimprovement is well recognised andhas been adopted across many otherspecialties. This is a credit to the testsites involved and their ongoingcommitment to improve services andshare their learning across the NHS.



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Introduction

Testing an idea, then realising what worksand how it can benefit patients is afantastic achievement.

The challenges that follow are:

This publication, the third in a series*,supports the Cancer Reform Strategy’s(2007) Transforming Inpatient CareProgramme. Its aim is to illustrate ‘how’NHS Trusts are spreading testedimprovements.

During 2007- 2009, NHS Trusts (40)across England tested out ideas toimprove the quality of the inpatientexperience by looking at valuing patient’stime, shifting care from an inpatient to anambulatory care setting, reducingunnecessary lengths of stay and avertingunnecessary admissions into hospital forboth planned and unplanned care.Testing, identified four winning principles,

“We know what works. Thequestion is - can we spread this

across the NHS in 2 years, or like many NHS initiatives will

it take 20 years.”

Mike Richards National Cancer Director (2009)

Previous testing identified four winning principles that can improve length of staymanagement, avert unnecessary admission, deliver care in the appropriate care settings,improve efficiency, quality, promote value for money and importantly value the patients’ time.

Winning Principles

Winning Principle 1Unscheduled (emergency) patients should be assessed prior to the decision toadmit. Emergency admission should be the exception not the norm.

Winning Principle 2All patients should be on defined inpatient pathways based on their tumour typeand reasons for admission.

Winning Principle 3Clinical decisions should be made on a daily basis to promote proactive casemanagement.

Winning Principle 4Patient and carers need to know about their condition and symptoms to encourageself-management and to know who to contact when needed.

*www.improvement.nhs.uk/winning_principles

that if spread could make significantimprovements in quality, efficiency and thepatient experience.

Over the last 12 months it has becomeevident that Winning Principles 1 and 2,and the following models of care havespread significantly: • Communication Rapid Alert systems

reducing unnecessary length of stay by 25% in most tumour groups recognising the importance of valuing patient’s time.

• Breast 23 hour model 100% coverage across Pan Birmingham for 80% ofpatients. Reducing length of stay fromsix days.

• Acute Oncology Models being adoptedand adapted across the country to ensure patient safety and reduce delays.

• Applying an enhanced recovery approachfor elective surgery can reduceunnecessary length of stay by 50%.

Evidence from the case summaries withinthis publication suggests that the adoptionand adaption is due to the principles andmodels: • Being easy to apply• Having a clear purpose and evident

in practice • Simple to understand • Meaningful to patients and professionals • Bring together quality improvement,

innovation and efficiency.

If Winning Principles 1 and 2 were widely adopted by all Trusts in England the combinedimpact could mean releasing 25% of bed capacity in most tumour groups. By addingPrinciples 3 and 4 we would see a potential further impact on bed capacity movingtowards releasing a million bed days.

“The Transforming Inpatient Care Programme will improve quality of care for patients and could save the NHS a million bed days.”

Mike Richards National Cancer Director (2009)


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At a time where the economic future isuncertain, David Nicholson, NHS ChiefExecutive has stated that:

Why we need to spread what works across cancer inpatients?

• Inpatients is an area that’s had little attention

• England has higher bed utilisation for cancer than any other country

• Emergency admissions have risen by 47% in the past eight years and elective by 8.6%

• 40% of all cancer admissions are emergency, but they use 60% of bed days

• Inpatient care for cancer patients accounts for 12% of all inpatient beds

• Over half (ie over £2 billion) of thetotal expenditure on cancer in England goes on inpatient care

• 60% of all cancer admissions are elective but they use 40% of beds days

• 2007-2008: 4.7 million bed days were cancer related.

“Now is the time to beinnovative and adopt anddiffuse the well-evidenced

things we should all be doing.We need to look at each system

and process to see if it iscapable of taking us through

this big challenge”

David NicholsonNHS Confederation (2009)

“Quality improvements throughgreater efficiency and

redesigning services can providethe budget savings necessary to

navigate this crisis"

Nigel EdwardsNHS Confederation Director of Policy (2009)

Improving quality is a journey thathas no end point; there is alwaysmore that can be done. Spreading theWinning Principles will be the start of the journey for many as thesummaries in this publicationillustrate there is ‘not a one size fits all’ approach to spread. “Been in hospital for five

days, it’s cost me over £20 towatch the TV and make calls

to my family, to kill theboredom. Why couldn’t

I have taken the tablets athome and got them from theGP, would have only cost me

something like £6 for theprescription and shoe

leather!”Extract from a patient diary

Most importantly patients have told usthey do not want to be in hospital.

Why we need to spread the Winning Principles?

Quality improvement can drive efficiency.


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Understanding spreadThe concept of spread is often implicitwithin the large amount of literatureavailable on change and organisationalmanagement. Such literature containscontributions from many differentacademic disciplines.

From the evidence the key messagesappear to be:• Spread has a range of meanings and

language

rather the exception in our quest/goal totransform the inpatient experience forcancer patients across England.

Capturing the learning to support spread The NHS Trusts shared their experience ofspread covering three aspects: 1. What improvements/Winning

Principle(s) have spread?2. How has spread been achieved?3. What impact has been made?

Data analysis was undertaken usingNational Hospital Episode Statistics (HES)and cross referenced with local data.Organisations completed a learning diarythat provided an ongoing evaluation ofprogress. They provided case studies andtook part in completing an electronicspread survey (spread planner) thatassessed spread and coverage, thisprovided further qualitative intelligence.

The spread survey was also used withnon-test sites to evaluate if theimprovements and principles were beingmore widely adopted. This was not aboutresearch, but checking how far spreadhad been achieved and how this wasoccurring. Collectively this data providedthe opportunity to undertake a thematicanalysis to draw out the learning and keymessages. The organisations involvedwere predominately NHS Acute Trusts andFoundation Trusts (integrated testing isunderway with Acute, Primary Care andSocial Care, the intention is to evaluate thelearning from these sites in early 2010).

The selection of NHS Trusts included inthis publication began testing ideas in2007. To date they have all achieved adifferent pace of spread that wasculturally and contextually specific. Allhave spread the Winning Principles andapplied them to different testedimprovements with a range of impact(detailed case studies are available at:www.improvement.nhs.uk/cancer).

Fig 1: The Transforming Inpatient Framework for Spread(NHS Improvement 2009)

SpreadMaking the Connections

A Visionfor Quality

Improvement

• Spread is often difficult to define • Successful spread can be active

(dissemination) and passive (diffusion) • The process of spread does need an

agreed spread strategy, time, focus, and monitoring

• The pace of spread varies and is influenced by many variables.

Defining spreadSpread is the process whereby we see thefour Winning Principles become the norm

SystematicImprovement

Approach

OrganisationalCulture and Fit

SpreadSimple

Principles &Messages

LeadershipEngagement

Accountability

Alignmentwith

Opportunities& LeversPatient

Centred

Learning& Unlearning

CollaborationPartnerships

& TeamWorking

ContinuousMonitoringProgress &

Impact

LinkedStrategic &Operational

Change

SpreadStrategy

A framework for spread

Through evaluating the learning and lookingat how the test sites have spread the WinningPrinciples, 12 common themes have emerged.These have been applied to a framework forreference to support organisations in theirquest to spread “The Transforming InpatientFramework for Spread” (NHS Improvement,2009). Fig 1.

The framework was developed drawingupon Pettigrew’s (1993) receptive contextmodel, Fraser’s (2002) framework foraccelerating spread and Rodger’s (2003)diffusion of innovations. This builds uponearlier work in cancer improvement by theCancer Services Collaborative‘Improvement Partnership’ whereWilliamson’s (2007), work identified thecritical factors for whole system change of a clinical speciality and Driver’s (2008)evaluation of the factors affecting theachievement of cancer waiting times in the domains of leadership, performanceand service improvement.


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Winning Principle 1

1. Unscheduled (emergency) patients should be assessed prior to the decision to admit. Emergency admission should be the exception not the norm.

The following five NHS Trusts spreadWinning Principle 1. Four tested andspread the same improvement(communication alerts) and approachedspread in different ways. Evaluation oftheir learning against the spreadframework identified common themesacross these Trusts (fig 1).

