Improvement and Support Team

Transcription

1 Improvement and Support Team 18 Weeks Service Redesign and Transformation Programme 2009 report NHS Board template NHS Board: NHS Lanarkshire Completed by Cathy Dunn, Programme Manager Signed off by the Executive Lead On 9 th July 2009 Rosemary Lyness Director of Acute Services IST 18 weeks Publications 2009 report Template for NHS Boards 1

2 NHS Board Key team members Governance structure Programme priorities: Specialties NHS Lanarkshire Executive lead Yes Clinical lead(s) Yes Programme Manager Yes Service Improvement Manager(s) Yes Information Manager(s) Yes Appointed (yes/no) Other(s) (please state role) Administration Not yet appointed (please add anticipated recruitment deadline) (if so why) In place Not yet in place (if so why) Programme Board Yes Active project plan Yes Risk reporting Yes Patient and public involvement Yes Equality and diversity impact assessment Sustainability strategy In progress Communications plan Yes Improvement action plan in place with project lead In progress Draft available however awaiting the National EIDA to cross reference No improvement plan yet in place (if so why) Comments Neurology Yes Dermatology Yes Orthopaedics Yes Audiology Yes Dental specialties/ Orthodontics Yes Plastics No Minors only in Lanarkshire. Consultant service provided by NHSGGC. Lanarkshire participates in the Regional Plastics Group and links to the National Task and Finish Group. Other priority specialties (please Clinical Service Improvement IST 18 weeks Publications 2009 report Template for NHS Boards 2

3 specify) Groups exist for all specialties Work to date involves: DCAQ completion of the capacity plans. Communicating the principles and definitions and relating to specialty pathways Arrange of demand side solution pilots Pathways development for example Hernia, gallstones, Orthotic,etc, Workforce in relation to the specialties e.g. urology Diagnostics Physiological measurement - Cardiac - Respiratory - Neurophysiology Improvement action plan in place with project lead No improvement plan yet in place (if so why) Difficulties with the ability to measure the 13 key tests. Data quality issues around the baseline measurement. Date on which case study is expected to be available Radiology Yes Endoscopy Yes Other diagnostic areas (please specify) Orthopaedic Referral protocol for ESPs to refer directly for MRI as part of the knee pathway Audiology Audit of referral to MRI for sensory hearing loss Rheumatology Service improvement IST 18 weeks Publications 2009 report Template for NHS Boards 3

4 commenced on dexa scanning Whole systems improvement Improvement action plan in place with project lead No improvement plan yet in place (if so why) Date on which case study is expected to be available Improved referral processes Yes RMS is in place. Continuous improvement action plan developed. Analysis of GP demand by specialty has been completed. Process for engagement with practices and locality agreed. evetting introduced in ENT rollout Programme developed Poster presentation included Appendix A Access to pre-assessment services Yes Revised pathway developed Aim is that all patients identified as requiring surgery will be pre-assessed within two weeks of their outpatient appointment. Other service improvements outlined in poster presentations Poster presentations included in Appendix A Increasing same day surgery rates Yes Audit of patients attending for a daycase procedure did not meet the discharge criteria. Poster presentation IST 18 weeks Publications 2009 report Template for NHS Boards 4

5 included in Appendix A Reducing cancellations and DNAs Yes Baseline Data for all specialties has been completed for outpatients Priority areas have been identified and are being managed through the Outpatient Workstream. Reducing length of stay See improved Discharge Pilot for outpatients IV antibiotic tested over the winter period evaluation in progress Improved theatre utilisation Yes LEAN programme in theatre continues. Theatre utilisation embed in weekly Theatre Operational Groups (TOGs) Poster presentation included in appendix A TOG s Terms of Reference included Standard Operating Procedures for Theatres being developed. Improved discharge planning Yes Inpatient capacity management workstream of the emergency access programme Refreshed approach to traffic lights discharge prediction IST 18 weeks Publications 2009 report Template for NHS Boards 5

