Contents page. Storyboard Storyboard Title Organisation. Citizens at the Centre of Service Design and Delivery

Transcription

1 Contents page Storyboard Storyboard Title Organisation Citizens at the Centre of Service Design and Delivery Integrated Mental Health Day Opportunities Service ABM University NHS Trust Sue Bevan/Vernon King Streamlining the Parent Education Programme ABM University NHS Trust Dianne Jones/Dawn Dilks The development of a vocationally-based Occupational Therapy service in adult mental Cardiff and Vale NHS Trust health with service users to the fore of design and delivery, offering occupational and vocational assessment, advice and guidance leading to individualised vocational opportunities across a range of interagency settings Cherry Stewart Developing a Flexible and Sustainable Workforce HI-ProfILE - Health Informatics Professional Development Informing Healthcare Jacqueline Barker/Susan Thomas Skills Development Programme Hywel Dda NHS Trust Susan Morgan Radiology & Endoscopy Quick Hits have an Impact ABM University NHS Trust Ian McLelland/ Melanie Marchetti

2 Storyboard Storyboard Title Organisation Improving Patient Safety ASAP: Appropriate skills for appropriate places Powys LHB Marie Lewis Improving warfarin safety within an NHS Trust Conwy & Denbighshire NHS Trust Philippa Rogers/Don Hughes/Uttam Chouhan/Katie Firth/Dr David Gozzard Is 95% hand hygiene compliance an achievable target? Gwent Healthcare NHS Trust/ University Elizabeth Waters/ Moira Bevan of Glamorgan Leading on Service Improvement Cardiology Outpatient (Open Access) Project ABM University NHS Trust Dr Jonathan Goodfellow/Samantha Victor Challenging Chronic Disease - Collaborative Continuums of Care Camarthenshire LHB/Hywel Dda NHS Wendy Churchhouse/Claire Hurlin Trust Redesigning SLT services to effectively meet need Gwent Healthcare NHS Trust Dr Alison Stroud/Nicola Bailey Wood/Alison Llewellyn/Jayne Tibbs Promoting Better Health and Avoiding Disease Proactive Approach to Continence Care in a Rural Community Hywel Dda NHS Trust Linda Kriewald Crisis Resolution Home Treatment Service ABM University NHS Trust Malcolm Jones Improving the health of people with learning disabilities ABM University NHS Trust Prof Mike Kerr/Dr Glyn Jones

3 Storyboard Storyboard Title Organisation Promoting Better Health and Avoiding Disease Health Challenge Newport, Going for Gold: More People, More Active, More Often Newport LHB Claire Beynon Working Seamlessly Across Organisations Developing a Children's Integrated Disability Service (CIDS) North East Wales NHS Trust/ Judy Evans Flintshire LHB Breaking service boundaries to fix failing hearts Carmarthen LHB/Hywel Dda NHS Trust Wendy Churchouse/Helen Llewellyn-Griffiths/Rhoswen Davies Condition Management Programme ABM University NHS Trust Sara Forster

4 Working Seamlessly Across Organisations NHS Wales Awards 2008 Storyboard submissions 1. Storyboard Title Developing a Children s Integrated Disability Service (CIDS) 2. Brief Outline of Context This community service for disabled children and their families is based in an NHS Trust Children s Centre and brings together specialist social workers, local authority occupational therapy staff, a specialist teacher, care coordinators, community learning disability nurses, special school nurses and Diana nurses in an integrated team. 3. Brief Outline of Problem The initial driver for change was the Inspection of Children s Services Management and Practice (2000) in Flintshire County Council which recommended that: The Children s Services Division should strengthen its arrangements for managing and developing its work with children with disabilities services Working in partnership the three organisations (LHB, NHS Trust and Local Authority) initiated extensive consultation with families, professionals and organisations, and took into account evidence from research. The results identified many services across the partner organisations inequitable, fragmented and lacking in coordination with families of disabled children ill informed, confused and frustrated. 4. Assessment of Problem and Analysis of its Causes Of the 1,100 disabled children living in Flintshire, there is an increase in the numbers of children with both complex health care needs and autism. An initial consultation exercise with both parents and separately professionals highlighted the fact that organisations, departments and agencies differed in their models of service delivery. There were examples of good joint working hampered by existing organisation structures. Four highlighted areas for improvement were identified, and task and finish groups were held, which included parents, professionals and Voluntary Sector representation.

5 Working Seamlessly Across Organisations The resulting report to all agencies highlighted the need for a single multi-agency team for disabled children, young people and their families, based on a single site, and providing a single simple pathway for families to access information, assessments and services, with one single manager, and included the development of care coordination. 5. Strategy for Change Stage 1 audit, vision building, and getting buy in from all agencies.(transfield and Smith 1991 model of change). One dedicated manager undertook the work, overseen by a multiagency management board. Within this period quick wins for families were achieved. Stage 2 Implementation of the model. The cascade sharing the vision throughout the organisation, and the sprint the major phase of implementation (Transfield and Smith 1991) The CIDS Management Board led the application for additional funding for key posts - Service Manager, Team Manager and two care co-ordinators, and ensured implementation of the action plan. Staff from all agencies, were involved in planning the detail. A stakeholder group of significant professionals on the periphery of the core team was established to influence the delivery of the model. Successful funding applications ensured the accommodation was fit for purpose, with the necessary I.T. for all staff. Relocation of council staff onto the one site with their health colleagues took place STEP CHANGE. Shared values and objectives and joint protocols were developed. These systems and processes all assisted in giving disabled children, young people and their families a single point of entry to the service, appropriate timely information, allocation of work without duplication and as each new system is put in place, stopped us asking families the same questions. The process of approval of these protocols was initially via the staff team, then the project group and finally the board, with annual consultation with families. The performance ratchet maintaining commitment and momentum (Transfield and Smith 1991)

