CLINICAL STRATEGY AND PROGRAMMES DIRECTORATE

CLINICAL STRATEGY AND PROGRAMMES DIRECTORATE NATIONAL CLINICAL PROGRAMMES Overview Joan Gallagher ONMSD, CSPD Overview of Programme design Nursing and Midwifery inputs and the National Clinical Programmes Programmes specifics deliverables and impact on the Nursing and Midwifery National Clinical Programmes Mission: Deliver better care, through better use of resources Objectives: Improve Quality Improve Patient/Service User Access Improve value Role: Define how services will be delivered, measured and resourced. Provide clinical leadership Agreed Key Principles 1. Clinically led multidisciplinary teams 2. Structured programme management approach from design to implementation 3. Nationalise existing best practice 4. Engage patients 5. Make evidence based, data driven decisions 6. Local ownership 7. Align stakeholders - Government, Management, Colleges, Unions, Patients/Service users and professional disciplines/groups. 4 Service input to design include: Clinical Leads National Programme Managers Local Programme Managers Regional Co-ordinators Clinical Advisory Groups, DONM Reference Group, Therapy Professionals Committee Strong multidisciplinary approach 25 Programmes have Lead Clinical Nurses/Midwives from the services and nominated by Directors of Nursing and Midwifery (DONMs), on their working groups. 15 Programmes have other senior nurses and midwives on working groups. Over thirty Allied Health Professionals involved with the programmes. Over 30 Pharmacists involved. Agreed Programme Management Approach Structured programme management 8-step approach from design to implementation 1 2 3 Define 4 5 6 7 Scope Measure & Initiate the Set key analyse Validate Detailed program program Goals issues & performance solutions solution solutions design Implement solutions 8 Sustain & improve performance 6 1

Clear accountability, safe management and continuous improvement: (6) Develop change capability to implement agreed actions (5) Define governance for agreeing action to address Safety, Quality, Access & Value issues (1) Agree standards & targets Safety, Quality, Access & Value Safety Quality Access Value Service user involvement (2) Agree how safe and effective service is delivered Symptoms Diagnose Refer Treat (3) Agree who is accountable (4) Establish means of measuring safety & effectiveness 30 + National Clinical Programmes Acute Coronary Syndrome Acute Medicine Anaesthesia Asthma Audiology Care of Older People COPD Critical Care Cystic Fibrosis Dermatology Diabetes Emergency Medicine Endoscopy Epilepsy Heart Failure Mental Health Neurology Obstetrics & Gynaecology OPAT (Home IV self or professionals) Ophthalmology Orthopaedics Paediatrics & Neonatology Palliative Care Pathology Primary Care Radiology Rare Diseases Rehabilitation Medicine Renal Rheumatology / MSK Stroke Surgery Transport and Retrieval Plus Cross Programme Initiatives such as: Prevention of Chronic Disease, Medicines Management, Quality Improvement, HCAI. 7 * Group Lead Unscheduled Unscheduled Care Care AMP EMP Surgical (Elective & Acute) Anaesthetics Retrieval & Transport Orthopaedics (incorporating trauma and elective) Critical Care Clinical Strategy & Programmes Proposed Governance Structure NCP NCP Advisory Group Advisory Group National CD & National CD & NCP Steering Group NCP Steering Group Liaison meetings Liaison meetings (e.g. College CEOs) (e.g. College CEOs) Group Lead Long Te rm Long Te rm Conditions Conditions (Acute to (Acute to Community) Community) Group Lead Cardio / Cardio Cere bro- / Cere bro- Vascular Vascular Disease Disease Respiratory Stroke - COPD Heart Failure - Asthma ACS - Cystic Fibrosis Diabetes Dermatology Neurology Rheumatology/ Epilepsy Musculo Skeletal Renal Mental Health Rehab Medicine Rare Diseases Palliative Care Care of Older People `Ophthalmology CEO HSE Clinical Strategy Clinical Strategy & Programmes & Programmes National Clinical Programme Groups National Clinical Programme Groups Primary Care Lead Prima ry Ca re Prima Prog ry ramme Ca re Prog ramme GP Co-Leads Group Lead Diagnostic / Diagnostic Support / Support Services Services Radiology Pathology (gui deli nes ) Audiology OPAT Endoscopy Quality & Patient Quality & Patient Safety Safety Group Lead Women Women & Children & Children Obstetrics & Gynaecology Paediatrics & Neonatology Special Special Delivery Delivery Unit Unit CSPD Support Team Cross Programme Initiatives Outpatient services Health Informatics/ Intelligence / IT Quality Improvement Chronic Disease Prevention Integrated Care (long-term conditions) Standards and Guidelines Medicines Management HCAI Advocacy Engagement Service input to design include: Clinical Leads National Programme Managers Local Programme Managers Regional Co-ordinators Clinical Advisory Groups, DONM Reference Group, Therapy Professionals Committee Strong multidisciplinary approach 25 Programmes have Lead Clinical Nurses/Midwives from the services and nominated by Directors of Nursing and Midwifery (DONMs), on their working groups. 15 Programmes have other senior nurses and midwives on working groups. Over thirty Allied Health Professionals involved with the programmes. Over 30 Pharmacists involved. * Programme Group Leads to be appointed following an expression of interest and selection process. V0.162013 Members of the CSPD Team Aveen Murray Sarah McCormack Valerie Twomey Mairead Gleeson Emma Benton Joan Gallagher Idowu Akingbagbohun Executive Support/CSPD Office Manager Unscheduled Care Group (& National Programme Management Office) Long term conditions Group (& Liaison) Cardio-/Cerebro- Vascular Diseases & Primary Care Groups (& Operations) Diagnostics Group (& Therapy Liaison) Women & Children Group (& NCP Liaison, ONMSD) PA to Dr. Àine Carroll Across CSPD & QPSD Maeve Raeside (BM); Sonia Shortt (HR); Carmel Cullen (Comms) Questions & Contact Details For online information on the Programmes visit: www.hse.ie/clinicalprogrammes Contact the HSE National Clinical Programme Offices @: nationalcsp@hse.ie for Clinical Strategy and Programmes - Dr. Aine Carroll Dr. Steevens' Hospital, Dublin 8. Tel: 01 635 2000 2

