Item 7 Report to board, 26 July 2017 Report title Service Improvement and Sustainability Quarterly Summary Q1 2017/18 Report from John Quinn, Chief Operating Officer Prepared by Komal Whittaker-Axon, Director of Service Transformation Previously discussed at Attachments Paper Brief summary of report This quarterly report provides an update on progress of the service improvement and sustainability programme and provides high-level detail on projects underway. Action Required/Recommendation. Board is asked to note the progress being made across the SIS programme to date. For Assurance For decision For discussion To note
Executive Summary This quarterly report provides assurance that the service improvement and sustainability programme is delivering to plan, and provides high-level detail on projects underway. All aspects of the programme are delivering to plan with the exception of the cost improvement plan (CIP) project, a progress plan to date, along with dates for delivery in 2017/18 is included in the report. CIP achievement in Q1 was 0.956m vs a plan of 1.336m (72%), delivery to date is predominantly on nonincome related CIP s; slippage is largely due to income schemes. Full year forecast is to deliver the target of 8.2m, of which 6.14m has been identified to date. Outpatient transformation project has completed Value Stream Maps for over 30 new patients attending glaucoma clinics at City Road. Data on actual journey times of these patients showed a variation between 1hr 27mins to 4hrs 24mins. Nine specific contributions to delays in these patients pathways have been identified to be resolved. To improve patient experience through clinics, 253/350 patient experience questionnaires were completed in June 2017. These are currently undergoing analysis to determine interventions put into place to enable improvement of the glaucoma patient experience at City Road. The three month pilot of the patient self check-in kiosk was completed in June, the kiosks improved the waiting time to check in, therefore reducing the queues, however it did not improve the patients waiting time in clinic. A full options appraisal is being presented to SIS board at the end of July 2017. 2
Introduction The service improvement & sustainability (SIS) programme focuses on making Moorfields fit for today and fit for tomorrow moving toward Oriel, with the key objectives of the programme being: Optimise patient experience Minimise patient waiting times Deliver financial efficiencies Through: Standardising processes and systems, reducing variation Embedding changes in day to day operations Creating a culture dedicated to continuous improvement The SIS programme currently contains five distinct projects: 1. Cost Improvement plan - Deliver support, guidance and a level of challenge, for each financial year acknowledging that delivery will become more challenging over time. Providing Programme management office (PMO) support for identification and delivery of organisational wide cost improvements. 2. Outpatient Transformation - To review and streamline all outpatients pathways across the Trust in order to embed and sustain best practice. Commencing with Glaucoma, Medical Retina and External Disease in 2017/18 and rolling out to other services in from 2018 onwards. 3. Clinical administration improvement To modernise our existing administration systems to support and enable change within other service improvement programmes. Develop administrative operational delivery/practice models for all services including outpatient booking/call centre centralisation, administrative role development and electronic referral compliance. 4. Theatre Improvement To streamline all surgical patient pathways to maximise theatre utilisation, through process and workforce redesign and development. Enable maximum utilisation of new builds/ refurbished theatres through introducing best practice. To develop new ways of working / skills mix to support theatre improvement and staff engagement and ultimately keep and attract top talent. 5. Urgent Care Transformation To streamline patients through the urgent care pathways. Reviewing demand to enable patients to be treated in appropriate services, and exploring/realising opportunities with the primary and secondary care interface. The programme is being delivered using a formal credible change methodology Lean Management/Six Sigma. This methodology is used to identify and eliminate waste in the system. Continuous improvement capacity and capability A key function of the SIS programme is to ensure that the organisation has the skills and capacity to become a continuously improving organisation. This will support the ongoing improvement of the organisation up to and beyond Oriel as well as providing a key element to the Trust achieving outstanding status for the CQC. 3