6 Working Seamlessly Across Organisations There is a move now to achieve a Section 33 Agreement Integrated Provision. (Health Act Wales 2006). Work continues towards shared files and a single assessment process. Key Actions Timetable Research and design of model agreed by all agencies Appointment of key professionals Development role of care coordinator August 2004 February 2005 Council staff re located February 2005 Development of systems structures and processes June ongoing External evaluation November 2005 Move to formal Section 33 April 2008 agreement 6. Measurement of Improvement An external evaluation by NCH November (a) An evaluation of the preparedness of both staff within the team and the CIDS project board for full integration July 2006 (b) Annual consultation with parents. (c) Three comparative case studies (before and after). (d) An evaluation of the Flintshire Cymorth Programme. 7. Effects of Changes Multi agency team co-located on a single site the evaluation by NCH concluded that staff in one key location had been a success for disabled children, their families and staff alike, with the majority of families interviewed believing that multi agency services had improved their quality of life. Care co-ordination the above evaluation noted the development of this new role had enhanced the quality of the service received by families. The three case studies undertaken illustrated how a greater degree of co-ordination has achieved better outcomes for families. Children and young people were better supported and work was focussed on assisting them to achieve their potential whilst trying to ensure that parents felt sufficiently supported to enable them to continue to provide care for their disabled offspring and to improve their parenting capacity.

7 Working Seamlessly Across Organisations The problems encountered within the change process included:- Staff did not understand the new role of care co-ordinator Staff who were already based at the Children s Centre not realising that the development of the Team would affect them. Developing a help line rota, with all staff taking part in the process to ensure a single point of entry for families. It required a change in title (agreed by the team), direction from a manager and negotiations with the unions. 8. Lessons Learnt To develop long term change to meet the needs of disabled children and their families:- involve families in the design, planning and evaluation, involve staff from both the core team and in the wider context, develop a strong management board Go for some quick wins Take time to communicate and be careful with the use of language 9. Message for Others Keep outcomes for disabled children, young people and their families at the forefront of your planning. Too many people ask too many questions it is exhausting and wears you down (quote from parent during consultation - Patti Colquhoun 2002) Working together reduces gaps, boundaries and duplication. It breaks down the communication barriers, reduces frustration and is a most rewarding way to achieve outcomes for families. Go for it.

8 Leading on Service Improvement NHS Wales Awards 2008 Storyboard submissions 1. Storyboard Title Cardiology Outpatient (Open Access) Project 2. Brief Outline of Context Redesign of Cardiology Outpatient services have been taking place in Bro Morgannwg NHS Trust for the past two years. Non-invasive cardiac investigations were made directly available to local GPs a new open access service. Development of this new service involved discussion and close collaboration with Cardiologists, GPs, LHBs in Bridgend and Neath Port Talbot, Medical directorate managers, outpatient services managers, nursing staff, cardiac physiologists and administration staff in the Princess of Wales Hospital and Neath Port Talbot Hospital. 3. Brief Outline of Problem Bro Morgannwg NHS Trust cardiology outpatient services had seen increasing waiting times and waiting lists for new patient appointments. Extra clinics to keep waiting times within targets (18 months in at the time) were only a temporary solution. The system needed redesign. Simple modelling of capacity and demand with variance was performed and indicated the need for redesign to achieve improvements. We performed: 1. A baseline review of a cohort of 200 patients who had been through the outpatient service and identified that over 60% had normal investigations and were only seen once by the Consultant (i.e. discharged at first visit) 2. Process mapping of the patients journey from primary care through secondary care investigation and diagnosis and found far too many steps (>40) and delays Having identified problems with the existing service we proposed the following: 1. Redesign to reduce number of steps in patients journey (to <20) 2. Allow GPs access to all non-invasive cardiological tests, eg Echo (transthoracic),exercise Test, 24Hr ambulatory ECG, 24Hr BP monitor, 7 day event monitor