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Quality improvements

The patient is on the rightpathway and seen by theappropriate clinical team

Reduced number ofdiagnostic tests/invasiveprocedures

Upper Gastrointestinal (GI)have demonstrated areduction in diagnosticstests/invasive proceduresfrom three to two testsper patient

The clinical team thatknows the patient isalerted; this is a familiarface in time of crisis

Recurring Admission Patient Alert (RAPA)

RAPA is a simple communication solutionthat ensures that everyone knows theirpatient has arrived at the hospital. Theimprovement benefits known cancerpatients and where admission is requiredpatients go to the right place, on theright pathway or the admission is avertedand redirected to the appropriate caresetting.

The improvement idea was ‘pulled’ from Sherwood Forest Hospital NHSFoundation Trust and adopted locally. Itwas initially tested on one site, LincolnCounty Hospital, and is now spreadingacross the four hospital sites of theUnited Lincoln Hospital NHS Trust.

United Lincolnshire Hospitals NHS Trust

How was spread achieved?

“We used a systematicapproach taking one tumoursite at a time, demonstrating

the evidence of why theimprovement works and

measuring the benefits. Wekept the approach simple and

positioned in theorganisation. From being

involved with RAPA inSherwood Forest I knew the

principle was right, but alesson learned was that you

cannot simply ‘cut and paste’the improvement into

another organisation; it needsto be tested and owned to

encourage engagement and spread.”

Julie PipesCancer Manager


Coverage

Upper GI – 3 x hospitalsites (Lincoln CountyHospital, Louth CountyHospital and GranthamDistrict Hospital) withinUnited Lincoln HospitalsNHS Trust

Urology – 3 x hospital sites(Lincoln County Hospital,Louth County Hospital andGrantham District General)within United LincolnHospitals NHS Trust

Lung – Pan United LincolnHospitals NHS Trust(Lincoln County Hospital,Louth County Hospital,Grantham District Generaland Pilgrim Hospital)

Efficiency benefits

Testing in urology andUpper GI in 1 site (LincolnCounty Hospital) reducedbed days by 96 =savings* £19,400(October – December2007)

Impact of spread forUrology and Upper GI(across three hospitalsites) has the potential toreduce bed days by 499.2per annum = savings*£99,840.00

Invest to Save - 5 xsmart phones purchasedfor key workers to receivealerts at a cost of £870(£175.00 each) + £600p.a. (£120.00 each) linerental (contract)

* based on cost savings of circa £200 per night per patient

What has been the impact?

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Evidence from testing supporting spread reductions in length of stay for Urology and Upper GI

“This is a really importantpiece of work showing

genuine improvement in thequality of care that we deliver

to an already vulnerablegroup of patients. It is

important that all patientsreceive timely care provided

by the right person in theright place - this is especially

important for cancer patients.Early assessment is key to this

and ensures that the patientand family are treated withdignity. I am pleased to see

that this programme of workis being extended to cover

other specialties”

Dr Richard Lendon Director of Performance


Minimum 1 Day 0 Day 0 Day 0 Day

Maximum 55 Days 28 Days 45 Days 25 Days

Median 7 Days 2 Days 7 Days 7 Days

Average 10 Days 7 Days 10 Days 8 Days

Length of stay in baseline

Length of stay for test period

Length of stay in baseline

Length of stay for test period

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How was spread achieved?• Increasing awareness:

• Palliative Care Pathway launched at the Hospital Grand Round meeting inOctober 2008

• Meetings with A&E and Emergency Assessment Unit staff

• Attendance at on call handover meetings

• Junior doctors teaching sessions to increase awareness and understanding.

Productivity alone cannot ascertain theeffectiveness of a complex interventionlike palliative care input/palliative carepathway in the care of a patient (wherethere are so many variables that influencewhether or not patients are admitted andhow long they stay) in terms of directlyinfluencing variables like length of stay(LOS) or averting admission is extremelydifficult.

The key is to focus on integrating thepathway and the quality improvementsthis will drive the efficiency gains.

Through working acrossboundaries, a palliative carepathway was integrated intomainstream medical andsurgical care with the aim toimprove the quality of care for end of life patients.

The pathway was triggered by alert notifications to thecommunity team and clinicalnurse specialists for acutecancer admissions, to optimisethe appropriateness ofadmission, place of admission,management and length ofstay.

The Hillingdon Hospital NHS Trust


Improved communication amongst teams

Alert notifications regarding cancer patients A& Eattendances and any subsequenthospital admissions to communityspecialist palliative care team andspecific tumour clinical nursespecialists

Junior doctors receive teaching on the palliative care pathway

Coverage

Organisationwide

CommunitySpecialty PalliativeCare Team

Efficiency benefits

Analysis will be completedmid July 2009 preliminarydata has shown

A&E attendances:Jan/Feb 2008 n = 117Jan/Feb 2009 n = 99

A&E attendances resulting in admission:Jan/ Feb 2008 n = 55Jan/Feb 2009 n = 45

What has been the impact?• Collaborative and close working with site specific Clinical Nurse Specialties in three tumour groups, Upper GI, Urology and Lung and with the Community Specialty Palliative Care Team

• Sharing the message and principles• Poster presentation – The Pan

London End of Life Care Conference awarded joint 2nd prize

• Ongoing monitoring and analysis• Active leadership from the Palliative

Care Consultant.

The Hillingdon Hospital Palliative Care Pathway


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Emergency Admission Unit (EAU) Alert

Emergency Admission Unit Alert is anelectronic system developed through theexisting patient administration systemwhich searches for all known cancerpatients and alerts the relevant CancerNurse Specialist when the patient arrivesin the Emergency Admission Unit.

Northampton General Hospital NHS Trust

How was spread achieved?

“Following the initial testing in lung the results were shared at the clinical nurse specialist meeting with the cancer

steering group and with all the cancer clinical leads in the hospital. Clinical engagement was gained as well as theagreement to rollout the alert principle across the other

specialties, using the electronic system.

The cancer steering group reports to the hospital managementteam and the clinical quality effectiveness group. The progress

of roll out was reported quarterly to these groups. This ensured clinical and managerial support.

The service improvement facilitator (from the cancer network)became part of the Trust service improvement team and

supported the spread of learning from the testing.

A lesson learned which came to light when completing the spread planner survey was that we could have improved

our communication internally with the wards.”

Karen Spellman Cancer Lead Manager

Northampton Hospital NHS Trust

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Increased number ofpatients receiving‘Preferred place of care’discussion

Proactive referral to thespecialist palliative careteam

Early assessment by thespecialist team hasensured timely proactivemanagement of thepatients care

Coverage

Across selectedclinical teams:

GynaecologyHaematologyHead & NeckLungTesticularThyroidUpper GastroIntestinal(Upper GI†)UrologySkin

Efficiency benefits

Reduction in LOS for Lungcancer patients by 7.4 days per patient



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Influenced length of stay

Period of data collection

April-June 2006(baseline)

July 2006-December 2007(paper fax alertfrom EAU)*

April-November2008 (electronicalert)**

Number ofadmissionsalerted

16

49

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Averagelength of stay (days)

12.5

9.7

5.1

*Between Dec 2007 and April 2008 the new electronic alert system was being developed andtherefore no data was captured on length of stay.

**Since November 2008 the alert system has been implemented and the evaluation is currently under review.

†Upper Gastrointestinal (Upper GI).N

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HaematologicalHead & Neck

LungHead & Neck

Upper GIUrological

Yes Not Recorded No

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Recurring Admission Patient Alert (RAPA)

RAPA is a process that supports the co-ordination and timely care for patientsadmitted as an emergency, alertingmembers of the clinical teams when theirpreviously diagnosed cancer patients arebeing re-admitted to the acute hospital.

Initial testing commenced in Kings MillHospital and has now been successfullyimplemented across Sherwood ForestHospitals NHS Foundation Trust.

How was spread achieved?RAPA has now been implemented acrossall nine tumour sites at Sherwood ForestHospital NHS Foundation Trust andHospital Specialist Palliative Care Teams.