Nursing and Midwifery and the National Clinical Programmes ONMSD Positioning & Influencing Nursing & Midwifery Journey Appointment of Nursing & Midwifery Services Director Clinical Strategy & Programmes Directorate (CSPD) Office of the Nursing & Midwifery Services Director Key decision-makers Political System Govt. Departments Statutory Bodies World Health Organising European Parliament International Alliances OECD Nursing & Midwifery inputs 1. NCP Liaison, ONMSD, CSPD 1. Linking nursing & midwifery (N&M) to the National Clinical Programmes (NCPs_; point of contact, assists in ongoing shaping of the NCP & facilitates interdisciplinary working in Programmes and across programmes and services. Lead Clinical Nurse/Midwife - from clinical practice who join national working group, to bring a collective view to the NCP 1. Nominated by Directors of Nursing, supported by ONMSD/NMPD, N&M Special Interest/Reference Groups and/or Communication Networks/relevant Professional Associations 1. Nurse/Midwife Service Planner (NMPD staff assigned to larger NCPs whose focus is primarily Integrated Workforce Planning (WFP) 2. Professional Development Co-ordinators for Practice Nurses NLIC ONMSD Nurse Leads HSE Regions -Area & Unit Directors & CNMES Nurse and Midwife Medicinal Product Prescribing Administration 3. Director of Nursing/Midwifery Reference Group Other ONMSD Leads on NCPs Acute Medicine Programme Ms. Avilene Casey, DON Emergency Medicine Programme Ms Ger Shaw, DON Palliative Care Programme Ms Lorna Peelo, ONMSD Lead NEWS Ms Eilish Croke, National Lead Medicines Management Dr. Helen Flint, DON, ONMSD Lead Productive Ward Mark White (p/t) National Lead Clinical Governance Development Ms. Maureen Flynn, ONMSD & QPSD Research & Development Lead Ms. Sarah Condell Midwifery Lead Ms. Sheila Sugrue also on O&G programmes ONMSD reps (ONMSD staff or Directors of Nursing/Midwifery nominees) on Clinical Advisory and Steering Groups N&M Leadership & Innovation Centre Ms Cora Lunn Nursing & Midwifery Outputs 1. National Early Warning Score system is being implemented 2. Productive Series - Productive Ward & the Productive Operating Theatre (tpot) 3. Continuing Education Programmes for Nurses Stroke, Diabetes (foot care) and Asthma. Others being developed; also links to formal 3 rd level education programmes 4. Workforce Planning documents (surveys chapters) in Models of Care (service planners with national working group) 5. Lead Clinical N&M input to working groups - advising on design and implementation of the models of care taking a lead on certain work-streams e.g. EMP or ensuring role clarity or promoting expanded roles.. 6. Other: Self Care/Management Framework. Supporting SDU work e.g. Discharge/ bed management Collaborative 3

