The Clinicians Guide to Applying the 10 High Impact Changes. A guide for clinicians

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1 The Clinicians Guide to Applying the 10 High Impact Changes A guide for clinicians

2 DH INFORMATION READER BOX Policy HR/Workforce Management Planning Clinical Estates Performance IM&T Finance Partnership Working Document Purpose Best Practice Guidance ROCR Ref: Gateway Ref: 4973 Title Author Publication Date 14 June 2005 Target Audience Circulation List Description Cross Ref Superseded Docs Action required Timing Contact Details For Recipient s Use The Clinicians Guide to Applying the 10 High Impact Changes NHS Modernisation Agency Medical Directors, Directors of Nursing, Allied Health Professionals, GPs, Healthcare Scientisits, Mental Health and Ambulance Trusts A summary of the 10 High Impact Changes for Service Improvement and Delivery, this evidence-based guide for clinicians suggests ways to implement the 10 High Impact Changes and gives local examples of where these changes have already had dramatic impact on patients and staff. The 10 High Impact Changes for Service Improvement and Delivery, The PCT Guide to Applying the 10 High Impact Changes, the Improvement Leaders Guides N/A N/A N/A Maggie Morgan-Cooke NHS Modernisation Agency 4th Floor St John s House East Street Leicester LE1 6NB

3 The Clinicians Guide to Applying the 10 High Impact Changes 3 The Clinicians Guide to Applying the 10 High Impact Changes We know these changes work and we have the evidence to prove it. Contents Introduction... 4 Change No Treat day surgery (rather than inpatient surgery) as the norm for elective surgery Change No Improve patient flow across the whole NHS system by improving access to key diagnostic tests Change No Manage variation in patient discharge thereby reducing length of stay Change No Manage variation in the patient admission process Change No Avoid unnecessary follow-ups for patients and provide necessary follow-ups in the right care setting Change No Increase the reliability of performing therapeutic interventions through a Care Bundle approach Change No Apply a systematic approach to care for people with long-term conditions Change No Improve patient access by reducing the number of queues Change No Optimise patient flow through service bottlenecks using process templates Change No Redesign and extend roles in line with efficient patient pathways to attract and retain an effective workforce Conclusion Further information... 30

4 4 The Clinicians Guide to Applying the 10 High Impact Changes Introduction Through its work with thousands of NHS clinical teams over the last four years, the NHS Modernisation Agency identified 10 High Impact Changes to support improved patient care and published them in September If these changes were adopted across the NHS to the standard already being achieved by some NHS organisations there would be a quantum leap improvement in patient and staff experience, clinical outcomes and service delivery and waiting lists would become things of the past. There is little or no value in processes that cause unnecessary queues and delays; that keep people in hospital longer than is strictly necessary (with all the attendant risks associated with Healthcare Infections); that call them to clinics more often than needed. There is a need to examine and improve every part of the system and for clinicians to drive the improvements to be sure that they are in the patients best interests. This guide has been written by a group of clinical leaders to promote the potential of the 10 High Impact Changes by NHS clinicians. A detailed website supports the 10 High Impact Changes and can be found at: Who is the guide for? This guide is aimed at any clinician interested in the implementation of the 10 High Impact Changes and has been written to support clinical leaders across all healthcare organisations. In acute hospitals it is for medical directors, medical managers, consultants and registrars, directors of nursing, matrons and ward managers, allied health professional leads and healthcare scientist leads of service. In primary care it is aimed at PEC chairs and their membership, primary care teams and practice based commissioning teams. Equally, it is aimed at clinicians working in Mental Health and Ambulance Trusts. Potential benefits Each of these 10 High Impact Changes is already being used by some NHS organisations. If the changes were adopted systematically by the whole NHS, and produced the same results as those organisations are already achieving: millions of patients experiences would be improved by more personalised, appropriate, timely and streamlined care delivery hundreds of thousands of clinician hours, hospital bed days and appointments in primary and secondary care would be saved waiting lists would be virtually eliminated clinical quality and outcomes would be tangibly improved it would be easier to attract and retain staff, with more enjoyment and pride at work there would be more reliable, flexible processes of care helping NHS organisations offer an efficient and responsive service which meets local and national goals Creating a Patient-led NHS Delivering the NHS Improvement Plan The NHS has made huge steps in providing faster, more convenient access to care through increases in capacity and changes in the ways of working. There is still much to do but a good foundation has been established. At the same time we have introduced clinical governance, standards and new arrangements for securing patient safety. In other words we are making sure we can improve the quality and quantity of the services we offer. But the ambition for the next few years is to deliver a change which is more profound to change the whole system so that there is more choice, more personalised care, real empowerment of people to improve their health a fundamental change in our relationships with patients and the public. In other words, to move from a service that does things to and for its patients to one which is patient-led, where the service works with patients to support them with their health needs. Source: Creating a Patient-led NHS Delivering the NHS Improvement Plan, Department of Health, March 2005

5 The Clinicians Guide to Applying the 10 High Impact Changes 5 Why read this publication? It will not take long to read and will illustrate what you need to know to lead and participate in improvements given your responsibility to continuously enhance the quality of patient care and achieve good outcomes of care for patients. Clinicians have a unique role and already contribute to major improvements in patient care. If they further adopt these principles around the 10 High Impact Changes and implement them this will give further gain in terms of service improvement and delivery. The NHS recognises the value clinical leaders have in improving services for the benefits of patients. As well as providing frontline experience (within a specialty, or across organisational boundaries) many have also encouraged and develop other clinicians to support service improvement within their organisations. Clinical leaders have championed programmes, improving quality and outcomes for patients using their professional networks to spread evidence-based practice and improvement. Clinical teams continue to be powerful drivers for system reform. Table 1: Potential NHS performance improvement strategy Design the system to continuously improve Take a process view of patient flow across departmental and organisational boundaries Work smarter by: focussing on the bottlenecks that prevent smooth patient flow managing and reducing causes of variation in patient flow segmenting patients according to their specific needs Implement measurement systems for improvement that reveal the true performance of the system and the impact of any changes made in real time. Every system is perfectly designed to get the results it gets. If we want better outcomes, we must change something in the system. To do this we need to understand our systems. Don Berwick, President and CEO, Institute for Healthcare Improvement (IHI), USA How is the thinking behind the 10 High Impact Changes different? The improvement philosophy underpinning the 10 High Impact Changes starts from a different mindset. The system should be designed not just to avoid performance failure, but also to enable continuous improvement across the whole organisation or community. The components are shown above right in Table 1.