Showcasing at different hospital forumshas enabled non-cancer specialties,including the Integrated Discharge Team,Cardiology, Respiratory, and Diabetes tobenefit from RAPA.

The principles have been adopted inalerting specialties/wards to patientsbeing admitted to the hospital who areknown to be MRSA or C Diff positive.This will inform staff of the need tofollow trust protocols and provide mostappropriate care to patients.

Sherwood Forest Hospitals NHS Foundation Trust

The Trust won the 2007 MedicalInnovation Futures Award for thisinnovative initiative.

The Trust held a RAPA showcasing eventMay 2008. Delegates came from as far asBrighton and Gateshead. RAPA iscurrently being tested and implementedat Doncaster hospitals and we have othersites still coming for a demonstration onhow RAPA works!

Along with other service improvementssuch as the discharge planning tool andexpansion of the Integrated DischargeTeam this allowed our overall averagelength of stay to steadily decrease for thetrust as a whole despite an increasingnumber of service users. The graphs showfigures for length of stay in days for thefinancial year broken down by electiveand non-elective admissions.


Defined emergencypathway

Patient is assessed toadmit rather thanadmitted to assess

Timely and appropriatesupport/interventions

Promotes ongoingcontinuity of care

Early discharge supported

Supports patient choiceand preferred place ofcare

Coverage

Organisation wide acrossnine cancer tumour sites

Hospital SpecialistPalliative Care Team

Non-Cancer Specialistareas, Cardiology,Respiratory, and Diabetes

Infection control alerts -known MRSA/CDiffpatients are alerted to theInfection Control Teamwhen they arrive inhospital

Other hospital sitesoutside of trust -Doncaster Hospitals

Efficiency benefits

Lung tumour site hasreduced length of stay by25%, releasing a potential560 bed days per year

This equates to a potentialredistribution of £112,000based on £200.00 per day

Reduced length of stay forall elective and non electivecancer admissions

Reduced length of stay forall elective and non-electiveadmissions acrossorganisation


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A snapshot analysis in April 2009 showedsustained length of stay in the originalfour test tumour sites, Breast, Lung,Upper GI and Gynaecology

Comparison of median LOS for theoriginal test sites, pre, during andpost RAPA.

Reduced length of stay for all elective and non elective cancer admissions

Reduced length of stay for all elective & non-elective admissions across organisation

Comparison of median LOS for non-electivebreast patients, pre, during and postimplementation of RAPA

Comparison of median LOS for non-electivegynaecological patients, pre, during andpost implementation of RAPA

Comparison of median LOS for non-electivelower GI patients, pre, during and postimplementation of RAPA

Comparison of median LOS for non-electivelung patients, pre, during and postimplementation of RAPA

Elective Inpatients Average Length of Stay

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02005/06 2006/07 2007/08 2008/09

Financial Year

3.43 3.3

2.77 2.76

Non-elective Admissions Average Length of Stay

2005/06 2006/07 2007/08 2008/09

4.53 4.53 4.443.89

Elective Cancer Patients Admissions Average Length of Stay

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Non-elective Cancer Patients Admissions Average Length of Stay

2005/06 2006/07 2007/08 2008/09

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Apr 09 Post RAPA

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Preferred Priorities of Care(PPC) Implementation /Advanced Care Planning (ACP)

Spreading the Gold StandardsFramework, Preferred Priorities of Careand the Liverpool Care Pathway in orderto reduce length of stay and avertunnecessary admissions. This isintegrated work with the National End of Life Care Strategy.

How was spread achieved?Raising awareness – Poster Campaign(including on the back of toilet doors).Increased staff awareness of theimportance of identifying patients in theirlast year of life.

New learning and feedback• The communication department

developed a new two day enhanced communication skills training for frontline staff (Level 2). Five training sessions have been allocated for this year and will be co-facilitated by End ofLife Project Manager and key members of the Palliative Care Team

• A teaching programme has been developed for all ward staff to raise awareness of recent National developments regarding care at the endof life. The North West End of Life CareModel (NHS North West 2008) has been adapted and developed into achecklist for all ward staff to use

The Christie NHS Foundation Trust

• Raise awareness of the potential risks to the organisation, staff and patients ifend of life and advanced care planning is not implemented

• Giving feedback to each ward area of the results from base-lining testing identifying the actual and potential benefits

• Ward and medical staff are encouragedto use the surprise question amongst staff to identify potential patients in their last year of life. "Would you be surprised if this patient were to die in the next 6-12 months?“

• Working collaboratively with identified medical teams to facilitate active decision making and improve end of life care.

Challenges• The biggest challenge has been

changing the mindset of health care professionals regarding end of life care

• Importance of promoting the principles and gaining high level management support and awareness.

• Internal and external sharing of information through various means including e-mail, intranet, phone contact, letters and updates in the hospital bulletin.

260 (91.87%) of these patients have subsequently died and 211 (81.15%) achieved their end of life care

“The link between hospital and community services has beeninvaluable and has led to a much smoother transition to shared

care with the community health team and oncology services.The patients and their relatives involved have expressed a great

deal of satisfaction with the level of care and support, bothphysical and psychological, that they have received.”

Dr Sacha HowellHonorary Consultant in Breast Medical Oncology,

The Christie NHS Foundation Trust

Total PPC discussions

300

250

200

150

100

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DiscussionsDeceasedPatients

Still Alive Not AchievedPPC

Achieved PPC

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Improved patient choice andexperience. 283 preferredpriorities for care discussionsfacilitated

260 (91.87%) of these patientshave subsequently died and 211(81.15%) achieved their end oflife care wishes

Averted inappropriate admissions

Moved care out of the hospital toanother setting (shifting care)

Facilitated rapid discharge

Improved clinical decision making(end of treatment decisions)

Increased staff awareness of theimportance of identifyingpatients in their last year of life

Timely and effectivecommunications across all sectorsand disciplines

Developed teaching programmes

Coverage

One organisationstarted with ovarianand lung cancerManchester patientsonly

Known patients frompalliative care team

Ward 1 – ovarian andbreast cancer patients -15 consultantsinvolved

Spread strategy tosystematically addresseach tumour site andward

Efficiency benefits

Over 15 months releasedcapacity of 1,134inpatient bed days foractive anti-cancertreatments. This equatesto 76 bed days per month

This equates to aredistribution of£226,800 based on £200per day

59 re-admissions wereaverted over 15 months,this equates to fourpatients per month



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The Christie NHSNHS Foundation Trust

Raising awareness poster

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National overview: Spreading Winning Principle 1 towards a million bed days

National Overview (HES 2006/7)• Emergencies inpatient episodes

have increased by 51% over nine years

• Emergency admissions via A&E haveincreased particularly rapidly (144%)

• There are nearly 200,000 admissions pa via A&E

• The equivalent to 540 per day. This equates to three patients per day, per average size NHS Trust

• Emergencies use 60% of bed days (almost three million)

• Emergency bed days have increasedby 14.5% over nine years

• In 2006/7 there was 417,646 emergency inpatient episodes = 2,963.987 bed days

• Average length of stay for emergency admissions is 7.1 days.

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Winning Principle 1Unscheduled (emergency) patientsshould be assessed prior to thedecision to admit. Emergencyadmission should be the exception not the norm.

Winning Principle 1 is being adoptedand adapted into rapid alert systems,defined emergency pathways andacute oncology approaches. Reducinglength of stay and avertingunnecessary admissions. This has thepotential to reduce emergency beddays by 25%.

National cancer emergency bed days total numberReleasing 25% = 740,996 bed days

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Winning Principle 2

2. All patients should be on defined inpatient pathways based on their tumour type and reasons for admission.

The following five summaries focus onspreading Winning Principle 2. Theyillustrate the spread of change in clinicalpractice, new care pathways and shiftingcare from an inpatient to an ambulatorysetting. All five NHS Trusts have beensuccessful in spreading the improvementsto the places they wanted them to go,across clinical teams, organisations andcancer networks. The learning applied tothe spread framework shows thecommon themes.


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Pan Birmingham Network

Move to 23 hour stay modeland wound drains as theexception for breast cancer surgery (excludingreconstruction) across a Cancer Network.