and the CSF!... Nurses and Midwives local ownership, leadership and buy-in enabling NCPs Tangible Programme benefits delivered Acute medicine: Model of care and guidelines developed Not just saving bed days but changing behaviours Benefits achieved through changes to rostering and availability of senior clinical decision makers (AvLOS) has reduced from 8.1 (Dec 2011) to 7.2 in the reported December 2012 data. 125,000 bed days saved to date and significant decrease in trolleys Early Warning Score implemented in 34 sites AMNIG (Acute medicine nurse interest group) National EWS (NEWS) http://www.hse.ie/eng/about/who/clinical/natclinprog/acutemedicineprog/earlywarningscore/ ViEWs parameters, Patient Flow & communication tool Impact to Daily practice Emergency Medicine Programme Irish Committee for EM Training; Dr Philip Dept Crowley of EMP Medical IAEM Dr. Aine Carol Quality Health/SDU Advisory & Patient Director of Safety Programmes Irish Nat Board RCSI College of EM General Practise Liaison Committee Academic Committee IAEM Nursing Guidelines Group EMP Working Group Regional Leads Paediatric EM Lead Nursing & ANP Co-leads Therapy Professional Pre-hospital Emergency Care National Ambulance Service Programme Manager Administrative Support Office of Director of Nursing & Midwifery Therapy Professions Committee Patient Representative EMP Medical Advisory Group Consultants in EM Emergency Nursing Interest Group (ENIG) All EDs Represented 7 4

Tangible Programme benefits delivered Emergency Medicine The Emergency Medicine Model of Care developed 28 implementation teams established and site visits to all EDs to communicate and promote the programme have completed. First Steps - A set of early implementation recommendations Initiatives to improve processes, safety, quality and value commenced in each ED. The Manchester Triage has been rolled out and is in use in all EDs nationally. Ten implementation guidelines to improve ED processes are complete and distributed. Clinical tools for Paediatric Triage, ED Monitoring, Infection Control, Mental Health Triage, Patient Visiting Protocol have progressed. Staffing Model LIUs July 2013 ANP Framework July 2013 Ambulance handover training & protocol June 2013 Major Emergency Plan Template June 2013 E.G. Nursing Documentation EMP Impact to Daily practice Tangible Programme benefits delivered Surgery Elective and Acute Surgery Models of care developed Agreement with all surgical specialities on Day Case and Avlos targets New practices being introduced e.g. standardised surgical preassessment 14,186 more day cases seen and a reduction in inpatient volumes of 7,523 Avlos for Hip and Knee replacement reduced by two days 2.9m in efficiency and cash savings in 5 targeted theatres Establishment for National Office of Clinical Audit (NOCA) for surgery, critical care and Orthopaedics Launch of national policy and procedure on safe surgery - July 17th 2013, in collaboration with the RCSI and COA. National Quality Assurance Intelligence System (NQAIS) & Elective Surgery Average Length of Stay (AvLOS) Three documents circulated Aug 2013: NQAIS AvLOS Elective Surgery Information Governance Policy; This document outlines the roles and responsibilities of users of the application particularly in relation to the security of data. (Please see information on Appendices below). Standard Operating Procedure for System Access and Removal; This document details the methods for acquiring access to the application. (Please see information on Appendices below). NQAIS AvLOS Elective Surgery Notes; User s Guide NB: Appendices are at the back of the Information Governance Policy and the Standard Operating Procedure. Appendix 1, NQAIS AvLOS User Agreement; One of these forms should be completed for each member of staff requiring access and returned to the National Surgery Programme office Appendix 2, NQAIS AvLOS Application Form for Access for Hospital Staff. This form should be completed by the hospital manager and should include the names and details of staff for whom access is approved, and returned to national surgery programme office. Example Programme benefits delivered Stroke Stroke standardised in 28 units AvLOS for stroke patients has dropped by 2 days with 6,700 fewer bed days were spent in hospital Thrombolysis rates have increased to 9.5% leaving Ireland with one of the highest rates in the world Foundation education Programme MDT developed 5