6 6 The Clinicians Guide to Applying the 10 High Impact Changes Understanding the system Health and social care organisations are complex adaptive systems. Systems in the sense that there is a coordinated action towards some purpose. Complex in the sense that there are many invariant relationships among parts of the systems making detailed behaviour hard to predict. Adaptive in the sense that the people that make up the systems can change and evolve in response to new conditions in the environment (Plsek 2000). This means that we cannot always predict the outcome of change processes because there are so many things involved that creating a change in one part of the system may have consequences elsewhere. When we look at what really goes on at the grass roots level things often appear much more complex: How often do you think about why you do things the way you do? Is it efficient, is it evidence-based or is it how things have always been done because that is the system and the system cannot be changed? Finally, do we use resources most effectively in our service delivery? By understanding the sytem we can have the biggest impact on patient experience through improvement. (See NHS Modernisation Agency s Improvement Leaders Guides or go to The Government s White Paper Choosing Health: making healthy choices easier*, on public health, further reinforces the adoption of the 10 High Impact Changes through their underlying principles of informed choice; personalisation of care and working together. These 10 High Impact Changes are an invaluable source of ideas. Yet the real challenges lie in implementation. We will only secure the benefits described here if we make a purposeful, directed effort to lead from the front and review the potential of these changes within the NHS. We need to help frontline staff to develop ownership about how to do things differently and provide a culture to encourage change at grass roots with all healthcare staff. We need to empower staff to have the courage to break with ingrained habits plus the energy and perseverance to meet the challenges of transforming healthcare which is patient-led. NHS organisations with the new performance mindset reflected in the 10 High Impact Changes work smarter rather than harder. The 10 High Impact Changes are now part of every Local delivery Plan (LDP) and a key NHS deliverable over the next three years. * This document is available from

7 The Clinicians Guide to Applying the 10 High Impact Changes 7 We know these changes work and we have the evidence to prove it Implementing the 10 High Impact Changes across the NHS to the level that has already been achieved by frontline teams could produce dramatic improvements. For example: 1 Change N o 1: Treating day surgery (rather than inpatient surgery) as the norm for elective surgery could release nearly half a million inpatient bed days each year Change N o 2: Improving patient flow across the NHS by improving access to key diagnostic tests could save 25 million weeks of unnecessary patient waiting time. Change N o 3: Managing variation in patient discharge, thereby reducing length of stay, could release 10% of total bed days for other activity. Change N o 4: Managing variation in the patient admission process could cut the 70,000 operations cancelled each year for non-clinical reasons by 40%. Change N o 5: 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. Change N o 6: 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. Change N o 7: Applying a systematic approach to care for people with long-term conditions could prevent a quarter of a million emergency admissions to hospital. Change N o 8: 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. Change N o 9: Optimising patient flow through service bottlenecks using process templates could free up to 15-20% of current capacity to address waiting times. Change N o 10: 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.

8 8 The Clinicians Guide to Applying the 10 High Impact Changes 1 Change N o 1: Treating day surgery (rather than inpatient surgery) as the norm for elective surgery Evidence shows that patients overwhelmingly endorse day surgery, which provides timely treatment, less risk of last minute cancellations, lower incidence of hospital acquired infections and an earlier return to normal activities. Patients also benefit from the latest advances in minimally invasive anaesthetic techniques and pain relief. Clinicians can lead the provision of high quality care for appropriate patients and release inpatient beds for more major cases. Throughput of patients can be significantly improved by booking patients at a time mutually convenient to them and thereby improving access to day case services. Day surgery is particularly suited to providing patient-centred treatment as it is safe, efficient and effective, and provides the least possible disruption to their lives. If day surgery centres are managed efficiently, they increase the capacity for inpatient services and help to meet national and local goals. Significant variations in day surgery exist between Trusts for no explicable reason. New facilities are enhancing the capacity but require corresponding changes in clinical practice. The Audit Commission s basket of procedures 1990 lists twenty that can routinely be performed as day cases. The updated basket 2001 includes twenty-five procedures. The British Association of Day Surgery have proposed a list of more complex procedures that can also be performed as day cases. Service improvement leaders working with day surgery clinicians and the British Association of Day Surgery, identified ten common (i.e. straightforward) day case procedures. Eight are drawn from the Audit Commission basket, with the remaining two drawn from the BADS trolley of procedures. The ten common procedures are shown on page 9 in Table 2. These have the potential to deliver large gains because of the volume of patients involved. There is clinical consensus that these are appropriate and achievable, against this background clinical leaders in this field have suggested goals for day case rates for these procedures. The Department of Health has developed a day surgery benchmarking tool. It enables NHS acute trusts to compare their day surgery rates with the AC basket procedures with those of other organisations. The Day Surgery Benchmarking Tool can be downloaded from Day surgery practice varies enormously for no good reason, and many patients are being denied the opportunity to recover at home. In the past, patients have largely been offered day surgery on the basis of rather restrictive selection criteria. The new standard must be: is there any justification for admitting this case as an inpatient? Mr David Ralphs, past President British Association of Day Surgery (BADS) For further information please visit

9 The Clinicians Guide to Applying the 10 High Impact Changes 9 Trusts have found that they could make significant improvements in their day surgery rates by addressing the following operational issues: establishing dedicated facilities for day surgery admitting patients on the day for day case procedures planning discharge prior to admission so that overnight stays for nonclinical reasons are avoided having robust coding arrangements in place for patients who undergo day surgery improving utilisation and organisation of theatres implementing clinical protocols containing anaesthetic criteria enhancing clinical leadership to oversee the service (evidence suggests that an identified clinical lead improves commitment to increase day surgery rates). To implement Change No1 it is suggested that organisations: undertake a baseline diagnosis of day case potential in the trust (comparing current day case rate performance to best practice day case rates) gain widespread clinical and managerial support for a strategy of day case surgery (rather than inpatient care) as the default set ambitious goals for day case rates (procedure-specific, specialtyspecific and trust-wide) ensure that robust clinical coding is in place implement standardised protocols for admission and discharge of day surgery patients engage surgeons across all specialties to utilise day case surgery ensure that the whole patient journey from GP referral to discharge is optimal. Case Study Adaptation to Mental Health Services South Essex Partnership NHS Trust has adapted Change No1 to modernise mental health services. The Trust has interpreted treat day surgery as the norm for elective surgery to focus on the management of admissions for informal patients. Medical staff within the Trust have changed working practice to target the prevention of admissions and improve discharge arrangements by focusing on: the Trust s new assessment and recovery unit, and the development of five crisis resolution home treatment teams The assessment unit provides support to the crisis teams by providing an inpatient facility which operates to a maximum of 72 hours. This provides sufficient time for community services to organise the appropriate help and support to facilitate an early discharge. Both the assessment unit and recovery unit together with the crisis resolution home treatment teams work in providing integrated support for people with mental health problems. Early results are encouraging. The Trust has generated sufficient capacity to prevent any acute out of area placements which previously were in constant demand with over 40 people placed out of area at the time this change commenced. Table 2: Ten procedures that can easily be done as day cases Procedure Current national day case rate (%)* 1 Inguinal hernia Varicose veins Termination of pregnancy Cataract SMR Extraction of wisdom teeth Cystoscopy / TURBladderTumor Arthroscopy menisectomy Excision of Dupuytren s Contracture Myringotomy / grommets Source: Hospital Episode Statistics (HES) for 2002/3. Based on admissions (FFCEs) Potential national day case rate (%)** * National day case rate is calculated by dividing the total number of elective day case admissions across all providers (Trusts and PCTs) by the total number of elective admissions for each individual procedure. ** Potential day case rates are drawn from an exercise undertaken with a group of clinical leaders to estimate what the best possible national rate could be based on an international comparison.