The SIS programme is adopting the Capability Maturity Model Integration (CMMI), to enable measurement of the maturity levels of the individual elements of the programme. This well-established model is used to guide process improvement across a project, division, or an entire organisation. SIS programme is currently in its infancy and therefore at level 1 in it maturity phase (against a five step model) and with an overall aim of achieving the top level by year 5 of the programme. Programme overview The programme is being delivered using Lean management/six Sigma methodology, as described below. Programme Plan The programme is delivering to plan with the exception of the cost improvement plan (CIP) project. The table below shows a high level progress plan to date (for live projects), along with dates for delivery from 2017-2020. Improvement stage Project Workstreams Defined Measure Analyse Improve Control Benefits/KPI Project on time CIP N/A y y y y 8.2mil savings for 2017/18 N Outpatients Glaucoma Q3 17/18 Q4 17/18 Q3 17/18 5% 30min improvement in Glaucoma journey times at City Road 30 60% improvement in patient experience in Glaucoma at City Road 10% improvement in journey Medical Retina Q4 17/18 Q1 18/19 Q4 18/19 times 10% improvement in journey External Disesaes Q3 17/18 Q1 18/19 Q2 18/19 Q1 19/20 times Kiosk Q2 17/18 Q4 17/18 Improved patient flow 100% Electronic GP referrals Clinical Adminstration Directory of Services Q2/3 17/18 Q4 17/18 by 01/04/2018 E-referral Q2/3 17/18 Q4 17/18 Improved Efficiency above Theatres Start times/efficiency Q2/3 17/18 Q2/3 17/18 Q4 17/18 85% utilisation 95% patients been treated Urgent Care ECDS/workforce Q2 17/18 Q3 17/18 Q4 17/18 within four-hour of arrival in 4
All service improvement work streams are currently in between the define and analyse phases of the lean process cycle, where baseline data is being collated, and analysed in conjunction with patient value stream mapping to give a current state. Q1 2017/18 Project updates 1. Cost Improvement Plan The graph above shows an upward trajectory on CIP delivery. Summary of Performance: CIP achievement in Q1 was 0.956m vs a plan of 1.336m (72%). The shortfall against target is 0.380m. Delivery to date is predominantly on non-income related CIP s; slippage is largely due to income schemes. Full year forecast is to deliver the target of 8.2m, of which 6.14m has been identified to date. The divisions/corporate departments along with SIS team are continuing to identify further schemes to bridge the gap that currently exists within the CIP program. The table below show delivery by division and corporate areas in month 3 2017/18. Division / Corporate Department Full ear Target ( '000) Value of Schemes Identified ( '000) TD Target (original phased budget) ( '000) TD Amount Achieved ( '000) TD Variance ( '000) Full ear Forecast Amount ( '000) Forecast % Achievement of Target TD Amount Achieved as % of Full ear Target Moorfields North 1,129 629 146 60 (86) 1,129 100% 5% Moorfields South 915 487 95 73 (22) 915 100% 8% City Road 4,033 3,602 779 575 (204) 4,033 100% 14% Access 435 153 7 7 0 435 100% 2% Corporate 1,688 1,271 310 241 (68) 1,688 100% 14% Total 8,200 6,142 1,336 956 (380) 8,200 100% 12% Fortnightly meetings for each division have been initiated to ensure deliverability against identified schemes and to continue to identify new schemes. Run-rate reduction schemes have also been identified and are delivering, which will improve the Trusts financial bottom line. Although these are not strictly cost improvement plans and do not count in the above figures they do improve the financial health of the Trust. 5
