WHOLE SYSTEMS IMPROVEMENT

1. WHOLE SYSTEMS IMPROVEMENT

2. CONTENT • Overview of NHS Tayside and the challenges facing it • The NHS Tayside improvement journey • Centre for Organisational Effectiveness • A Whole Systems Approach • The Improvement Programme and Projects • Virtual Ward Demonstrator • Medicine for the Elderly Demonstrator • Outpatients Efficiency Demonstrator • The Benefits

3. THE BALANCING ACT…. • NHS Tayside delivers healthcare to over 400000 patients with a budget in excess of £750m. We employ over 14000 staff and provide a comprehensive range of primary, community and acute hospital services for the populations of Angus, Dundee and Perth and Kinross. • NHS Tayside’s principal health organisations comprise the NHS Tayside board, the single delivery unit and the Community Health Partnerships in Angus, Dundee and Perth & Kinross. • Meeting Scottish Government Efficiency & Productivity SR10 challenge, £27.4m in 2010, £30.0m in 2011/12following November’s budget. • Continuing to deliver against the Scottish Patient Safety Programme and meeting the demands of the recently announced NHS Scotland Quality Strategy • Demographic challenge around Older People’s services

4. HEALTHCARE DEMAND IS GROWING A new Ninewells Hospital by 2031! NHS Tayside +148 beds 2016 +517 beds 2031

5. IMPROVING QUALITY REDUCING COSTS Our Choice Surviving – the 5% Thrive – the 95%

6. 2009-2011 – A TACTICAL JOURNEY TACTICAL STRATEGIC PRODUCTIVITY & EFFICIENCY SERVICE OPTIMISATION CRES TRANSFORMATION DEALING WITH THE 5% SPENDING THE 95% BETTER

7. 2010-2012 – A BLENDED APPROACH TACTICAL STRATEGIC PRODUCTIVITY & EFFICIENCY SERVICE OPTIMISATION CRES TRANSFORMATION CRES DEALING WITH THE 5% SPENDING THE 95% BETTER

8. 2010-2012 KEY OUTCOME AREAS TACTICAL STRATEGIC PREVENTION OF ADMISSION IMPROVED DAY CARE MEDICATION REVIEWS INTERMEDIATE CARE CARE HOME INTERFACE HOUSING / HOMECARE SUPPORT CASE MANAGEMENT IMPROVED PATHWAYS ENABLING TECHNOLOGY IMPROVED SERVICE LIASON AND DISCHARGE REDUCE LENGTH OF STAY AND BED DAYS INTEGRATED HEALTH AND SOCIAL CARE SERVICES WORKFORCE REDESIGN SELF CARE AND ENABLEMENT VIRTUAL WARDS COST MINIMISATION WORKFORCE EFFICIENCY TELEHEALTH / TELECARE NEW MODELS OF CARE- DEMENTIA, FALLS AND END OF LIFE WORKING WITH COMMUNITIES - COPRODUCTION

9. Identifying the areas for improvement.. WHOLE SYSTEMS ANALYSIS Assess the performance of the whole health system with respect to local and national targets Identify areas of existing & potential constraints within the whole system To consult with stakeholders across the whole system & recommend areas of priority Assessing the management information requirements to support better patient flow management

10. STEPS TO BETTER HEALTHCARE Tayside Centre for Organisational Effectiveness www.t-coe.org.uk IMPROVEMENT ACADEMY INNOVATION HUB & E HEALTH DEVELOPMENT&SUPPORT Mental Health Theatre Capacity Workforce Efficiency Integrated Care Older People Mental Health Optimising Facilities Prescribing Medicines Others Labs, Maternity Finance Support Scenario Planning, Financial Baselines, Benefits Tracking, Business Cases Workforce Support Workforce Modelling, Engagement & Communications with staff Comms Support Communications with public and staff OE Support Organisational Effectiveness support (includes eHealth)