10 10 The Clinicians Guide to Applying the 10 High Impact Changes 2 Change N o 2: Improving patient flow across the NHS by improving access to key diagnostic tests Evidence shows that waiting for key diagnostic tests or the results of tests are often a major bottleneck in the care of patients. These delays are not necessarily caused by lack of resources in many cases delay could be eliminated simply by redesigning our processes and systems. Evidence from diagnostic services across the NHS tells us that systematic application of some basic redesign tools to match demand and capacity can have a dramatic effect on the flow of patients through the system. Service improvement leaders recommend focusing on tests that are widely used to achieve the best results: common candidates include radiology, pathology, endoscopy, cardiology and lung function. Evidence-based protocols enhance the redesign of the system to ensure that inappropriate or duplicate tests are avoided. In health and social care, there are many sources of variation which impact on flow. Improvement teams have found that most of the variation is caused by the way we organise and deliver our services. This includes: the way we schedule elective admissions working hours of staff how staff leave is organised availability of clinical equipment. Variation can have a considerable impact on patient flow. A useful website to understand variation has been developed by a Thoracic surgeon, Mr Richard Steyn: please see Improving access to diagnostic tests also improved staff morale and performance. Pilot sites report that frontline workers felt like they had been firefighting, and were now able to focus on providing improved quality of care for their patients. Case Study Ealing Hospital CT Scanning Access Ealing Hospital has improved access to CT scanning. Having identified variation in demand and capacity for CT scans the trust pinpointed several causes for it: several carved out slots were allocated for mental health or paediatric patients without regard for demand delays caused by staff locating reports, films or handling requests for scans during patient scanning sessions although 75% patients required contrast injections there were too few radiologists to meet the demand also some patients were not given sufficient information in advance and arrived unprepared for an injection. Improvements introduced have reduced the waiting times for CT scanning from 6 to 3 weeks by: eliminating carve out by ensuring patients are allocated the next available slot in a sequential order based on their clinical needs matched to the available capacity ensuring the next patient is prepared and waiting for scan reducing delays through redesign of the processes redefining roles; training radiographers to give contrast injections and coordinating radiologists rotas to provide sufficient cover and improving information to patients in order that they are prepared for the contrast injection telephoning patients ahead of the procedure confirming attendance and answering any questions in advance.

11 The Clinicians Guide to Applying the 10 High Impact Changes 11 Segment or Carve-out? We need to understand the difference between segmenting patients (which is about designing a whole care process which enables different groups of patients to flow through the system avoiding delays), and carving out or ring-fencing capacity for certain groups of patients (which, although meant to reduce the time patients wait, actually makes queues longer). Carving out has been one of the most common strategies in the NHS for reducing patient waiting time. It reserves specific packets of capacity in the system for different types of patient, irrespective of the demand or the process variation (i.e. reserving specific slots for urgent patients in a community clinic, operating schedule or outpatient service). As a consequence there is a constant mismatch between case mix, process type and the reserved capacity pockets. This results in persistent queues and delays that may put the patient with unsuspected and serious pathology at risk. It also increases the overall system costs, and exhausts staff because waiting list initiatives are required to eliminate the backlogs that build up as a result. Change No8: reducing queues, provides proven techniques for eradicating or minimising carve out. For further information please see Improvement Leaders Guides: Improving flow or visit improvementguides Case Study Waiting Times in Leeds Teaching Hospitals Leeds Teaching Hospitals NHS Trust has cut waiting times for key diagnostic tests to under 13 weeks. This was achieved through a complete reassessment of waiting lists and scheduling processes. The hospital validated every patient on the waiting list and provided doctors with better referral guidelines for other procedures. The hospital then applied Change No9: process templates, to improve the efficiency of its services and worked with staff and patients to reduce the percentage of booked appointments that were previously not utilised. To implement Change N o 2 it is suggested that clinicians: gain high-level support for the strategy and provide clinical leadership and ownership support a patient-centred approach which links processes, workforce and advances in technology involve service users at every stage of the change process map the existing flow of patients, matching capacity with demand identify potential capacity and the resources required to deliver it look for ways to simplify or automate your booking and administrative processes understand the Did Not Attend (DNA) rate for each diagnostic test and identify ways of reducing it ensure that waiting lists are appropriate through regular audit develop referral protocols which are regularly audited by specialties or practices. The right person trained in improvement methodology and supported by radiologists can deliver enormous improvements. Dr Conail Garvey Consultant Radiologist Royal Liverpool Hospital NHS Trust and National Clinical Lead for Radiology Service Improvement