9 Leading on Service Improvement 3. All tests ordered are reported on by Consultant cardiologists and results and advice sent by letter to the requesting GP. Patients with normal test results would stay within primary care. This in practice meant that 60% referrals now stayed in primary care with only 40% needing review in outpatient clinic. 4. Developed referral guidelines with primary care to guide referrals to the clinic or open-access investigations The methodology we employed to deliver the changes was: 1. Action research using PDSA cycles of iterative change to achieve the best outcomes 2. Employed a GP with special interest in cardiology (GPwSI) into the service to act as liaison between primary and secondary care 3. The results of the changes were evaluated against preset outcome indicators 4. Assessment of Problem and Analysis of its Causes Identifying problems in the system was the first step to assessing the problem. The system of referral from primary care to secondary care had not altered significantly since the inception of the NHS in Most patients were pre-investigated before attending an outpatient clinic. This allowed for basic triage of all referred patients. Those with significantly abnormal test results were seen urgently, whereas those with normal tests waited up to 78 weeks to be seen. A retrospective analysis of a cohort of 200 patients referred to the service revealed that approximately 60-70% had normal test results regardless of whether the presenting complaint was one of chest pain, palpitations or breathlessness. 5. Strategy for Change Following consultation with LHB representatives, GPs and development of guidelines, the GPs were given open access to diagnostic testing for three main symptoms, which form over 80% of the total referrals, namely; chest pain, breathlessness and palpitations. Thus, local GPs have improved access to all noninvasive cardiology tests, enabling patients with normal test results to be excluded from cardiology clinics. Change was initiated following discussion with managers, the Local Health Boards and GPs in the Bridgend and Neath Port Talbot areas. Clinical guidelines were developed in collaboration with Primary Care for the three main symptoms chest pains, palpitations and breathlessness, which form a major bulk of the referrals. An electronic referral from was drafted, which was user friendly and

10 Leading on Service Improvement had all the relevant details of the patient symptoms, risk factors and past medical history along with the results of the relevant investigations for that particular referral. The standard referrals to secondary care were also prioritised by Consultants and diverted to an outpatient clinic or open access investigations. 6. Measurement of Improvement GP satisfaction surveys were conducted at 1 month, 3 months and 6 months of starting the new system and provided positive feedback. In addition, simultaneous patient satisfaction surveys were also carried out with unanimously positive results. Reduction in Waiting time ( p<0.01) Reduction in Waiting list (p<0.01) Increase in the number of cardiac tests performed (40%, p<0.05) Increase in GP referrals 11.6% per annum However, the analysis of new patient clinics revealed that there was a trend towards improvement in the activity of clinics following the introduction of the open access tests. There was a significant improvement in DNA rate and a significant reduction in discharge rate. 7. Effects of Changes The open access service has led to: 1. Reduced waiting lists for cardiology outpatient appointment (1100 in 2004, 483 in December 2007, p < 0.001) 2. Reduced waiting times (routine 17 months 2004 c.f. 4 months 2008, p < 0.001) 3. Reduced waiting times for urgent patients (230 days in 2004, c.f. within 7 days 2008) 4. Empowerment of local GP s to manage simple cardiac conditions 5. Improved access to secondary care diagnosis and treatment for local patients 6. Appropriate use of Cardiology outpatient appointments for patients with significant cardiac problems 7. Continued improvement in service delivery 8. Lessons Learnt Involvement of primary care at start of project 1. Set up an inclusive project team with representation from all affected parties 2. A GP liaison 3. Regular reports to all parties involved

11 Leading on Service Improvement 4. Importance of a baseline review and process mapping to inform about problems with current system 5. Excellent communication 6. Listen to criticism and act 9. Message for Others Service redesign can rapidly improve cardiology health care delivery by providing a range of new assessment options tailored to patient needs. This form of multidisciplinary action research coupled with detailed outcome measurement could have wide application in the NHS.

12 Promoting Better Health and Avoiding Disease NHS Wales Awards 2008 Storyboard submissions 1. Storyboard Title Proactive Approach to Continence Care in a Rural Community 2. Brief Outline of Context A bilingual, open access, District Nurse led continence clinic was established in a rural practice, designed to meet the specific needs of clients within the community. There has been a positive response to the initiative with audit demonstrating that both objective and subjective aims have been achieved. 3. Brief Outline of Problem An earlier local study of continence services had suggested that there were potential barriers in seeking help for those suffering from incontinence. This was particularly evident in remote areas. The aim therefore was to ensure that those living in the most rural areas had accessibility to continence services, thus ensuring equity across the county and reflecting the ethos of the Designed for Life (2005) agenda. 4. Assessment of Problem and Analysis of its Causes According to The Department of Health (DoH) (2000) 6 million people in the United Kingdom suffer with urinary incontinence. The earlier local study highlighted the reluctance to seek help for incontinence and with the increasing number of referrals to the District Nursing service for incontinence assessment the idea of setting up a clinic was conceived. Discussions then followed between the District Nurse and Continence Advisor. The concept was presented to the head of District Nursing and to General Practitioners from two rural practices. The proposal was accepted and accommodation to run a clinic was secured at a GP Surgery. Plans were then drawn up to take the venture forward. 5. Strategy for Change The Practice News Letter and Health Promotion board displayed in the practice informed the practice population of problems associated with urinary incontinence and the ease of access to the clinic. (March 2005)