How was spread achieved?‘Pulling the idea’. Following the visit toKings College Hospitals NHS FoundationTrust, London, two consultants at eachtrust were happy to test the use of drainsas the exception rather than the norm.The concerns that the consultants hadprior to the visit at Kings were alleviatedby meeting face to face with the cliniciansat Kings. The spread of the change inclinical practice had already started.

Following the early testing this workstream became a rolling agenda item atthe Network Site Specific Group (NSSG)for Breast at which the surgeons andother clinicians came together on a bimonthly basis. Within a few months itwas evident that this testing wassuccessful and when asked at the NSSGfor other test sites, we got sign up fromall the other Acute Trusts within theNetwork and at one Trust we had buy-infrom both hospital sites within the Trust.

We then went along the same base liningfor all other test sites and it soon becameapparent that the issues in the pathwaythat were evident in the initial testingsites were also similar to those in the newtest sites. We were able to share thelearning from the initial sites and adaptthe protocols that were developed for usewithin the new test sites.

The way in which testing moved intospread was:

• By the teams owning the testing ideafrom infancy.

• Sharing the learning from other testsites on a regular basis at the NSSG.

• Testing evolved into spread within theorganisations as well as acrossorganisations by regularcommunication and raising the profilelocally by sharing the findings.

• At all Trusts there were surgeons whowere not involved in testing, however,their lengths of stay have also beenreduced. The Pan Birmingham Networkhas shown that spread has beenachieved and the work is beingsustained.


Insertion of drains theexception rather than thenorm – aiding patient mobilityand early discharge

Drainage of seroma theexception rather than thenorm – less invasiveinterventions and reducing therisk of infection

Patients satisfaction identifiedthey liked the new model

Coverage

All breast care excludingbreast reconstructionsurgery across the PanBirmingham Network

Sandwell & WestBirmingham NHS Trust (City Hospital)

Heart of England NHSFoundation Trust (GoodHope and Solihull)

University HospitalsBirmingham NHSFoundation Trust

Walsall Hospital

Efficiency benefits

Reduce unnecessary LOSfrom six days to 23 hours

Establishing theappropriate length of stayfor 80% of breastpatients includingmastectomy excludingbreast reconstructionsurgery

Potential to benefit 1,524patients a year (all breastcare cancer and noncancer excluding breastreconstruction)


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Baseline and potential cost savings

Test sites

Sandwell & WestBirmingham

University HospitalBirmingham

BirminghamHeartlandsHospital

Good HopeHospital

Walsall Hospital

Network Total

Total numberof episodes

473

394

270

156

231

1524

Potential cost savings for breast across the Pan Birmingham Cancer Network

Averagelength of stay

5.32

4.04

5.19

5.03

3.95

4.70

Inpatient cost at £200per day

503,272

318,352

280,260

156,936

182,490

1,432,560

Day case cost at £250per day

118,250

98,500

67,500

39,000

57,750

381,000

Potentialsavings

385,022

219,852

212,760

117,936

124,740

1,051,560

Test sites

Sandwell & WestBirmingham NHS Trust

Heart of England NHSFoundation Trust

Walsall Hospitals NHSTrust

University HospitalBirmingham NHSFoundation Trust

Number ofconsultants testing model

2

2

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3

The Pam Birmingham 23 hour model has now spread and is being sustained

Additional consultants involved in spread

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Baseline length of stay and the sustainability results for three of the organisations 2009

Sustainability data

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Baseline Testing Consultant NonTesting Consultant

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The national picture is showing that length of stay is decreasing:

Breast Cancer Surgery

The National Picture - Breast Cancer Surgery Trends

Breast Cancer Surgery: Trends in AverageLength of Stay (HES 1997-2008)

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Breast Cancer Surgery: Trends in Bed Days (HES 1997-2008)

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Breast Cancer Surgery: Trends in Procedures(HES 1997-2008)

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Mastectomy: Distribution of Inpatient Length of Stay (HES 2007-2008)

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Wide Local Excision: Distribution of InpatientLength of Stay (HES 2007-2008)

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Reducing length of stay forcolorectal surgery patientsusing enhanced recoverytechniques. The enhancedrecovery pathway sets outwhen patients should beexpecting to eat, drink,mobilise or practice changingtheir stoma bag.

How was spread achieved?The principles of Enhanced Recovery wereinitially introduced by one surgeon. Someof the key principles have been adoptedby the other three surgeons in oneorganisation so that other patients havealso benefited. Early diet andmobilisation along with effective paincontrol have been accepted more widelyalthough issues around bowel preparationcontinue.

Other sites within the region, Heart ofEngland NHS Trust, Walsall Hospitals NHSTrust and University Birmingham NHSFoundation Trust are learning aboutEnhanced Recovery and implementingmany of its principles. Two local studydays have been held to raise the profile of Enhanced Recovery principles.

A local forum for sharing ideas across theNetwork and has been established ‘TheMidlands Enhanced Recovery Forum’.

Events have been held locally and this hashelped to spread Enhanced Recovery tothree other organisations within theNetwork.

Enhanced Recovery is now beingdiscussed at the Colorectal Network SiteSpecific Group to ensure disseminationacross the local health economy and alsoprovide a means for ensuring that spreadis continuously monitored.

Sandwell and West Birmingham Hospitals NHS Trust: City Hospital


Patients informed of the postoperative milestones they areexpected to achieve resultingin quicker recovery times

Patients able to drink up totwo hours before theiroperation

Strong laxative preparation notrequired

Alternative analgesiaminimising opiod side effects

Optimal use of IV fluids duringoperation guided byoesophageal DopplerReestablishment of enteralnutrition from day of operation

Patients are encouraged tomobilise from day one

Development of multimodalmodel of care enhancedrecovery pathway

Coverage

Sandwell & WestBirmingham HospitalTrust; City Hospital

Heart of England NHSTrustWalsall Hospitals NHSTrustUniversity BirminghamNHS Trust

The Colorectal NetworkSite Specific Groupensures disseminationacross the local Healtheconomy

Efficiency benefits

Reduce unnecessary LOSfrom 16 days to 5 days(ranging from 8 to 3)

Potential to benefit 150resections patients a year


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The improved local Enhanced Recovery Pathway Patients are informed about the benefits and requirements prior to surgery both withinthe outpatients setting and also at pre-assessment. This preparation is seen as key toensuring that patients and their families are well prepared for their stay and dischargefrom hospital.

Traditional pathway

Working in partnership with patients - All patients are given a milestone card to aid with early independence after surgery

“The biggest challenge to introducing enhance recovery to our team was trying to change their deeply

held ideas about patient recovery”

Mr Satish BhaleraoConsultant, Sandwell & West Birmingham Hospitals

Day 0 Surgery performedDrip, fluids, drain(s)Catheter/nasogastric tube

Day 1 Monitoring post op/sit out

Day 2 Monitoring post op/?Short walks/sips

Day 3 Monitoring post op/nasogastric down/flatus passed/sips

Day 4 Oral fluids/short walk

Day 5 Drip down/drain out

Day 6 ?Small soft diet

Day 7 Diet if tolerated/monitor bowel movements/walking

Day 8 ?Wound clips removed

Day 9 Patient independent

Day 10 ?Discharge depending on patient recovery/complications

Enhanced Recovery Pathway

Day 0 Surgery performedDrips, fluids, drain(s), catheterDrinking tea/juiceWalking short distancePain relief via PCA/epidural Catheter in

Day 1 Eating foodWalking around wardPain relief orally

Day 2 Epidural downDrip downCatheter out

Day 3 Patient independent

Day 4 Discharged

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The National Picture - Colorectal Cancer Surgery Trends


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Colorectal Cancer Surgery

Colorectal Cancer Surgery: Trends in AverageLength of Stay (HES 1997-2008)

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Colectomy: Elective - Length of Stay (HES 2007-2008)

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East Kent Gynaecological Oncology Centre

Improving patient care withshorter hospital admissions

Many cancer patients’ journeys includeavoidable prolonged hospital admissionsand significant variations in length of stay.

The East Kent Gynaecological OncologyCentre identified and addressed obstaclesin the inpatient pathway saving resourcesfor redirection to areas of clinical needand improved patient experience avoidingdelays in investigations and treatment.