12 12 The Clinicians Guide to Applying the 10 High Impact Changes 3 Change N o 3: Managing variation in patient discharge, thereby reducing length of stay Variation types One of the most effective strategies for reducing total patient journey time is to focus on the bottlenecks in the process. Managing variation in patient discharge leads to Change No3. Traditionally, we have concentrated on managing admission processes rather than discharge processes. However, there is generally more variation in patterns of patient discharge (due to processes such as ward rounds, availability of test results, take-home medications) than patterns of admission. Consequently, patient lengths of stay are highly variable and unpredictable. Variable and unnecessarily prolonged length of stay affects the whole hospital system in terms of bed availability, transfers from A&E, clinical outcome and patient experience. Clinicians understanding the causes of this variation may systematically manage and reduce the variation. Natural variation is an inevitable characteristic of any healthcare organisation and steps need to be taken to manage it. Sources of natural variation include: differences in symptoms and diseases that patients present with the times of day that emergency patients arrive. Artificial variation is created by the way the system is set up and managed. Sources of artificial variation include: the way we schedule elective admissions how staff leave is planned. Understanding the different types of variation would help us not to react unnecessarily to causes of natural variation. The regular and routine measuring by statistical process control (SPC) is a reliable way to make appropriate decisions. For further information please see Improvement Leaders Guides: Improving flow and Measurement for improvement, or visit NHS hospitals have identified significant variation in the length of hospital stay for patients with similar clinical requirements. A patient admitted on a Friday may have a length of stay that is 25% longer than a patient admitted on a Tuesday. A patient with an uncomplicated heart attack should follow a fairly standard protocol, and have an inpatient stay of 5 days. However, several studies have shown that the length of stay varies between 3 and 7 days if not more, due to differences in processes. At one trust, 51% of inpatients stayed in excess of 5 days between October 2002 and October By making changes to utilisation of beds and discharges processes a significant improvement was made. Typically, organisations tend to concentrate on patient lengths of stay exceeding 28 days. Yet this is less than 20% of patients. Efforts should also focus on addressing the bottlenecks for the remaining 80% of patients. One Trust saw a 50% decrease in cancelled operations and 10% higher elective admissions, after reducing variation in length of stay and discharge times. Trusts working with service improvement leaders have identified two categories of discharge variation: by day of the week, and by time of the day. They found that matching the hour of the day at discharge to the times beds are required for transfer from A&E had a significant positive impact on A&E waiting times. The discharge process, and therefore variations in length of stay are largely in clinicians control, presenting significant opportunity to redesign the system and benefit patients. Variation is a major reason for queues in the NHS. Smoothing variation in discharge processes (thus reducing variation in length of stay) will lead to substantial improvement in delivery and be sustainable due to real system improvements.

13 The Clinicians Guide to Applying the 10 High Impact Changes 13 By smoothing variation in patient length of stay and discharge, clinicians and managers can: put patients in control improving their certainty, choice and ability to plan their lives around the hospital stay reduce the amount of time patients spend in hospital, therefore improving the patient experience improve the flow of patients through the system, reducing queues, waiting lists and backlogs. Results indicate that Trusts that have worked on discharge pathways and predicted dates of discharge have generally reduced their lengths of stay. These are long-term changes in the way the NHS works, and gathering an evidence base is necessary work in progress given the wide variety of practice across the acute sector. For patients, local improvements indicated: greater coordination of care, in advance certainty, patient control and ability to plan post-hospital care less feelings of helplessness due to delays in discharge shorter length of stay. For staff, local improvements indicated: fewer hassle factors due to better pre-planning of care less stress in the working environment. Figure 1: Total Admissions & Discharges /05/ /05/ /05/ /06/ /06/ /07/ /07/ /08/ /08/2002 Discharges vary more than Admissions Source: Kate Silvester/Richard Lendon/Improvement Partnership for Hospitals 04/09/ /09/ /10/ /10/ /10/ /11/ /11/ /12/ /12/2002 High Impact Changes which address variation in patient flow The gains from addressing discharge variations will be more significant if a holistic approach to managing variation is adopted, that combines Change No3: manage variation in patient discharge, Change No4: manage variation in the patient admission process, Change No5: avoid unnecessary follow-ups, Change No9: optimise patient flow through service bottlenecks using process templates and Change No10: redesign and extend roles. To implement Change No3 it is suggested that clinicians: map the processeses, identify bottlenecks and main causes for delay map the information flows and responsibility for direct patient care at all points in the patient journey measure and analyse current patterns of discharge by day of week, hour of day, specialty, etc analyse all inpatient stays by length of stay, to identify where improvements in the discharge process will have the greatest impact plan for discharge as part of the preadmission arrangements or early on during admission to ensure an efficient interface of information is available in real time between secondary and primary care. There is usually far more variation in the patterns of patient discharge from hospital than in patterns of admission.

14 14 The Clinicians Guide to Applying the 10 High Impact Changes 4 Change N o 4: Managing variation in the patient admission process In the past, it has been assumed that it is the emergency admissions that impact on elective planned admissions because it is assumed that emergency admissions are highly variable and more unpredictable. However, repeated case studies have shown that elective admissions are often the major cause of variation across the system, being far more variable and unpredictable than emergency admissions in many centres. This is due to the way that elective surgical scheduling is planned. Many hospitals have embarked on the redesign of their elective scheduling systems as a high impact strategy to improve emergency admissions. For example, leaders of one NHS Trust have undertaken a concerted effort to manage the elective and emergency flow. This has enabled them to predict and match demand and capacity much more accurately in real time. Results include: This change can be applied to any healthcare organisation, particularly those that schedule patients on an elective basis. This ranges from primary care services to treatment centres to community hospitals to major acute centres. An average district general hospital could increase the throughput of patients by 10% within existing capacity. Alternatively this could free up capacity to reduce the elective waiting list and/or achieve financial balance. Furthermore, the evidence suggests that this change can: improve access to beds for all patients requiring admission deliver or exceed the 4-hour A&E wait target eliminate on the day cancellations of elective patients minimise medical outliers. 68% reduction in medical outliers 44% reduction in last minute cancelled operations 8.2% increase in elective inpatient activity

15 The Clinicians Guide to Applying the 10 High Impact Changes 15 As with Change No3: Manage variation in patient discharge thereby reduce the length of stay, smoothing the variation in admission processes will have widespread effects across the whole system. Progress would undoubtedly lead to a substantial improvement in delivery, with the desirable side-effect of achieving and exceeding the access goals in the NHS Improvement Plan*. However, more importantly, achievement of these goals would be sustainable due to true system improvements. Figure 2: Emergency & Elective Admissions April-November 2002 Number of Admissions Emergency admissions Elective admissions For patients, the evidence suggests that local improvements indicated: more personalised service including more choice for patients an improved patient experience through the provision of better care without delay certainty of admission for an elective admission /04/ /04/ /04/ /05/ /05/ /06/ /06/ /07/ /07/ /08/ /08/ /09/ /09/ /09/ /10/ /10/ /11/2002 Which is most variable Emergency or Planned? Source: Richard Lendon/Improvement Partnership for Hospitals For staff, the evidence suggests that local improvements indicated: enhancement of the working environment for clinical teams contributes to a stress-reduced environment and improved staff retention it resulted in improved patient flows with fewer patients in each clinical area at a time the right patient, is in the right place, at the right time. To implement Change N o 4 it is suggested that clinicians: map the processes and existing patient flows across the whole patient elective planned admission pathway (for both elective planned admissions and emergency admissions) link the value-adding steps in each process, where possible, and combine steps or perform them in parallel; only sequence steps where one is dependent on the previous one measure and analyse elective and emergency demand by day of week and hour of day reduce variation in elective admission patterns consider methods of reducing variation in emergency admissions map the common emergency admissions conditions to each practice to understand whether alternative treatment could be provided in a more appropriate care setting. * This document can be found at