Impact to Daily practice Network Models Critical Care Programme Contents CCP vision requires a sustainable Critical Care Model CCP identifies changes required to transform critical care service: delivery CRITICAL CARE PROGRAMME Clinical Patient Experience Outcomes People CRITICAL CARE MODEL CAPACITY PLANNING INTENSIVE CARE AUDIT HEALTHCARE ASSOCIATEDRe INFECTION SURVEILLANCE QUALITY Right care, right now ACCESS Right care, right now COST effective and efficient care JFICMI / ICSI National Standards Critical Care Model Hub-and-spoke Differentiated, low-risk patients Critical Care Programme Model of Care Model 3 Hospital Model 4 Hospital (regional) Model 4 Hospital (supraregional) ACUTELY ILL PATIENTS CRITICALLY ILL PATIENTS Level 2,3 critical care Level 2,3 critical care Advanced Paramedicine, Critical Care Retrieval Level 2,3,3S critical care NCP for Critical Care Impact to Daily practice JFICMI / ICSI National Standards Nursing Quality requirements and Ratio calculations agreed by DONRG (2012) 2012 Census completed to include: Bedstock Nursing workforce Age profiles of nursing staff 88% of staff are <50years of age Qualifications of nursing staff - 69% hold an ICU quals & 24% hold no formal qual. in ICU Present work-stream: development of a strategy and national education framework for new entrants to the critical care environment that will be geographically reckonable Retrieval 6

Example Programme benefits delivered Epilepsy Twelve Standard Operating Procedures (SOPs) developed and approved for implementation. New nurse led model of care contributing to reduction in readmissions 10% reduction in bed days used for epilepsy in-patient admission with a 0.5 reduction in average Length of Stay Awarded an international Nursing award for its description of the new National Epilepsy Service of Ireland. (The 'Limelight' award is part of the international care challenge series by Sanofi which allows nurses from around the world showcase nursing innovations) U Tube clip Example Programme benefits delivered COPD Average length of stay down from 8.7 to 7.9 days, more than 18,000 fewer bed days used for COPD patients Asthma An adult education programme in primary and secondary care supported by an online e-learning programme is now in place. The programme contributes to the work underway to reduce asthma deaths by 90% in ten years and Emergency Department visits by 10% (2,000) over three years. Diabetes National Foot-care and retinopathy screening service being rolled out New integrated care model between primary and secondary care to be rolled out in 2013 Example Programme benefits delivered Obstetrics and Gynaecology Twenty National Clinical Guidelines were published. 650,000 saved through national procurement of machines No new cases of early pregnancy misdiagnosis Palliative care New national competency model being developed for all palliative care roles The development of a rapid discharge pathway for patients who wish to die at home underway Developing a competency framework to support managers, teams and individuals to identify appropriate palliative care Dermatology and Rheumatology 30% more patients being seen Orthopaedics Piloting resource allocation /prospective funding successfully Example Programme benefits delivered Older Persons Model of care defined and launched The components for a Specialist Geriatric Service (SGS) include; The establishment of dedicated specialist geriatric team Dedicated in-patient specialist geriatric wards Dedicated in-patient rehabilitation Dedicated off site rehabilitation Community outreach to nursing homes Ambulatory day hospital Access to long term residential care Access to home supports ED/AMU Specialist Ward 18days 18 days Rehab Ward 42 days 42 Days Discharge Clearly requires the MDT team Comprising among others CNS Physiotherapist Occupational Therapist SALT Dietician Social Worker Geriatrician Dedicated Discharge Planner Nominated Case Worker in PCT Business Manager Admin support Follow up 7