6 system has improved performance of traffic lights, reduction in boarding and length of stay Better use of in-patient capacity to balance emergency and elective demand Workforce Reducing new: review rates Yes (in progress) National HEAT target ratios have been applied per specialty and are being examined by outpatient s workstream. In place Not yet in place (if so why) Impact of working time directives and new staffing contracts considered within programme plan Yes To date impact of MMC has been factored into the capacity planning. Information and pathway measurement Leave policy covering all staff including medical staff Clinical outcoming recording in all specialties Exploring the possibility of graduate ultrasound training Audiology Workforce skills analysis undertaken and is in the process of implementation In progress Discussions commenced with Programme Clinical Lead In place Not yet in place (please state expected (if so why) implementation date) Yes for all NEW patients First phase of the programme implemented. Reports developed and performance management arrangements are being agreed. IST 18 weeks Publications 2009 report Template for NHS Boards 6

7 Process for linking non-admitted pathways Next phase will include the integration of outpatient procedure coding per specialty. Poster Apeendix A In progress Initial output of clinic outcomes is given high level linkage at specialty and Consultant level. Process for linking admitted pathways In progress Ardentia have completed a scoping exercise for NHSL Patient tracking list In process Element of patient tracking still related to stage of treatment targets. Engagement and review of Admin and Clerical roles Process to support managers to undertake demand, capacity, activity, queue analysis Yes Lanarkshire had a DCAQ training day facilitated by Kurtosis. Capacity plans have been developed based on this methodology for all specialties Access policy Being developed Access policy is in draft Involvement of key staff groups Use of No Delays Scotland patient journey analyser Medical staff Yes Administrative services Yes Allied health professionals Yes Health care science Yes Primary and community services Yes Yes No delay is being introduced to the specialties through the Clinical Service Improvement Groups Strategy for engagement in place No formal approach to engagement yet Details of any projects underway IST 18 weeks Publications 2009 report Template for NHS Boards 7

8 Integration across agendas Projects underway (please provide key details) No projects yet initiated Comments Long term conditions Scoping audit in Dermatology to assess if patients who attended as a return have been educated in self management A strategic matrix has been developed that identifies the interdependencies of the programmes and the lead for delivery Patient Safety Yes As above Releasing time to care Yes As above Patient experience Yes As above Strategic lean Yes LEAN proof of concept complete.programme plan being developed and will include diagnostics Mental health Yes As above Productivity and efficiency Yes As above IST 18 weeks Publications 2009 report Template for NHS Boards 8

9 Appendix A Please find enclosed Poster Presentations that have been prepared these outline the detail required to format the case study proforma TOGs%20poster.pdf Same%20Day%20A dmission.pdf Environmental%20I mprovements.pdf Visual%20Manageme nt.pdf Continuous%20Runn ing.pdf Patient%20Flow.pdf Preadmission%20Ass Rationalisation%20o essment.pdf f%20prosthesis.pdf CTP.QUASER pdf (167 KB) CTP.FMCREA L.pdf (351 KB... TOR TOG (3).doc Details of Improvement What was the problem? How was this identified? What were the implemented improvements (tools/techniques)? What is the situation now? How is the change sustainable? Sustainability can be defined as being achieved when new ways of working and improved outcomes become the norm. Describe how this improvement is sustainable. Measurable outcome E.g. DNA rates, CNA rates, DCAQ, time from referral to report available, waiting times. What are the patient benefits? e.g. qualitative data results of patient surveys, patient stories, quotes from patients. What are the staff benefits? e.g. qualitative data results of staff surveys, staff stories, quotes from staff. What are the organisational benefits? How did staff feel before the improvement/during the improvement and after the improvement? What are the lessons learnt and what would you do differently next time? What plans are there to spread the improvement? Name, title, and phone number for key contacts: Contact Name Telephone number Case study owner Key department contact (e.g. clinical lead/unit manager) IST 18 weeks Publications 2009 report Template for NHS Boards 9