16 16 The Clinicians Guide to Applying the 10 High Impact Changes 5 Change N o 5: Avoiding unnecessary follow-ups for patients and providing necessary follow-ups in the right care setting Nationally, over a year Trusts issue 37 million follow-up appointments, asking patients to return to hospital to have their progress checked, undergo tests or receive test results. A significant proportion of follow-up visits are clinically unnecessary, inconvenient and cause unnecessary anxiety for patients, as well as wasting valuable resources. 75% of all outpatient Did Not Attend (DNA) figures are for follow-up appointments. Followup DNA rates vary between specialties and locations, but between 10 to 40% is common. Much of the current management redesign agenda has focused on the front end of the patient process through appropriate demand management and thereby avoiding initial hospital visits. However, follow-up arrangements have not typically been a focus, yet the evidence shows that there are great gains to be made here. Follow-up visits should be seen as part of the front end of the patient s journey. To date, common practice has been to invite patients for a follow-up appointment just in case. Changing this precautionary presumption to one of no follow-up without a specific clinical reason (i.e. clinical need or patient-led request) would undoubtedly reduce the number of unnecessary follow-ups and DNAs. Case Study One stop clinics At the one-stop gynaecology postmenopausal bleed clinic in Mid-Yorkshire Hospital Trust, the patient receives examination, assessment, trans-vaginal scan and any other relevant investigations on the same day. If cancer is suspected, the patient receives an appointment for hysteroscopy before leaving the clinic. Patient visits are reduced from three to one. Many Trusts are challenged to achieve the target of six weeks from GP to initial outpatient consultation. Reducing clinically unnecessary and inconvenient follow-up visits will free up valuable clinical resources. Trusts must initially look to streamline the patient s journey, to create a one-stop approach where all relevant tests are planned, scheduled and booked to occur in one visit. This needs the visit process to be carefully coordinated, to ensure access to relevant tests occurs in sequence and that results are available within a timescale allowing colleagues to make timely and appropriate clinical decisions. A significant proportion of follow-up visits are clinically unnecessary, inconvenient, cause anxiety for patients and waste valuable resources.

17 The Clinicians Guide to Applying the 10 High Impact Changes 17 Where they are necessary, follow-up appointments should be delivered in the right healthcare setting and by the appropriate healthcare professional. This means investigating alternatives to the potential inefficiency of the present standard of a consultant-led, hospital-based, outpatient appointment. The first question should be, is a follow-up visit really necessary? If it is, the assumption should be that the follow-up can be performed in a primary care setting and should be instigated by the patient. Automatic secondary care follow-up should be used only where necessary and clinically appropriate. Follow-up does not have to mean that a patient is physically present: telephone calls, questionnaires, web-based services and group visits can all help replace the traditional visit. Case Study Nurse-led follow-up clinics Audiology (Bradford) Nurse-led specialists have released 750 consultant follow-up appointments in a year. If this were extrapolated nationally, this would release more than half a million follow-up appointments each year. Aural care (East Lancashire) A single nurse has released 770 consultant follow-up appointments in a year. If this was extrapolated nationally this would release nearly 800,000 follow-up appointments each year. Initially, a one-stop visit costs more than a traditional first appointment, but this will be offset by removing following visits. The additional costs of clinical nurse specialists and primary care follow-ups will have to be weighed up against the reduction in follow-ups and the released consultant time locally. In terms of management time; a nominated person is needed to lead the changes. There will also be a need to buy clinical engagement through evidence that these changes work (either gathered locally or by visiting organisations already doing this successfully). Some physical redesign may also be needed, remodelling facilities to bring together activities. To implement Change N o 5 it is suggested that clinicians: are involved at the beginning with the redesign of the patient s journey undertake a process map of the patient s journey co-develop services with patients and carers gain widespread clinical and managerial support to take forward an agreed redesign strategy test out new ideas, i.e. ask the patient whether they wish to have a follow up appointment consider setting up single visit clinics commission follow-up care where appropriate in alternative healthcare settings. Urology (Weston Area) Nurse-led follow-up clinics for bladder cancer patients benefits 100 patients a year, redirecting consultant time to see more new patients.

18 18 The Clinicians Guide to Applying the 10 High Impact Changes 6 Change N o 6: Increasing the reliability of performing therapeutic interventions through a Care Bundle approach The Care Bundle approach encourages clinical teams to examine the way they deliver therapeutic interventions. It is a direct way of improving the delivery of clinical care to achieve improved clinical and organisational outcomes. Care Bundles can assess a clinical process systematically by linking the evidence for a group of therapeutic interventions, agreed by clinicians locally, with a simple yes/no checklist, to determine whether those interventions were performed. By comparing the actual delivery of care with that expected, clinical and non-clinical staff can make local organisational changes to improve the delivery of therapeutic interventions. This high impact change provides a method by which, in Wennberg s phrase (Fisher 2003) unwarranted variation in clinical care can be reduced. At the same time, equity of care is improved by ensuring that patients with the same clinical condition are managed consistently. Case Study University Hospitals Coventry and Warwickshire NHS Trust University Hospitals Coventry and Warwickshire NHS Trust critical care unit looked at their care processes for the ventilated Care Bundle and improved the delivery of all four elements. They tailored the critical care unit data system to give timely feedback on care processes, making the monitoring of the clinical process integral to the clinical process itself. The reliability of giving therapy increased; patient throughput increased by 9% in one calendar year without any change in occupancy; and the pharmaceutical costs of sedation reduced. Examples of three Care Bundles: Elements of a ventilator Care Bundle Elements of a tracheotomy Care Bundle Sepsis management Care Bundles Elements of two Care Bundles: Elements of a ventilator Care Bundle DVT prophylaxis Peptic ulcer prophylaxis Prevention of ventilator associated pneumonia by elevation of the head of the bed Managing sedation effectively Elements of a tracheostomy Care Bundle Humidification Tube patency/inner tube care Suction Safety equipment availability Cuff pressure Tracheostomy dressing/tapes Using Care Bundles shows how clinical governance can be used to reduce unwarranted variation in clinical care.

