The Change Challenge Combining service redesign and IT to transform the NHS

1. The Change Challenge Combining service redesign and IT to transform the NHS Mark Outhwaite Director Technologies in Health Group NHS Modernisation Agency

2. High 5. Business scope redefinition 4. Business network redesign Degree of business transformation 3. Business process redesign Revolution Evolution 2. Internal integration 1. Localised exploitation Low Range of potential benefits Low High Where do we get the benefits? In NHS 80% of benefits derived from process re-engineering

3. www.modern.nhs.uk

4. Change No1: Treating day surgery (rather than inpatient surgery) as the norm for elective surgery could release nearly half a million inpatient bed days each year. 1 Change No2: Improving patient flow across the NHS by improving access to key diagnostic tests could save 25 million weeks of unnecessary patient waiting time. 2 Change No3: Managing variation in patient discharge, thereby reducing length of stay, could release 10% of total bed days for other activity. 3 Change No4: Managing variation in the patient admission process could cut the 70,000 operations cancelled each year for non-clinical reasons by 40%. 4

5. Change No5: Avoiding unnecessary follow-ups for patients and providing necessary follow-ups in the right care setting could save half a million appointments in just Orthopaedics, ENT, Ophthalmology and Dermatology. 5 Change No6: Increasing the reliability of performing therapeutic interventions through a Care Bundle approach in critical care alone could release approximately 14,000 bed days by reducing length of stay. 6 Change No7: Applying a systematic approach to care for people with long-term conditions could prevent a quarter of a million emergency admissions to hospital. 7 Change No8: Improving patient access by reducing the number of queues could reduce the number of additional FFCEs required to hit elective access targets by 165,000. 8

6. Change No9: Optimising patient flow through service bottlenecks using process templates could free up to 15-20% of current capacity to address waiting times. 9 Change No10: Redesigning and extending roles in line with efficient patient pathways to attract and retain an effective workforce could free up more than 1,500 WTEs of GP/consultant time, creating 80,000 extra patient interactions per week. 10

7. What is the potential? • enhance the experience of millions of people who use NHS services • save millions of: • hours of clinician time • appointments in primary and secondary care • hospital bed days • virtually eliminate waiting lists • tangibly improve clinical quality • create enjoyment and pride at work • help NHS organisations achieve local and national goals and financial balance

8. “Trying harder will not work. changing systems of care will.” (Institute of Medicine; 2001)

9. The Improvement Dividend Framework

10. But what about the benefits from IT?

11. US evidence on e-prescribing

12. A UK Adverse Drug Reactions Study • ADRs continue to represent a considerable burden on the NHS, accounting for 1 in 16 hospital admissions and 4% of the hospital bed capacity • Most ADRs were predictable from the known pharmacology of the drugs and many represented known interactions and are therefore likely to be preventable. • Over 2% of patients admitted with an adverse drug reaction died, suggesting that adverse effects may be responsible for the death of 0.15% of all patients admitted Adverse drug reactions as cause of admission to hospital: prospective analysis of 18,820 patients. Munir Pirmohamed, Sally James, Shaun Meakin, Chris Green, Andrew K Scott, Thomas J Walley, Keith Farrar, B Kevin Park, Alasdair M Breckenridge BMJ VOLUME 329 3 JULY 2004

13. And that adds up to: • at any one time the equivalent of up to seven 800 bed hospitals may be occupied by patients admitted with ADRs • ADRs causing hospital admission are responsible for the death of 5700 patients (3800 to 7600) every year. The true rate of death taking into account all ADRs (those causing admission, and those occurring while patients are in hospital) may therefore turn out to be greater than 10,000 a year

14. Results from US research on CPOE • 53% - 83% reduction in serious medication errors • The use of decision support for clinical decisions can also result in major reductions in the rate of complications associated with antibiotics,and can decrease costs and the rate of nosocomial infections. • Information technology can substantially improve the safety of medical care by structuring actions,catching errors, and bringing evidence-based,patient-centered decision support to the point of care to allow necessary customization. • But in US Computerised Physician Order Entry is fully implemented and being actively used in between only 0.8% and 1.3% of the nation’s hospitals Improving Safety with Information Technology, David W.Bates,M.D.,and Atul A.Gawande,M.D.,M.P.H. N Engl J Med 2003;348:2526-34.

15. The Receptive ContextSo what are the characteristics of organisations that get the most out of IT investment? Evidence from industry

16. The synergy between investment in organisational capability and in IT Erik Brynjolfsson Centre for ebusiness@MIT http://ebusiness.mit.edu

17. Seven Practices of Effective Digital Organisations • Move from analogue to real-time digital business processes • embed standard procedures in technology and • use IT to manage the enterprise with ‘live’ information • Distribute decision-rights (delegation) • Foster open information flow and access • Link incentives to performance • Maintain and communicate goals • Hire the best people • Continually invest in human capital Erik Brynjolfsson Centre for ebusiness@MIT http://ebusiness.mit.edu

18. Typical current NHS performance improvement strategy • design system to prevent performance failure • create awareness of targets and performance requirements • raise leadership intent to deliver them • seek to improve the performance of specific departments, specialties or parts of the system • work harder • implement measurement systems to monitor compliance with the required performance Source: Helen Bevan/Richard Lendon/Institute for Healthcare Improvement 2004

19. Potential future NHS performance improvement strategy • design the system to continuously improve • take a process view of patient flow across departmental & organisational boundaries • focus on bottlenecks that prevent smooth patient flow • work smarter by • segmenting & scheduling patients according to their specific needs • managing and reducing causes of variation in patient flow • implement measurement systems for improvement that reveal the true performance of the system and the impact of any changes made in real time Source: Kate Silvester/Helen Bevan/Richard Lendon/Institute for Healthcare Improvement 2004

20. High 5. Business scope redefinition 4. Business network redesign Degree of business transformation 3. Business process redesign Revolution Evolution 2. Internal integration 1. Localised exploitation Low Range of potential benefits Low High Where do we get the benefits? 80% of benefits derived from exploitation of IT - technology driven change

21. Medical informatics is as much about computers as cardiology is about stethoscopes… Any attempt to use information technology will fail dramatically when the motivation is the application of technology for its own sake rather than the solution of clinical problems. Enrico Coiera (1995)