They are using a number of spreadstrategies to ensure the messages areshared amongst peers both locally andnationally. Clinical engagement was a keydriver in their spread strategy andcommenced right at the beginning withall the key people being involved. Theimprovements were clinically led andclinically focused. The major factorresponsible for the reduction of stay wasa patient and staff awareness programmeof early post-operative mobilisation anddischarge, leading to an expected hospital stay.

How was spread achieved?• A systematic approach• National publication to spread

amongst peers• Gynaecology NHS Leads Group• Network Site Specific Group (NSSG )• Discussions with Sheffield Teaching

Hospitals NHS Foundation Trust re enhanced recovery model

• Patient and staff awareness programmefor expected length of stay.

This work reflects many of the principlesof enhanced recovery.


Patients know what theirlength of stay is expected tobe prior to surgery

Women are engaged indischarge planning prior tosurgery

Patients are happy to gohome sooner without the re-initiation of bowel functionand take prescribed gentlelaxatives in their own home

Patients do not have to stayin with their urinary catheters

Wound management can bedone in the community

Coverage

Involved patientsadmitted for gynaeoncology surgery in EastKent gynaecologicaloncology centre;represents collaborativework with MDT,particularly nursing andmedical staff

Efficiency benefits

The overall length ofstay for majorgynaecological surgeryreduced from 8-7 daysto 4-3 days

32.1% of patients for abdominalhysterectomy includingovarian, uterine andcervical malignancywere discharged withinfour days instead of 8.1days in 2006

Referrals to socialservices, palliative careteam and occupationaltherapy reduced from13 days to seven days


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The National Picture - Gynaecologial Cancer Surgery Trends


Gynaecological Cancer Surgery

Gynaecological Cancer Surgery: Trends in AverageLength of Stay (HES 1997-2008)

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Gynaecological Cancer Surgery: Trends in Bed Days(HES 1997-2008)

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Gynaecological Cancer Surgery: Trends in Procedures(HES 1997-2008)

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Abdominal Excision of Uterus: Elective Length of Stay(HES 2007-2008)

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Vaginal Excision of Uterus: Elective Length of Stay(HES 2007-2008)

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Example of Enhanced Recovery Elements

For further information on the National Enhanced Recovery Programme visit www.18week.nhs.uk or www.improvement.nhs.uk/cancer

Referral from Primary Care

Admision

Follow-Up

Pre-Operative

Intra-Operative

Post-Operative

• Optimising pre-operative haemoglobin levels

• Managing pre existing co-morbidities eg diabetes • Planned mobilisation

• Rapid hydration & nourishment

• Appropriate IV therapy• No wound drains• No NG (bowel surgery)• Catheters removed early• Regular oral analgesia• Paracetamol and NSAIDS• Avoidance of opiate based

analgesia where possible or administered topically

• Minimally invasive surgery• Use of transverse incisions• No NG tube (bowel

surgery)• Use of LA with sedation• Epidural management

(inc thoracic• Optimised fluid

• Optimising health/medical condition

• Informed decision making• Pre-operative health & risk

assessment• PT information &

expectation managed• DX planning (EDD)

• Optimised fluid hydration• Reduced starvation• No/reduced bowel

preparation (bowel surgery)

• Audit & outcomemeasures

• DX on planned dayTherapy support (stoma, physio)

• 24hr telephone follow up

The three summaries; mastectomy, colorectal resection and gynaecology have all illustrated how some of the principles of Enhanced Recovery are being adopted across different tumour sites.


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St Helens and Knowsley Hospitals NHS Trust

Inpatient pathways forCarcinoma of UnknownPrimary: (UKP) for elective and emergency patients

How was spread achieved?The local work is now well recognised inthe network with the imminent formationof a Clinical Network Group and thedevelopment of guidelines.

The Unknown Primary Pathway will be acore function of the new Acute OncologyTeam in each Trust.


Multidisciplinary approach

Radiology alerts

Improved clinical decisionmaking

Reduce the number ofunnecessary investigations

Patient seen within 24 hoursof admission

Efficiency benefits

Reduction in unnecessaryinvestigations from five toaverage of three

Reduction in LOS from 22days to 12 days (range 9-22)

Reduction from diagnosis toreferral five days to twodays (range 1-5)

Reduction from referral toteam to being seen fromtwo days to 0.5 days


“Spread is through gainingsupport at the cancer centre

and rolling this out withsupport from commissioners”

Dr Ernie MarshallMacmillan Consultant Medical Oncologist

The Unknown Primary Pathway is being spread throughout the Network

Whiston Hospital has sustained their changes

Coverage

Whiston Hospital

St Helens Hospital

The WhittingtonHospital NHS Trust,London

25

20

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/investigates per patient

Baseline Test Cycle 1 2008

Length of stay

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Barking Havering and Redbridge University Hospitals NHS Trust

Shifting care from haemato-oncology inpatientsto day case - inpatientprocedures to day case andinvesting to save

How was spread achieved?Moving from testing to implementationtook longer than expected.

The first business case was rejected.

The second business case focused on thesavings from reducing length of stay. Thiswas due to the organisations financialposition. The involvement of the medicaldirector was a key turning point.

On getting the business case accepted,the recruitment process took much longerthan expected.

Now all 12 consultants in haemato-oncology use the beds but wehave learnt that shifting inpatientprocedures to day case should involve allparties from day one including radiology.Clinical engagement is the key to itssuccess.

“I supported this project asclinically it would deliver interms of reducing patients’

length of stay; I understoodthe executive teams

reservations in terms of thefinancial input, but knew that

this would deliver bothclinically and financially.”

Dr Yasmin DrabuMedical Director


Less unnecessary time inhospital for patients

Patients satisfaction shows they preferredbeing treated as a day case rather than having an inpatient stay

Improved access tospecialist nurse adviceduring assessments/treatments

Coverage

Initially suitablepatients weretransferred into theday case beds

All consultants inhaemato-oncology- 12 in total

Efficiency benefits

Identifying the procedures thatcould be conducted as a daycase improved inpatient bedutilisation by 80%

Invest to save – four beds on theday-case unit

To date 68 patients have beentransferred from inpatients today cases

1652 hours = 68 bed days havebeen saved

Patients previously admitted forintravenous antibiotics to thehaematology oncology wardLOS has been reduced from 113hours five nights stay in hospitalto four hours over five days


Current procedures that have shiftedfrom inpatient to day case

Ascetic drain

Blood and platelet transfusions

Skin biopsy

CT guided biopsy

U/S guided biopsy

Hickman line insertion

Bone marrow

Consultant review

IV fluids

Day case does not mean all day

Efficiency

Total number of patients in admission avoidance 68beds since February – May 2009

Number of patients who would have had inpatient 22spell for this procedure

Number of bed days saved to date 1652 hours = 68 bed days

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National overview: Spreading Winning Principle 2 towards a million bed days

National Overview (HES 2006/7)• Elective inpatient bed days account for

35% of bed days• 2006/7 average length of stay for

elective admissions was 5.2 days• 2006/7 there was 339,038 elective

inpatient episodes = 1,750,223 bed days.


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

Winning Principle 2 is being adopted andadapted into defined tumour specificpathways, enhanced recovery approachesand shifting care such as procedures frominpatients to alternative delivery settings.The spread of this principle and modelshas the potential to reduce elective beddays by 25% and in some tumourgroups adopting the enhanced recoveryapproach up to 50% released bed daycapacity.

National cancer elective bed days total numberReleasing 25% = 437.555.

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Winning Principle 3

3. Clinical decisions should be made on a daily basis to promote proactive case management.

Winning Principle 3 is not a stand aloneprinciple as clinical decision making is akey component across all improvementsand an integral part of all the principles.

Regular, timely clinical decision makingcan make a significant impact on qualityimprovement, efficiency and the inpatientexperience, but often requires a changeof mind set, practice, system andbehaviour in order to gain the benefits.

The evaluation of learning showed thefollowing common themes.


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The previous summaries have highlighted the importance of clinical leadership,consultation, communication and providing evidence as an enabler for spread. Thefollowing summaries highlight some of the obstacles to spread and how they wereovercome.