13 Promoting Better Health and Avoiding Disease The GP S and practice staff were made aware that the clinic would commence in July 2005, held on a monthly basis and would accept male and female clients of any age group. Develop protocol and referral forms for the clinic by July 2005 Develop Audit Tool for use on an annual basis. Collate evidence to support effectiveness of the clinic. Disseminate experience and findings to colleagues at Carmarthenshire NHS Trust Professional Group Meetings. Attend and present annual report at the GP Professional Group meeting. 6. Measurement of Improvement Audit for revealed resolution of incontinence in 50% of clients. Audit figures for revealed clinic attendance at full capacity with a waiting list. Consequently following discussion with the GP and District Nurse manager it was agreed to hold a weekly clinic in order to accommodate the increasing demand. 7. Effects of Changes Objectively, an audit demonstrated resolution of incontinence in 50% of clients seen during the first year. Subjectively, a client satisfaction survey revealed that 68% would not have approached another professional if the service was not available and that 97% would recommend the service to others. 8. Lessons Learnt The sensitive nature of the condition required promotion of client awareness and educating colleagues to this taboo subject. This was done via the GP Newsletter and the local press. Securing funding for necessary equipment such as a bladder scanner was difficult. Consequently, through positive education of clients, staff and the general public, equipment was secured by numerous collaborative fund raising activities. 9. Message for Others A positive attitude towards Urinary Incontinence by the Health Care professional is paramount in their approach to providing holistic evidenced based care to clients who endure such distressing symptoms. As Woodward (1995) describes nurses often resort to providing incontinence pads to manage the problem but managing in this way is proved to be false economy. This can also be detrimental to the client as it can seriously affect physical and mental health.

14 Promoting Better Health and Avoiding Disease Promotion of continence is therefore achievable providing there is a positive professional attitude.

15 Improving Patient Safety NHS Wales Awards 2008 Storyboard submissions 1. Storyboard Title ASAP: Appropriate skills for appropriate places: 2. Brief Outline of Context The two-day residential training is held in a remote Welsh farmhouse. This enables the scenarios to be acted out in home surroundings realistic to a community midwives work. Midwives are required to bring with them their own equipment, which they would normally carry in the community and use this throughout. The obstetric emergencies included among others: Undiagnosed breech delivery on the stairs, cord prolapsed in the lounge, shoulder dystocia in the bathroom and a PPH in the bedroom. Attendees have to work through their actions and practice their skills. Feedback is given to attendees via the use of OSCE score sheets. The courses have so far been piloted using internal midwives and will this year be run for external midwives allowing us to share our work across the UK. 3. Brief Outline of Problem Midwives have been providing expert maternity care to women and there families for many years. The challenges faced by midwives in providing an up to date evidence based service can be many and wide-ranging. One difficulty encountered by midwives who are now expected to be skilled in many areas of practice and remain up to date in a rapidly changing field of evidence is that of competence in specific skills. This is difficult for most midwives but can be even more challenging for midwives who work in small midwife led units in the community, using some skills very infrequently. An essential element in supporting midwives to maintain their competence and provide a quality service is pro-active midwifery education and development. 4. Assessment of Problem and Analysis of its Causes Midwives need to be prepared for the unthinkable and be equipped to deal with it. There are several training courses aimed at preparing midwives for dealing with obstetric emergencies but most focus on caring for women within a DGH working as part of the medical team. They are usually held in classroom type settings. Training needs to be available for midwives working in the community.

16 Improving Patient Safety We have developed a training programme which offer midwives the opportunity to practice obstetric emergencies and other key areas of midwifery care within a home setting. Whilst still promoting the midwives role in normality and facilitating normal birth. 5. Strategy for Change To deliver a training programme, which would meet the needs of community midwives and encourage partnership working with local paramedics. To enable midwives to practice key emergency skills To encourage team work and communication To promote care in the community as a safe option for women. The set up: The two-day residential training is held in a remote Welsh farmhouse. This enables the scenarios to be acted out in home surroundings realistic to a community midwives work. Midwives are required to bring with them their own equipment, which they would normally carry in the community and use this throughout. The obstetric emergencies included among others: Undiagnosed breech delivery on the stairs, cord prolapsed in the lounge, shoulder dystocia in the bathroom and a PPH in the bedroom. Attendees have to work through their actions and practice their skills. Feedback is given to attendees via the use of OSCE score sheets. 6. Measurement of Improvement All attendees are asked to complete an evaluation form and to score each session on a scale of one to five. There is also a space for comments and recommendations for change. All internal attendees have expressed that they had thoroughly enjoyed both days and valued the opportunity to practice these skills in realistic settings using their own equipment. The obstetric emergency drills were scored five [excellent]. 7. Effects of Changes Since completing the workshops midwives in Powys have experienced several Obstetric emergencies in the Home. They have all been dealt with appropriately and midwives have been commended by the DGH for the excellent care provided. Midwives who have reported such incidences have stated that they felt more confident as a direct result of attending the workshop. An improvement in midwives confidence and competence can result in a safer provision of care within the home. The problem with such workshops is one of resources and prioritisation. They are not the

17 Improving Patient Safety cheapest way and it can be difficult to release staff for two days. However it is believed that this needs to be a priority in service provision as adverse outcomes in this area can be catastrophic for clients, midwifes and the organisation 8. Lessons Learnt Midwives will only take the training seriously if the scenarios are real to them and appropriate to their place of work. It is essential when planning such programmes to reflect real cases and real environments. The biggest success of this course is that it is held in a home setting and not in a class room. Midwives do get board and will assume what is going to happen next. It is therefore essential to continually change the scenarios and the set up to maintain the element of surprise. Some midwives find the days very stressful and can become over whelmed by the realness of working through difficult situations. More time is needed in the programme for debrief and general calm discussion to allow reflection on feels and anxiety 9. Message for Others This training is an excellent example of doing training that is tailored to the individual staff needs and reflective of their real work environments. You need to think about what your particular group of staff need and look at providing training appropriate to meet that need