19 The Clinicians Guide to Applying the 10 High Impact Changes 19 Existing evidence and data indicates that the creative abilities and motivation of managerial and clinical staff can make significant improvements to clinical processes and patient outcomes clinical outcomes, in terms of reduced morbidity, and service outcomes in terms of bed availability. The steps of a Care Bundle are: agreement among clinical and non-clinical professionals to measure processes of clinical care to reduce avoidable morbidity and mortality selection of a small number of therapeutic interventions to be measured, based on the available evidence of their effectiveness, standards of best practice, or the logic of their applicability agreement of local guidelines showing the indications and exclusions for the particular therapeutic interventions use of simple yes/no checklist to measure and give timely feedback on the delivery of the therapeutic interventions according to local guidelines facilitation of creative discussion to develop ways for improving the reliability of care. To implement Change N o 6 it is suggested that clinicians: identify specialties or diagnoses which could benefit from close attention to a small number of elements of care help to make the introduction of Care Bundles an explicit part of the organisation s clinical governance strategy involve hospital clinical audit/effectiveness departments to support the process allow clinical staff to decide on relevant elements of care regularly audit the compliance of the Care Bundle disseminate Care Bundles to all clinical groups for compliance and inclusion in clinical protocol manuals across organisations. The Care Bundle concept is able to provide a mechanism for timely measurement to show that clinical guidelines are being followed. While similar to an audit cycle, the difference is the speed with which the feedback takes place. In audit, data is analysed retrospectively, but a Care Bundle is monitored prospectively. However, the best results have been obtained where measurement has been incorporated into the daily routine. Care Bundles is an approach which systematically assesses a clinical process.

20 20 The Clinicians Guide to Applying the 10 High Impact Changes 7 Change N o 7: Applying a systematic approach to care for people with long-term conditions A key priority for the NHS is patient choice and the development of personalised services. There is growing recognition that our current focus within the NHS on managing acute episodes of care is no longer appropriate, either in terms of the type of care offered or in terms of managing large and increasing numbers of patients who suffer from one or more long-term condition(s). For more information on the Longterm Conditions National Service Framework (NSF) please see According to NHS data, 2% of patients with chronic conditions account for more than 30% of unplanned hospital admissions. Clearly, addressing this issue with better management of long-term conditions could dramatically improve patient care and cost-efficiency. Case Study Luton Evercare Pilot Programme Luton is an extremely challenging community for the local primary care trust: more than 30% of the population is from an ethnic minority; the community is economically deprived; and has high levels of light industry This means we have quite high levels of conditions like coronary heart disease, diabetes and asthma, explains Dr Ian Winstanley, Director of Patient Services at Luton Teaching PCT. It doesn t take a genius to see that it s taking up a high proportion of our spending and time these cases account for two-thirds of our accident and emergency admissions. In 2002, Luton was selected as one of the sites to take part in the Evercare pilot programme, a system created by US company United Health Group for proactively managing patients with long-term conditions. The aim of Evercare is to reduce hospital admissions by encouraging patients to manage their own illness, with the support of multidisciplinary teams. Reducing hospitalisation is vital in maintaining the health of patients with long-term conditions. The biggest problem for doctors is that we see these patients when they re too sick, he says. It takes too long to rehabilitate someone after a hospital stay, and they are likely to pick up secondary infections or complications. As part of the Evercare programme, Luton PCT created multidisciplinary teams headed by specially trained assistant practitioner nurses, who work with patients in the community. Each nurse has a caseload of around 50 patients and is responsible for grading each patient as a red, amber or green case. Depending on the code assigned to their case, patients may receive support from the local health visitor, social worker or other healthcare professionals. The community-based approach has reduced emergency admissions by almost 70% in the first six months. Dr Winstanley believes the benefits could be even greater: What we re doing, which we couldn t before, is working with whole families to address issues such as obesity or poor lifestyle.

21 The Clinicians Guide to Applying the 10 High Impact Changes 21 Experience gained in primary care about the benefits of more proactive, systematic approach to managing patients with long-term conditions underpinned by good prevention is being strengthened by our recent learning from US models of care. By identifying the local population with long-term conditions and then understanding the personalised needs of these people within the community health and social care services can be more closely matched to individual requirements. Through risk stratification, a strong focus is applied to: encourage patients to be actively involved in their treatment by recognising the role that self-care management plays through education and prevention systematic disease management that includes automatic recall, review and reassessment with individualised care planning case management for those at high risk of deterioration and admission to hospital. It is estimated that 500,000 patients with longterm conditions would benefit from this high impact change. These patients account for nearly 30% of the four million emergency admissions in the NHS each year. At present, 78% of all healthcare spend relates to people with long-term conditions, and 80% of GP consultations relate to long-term conditions. The burden will increase further: by 2030, the NHS Modernisation Agency predicts the incidence of long-term disease in patients over 65 will more than double. To implement Change N o 7 it is suggested that clinicians: use information systems to identify patients with long-term disease stratify patients by risk involve patients in their own care encourage participation in active care plans and expert patient programmes use multidisciplinary teams led by a key professional worker (often a nurse) use highly personalised services for patients with complex needs. People with long term conditions are often treated in hospital following emergency admission because they have not been able to control their condition in the community. Systems need to develop the primary care interface to help patients manage their condition in the community. 2% of patients with long term conditions account for more than 30% of unplanned hospital admissions.

22 22 The Clinicians Guide to Applying the 10 High Impact Changes 8 Change N o 8: Improving patient access by reducing the number of queues Multiple queues are an endemic feature of the way we manage patients waiting in the NHS. Patients may be split into separate queues by degree of urgency, location, clinical condition or by individual clinicians within a specialty or primary care team. Personalised or pooling team referrals (previously referred to as pooling ) can dramatically reduce average waiting times by sharing work among a team of consultants. Carving out queues for particular patient groups can introduce additional delays, because multiple queues make it impossible to accurately match capacity and demand. It is not unusual to see more than 100 separate queues within a single clinic schedule, creating an enormously complex scheduling task. Personalised or pooling team referrals are particularly effective because patients are referred to a team of consultants, rather than an individual clinician. This system is fairer for patients and reduces average waiting times substantially because work is shared. Quality of care is the responsibility of all in the clinical team. Carving out queues for particular patient groups can introduce additional delays, because multiple queues make it impossible to accurately match capacity and demand. Case Study Reducing GP Referral Time In one pilot project, eliminating carve-out and sharing referrals in an ovarian cancer patient pathway, the time from GP referral to first definitive treatment was reduced from over 140 days to less than 40 days. At Rotherham General Hospitals Trust, clinic waiting times have been reduced from approximately 16 weeks for first appointment to four weeks by eliminating carve-out and allocating patients sequentially to the next available clinic slot. Personalised team referrals are part of a whole-system reform in Northamptonshire Healthcare trust, which has seen the wait for a routine appointment reduced from six months to three. Other benefits have been an 85% reduction in cancelled clinics, and did not attendances reduced from 12% to 8%. Clinicians taking part in pilot projects also reported that personalised team referrals improved team working and improved clinical outcomes by delivering care through teams. Staff also saw substantial reductions in the clinical, managerial and administrative time dedicated to managing queues and waiting lists.