Local Irish Evidence Length of stay, discharged home, re-attendance and readmission Programme for Older People Organisational Chart 2013 RCPI HSE DG & Directorate Benefits for the Older Person More likely to get out of hospital quickly ISPGM ( Institute affiliated to the RCPI) Advisory Group Chair Clinical Strategy & Programmes Quality & Patient Safety Less likely to decline functionally when in the hospital Clinical Advisory Group National Clinical Lead Programme for Older People National Programme Manager More likely to go home Less likely to go into a nursing home No more likely to be readmitted to hospital Networks will consist of the following representatives: Clinical Lead Nursing Lead H&SCP Lead Primary Care Lead Older Persons Specialist Public Health Lead Patient representative Hospital Management Community Management National Working Group Regional Network for Older People Local Implementation Teams Sub Groups Productive Series Medications Management Changing prescribing patterns Use of Preferred Drugs Identified Lansoprazole for Proton Pump Inhibitors (PPIs) and Simvastatin for statin medications Other drug groups will have preferred drugs announced shortly, such as Angiotensin Converting Enzyme (ACE) inhibitors and Angiotensin II Receptor Blockers (ARBs). Savings of 20m to be achieved in Year 2013 Visit: http://www.hse.ie/yourmedicines Productive Ward Releasing Time to Care Front Line staff redesigning and streamlining the way staff deliver care. 35 wards involved Reduced falls, stock savings and reduced unplanned absences with one hospital reporting uncertified sick leave rates from an average of 30 shifts per month to single figures over a 9 month period. This improvement in unplanned absenteeism alone has the potential to save 147.67 (mid-point of staff nurse/midwife scale) per 8-hours shift, equating to approximately 3k per month or approx 36k per year from one ward alone 8

Example Programme benefits delivered Productive Series Productive Theatre TPOT Activated in 19 sites Increased utilisation of available theatre capacity, Increased utilisation of available ward capacity, Increase bed stock capacity through AVLos implementation, Increased number of theatre lists starting on time, Reduced overruns within theatres complex, Decrease in inventory costs. These modules create TPOT Intangible Programme benefits delivered Clinical leadership Fostering clinical leadership provides direction to inform key national strategies e.g. smaller hospitals policy, new hospital network design Help to address patient and media concerns arising from serious incidents e.g. misdiagnosis of in early pregnancy, review of diagnostic procedures, hip replacement issues Improved partnership approach in health care management - collaborative rather than confrontational Role model for future clinical leaders Challenges Productivity additional working hours Cost extraction - 1billion from Pay & Pensions Bill by 2015 Reform workforce restructuring, redeployment, headcount reduction Breaks down clinical silos Reform Establishment of Hospital Groups Implementation of Smaller Hospitals Framework Reorganisation of Integrated Service Areas In summary - inputs 10 Programmes have a Service Planner (SP) on their national working groups. 15 Programmes have other 'ONMSD' nurses & midwives on working groups e.g. AMP, EMP, Pall Care, Med Mgt, O&G NEWS lead (Eilish) and Productive Ward lead (Mark). 25 Programmes have Lead Clinical Nurses/Midwives (n=34hc), resourced from the services and nominated by DONMs on their working groups - exception HCAI Nr is NMPD staff. 9 Programmes have a nursing interest group and others use existing professional groups and associations. 7 Programmes have a PDC for Practice Nursing (n = 5hc) There is one NCP Liaison and one DONM Reference Group (NCP) and other ONMSD/NMPD/CNME Staff on NCP (NCP related) Projects e.g. Clinical Governance Development (Maureen Flynn) & Research Support (Sarah Condell), Education groups (CNME staff) and other Steering and Advisory Groups (ONMSD & DONMs). 9

In Summary Its all about teamwork and integration to improve patient care, choice and ways of working Thank you Contact me: Joan Gallagher JoanE.Gallagher@hse.ie 01 6352313 Nursing & Midwifery Outputs 1. National Early Warning Score system is being implemented 2. Productive Series - Productive Ward & the Productive Operating Theatre (tpot) 3. Continuing Education Programmes for Nurses Stroke, Diabetes (foot care) and Asthma. Others being developed; also links to formal 3 rd level education programmes 4. Workforce Planning documents (surveys chapters) in Models of Care (service planners with national working group) 5. Lead Clinical N&M input to working groups - advising on design and implementation of the models of care taking a lead on certain work-streams e.g. EMP or ensuring role clarity or promoting expanded roles.. 6. Other: Self Care/Management Framework. Supporting SDU work e.g. Discharge/ bed management Collaborative Nursing & Midwifery Expanded Practice & Extended Skills Sets Role expansion involves becoming more competent, reflective, autonomous practitioners and developing expertise and skills to meet patients / clients nursing needs An Bord Altranais, 1999 N&M prescribing Medicinal products & Ionising radiation (X-Ray) IV cannulation The Bord Altranais agus Cnáimhseachais na héireann (Nursing & Midwifery Board of Ireland) Nurse facilitated & nurse led discharge 10