18 Working seamlessly across organisations NLIAH submission Story board title Breaking service boundaries to fix failing hearts 2. Brief outline of context The Nurse led heart failure service was a joint initiative between Carmarthen Local Health Board and Carmarthenshire NHS Trust, West Wales; serving a population of 175,000. The region is predominately rural with large areas of urbanisation resulting in pockets of social deprivation. A team of 3 heart failure specialist nurses was formed in It was part of a chronic disease service, consisting of 1 co-ordinator, 3 diabetic specialist nurses, 2 chronic obstructive pulmonary disease specialist nurses [COPD], 1 COPD physiotherapist and 2 administrators. The heart failure service was designed to cater for the needs of patients and their relatives/carers from diagnosis through to palliative care and death. Service provision includes, one-stop diagnostic clinics supported by the Cardiologists, inpatient reviews, follow-up and drug titration clinics, delivered in both hospital and community locations. House bound and hard to reach individuals are visited at home, including residential and nursing homes. 3. Brief outline Prior to 2006, the care of heart failure patients in Carmarthenshire was inadequate and inequitable. In addition, the knowledge of health professionals in regards to best practice was meager. A surge of new clinical research highlighted the poor outcomes associated with heart failure and the immense NHS costs attributed to avoidable, frequent medical admissions. Therefore, it was proposed that Carmarthenshire patients and their family/carers would benefit from seamless and integrated management; transcending primary, secondary & tertiary care, social care and voluntary agencies. Care would subsequently be provided at the right time, right place and by the right person. Furthermore, it was vital the new service became fully integrated into existing medical, nursing, social and voluntary services, in addition to the acute response / rehabilitation services, recently introduced as part of the modernisation and chronic disease strategy.

19 Working seamlessly across organisations Additionally, in order to sustain and improve evidence based care; an on- going, nationally validated education programme in the management of heart failure would be delivered locally. 4. Assessment of problem In response to three key documents (Tackling Inequalities in CHD in Wales [NSF] [2001], Wanless Report [2003] and Design for Life [2005], a service needs review was conducted between 2004/5. Inadequacy and inequality in the deliverance of structured, evidence based heart failure care throughout Carmarthenshire was identified. In addition, as part of their modernisation strategy, the NHS Trust and LHB were developing collaborative, innovative strategies to improve chronic disease management. A working steering group was formed to investigate the scale of the problem, and identify solutions based on the findings of other health communities within the UK and globally. Eventually, a pioneering solution, based on the Kaiser Permanente model was agreed. This included the joint appointment by Carmarthen LHB and the NHS Trust of 3 heart failure specialist nurses, as part of a chronic disease team. 5. Strategy for change Formation of steering group consisting of Cardiologists, GPs, nurse advisors, modernisation manager, Nurse directors from Trust and LHB and patient representatives [2005/6]. Appointment of chronic disease co-ordinator and 3 heart failure specialist nurses [January 2006] Co-ordination of top up, clinical assessment skills training for specialist nurses [March 2006] Personalised visits to Carmarthenshire GP surgeries, secondary care medical and elderly care teams, A&E, medical admission units, CCU/intensive care teams, district nursing teams and newly appointed admission avoidance teams/services; informing them of the heart failure service [June 2006] Identify 1 heart failure link nurse in each GP surgery [October 2006]. Baseline review of medical emergency admission rates and QoF data [2005/2006] Update needs analysis regarding current heart failure service and training needs in primary and secondary care [October 06- Mar 07] Introduction of Heart Save heart failure training course [2006/7]

20 Working seamlessly across organisations Produce evidence based diagnostic and treatment algorithms [June 2006] Update Heart failure section in the Carmarthenshire CHD tool kit, designed to facilitate standardised management for CHD patients throughout Carmarthenshire [November 2007]. Develop standardised clerking and communication documentation for the service [January 2008] Establish patient focus groups to evaluate and inform service development [November 2007] 6. Measurement of improvement Collated a directory of each heart failure GP link nurse, outlining their method of systematic GP follow up Medical emergency admission rates from the Trust and QoF data from each GP surgery was provided monthly to the LHB, and compared quarterly against the previous years data Staff questionnaires issued to primary and secondary care, ascertained their heart failure local management and training needs Evaluation questionnaire regarding the Heart Save heart failure course Patient focus groups and user satisfaction questionnaires Comparatives of quality of life scores [Minnesota QoL questionnaire] Comparatives in application of evidence based prescribing Referral waiting times for diagnostic echocardiograms 7. Effects of changes Reduced heart failure emergency medical admissions by a staggering 23.3%, [more than double the expected admission avoidance rate]. 37% improvement in patients Quality of Life scores 99% improvement in prescription rates of evidence based medication Reduced waiting times for diagnostic echocardiograms High levels of user satisfaction Excellent course evaluation and high pass rates Improved liaison and shared care between primary & secondary care, community rehabilitation, acute response services, palliative care and voluntary agencies.