23 The Clinicians Guide to Applying the 10 High Impact Changes 23 Reducing the number of queues within key services by 50-80% and introducing personalised team referrals can reduce average waiting times by 50%, with no change in underlying capacity. To implement Change N o 8 it is suggested that clinicians: map the existing flow of patient referrals to identify how queues are sub-divided in the system reduce the number of queues by implementing personalised team referrals where possible build team-based objectives into consultant contracts gain high-level clinical leadership support, because changes will impact on many teams and specialties ensure staff understand the patient perspective, particularly ideas of reduced delay and equity educate clinicians on evidence from queuing theory about personalised team referrals adopt the Clinically Prioritise and Treat (CPaT) methodology for every specialty where there are waits for outpatient and inpatient services (see introduce personalised team referral systems. Figure 3: Example of the number of queues in a typical endoscopy unit Number of Specialists SURGEON PHYSICIAN RADIOLOGIST Appointment types Flexi-sig urgent soon routine Colonoscopy urgent soon routine OGD urgent soon routine ERCP 73 QUEUES Reducing the number of queues within key services by 50-80% and introducing personalised or pooling team referrals can reduce average waiting times by 50%, with no change in underlying capacity.

24 24 The Clinicians Guide to Applying the 10 High Impact Changes 9 Change N o 9: Optimising patient flow through service bottlenecks using process templates Process templates are used to build up a picture of the time and resources required by a patient during their care process. They can be used to identify bottlenecks and reduce the effect of variation in demand and capacity at the bottlenecks to improve scheduling of patient care. They also have the potential to make a major contribution to providing effective care without the inherent delays for patients. A process template describes the process in terms of what happens to one patient at one time and allows staff to find the actual bottlenecks in the system. Once found, they can plan to unblock bottlenecks by: reducing the demand on the bottleneck by shifting work upstream or downstream and changing roles (e.g. training an ophthalmology nurse to measure visual acuities and eye pressures, rather than the ophthalmologist who in this case is the bottleneck in the process) increasing capacity (e.g. recruit more ophthalmologists) calculating the return on investment at the bottleneck (i.e. how many more patients could we treat by training the ophthalmologist nurse or employing another ophthalmologist?) scheduling patients, to improve flow through the resources in the whole system starting scenario planning (e.g. what is the impact if the ophthalmic nurse goes on holiday?) Case Study Process Templates Improve Productivity Endoscopy and radiology units working with service improvement leaders have been able to improve productivity by 40% through using process templates. Templates have also enabled them to identify the time constraints in the system, make appropriate investment decisions (role redesign, voice recognition software etc.) and improve patient scheduling. Some organisations, including the Thames Valley Cancer Network, have started looking at process templates for radiotherapy for example, how long patients need on machines to help schedule out delay. Within the emergency system process, one hospital used templates to clearly identify two distinct groups of patients; minor and major patients. Segmenting these patient groups into process template types and managing them within distinct resources initially resulted in an increase in the numbers of patients processed through A&E in under 4 hours from 50% to 85%. Process templates for the majors identified that the bottleneck was in the discharging of patients from the wards and in the initial assessment in A&E. The same junior doctor on call performed both tasks. The variation in demand for these 20-minute tasks can vary from 17 to 93 patients per day. Relieving that constraint, by moving to consultantbased wards in which the junior doctors only look after one ward and by scheduling the discharges before the admissions, resulted in a reduction in the length of stay of half a day for 80% of patients discharged from hospital. This resulted in no medical outliers, no surgical cancellations on the day (due to lack of bed) and an increase in the over all number of patients processed through A&E in less than 4 hours from 85% to 95%.

25 The Clinicians Guide to Applying the 10 High Impact Changes 25 The effectiveness of using process templates to schedule care will be limited by the extent of carve-out or ring-fencing of the shared resources in the total capacity of resources. For example, if a group of ophthalmologists see their own referrals in their individual clinics, the process templates and scheduling will improve the productivity of each ophthalmologist s clinic but not the whole ophthalmology unit. This will only occur if the team were to become a carve-out-free zone, introduce Personalised Team Referrals and pool their clinic capacity. Then, templates could be used to schedule the flow of patients through the whole ophthalmic resource to increase productivity, reduce waiting times, improve access and guarantee a robust schedule for booking. Process templates are one of the most effective tools for identifying and addressing the causes of bottlenecks in patient processes. The principles of improving the flow are: understanding the process and the system identify measures for improvement simplify the process control variation reduce variation ensure the system provides enhanced care for patients. These tools and techniques may be applied to whole systems of care involving several different pathways and patients crossing organisational boundaries. See Improvement Leaders Guide: Improving flow* at improvementguides and refer Change No2: Improve patient flow across the whole NHS system by improving access to key diagnostic tests. To implement Change N o 9 it is suggested that clinicians: consider using process templates prior to investment in additional capacity to ensure that the investment is required assume a minimum of 10% improvement in effective capacity at the level of a single bottleneck (i.e. endoscopy, chemotherapy or radiotherapy unit) understand how the patient s clinical condition and procedure relates to the process template: a hip replacement has a similar process template to a knee replacement, but a colonoscopy template is very different to either of the above undertake a quick time-and resource study of 20 to 50 consecutive patients going through the process. Managers need to time the individual steps to find out how long 80% of patients undergoing each task in the process take. Process templates use the time that the procedure takes for 80% of patients because if you use the average time, you will underestimate the time required for 50% of patients and will not be able to catch up on the schedule schedule (i.e. line up) the process template for sequential patients, enabling identification of the constraints, the changes and the costbenefits of the changes to be made use the above methodologies in developing business cases for new investment in capacity use the above methodologies when considering prior to recruitment new clinical staff. NHS teams using process templates report being able to free up around 30% of additional capacity within their existing resources. * Also see Improvment Leaders Guides: Matching Capacity and Demand pages which sets out steps to create a process template