11. INTEGRATED CARE(VIRTUAL WARDS) - THE CHALLENGE • Emergency admissions and associated bed days not hitting HEAT T12 target.. • Challenge around Health Population Management (HPM) • Lack of effective collaboration between Health and Social Care • Alignment of e Health with key HEAT T6-T12 outcomes • Key improvement areas: • Reduce over 65’s Emergency Beds • More effective HPM • Effective MDT working • Reduction in Polypharmacy

12. INTEGRATED CARE(VIRTUAL WARDS) - THE APPROACH • Next future state workshop brought together over 70 integrated care professionals and patient groups… • Followed up by local sessions in CHP areas… • NHS Tayside worked with partners to develop new HPM toolset – PEONY2 • Test of Change Demonstrators set up in each CHP • Wider collaboration with Social Care, Voluntary Sector and Social Care • Align outcomes with LDP, HEAT and Reshaping of Older People’s services

13. STEP TO BETTER HEALTHCARE – INTEGRATED CARE Art of the probable? What do you See? Tayside Community Today What now? Make it real! ‘Test of Change’ Demonstrators Tayside Community Tomorrow LEARN DESIRE ADOPT What do you Want? We are here 23/08/11 Prioritise Align Outcome based response Benefits Realisation Our Future Truly needs Based! Impact Assessment • Initial Outcome Areas • T12 Emergency Bed Days over 65’s • T6 Long Term Conditions admissions • Patient experience • Releasing Time for Community Care • Medication Concurrence

14. IHI CARE CO-ORDINATION MODEL Person Centred For people with multiple needs Personalised Multi-channel interface Family, associated assets Family Carer/s Peer Groups Social Care Voluntary Goals(G) Co-ordination(C) PATIENT IDENTIFICATION OUTCOMES Value Proposition Service Design Service Delivery Supporting with enabling technology CARE CO-ORDINATOR Feedback Feedback Predictive Risk Tools GP Systems Community Information Systems Telehealth Telecare Business Analytics Performance Management

15. ANGUS CHP – PATIENT PROFILE Virtual Wards focusing on Tier 4 , Innovative Step Down Services are key to success! Macro Integrator NHS Tayside and Angus Council LEVELS OF CARE 724 2% LTC Population North West 187 North East 191 South 346 LEVEL 4 INTENSE CASE MANAGEMENT VIRTUAL WARD ANTICIPATORY CARE PLANS PATIENT PASSPORTS CASE MANAGEMENT 28% LTC Population 10148 LEVEL 3 CASE MANAGEMENT North West 2631 North East 2673 South 4844 70% LTC Population PRO-ACTIVE CONTACT SUPPORTING SELF CARE LEVEL 2 SUPPORTED SELF CARE 25372 North West 6577 North East 6684 South 12111 PRO-ACTIVE CONTACT SUPPORTING SELF CARE LEVEL 1 HEALTHY COMMUNITIES 72487 66% Overall Population North West 18790 North East 19096 South 34601 LTC’s Asthma 6101 COPD 2056 CHD 5318 HBP 16423 Diabetes 4698 Obesity 11854 PREDICTED RISK PROFILE MICRO INTEGRATORS

16. ENSURE OUTCOMES ARE DELIVERED…. Project Definition Statement Benefits Statement Project Status Report Is used for: • Stating your case for change • Current state analysis • Evidence / Data • Envisaged Change • Summarise benefits Is used for: • Define benefits in detail • Define appropriate measures • Summarise enabling changes ( PP&T) • Summarise milestone tracking Is used for: • Report on delivery progress. • Report on Benefits Realisation against plan. • Escalate to Project Board or EMT for decision, support etc Multi- disciplinary Project Board, Clinical and Finance essential

17. RESHAPING CARE FOR OLDER PEOPLE – OUTCOMES 1

18. RESHAPING CARE FOR OLDER PEOPLE – OUTCOMES 2

19. User Device Access Applications TECHNOLOGY ENABLING INTEGRATED CARE Security Service Complex Case Management Collaboration Tools Glue Staff ID Virtual Database Case Management Clinical Portal RBAC Pro-active Contact PMS GP Community Health& Social TELEHEALTH PREDICTIVE RISK TELECARE BUSINESS ANALYTICS Prevention Integration Platform