21 Working seamlessly across organisations 8. Lessons learnt Ensure:- Adequate administrative support, office and storage space for clinical staff Effective systems of prompt communication between all agencies involved in the patients care Service models need to be flexible to suit users needs Patient involvement in service design is essential 9. Message for others By breaking the traditional models/boundaries and working across the interface of primary, secondary, social care and voluntary agencies; patients now have greater continuity and coordination of their care. By utilising a flexible continuum of care within a multi professional and multi agency chronic disease model, medical admissions can be significantly reduced; allowing patients to have improved access to care/services either in their homes or local communities. Therefore, shared goals and collaborative working is the key to sustainable management of change; allowing the NHS to shine and deliver a world class service in the global health care challenge of the 21 st century. References: Wanless, D [2003] Review of health and social care in Wales. HMSO/WAG. Cardiff Designed for Life: creating world class health and social care for Wales in the 21 st century [2005]. Wales: Welsh Assembly Government. DOH [2001] Tackling coronary heart disease in Wales : implementing through evidence. HMSO. Cardiff.

22 Leading on service improvement NLIAH submission Story board title Chronic Disease - Continuums of Care 2. Brief outline of context The Specialist nurse chronic disease service was a joint initiative between Carmarthen Local Health Board and Carmarthenshire NHS Trust, West Wales; serving a population of 175,000. The region is predominately rural with large areas of urbanisation resulting in pockets of social deprivation. The chronic disease team was formed in 2006, consisting of 1 co-ordinator, 3 heart failure specialist nurses, 3 diabetic specialist nurses, 2 chronic obstructive pulmonary disease specialist nurses [COPD], 1 COPD physiotherapist and 2 administrators. The service was designed to cater for the needs of patients and their relatives/carers from diagnosis through to palliative care and death. Service provision includes, one-stop diagnostic clinics supported by the Consultants, inpatient reviews, followup and drug titration clinics, delivered in both hospital and community locations. House bound and hard to reach individuals are visited at home, including residential and nursing homes. In addition education packages are delivered to patients and health care professionals. 3. Brief outline Prior to 2006, the care of heart failure, COPD and diabetic patients in Carmarthenshire was inequitable. In addition, the knowledge of health professionals and patients in regards to best practice was variable. A surge of new clinical research highlighted the poor outcomes associated with the above chronic diseases, and the immense NHS costs attributed to avoidable, frequent medical admissions. Therefore, it was proposed that Carmarthenshire patients and their family/carers would benefit from seamless and integrated management; transcending primary, secondary & tertiary care, social care and voluntary agencies. Care would subsequently be provided at the right time, right place and by the right person. Furthermore, it was vital the new service became fully integrated into existing medical, nursing, social and voluntary services, in addition to the acute response / rehabilitation services, recently introduced as part of the modernisation and chronic disease strategy.

23 Leading on service improvement Additionally, in order to sustain and improve evidence based care; an on- going, nationally validated education programmes in chronic disease management would be delivered locally. 4. Assessment of problem In response to 4 key documents (Tackling Inequalities in CHD in Wales [NSF] [2001], Diabetic NSF [2002], Wanless Report [2003], and Design for Life [2005], a service needs review was conducted between 2004/5. Inadequacy and inequality in the deliverance of structured, evidence based chronic disease management throughout Carmarthenshire was identified. And, as part of their modernisation strategy, the NHS Trust and LHB were developing collaborative, innovative strategies to improve chronic disease care. A working steering group was formed to investigate the scale of the problem, and identify solutions based on the findings of other health communities within the UK and globally. Eventually, a pioneering solution, based on the Kaiser Permanente model was agreed. This included the joint appointment by Carmarthen LHB and the NHS Trust of the chronic disease team. 5. Strategy for change Formation of steering group consisting of Consultants, GPs, nurse advisors, modernisation manager, Nurse directors from Trust and LHB and patient representatives [2005/6]. Appointment of chronic disease co-ordinator and 8 specialist nurses, 1 physiotherapist & 2 administrators[january 2006] Co-ordination of top up, clinical assessment skills training for specialist nurses [March 2006] Personalised visits to Carmarthenshire GP surgeries, secondary care medical and elderly care teams, A&E, medical admission units, CCU/intensive care teams, district nursing teams and newly appointed admission avoidance teams/services; informing them of the chronic disease service [June 2006] Identify link nurses in each GP surgery [October 2006]. Baseline review of medical emergency admission rates and QoF data [2005/2006] Update needs analysis regarding current service and training needs in primary and secondary care [October 06- Mar 07] Produce evidence based diagnostic and treatment algorithms [June 2006]