26 26 The Clinicians Guide to Applying the 10 High Impact Changes 10 Change N o 10: Redesigning and extending roles in line with efficient patient pathways to attract and retain an effective workforce Optimising roles along an agreed pathway or process of care leads to significant improvements for both staff and patients. It is known that by redesigning roles and matching them against skills and competences we can improve care, reduce waste, improve working lives and enhance patient care. Role redesign has a set of fundamental principles: The changes are based on the use of care systems, pathways and protocols. Any changes must ensure clarity, accountability and safety for the patient and staff. Close links are maintained with other developments in human resources. All role redesign takes account of the need for continuing personal and professional development and lifelong learning. Role redesign builds upon good practice and sound evidence. Introducing new ways of working and employing staff differently engages organisations to think about roles within their teams. Clinical leaders have a key role in valuing and developing staff through active engagement and feedback of their role. This could address issues, by significantly reducing delays; improving staff retention; and reducing costs of staff turnover. Extending administrative roles releases care-givers from clerical duties and improves communication between providers and patients. 49 trusts and GP surgeries taking part in the accelerated development programme for medical secretaries found that new roles enabled doctors to spend an average of three hours extra clinical time with patients per week. This change also improves the career path of administrative staff, improving retention and recruitment of these workers. Advanced practitioners, including nurses and allied health professionals are often able to undertake tasks previously performed by doctors. Developing assistant practitioner roles, meanwhile, can create additional workforce capacity and widen access to NHS careers by attracting candidates from more diverse backgrounds. These changes can deliver significant improvements in diagnostics, discharges and reducing queues. The evidence suggests that enhancing the role of medical secretaries would release an average of two hours and forty-five minutes of clinical time per doctor per week. Through new support worker roles in intermediate care, delayed discharges would fall by at least 2%.

27 The Clinicians Guide to Applying the 10 High Impact Changes 27 To implement Change N o 10 it is suggested that clinicians: identify the service problem that can be solved by new / amended roles assess the current workforce who does what? agree opportunities for new or redesigned roles with additional skills or training define protocols and guidelines to allow a wider range of professionals to provide care to patients agree a training and development plan write a business case for role sustainability. Reducing staff turnover by just 1% (to 13%) would save 90 million. For further information see the Improvement Leaders Guide: Redesigning roles or visit The NHS could see an extra 80,000 patients every week by deploying staff effectively through new ways of working and role redesign.

28 28 The Clinicians Guide to Applying the 10 High Impact Changes 10 Change N o10: Continued Case Study Role redesign and extension Pilot sites have redesigned and extended roles such as these, and achieved dramatic benefits. For example, introducing advanced practitioner roles in radiography has helped to reduce waiting lists because tests are no longer cancelled when a radiologist is not available. Pilot sites reported an 83% reduction in waits for plain film reporting and a substantial fall in the use of agency and locum staff. Peterborough and Stamford Hospitals Foundation Trust diabetes care team reduced the average length of stay of patient visits from three hours to just one hour by introducing a new role of diabetes care technician. The technician carries out most of the checks for the annual screening review, previously conducted by a consultant. When London Ambulance Service introduced a role of emergency care practitioner for paramedics and A&E nurses, they were able to respond to less urgent 999 calls and reduce the number of patients being brought into A&E wards. For example, 40% of patients were treated at the scene or referred directly to another care pathway, reducing A&E admissions from 70% to 57% in the trial. City Hospitals Sunderland Foundation Trust has dramatically reduced waiting times in radiology by introducing new extended roles. The hospital has recently appointed three advanced practitioner radiographers: one to support the existing radiographer-led barium enema service; the second to implement a radiographer A&E plain film reporting service; and the third to report on specific MRI scans. The advancer practitioner will work autonomously and will release consultant radiographers from those aspects of service, to allow them to specialise in other imaging modalities, explains Paul Stephenson, image service manager. The advanced practitioner role has meant the hospital has been able to introduce a comprehensive radiographer-led barium service, including barium enemas and barium swallows. The waiting times for these services have reduced significantly under the new regime: the average waiting time for routine barium enema examinations had fallen from 16 weeks to 10 days in 11 months. A radiographer-led barium follow-through service is now being developed. The hospital has also recruited three assistant practitioners. The new recruits were enrolled onto a two-year foundation degree to provide them with the necessary expertise to work in radiology. In addition to two days academic attendance, they receive on-the-job training for three days a week. Once qualified, these staff will do a proportion of the plain film radiography examinations, including referrals from minor injury units, GP and outpatient clinics. The radiographer will still assume responsibility for discharging the patient. The assistant practitioner will not undertake complex plain film examinations. Overall, the project has been a success, and two more assistant practitioners have been recruited.

29 The Clinicians Guide to Applying the 10 High Impact Changes 29 Conclusion The 10 High Impact Changes work. The 10 High Impact Changes affect large numbers of patients. The 10 High Impact Changes are evidence-based. Implementation across the NHS would produce dramatic improvements. Clinical Leadership is essential to making the 10 High Impact Changes a reality. Working with clinical teams these changes will deliver significant benefits affecting a large number of patients. Each High Impact Change is applicable to any given care setting. Figure 4: Biggest change required is in leadership thinking Performance high Raises overall level of performance Less fires break out at this level Fire-fighting Service & role redesign Chronic problems Acute problems low time

30 30 The Clinicians Guide to Applying the 10 High Impact Changes Further information Resources and information For more detailed information on the 10 High Impact Changes for Service Improvement and Delivery including a glossary of terms, please visit the website For further case studies please see the Improvement Partnership for Hospitals website at Useful websites: Other useful documents: To obtain a hard copy of the original 10 High Impact Changes for Service Improvement and Delivery: A guide for NHS Leaders, please call and quote ref MAHICRES To obtain copies of The PCT Guide to Applying the 10 High Impact Changes, please call and quote ref MAHICPCT To obtain further copies of this document The Clinicians Guide to Applying the 10 High Impact Changes for Service Improvement and Delivery: A Guide for Clinicians, please call and quote ref MAHICCLN To obtain copies of the Improvement Leaders Guides, please call and quote ref MAILG052 Improvement Leaders Guides The Improvement Leaders Guides, NHS Modernisation Agency, May 2005, contain tools and techniques you will find useful in adopting the suggestions made in this document. The 13 guides, available as a boxed set, provide a basic introduction to a range of models, frameworks and ideas and cover general improvement skills, process and systems thinking and personal and organisational development. For more information please see To order a boxed set of these guides please call and quote ref MAILG052.

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