20. INTEGRATED CARE(VIRTUAL WARDS) - THE BENEFITS • Test of change demonstrators commenced March 2011 following introduction of PEONY2… • Enabling technology being fully utilised • Aligning with local improvement initiatives eg CMR in Angus, Case Management and ACP’s across Tayside.. • Envisaged benefits across Patient Access, Service Redesign and Patient Experience: • Drive effective attendance at A&E • Reduction in unscheduled bed days • Effective discharge models • Focus on the right patients • Increase value multi-disciplinary team time • Net CRES of £1.5-2.0m per annum.

21. MEDICINE FOR THE ELDERLY-BUSINESS CHALLENGE • No standardised operating procedures, resulting in unwarranted variation at each stage of the patient journey.. • Over 40% of all patient admissions are elderly, and will GROW! • Variation in LoS across MfE wards.. • Average LoS higher that ‘best of breed’, around 28 days.. • Discharge planning not always linked to EDD.. • Issues around capability and capacity of downstream services..

22. MEDICINE FOR THE ELDERLY- OUR APPROACH • NHS Tayside Service Improvement team and Atos supported an MDT through a pathway redesign process… • A collaboration of extensive healthcare experience and application of LEAN thinking… • Initial review highlighted large amounts of waste and variation • 7 key improvement areas identified: • Admission Criteria • Inpatient management • Discharge planning • Social work redesign • Staffing profile • Co-located wards • Step up / Step down

23. MEDICINE FOR THE ELDERLY- BENEFITS • Wide variety of Service Improvements achieved, qualitative and financial… • Patient focus and removing waste has delivered a higher quality more cost effective service… • Key outcomes/benefits achieved: • Reduced inappropriate admissions • Reduced Length of Stay (28-18 days) • Lower re-admissions • Closure of 2 wards • CRES in excess of £1.4m per annum.

24. CAPACITY BUILDING IS… An approach to the development of sustainable skills, organisational structures, resources and commitment for healthcare improvement Hawe et al: 1999

25. CHARACTERISTICS REQUIRED TO DELIVER IMPROVED OUTCOMES Quality improvement education programme Evidence based learning Leadership development Build Infrastructure & Capacity • Alignment: • Will and commitment • Vision • Strategy • Culture • Measurement • Learning organisation • Technology & Innovation • Real time measurement and information systems Priorities maintained during crises Stability of general management and program management Supporting and enabling staff in their “day job” of improvement Adaptive internally and externally Ref: Staines 2009

26. TAYSIDE CENTRE FOR ORGANISATIONAL EFFECTIVENESSwww.t-coe.org.uk Mobilisation of trained experts in quality improvement organisational development and leadership to support improvement work. The focus of this expertise will be mobilised to support front line staff and clinicians to build capability in improvement methodology and support key improvement programmes Real time information and measurement resources to support quality improvement of clinical services. Enhance spread and share of good practice through use of technology e.g. Clinical Portal, Clinical Dashboards. Improvement & Development Support Technology Enabling Health A dynamic approach to knowledge transfer which supports our “All teach: All learn” philosophy in support of quality improvement. Develop an innovative education and training resource to build further out capacity and capability in improvement science. Knowledge Management Improvement Academy

27. MAKING BETTER PLACES,MAKING PLACES BETTER Our Stretch Challenge 2011-2015 “ those who are less able to coproduce and use public services as a resource in their lives, experience much more negative outcomes” This accounts for 40% of public sector expenditure in Scotland

28. SUMMARY • A whole system approach is key.. • Identify high impact projects and prioritise resource.. • Leadership aligned with core personal objectives key.. • Skills transfer critical to accelerate Continuous Improvement across whole system.. • Quality improvement with associated CRES can be achieved.. • Early engagement of whole system stakeholders essential.. • Pro-active internal/external communication policy.. • Build on best practice evidence and focus on reducing unwarranted variation…