24 Leading on service improvement Update Heart failure and Diabetic components of Carmarthenshire CHD & Diabetic tool kits, designed to facilitate standardised management for CHD and Diabetic patients throughout Carmarthenshire [November 2007]. Introduction of Heart Save heart failure training course [2006/7] Introduction of XPERT diabetic patient training course [2006/7] Development & introduction of integrated COPD care pathway [2006/7] Introduction of COPD telehealth pilot [2007/8] Develop standardised clerking and communication documentation for the service [January 2008] Establish patient focus groups to evaluate and inform service development [November 2007] Develop & test service satisfaction questionnaires 6. Measurement of improvement Collated a directory of each GP link nurse, outlining their method of systematic GP follow up Medical emergency admission rates from the Trust and QoF data from each GP surgery was provided monthly to the LHB, and compared quarterly against the previous years data Staff questionnaires issued to primary and secondary care, ascertained their local management and training needs Evaluation questionnaire regarding the education programmes Patient focus groups and user satisfaction questionnaires Comparatives of quality of life scores [Minnesota QoL questionnaire] Comparatives in application of evidence based prescribing Referral waiting times for diagnostic echocardiograms 7. Effects of changes Reduced emergency medical admissions for the 3 chronic conditions by a staggering 28.2%, [nearly 3 times higher than target admission avoidance rate]. 37% improvement in patients Quality of Life scores Significant improvement in prescription rates of evidence based medication [ up to 99% in some areas] Reduced waiting times for outpatient clinics and diagnostic echocardiograms Exceptionally high levels of user satisfaction; patient understanding of disease process and self care strategies Exceptionally high levels of carer satisfaction - Research into the benefit of telehealth to improve patient care and individual health trends.

25 Leading on service improvement Excellent course evaluations and high pass rates Improved liaison and shared care between primary & secondary care, community rehabilitation, acute response services, palliative care and voluntary agencies. 8. Lessons learnt Ensure:- Adequate administrative support, office and storage space for clinical staff Effective systems of prompt communication between all agencies involved in the patients care Service models need to be flexible to suit users needs Patient involvement in defining service model 9. Message for others By breaking the traditional models/boundaries and working across the interface of primary, secondary, social care and voluntary agencies; patients now have greater continuity and coordination of their care. By utilising a flexible continuum of care within a multi professional and multi agency chronic disease model, medical admissions can be significantly reduced; allowing patients to have improved access to care/services either in their homes or local communities. Therefore, shared goals and collaborative working is the key to sustainable management of change; allowing the NHS to shine and deliver a world class service in the global health care challenge of the 21 st century. References: Wanless, D [2003] Review of health and social care in Wales. HMSO/WAG. Cardiff Designed for Life: creating world class health and social care for Wales in the 21 st century [2005]. Wales: Welsh Assembly Government. DOH [2001] Tackling coronary heart disease in Wales : implementing through evidence. HMSO. Cardiff. DOH [2002] Diabetic NSF in Wales. HMSO. Cardiff.

26 Citizens at the centre of service design and delivery Formatted: English (U.K.) NHS Wales Awards 2008 Storyboard submissions 1. Storyboard Title Integrated Mental Health Day Opportunities Service 2. Brief Outline of Context A multi agency Task Team was established in 2000 to review historical Day Care Services provided at Cam Cyntaf Day Centre, Glanrhyd Hospital and Ty r Ardd Social Care Day Centre in the community. The client groups included 170 individuals with severe and enduring mental health to those with mild to moderate mental health problems. 3. Brief Outline of Problem The problem was duplication in provision eg both organisations provided garden projects and institutionalisation was inherent with service users dependent upon these services and not maximising their potential - service users were becoming reliant on the service rather than being empowered to become more independent and function within the community. The services for some had become a hindrance rather than a help to their recovery - service users were living in the community but returning on a daily basis to a mental health institution for support. The existing services were focussed on a maintenance model rather than one of recovery, and so many patients were likely to be in the mental health system for life. 4. Assessment of Problem and Analysis of its Causes January, 2000 a Review of Mental Health Day Services was undertaken by Bridgend County Borough Council and Bro Morgannwg NHS Trust. In 2001 a Joint Consultation Workshop involving staff, the voluntary sector, service users and carers undertook to develop a Model of Day Opportunities. In 2002 the Day Opportunities Sub Group was established involving voluntary sector partners, service user and carer representatives. A graded closure plan of Cam Cyntaf was developed with staff and service users to progress the integration of individuals into one statutory service. The closure of Cam Cyntaf was achieved in July, 2006 and the service renamed ARC (Assisting Recovery in the Community).

27 Citizens at the centre of service design and delivery Formatted: English (U.K.) 5. Strategy for Change The proposed change was a key strategic aim of the local Joint Mental Health Planning Team. Funding was secured to appoint a Joint Health and Social Care Manager to lead the new service. A Day Opportunities Sub Group was established with wide representation from all sectors, including service user and Patients Council representatives, patient Advocates and the voluntary sector. Continuous and ongoing meetings were held with staff and service users, both as groups and individual counsellings, to share the vision and provide support. The integration of the service users was undertaken over the period of one year with a staged approach for staff and service users to experience working and attending Ty r Ardd. The Strategy was supported by the Welsh Assembly Government and funding secured to provide a new purpose built facility in the town centre to be commissioned in December, Measurement of Improvement In the first year of integration there has been a 30% increase of activities accessed in the community supporting service users towards recovery. The number of referrals into the new service has increased from 103 for the period January, 2006 to December, 2006 to 200 in the period January, 2007 to December, ARC access in excess of 30 different Community Groups, services or innovative projects in the community. Individual satisfaction is monitored through the personal profile review, processes and the service is planning a formal Service User Satisfaction Survey in the next 12 months. 7. Effects of Changes Service users and staff have embraced the new service and the process of individual assessment and personal profile has significantly supported the process of normalisation within the community. This is enabling individuals to be a part of their local community and not be seen as set apart. The closer working relationships between services has resulted in a whole new way of working, maximising the use of resources. The process of change with this client group is resource intensive and requires substantial support for some individuals to make this cultural shift.