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Several strategies wereimplemented and tested to try to maximize efficiency,optimize timely clinicaldecision making and henceimprove both bed usage andthe inpatient experience forthe patients. They includedweekly multidisciplinary warddiscussions, daily ward paperrounds with the seniorregistrar, an admissionpriorities scoring system andbenchmarked length of staywith appropriate triggers fordischarge.

The testing of daily clinical decisionmaking seemed to demonstrate a positiveoutcome in that daily ward rounds by theoncology consultants did help to reducelength of stay. However, this came at asignificant cost of time. Without beingable to incorporate this amount of time inworkable job plans, it was not felt to be asustainable change. The senior registraron call for the ward now undertakes adaily paper ward round instead which isfully implemented and includes alloutliers.

How was spread achieved? This work has become integrated withinthe cancer network to support spread.

The project has been promoted throughthe Cancer Network via the ‘LeadManagers’ and ‘ChemotherapyImprovement’ groups and interest hasbeen shown in doing similar work atother Trusts.


Improved communicationbetween clinical teammembers - weeklymultidisciplinary warddiscussions

Daily clinical decision makingvia paper ward rounds toinclude outlier patients

Timely decision making

Admission priority scoringsystem “gold, silver & bronze”

Trigger point system fordischarge

Coverage

13 whole timeconsultants

Part of a plannedstrategy with theCancer Network

Efficiency benefits

75%of patients admittedon original planned date

Elective stays have beenreduced by an average ofone day per patient

Saving 21 bed days permonth

Potential to release 250bed days annually


% of all elective patients admitted on original planned date

% of priority elective patients admitted on original planned date

How often is 100% of daily admissions achieved

Average days delays for patients not admitted on original planned date

Elective patients admitted on their original planned date

Baseline

58%

64%

30%

2.75 days

TestingAug/Sept 07

62%

71%

40%

3.5 days

Nov 07

81%

93%

71%

1 day

Mar 08

88%

85%

79%

1 day

Mar 09

75%

82%

84%

1 day

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The Whittington Hospital NHS Trust - Acute Oncology Model

Acute Oncology Model of Care delivery aims to reducelength of stay for emergencyadmissions and avertunnecessary acute admissions.

This model of care had beenused by the acute oncologistwhen working in Southendand on moving hospital theapproach has been adopted bythe Whittington Hospital NHSTrust supporting the spread ofgood practice.

How was spread achieved? Peer to peer within the hospital so that allacute specialties were aware of theservice. This was achieved by visiting allthe multidisciplinary team meetings.


Acute oncologist available tosee new in-patient referralsdaily

Rapid access clinic for newpatients presenting acutelywith suspected malignancy

Coverage

Southend toWhittington coveringall specialities

Peer to peer withinthe hospital so thatall acute specialitiesaware of the service

Efficiency benefits

Shorter LOS for emergencyadmissions with newcancers

Admission avoidance forsome acute patients withsuspected cancer

Fewer unnecessary testsordered



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"Most patients prefer to be at home, not in hospital. There are good examples of hospitals where effective care with high quality outcomes for patients is provided with a

length of stay half that in other hospitals treating the same sorts of patients. All should be aiming to match

the achievements of the best."

Celia Ingham ClarkMedical Director, Whittington NHS Trust

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National overview: Spreading Winning Principle 3 towards a million bed daysis not just about numbers it’s about quality driving the numbers

Daily, timely clinical decision making is core business in qualityimprovement. To ensure patients stayin hospital for the appropriate lengthof stay and as safe and effective aspossible. Clinicians are the keycharacters and their timely decisionmaking is a ‘vital episode’, butcurrently there remains significantvariation in timely clinical decisionmaking which adds unnecessaryhours, days and delays onto apatients stay in hospital.

Winning Principle 3Clinical decisions should be made on a daily basis to promoteproactive case management.

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Transforming Care for Cancer Inpatients

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Winning Principle 4

4. Patient and carers need to know about their condition and symptoms to encourage self-management and to know who to contact when needed.

The first summary for Winning Principle 4 illustrates clinicians andpatients working together for a sharedcause. Theirs is a simple but strongmessage to reduce deaths fromneutropenic sepsis and a spreadpartnership – keeping the patient at thecentre was a dominate feature capturedfrom their learning.

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Blackpool, Flyde and Wyre Hospitals NHS Foundation Trust

Tested multiple approachescovering neutropenic sepsismanagement involvingpatients and clinicians with theaim to reduce mortality andlength of stay throughdeveloping an emergencypathway for the managementof emergency patients withneutropenic sepsis.

How was spread achieved? • Patient experience captured in a DVD

and distributed to over 500 patients a year, increasing patient and carer awareness for patients diagnosed with cancer

• Hospital wide patient group directive agreed and implemented for antibioticsgiven at point of entry by nurses and monitored

• Hospital direct admissions policy implemented and monitored. This is an agreed emergency pathway.

• Neutropenic sepsis management policy implemented and monitored

• Winner of the 2007/8 Blackpool, Fylde and Wyre Innovation Award.



Late emergencypresentation

High risk of mortality

Multiple emergency access points

Delay in treatment

Aim Improvement Tested & Spread

Quality Baseline 2007

Sustained 2008

Sustained 2009

Improve patientawareness/promote early presentation, selfmanagement andpatient’s confidence

Save Lives

Right place first time.Improve patient, primary and secondarycare awareness

Improve door totreatment time for 100% of patients

Promote self-management and confidence in the system

• Patient held alert card• 24 hour help line• Patient experience DVD

created by patients for patients

• One entry point• Direct admission to ward• Awareness campaign

to GPs• Press release• Direct admission policy• Neutropenic sepsis

management policy

• Patient group directive for antibiotics given at point of entry by nurse

• Staff training• Increased staff awareness

e.g. protocols, presents, laminated flow charts

Cancer PartnershipGroup undergoingaudit of patientviews – positivefeedback

Divisional audit onneutropenic sepsisto includepresentation times

• Increased patient awareness

• When to act, who to contact and where to go

Right CareRight PlaceRight Time

2 deaths

43% patientsdirect referralto correctward

8% receiveantibioticswithin anhour ofarriving athospital

0 deaths

60% ofpatients direct referral tocorrect ward


0 deaths

75%ofpatients direct referral tocorrect ward


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Coverage

Organisation wide

All entry pointswhere patients mayattend know whatcare is required

Efficiency benefits

Reduction in mortality

75% of patients direct referral to correct ward

77% receive antibiotics within an hour of arriving athospital

3 patients a week are admitted with neutropenic sepsis.LOS has reduced from 6 days to 4 days over the testperiod, which equates to 312 bed days saved per year

Cost of standard ward stay = £200 per day

This has the potential to save £62,400 per year

In addition, fewer patients present to A&E. In 2007 33%of patients presented to A&E; in the 2009 audit 5% of patients presented to A&E

Average A&E cost is £24 per person

This equates to 43 less A&E attendances per year whichequates to £1032 per year

Overall potential saving is £63,400 per year

Efficiency

Quality Improvement

Length of stay

% Receive antibiotics within 1 hour

30

25

20

15

10

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0Number of

PatientsLength of stay

(days): MaximumLength of stay(days): Average

Baseline Test (2008) Implemented (2009)

9080706050403020100

Presentation - Administration: % within 1 hour

Baseline Test (2008) Implemented (2009)

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Transforming Care for Cancer Inpatients

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Great Western Hospitals NHS Foundation Trust

Neutropenic Sepsis Pathway

Febrile neutropenia is a commonpotentially life threatening complicationof chemotherapy. Prompt diagnosis andtreatment are important. The GreatWestern Hospitals NHS Foundation Trustin Swindon are further improvingemergency care of adult haematologyand oncology patients admitted withsuspected neutropenic sepsis byencouraging earlier presentation andworking towards achieving a ‘door toantibiotic’ time of one hour or less. In addition, a scoring system;Multinational Association of SupportiveCare in Cancer (MASCC score 2009) toidentify low and high risk patients hasbeen introduced to ensure that the mostappropriate antibiotics are administered.The overall aim is to improve patientsatisfaction, reduce the length of stay(LOS) and target the use of intravenousantibiotic therapy.