28 Citizens at the centre of service design and delivery Formatted: English (U.K.) Within a client group of this size there will always be a small cohort who are extremely resistant to change and whose needs will need to be met for the foreseeable future. This needs to be acknowledged and successes and positive gains promoted to foster a change of mindset. 8. Lessons Learnt Change management requires robust and consistent communication to negate the rumours. Not to under estimate the impact of these changes on both the staff and service users involved. The appointment of the Service User Engagement Officer sooner would have assisted the process. 9. Message for Others The benefits of such a major change for service users and staff far outweigh the difficulties in achieving this and provides an innovative and modern service fit for the 21st century.

29 Citizens at the centre of service design and delivery NHS Wales Awards 2008 Storyboard submissions 1. Storyboard Title Streamlining the Parent Education Programme Bringing it into the 21 st Century. 2. Brief Outline of Context Midwives based in the Birth Centre at Neath and Port Talbot Hospital identified a need to modernise and streamline how parent education was delivered to pregnant women and their families. 3. Brief Outline of Problem Parent Education for pregnant women has traditionally been organised in weekly sessions. Before the 1990 s it was during the day and only for women. Midwives and Service Commissioners realised that the take-up for the session was not optimum and that with many women now working, holding the information programme in the day is not always convenient. The drop out rate becomes high as the sessions progress and continuity of midwife is not available depending on available rotas. Parent Education has since been offered for couples in six weekly evening sessions and is very popular, with demand outstripping supply, but again the drop out rate is high. 4. Assessment of Problem and Analysis of its Causes The high drop-out rates mean that information given out is often missed or has to be repeated at subsequent sessions. It is difficult to ensure continuity of midwife for the six-session programme. With the rise in birth rate and national shortage of midwives, midwifery managers are asking if this service is an effective use of precious midwifery time. At times, women are not receiving one-to-one support in labour and so a more effective use of midwifery time by providing these sessions in a concise one day programme has been implemented. 5. Strategy for Change Two midwives who facilitated the weekly sessions benchmarked with a Maternity Unit in the South East of England who had already piloted the one day Parent Education Sessions. Aims and objectives were agreed; Potential measurable standards and outcomes were identified; Programme for the day was developed; Pilot sessions (March 07 to June 07) were undertaken and evaluated. 6. Measurement of Improvement There is now a one day session providing comprehensive education to prepare for labour and learn about parenting skills to more women than previously; Comparing traditional sessions (2006) with the one day session (2007): 24 couples attended from Jul 06 to Jan couples attended from Mar 07 to Oct 07 Very often there would be a drop-out rate in the weekly sessions, particularly when instrumental births and breastfeeding was being discussed. There is a 0% drop-out rate on the one day sessions;

30 Citizens at the centre of service design and delivery The process has been streamlined potentially releasing six hours of midwifery time to provide one-to-one care in labour; Maximising the number of women giving birth in the Birth Centre by providing sessions within Neath Port Talbot Hospital enabling visits to the Birth Centre; This has helped to maintain the lowest Caesarean Section (CS) rate in Wales of 20%. Women who start labouring in the Birth Centre have between 3.5% and 5% chance of a CS. Team statistics show a reduction in CS rate from 25% to 20% during 2007; Numbers attending the session are monitored and evaluation forms analysed; Data regarding women who change their booking to the Birth Centre is collected; Women are able to meet other members of the team on duty at the time; Activity is monitored monthly; Normal birth rates, water for labour and breast feeding rates have increased; Discussing breast feeding at the session has helped to produce outstanding statistics for the first nine months of 2007: 47% breastfeed at birth with 51% of these women still breastfeeding at 28 days; Impressive team statistics: 86% women now receive home assessments; A team Midwife attended as Lead Midwife for 33% births in Birth Centre; 18% women used the birthing pool for labour; 5% birthed in the birthing pool; 61% women had intact perineum; 17% women changed their choice for place of birth to the Birth Centre. 7. Effects of Changes Through evaluation, women and their partners have expressed satisfaction with the new service. Comments from women and their partners: Much preferred doing parentcraft as a crash course on a Saturday as we both work full time and found the idea of 6 separate sessions daunting. I feel I have benefited from the well organised parent craft class and appreciated the friendly and professionally honest approach of the staff that ran this. It was especially helpful that this was run in a one day block. Excellent, very comprehensive and every issue we had was discussed. Also, lovely to see how personal the Birth Centre approach is and rid any doubts about using the Birth Centre. 8. Lessons Learnt The change has proved successful for both mothers and midwives. However, the venue is being reconsidered to ensure we can accommodate the full session in one location.