How was spread achieved? Trust wide by active disseminationthrough education and training of staffand availability of the pathway inappropriate clinic areas. Continuousaudit and education are important toraise the profile but challenging becauseof the large number of staff involved. Afull time Lead Chemotherapy Nurse hasbeen appointed to support this importantfunction.


Improved patient educationand satisfaction

24 hour contact – Triage help line

Nurse to nurse referral &improved communicationbetween AAU and theHaemato-Oncology Team

Suspected Neutropenic Sepsis pathway pack

All patients have anassessment of MASCC riskindex score on admission

Direct telephone number toambulance service for staff to arrange transport(previously arranged by GP)

Coverage

All chemotherapy patients

Inpatient Haemato-OncologyWard (Dove) and Day TherapyTreatment Centre (DTC), AcuteAssessment Unit (AAU) andEmergency Department (ED)

Dove and DTC, AAU and ED

AAU, Dove, DTC and ED.

AAU, Dove, DTC and ED.

AAU & Dove to Ambulance Service

Efficiency benefits

Earlier presentation of post chemotherapy complications

A faster and specialised system for providing advice for patientsfollowing chemotherapy treatment with the potential to reduceunnecessary GP appointments and hospital admissions

More timely referral for assessment and treatment

More timely and complete package for assessment andtreatment

An increase from 36% to an average of 69% of patientsreceiving intravenous antibiotics within one hour of arrival athospital prior to the introduction of MASCC scoring*

Introduction of a’ low risk’ antibiotic policy to reduce length ofstay where appropriate, but, * the need for medical assessmentof the scoring prior to treatment has extended the ‘door toantibiotic time’ (43%) and requires further work but over 86%received antibiotics within one hour of assessment

Improved timeliness of transport to hospital


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Antibiotics <1h

Gent <2h

Mean LOS

In hospital mortality

Audit results

May-Jun 2007

36%

67%

24 days

30%

Mar-Apr 2008

78%

60%

11 days

0%

Jun-Aug 2008

60%

28%

10 days

0%

Mar-May 2009

86%

0%

2.25 days

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Hull and East Yorkshire Hospitals NHS Trust

24 Hour Palliative CareTelephone Advice Line

Palliative care patients often presentedeither at clinic or A&E with commonsymptoms such as pain, nausea, vomiting,increased respiratory tract secretions andbreathlessness. The Humber andYorkshire Coast Cancer Network exploredmodels of service that would supportpatients and their families in their ownhome by providing a 24 hour helpline.This work has been spread using differentmodels across the Network.

How was spread achieved? The Palliative Care Steering Group, wasinitially formed to implement theguidelines as recommended by NICE. The Palliative Care Steering Group wasresponsible for dealing with any issues orconcerns that arise, supporting thelocalities and ensuring that the correctlocality measures and peer reviewmeasures are adhered to where palliativecare is appropriate.

Excellent cross boundary workingincluding communication and advice tohelp patients and their families avoid theneed for hospital admission at times ofdistress.

Quality improvement

Enhanced patient choice, awareness and self-management

Increase patient confidence in own decision making

Right pathway, right person, first time

Identified symptom pathways enhancing proactive prevention and care

Cross boundary working, helping patients and their families inavoiding the need for hospital admission at times of distress

Coverage

Each locality will maintaintheir own model of care

• Hull and East Yorkshire Hospitals

• Scarborough• Whitby• Ryedale Primary

Care Trust

Efficiency benefits

Reduced emergency admissionand length of stay

Hull & East Yorkshire Hospitalsfrom 119 calls 11% (13 patients)admitted to hospital 2 patientsattended day case unit saving 72unnecessary bed days and anestimated 47 hospital admissionswere prevented


St Andrew’s Hospice 24 HourHotline - Reason for Call

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07 months

Symptom Control AdviceMedication AdviceAdvice re Hospice Facilities

Syringe Driver AdviceDrug DosageSupport

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A wide range of information and advicehas been given to the callers, whichvaried from simple advice onmanagement of the patient at home,pain relief and radiotherapy side effects.All GPs, district nurses and Macmillannurses have been advised appropriatelyand have received follow up calls the nextworking day from the service lead.

Spread was further supported by havingagreed protocols, locality measures andadherence to peer review measures.

Lessons learntWe know that the service is working,although there is a need to ensure thereis continuous monitoring to be able toquantify the impact to ensure that thepatients following the calls are notending up in hospital via another route.


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National overview: Spreading Winning Principle 4 - Patients and qualityimprovement driving the numbers towards saving a million bed days

The main aim of Winning Principle 4is to encourage self-managementthrough:

• Putting patients first ensuring they have a choice and control in their life

• Promoting better support for the patient and carers

• Making sure that patients get the right help at the right time before reaching a crisis point

• Ensuring easy access to information, advice, support and advocacy

• Offering support that is tailor madeto meet the patients/carers needs.


42

Winning Principle 4Patient and carers need to knowabout their condition andsymptoms to encourage self-management and to know who to contact when needed.

Winning Principle 4 is being adoptedand adapted into support modelssuch as telephone helplines,information advice and key contacts.

Further work is needed to fullydevelop patient self-managementmodels.

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Further evidence supporting spread

The spread planner survey was sent tocancer networks for completion and thisprovided a snap shot of ‘how’ theWinning Principles and improvementswere being spread, moving beyond initialtesting.

One of the issues we are facing is toensure that good ideas and improvementsdo not get ‘trapped in location’ but travel(horizontally and vertically) to improve thequality of care. The cancer networkswere considered to be well placed in thiscontext and would capture informationfrom sites who had not been involvedin the initial testing.

The survey was not simply focused onnumbers about take up, but alsocaptured the different elements of ‘how’the spread was being achieved. Spread isa measure not only of increasing numbersbut also about the principles andprocesses that support this.

Emerging key messagesThe initial findings from the survey havethe potential to inform planning forspread, regardless if the intention is tospread with/across organisations, acrossnetworks, health communities orStrategic Health Authorities.

The survey provided a useful baselineposition and further evidence of thethemes for spread. There are someimportant messages, but no new mind-blowing messages or solutions for spread,but for many sites the spread plannersurvey has been used as a checklist tosupport local spread and their plans for‘scaling up’ improvement.

It is the intention to repeat the survey 3-6monthly and share this learning acrossthe NHS.



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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 focus for quality and efficiency

Clinical and managerialResponsibility for deliveryExecutive leadership

Local quality indicators and prioritiesCommissioning agreement and healthy competition

Patients involved in testingAccepted or rejected the improvement

Active disseminationPassive diffusion

‘One size fits no one problem’

Policies and procedures

Information Shared comparative data

StakeholdersOwnership and a distribution of responsibilities

Networking

Knowledge requiredCoaching

Changing practice and behaviourTraining

Transforming Inpatient Framework for Spread: Common themes and practices


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Initial findings and messages• The main focus for spread is

surrounding Winning Principle 1 and 2 - the emergency and elective pathways. Many sites commented that Winning Principles 3 and 4 were integral to all the principles

• The following models of delivery are being adopted:• Communication alert (RAPA) model • 23 Hour Breast Model of Delivery • Enhanced Recovery Approach• Developing Neutropenic Sepsis

Pathways• A number of sites do not have an active

spread strategy. Many stated that wheretesting was successful spread automatically followed across tumour sites if the baseline evidence and measure of benefits from testing was robust

• Network Site Specific Groups were viewed as important to spread improvement

• Clinical nurse specialists and middle managers were seen as the hardest to engage

• There were mixed views surrounding commissioning. Some viewed commissioning as the lever to ensure the improvement was sustained, whilst others viewed commissioning as a lever to make improvement happen

• Responses indicated that spread from initial testing in an organisation takes at least one year.

Spread is evident

80

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Year2008 2009

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Conclusions

Over the last two years, innovative waysof delivering services for inpatients withcancer have been tested with over 40pilot sites across England. The casestudies presented in this document comehighly commended, as practical examplesof what can be achieved.

The result is a number of credible,observable innovations whichdemonstrate real improvements in theway services are provided and delivered.Importantly, for patients they have valuedtime, ensure patients receive quickertreatment, minimise time in hospital andensure a more responsive service for thepatients and their carers.

Let us ask ourselves why would a patientwant to stay six days in hospital when 23hours is an option? By spending £175 ona smart phone, we could avert unecessaryemergency admissions and reduce ahospital stay for one patient by days!Should a patient stay 15 days or five daysby adopting an enhanced recoverypathway? How easy could it be to adoptBlackpool’s DVD to avert emergencyadmissions for neutropaenic sepsis?

Spreading innovations such as RapidAlerts, 23 hour models, enhancedrecovery approaches and neutropaenic

sepsis pathways from one clinical team toanother, from community to communityand widespread across England willalways be a challenge.

This work demonstrates how innovationshave been adapted and are spreading;just look at the concept of ‘rapid alerts’originated in Sherwood Forest HospitalsNHS Foundation Trust, on one site (KingsMill) in one specialty - lung, and nowspreading to Lincolnshire, London,Brighton, Doncaster and other sites. The23 hour model is now becoming thestandard across all of Birminghamhospitals with a potential saving of over£1 million per annum.

Our challenge to you is, if you were totake just one of these innovations andadapt to your local situation, just think of the impact you could make. Ourrecommendation is that you start withWinning Principle 1 ‘emergency patientsassessed prior to admission’ or WinningPrinciple 2 ‘all patients should be on adefined inpatient pathway’ and that you contact Ann Driver or a member of her team who can help you to turn this into a local reality([email protected]).

The tools, techniques and approaches are available for use and do not need to be reinvented, coupled with clinicalsupport.

Our evidence is compelling, the casestudies in practice making a difference forthe service and patients. 1 million beddays – is it achievable? From thisevidence, definitely.

From now on, our goal is to make theseinnovations the norm rather than theexception and see all potential inpatientswith cancer benefit from this goodpractice.

Janet WilliamsonNational Director, NHS Improvement


References and supporting information

Biddy J., Bevan H, Carter E., Bate P.,Robert G. (2009) The power of one,The power of many. Bringing socialmovement thinking to Health andhealthcare improvement; NHS Institutefor Innovation and Improvement

Cancer Commissioning Toolkitwww.cancertoolkit.co.uk

Department of Health; High QualityCare for All: NHS Next Stage Review(2008) www.dh.gov.uk

Department of Health NHS CancerReform Strategy (2007) www.dh.gov.uk

Driver A. (2008) Factors affecting theachievement of cancer waiting timestargets in NHS Trusts: an exploratorystudy. Unpublished thesis DoctorateProfessional Studies in health; MiddlesexUniversity, London

Fraser S. (2002) Accelerating theSpread of Good Practice: A workbookfor Health Care. Kingsham Press

Liverpool Care Pathwaywww.endoflifecare.nhs.uk/eolc/lcp.htm

McNulty T., Ferlie E (2002)Reengineering Health Care: Thecomplexities of organisationalTransformation. Oxford.

National Cancer Intelligence Networkwww.ncin.org.uk

National Cancer Services AnalysisTeam www.canceruk.net/natcansat

National End of Life Care Programmewww.endoflifecareforadults.nhs.uk

NHS Improvement (2008) TransformingInpatient Care: The Winning Principleswww.improvement.nhs.uk

NHS Improvement (2008) TransformingInpatients Care: Meeting the Challengetogether….delivering care in the mostappropriate setting, supportingdelivery. www.improvement.nhs.uk

NHS Modernisation Agency (2004)Manage variation in patient dischargethereby reducing length of stay; 10High Impact Changes for Service andImprovement and Delivery: A guide forNHS leaders, p32

Nordin AJ. (2007) Enhanced Recoveryfor Gynaecological Patients. CancerInpatient Case Studies: 4 WinningPrinciples, NHS Improvement, viewed 11November 2008www.improvement.nhs.uk/winning_principles/principles_2/queen_elizabeth.pdf

Pettigrew A. Whipp R (1993) ManagingChange for Competitive Success.Blackwell

Plesk. P.E. (2000) Spreading good ideasfor Better Health Care. VHA Inc

Rodgers E. M. (2003) Diffusion ofInnovations Free Press 5th Edition

The Gold Standards Frameworkwww.goldstandardsframework.nhs.uk

Williamson J. (2007). The critical factorsfor whole system change of a clinicalspecialty identified through theCancer services Collaborative‘Improvement Partnership’,Unpublished thesis Doctorate ProfessionalStudies in Health, Middlesex University,London


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48

Roll of honour

Barts and The London NHS Trust

Barking, Havering and RedbridgeUniversity Hospitals NHS Trust

Blackpool, Flyde and Wyre HospitalsNHS Foundation Trust: BlackpoolHospital & Preston Hospital

Brighton and Sussex UniversityHospitals NHS Trust

Cambridge University Hospitals NHSFoundation Trust; AddenbrookesHospital & Cambridgeshire PCT

Coventry PCT; University HospitalCoventry

Derby Hospitals NHS Foundation Trust

East Kent Hospitals University NHSFoundation Trust; Queen Elizabeth, theQueen Mother Hospital

East Midlands Cancer Network

George Eliot Hospital NHS Trust

Great Western Hospitals NHSFoundation Trust

Guys and St Thomas’ NHS Foundation Trust

Heart of England NHS FoundationTrust; Good Hope Hospital, HeartlandsHospital, and Solihull Hospital

Hull and East Yorkshire Hospitals NHS Trust

King’s College Hospital NHSFoundation Trust

Lancashire Care NHS Foundation Trust

Leicester County and Rutland PCT

Manchester PCT

Milton Keynes NHS Foundation Trust

Nottingham County Teaching PCT

Norfolk and Norwich Hospitals NHS Trust

Northampton General Hospital NHS Trust

Oxford Radcliffe Hospitals NHS Trust

Oxfordshire PCT

Pan Birmingham Cancer Network

Poole Hospital NHS Foundation Trust

Queen Mary’s Sidcup NHS Trust

Royal Berkshire NHS Foundation Trust

Royal Devon and Exeter NHS Foundation Trust

Sandwell and West BirminghamHospitals NHS Trust; City Hospital

Scarborough and North East YorkshireHealthcare NHS Trust

Sheffield Teaching Hospitals NHSFoundation Trust

Sherwood Forest Hospital NHSFoundation Trust

St Helens and Knowsley Hospitals NHS Trust; Whiston Hospital

The Christie Hospital NHS Trust

The Hillingdon Hospital NHS Trust

The North West London HospitalsNHS Trust; St Marks Hospital

The Whittington Hospital NHS Trust

United Lincolnshire Hospitals NHS Trust; Grantham and DistrictHospitals, Pilgrim Hospitals Boston, Lincoln County Hospital, County HospitalLouth and Lincolnshire PCT

University Hospital Birmingham NHS Foundation Trust

University Hospitals Bristol NHS Trust

University Hospitals of Morecambe Bay NHS Trust; Lancaster GPs

University College London HospitalsNHS Foundation Trust; The NationalHospital for Neurology and Neurosurgery

University Hospitals of NorthStaffordshire; Stoke PCT & NorthStaffordshire PCT

Walsall Hospitals NHS Trust

Whipps Cross University Hospital NHS Trust



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Transforming Inpatient Team: for further information

Ann [email protected]

Angie RobinsonNational Improvement [email protected]

Marie Tarplee National Improvement [email protected]

Catherine [email protected]



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NHSNHS Improvement

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

Telephone: 0116 222 5184 | Fax: 0116 222 5101

www.improvement.nhs.uk

NHS Improvement

With nearly ten years practical service improvement experience in cancer, diagnosticsand heart, NHS Improvement aims to achieve sustainable effective pathways andsystems, share improvement resources and learning, increase impact and ensure valuefor money to improve the efficiency and quality of NHS services.

Working with clinical networks and NHS organisations across England, NHSImprovement helps to transform, deliver and build sustainable improvements acrossthe entire pathway of care in cancer, diagnostics, heart and stroke services.

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Delivering tomorrow’simprovement agenda for the NHS

HEART STROKECANCER DIAGNOSTICS


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transforming care for cancer patients - spreading the winning principels and good practice

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