GNP April-June 17 2. Outpatient Transformation To review and streamline all outpatients pathways across the Trust in order to embed and sustain best practice. Commencing with Glaucoma, Medical Retina and External Disease in 2017/18 and rolling out to other services in from 2018 onwards. The outpatient programme is currently in the first two phases of the service improvement cycle (define and measure). The overarching key performance indicator set to measure success is: A reduction in the average Clinic Journey Times of 10% for new and f/up appointments by 31/03/2018 Glaucoma Measurement stage The key performance indicators set to measure success are: Reductions in Clinic Journey Times: Reduce transition times in Glaucoma patient pathways at City Road by a minimum of 5% of the baseline data by 30/09/2017 Reduce transition times in Glaucoma patient pathways at City Road by an average of 30 mins against the baseline by 31/03/2018 Patient Experience A 30% improvement in patient experience related to waiting times and information given in the City Road Glaucoma clinics by 30/09/2017 A 60% improvement in patient experience related to waiting times and information given in the City Road Glaucoma clinics by 31/03/2018 Value Stream Mapping (VSM) a lean management tool used to analyse the current state and to design a future state. It helps to identify steps in a process that add value (value added steps) to the patient and those that do not add value (non-value added/waste). VSM for new patients at City Road has been completed, with 30 patients being followed through their new appointments (all different clinics) over a month period. The map shows a variation in journey time of patients between 87mins and 264 mins, see VSM below: Glaucoma New Patient Pathway Value Stream Mapping Current state Value added steps (direct patient care) range:34-161mins (average 99mins) Non value added steps (waits) range: 25-129mins (average 68mins) Current patient journey time range: 87-264mins (average 166mins) Clinic Reception Desk Visual Field/GIS Glaucoma Imaging Service Visual Field/GIS Glaucoma Imaging Service Nurse/HCA Consultant PAS Patient arrives and checks in 1 2 3 0-47mins 2-20 mins OCT 5-35 mins 4 7 0-61mins 5-35 mins Visual Fields 2-20 mins 2-50 mins 5 6 Nurse Dilating 9-60 mins 4-36 mins Doctor 5-46 mins 8 Visual Fields OCT 2-53mins Dr and Dilate Dilating PAS 9 Patient Checked out 0-68mins Current journey times based on the VSM show a range between 87-264mins (1hr 27min 4hr 24mins). 6
GNP April 17 - Ideal Amount of time spent on patient value added steps (those spent undergoing diagnostics/in clinical consultation) ranged between 34mins and 161mins (34mins 2hrs 41mins) for those patient that were dilated. This range was influenced by whether the patient required dilation or not, and the complexity of the patients conditions. Non-value added (those spent waiting) ranged between 25-129mins (25mins 2hr 9mins). This was predominantly as a result in waiting for diagnostics. Nine specific contributions to delays (in VA and NVA steps) were identified: 1. Patient check-in 2. Clinic Profiles 3. Visual Fields capacity 4. OCT capacity 5. Nursing skill utilisation 6. Overall flow between processes in the clinic 7. Patient history taking and medical history taking 8. Medical Consultation Multidisciplinary skill utilisation 9. Clinic outcome completion In March 2017 the Glaucoma Service stratified the current Glaucoma pathways into five pathways of which one was the New Patient pathway. Glaucoma New Patient Pathway Value Stream Mapping Ideal Pathway Value added steps (direct patient care) range:60-100mins Non value added steps (waits) range: 8-15mins Ideal patient journey time range: 68-115mins Clinic Reception Desk Visual Fields GIS Glaucoma Imaging Service Nurse/HCA Consultant 7 5 6 15 min 5 min 30 mins 1 2 3 4 30 mins 20 mins Kiosk Patient arrives and checks in Visual Fields OCT Clinic Nurse VA, History, Pachymetry Dilating Doctor 8 9 Patient Checked out PAS 1min 3mins 3 mins The new pathway above will be piloted for 3 months starting in September 2017, a report on outcome of the new pathway will be presented in the Q3 SIS board report. To support the five stratified patient pathways a workforce model looking at developing Nursing and Optometrist roles has commenced. Delivery of the new workforce model will enable the pathways to be implemented across the organisation, support staff development and reduce patient journey times In June 2017 over 253/350 patient experience questionnaires were completed. These are currently undergoing analysis to determine actions to be put into place to enable improvement of the glaucoma patient experience at City Road. Outcome of these interventions will be measured in the month of September 2017. Medical Retina - Uveitis Measurement stage Results of pilot data of A&E uveitis patients presented to the steering group. Further analysis of data in progress. Principles of new workforce needs agreement with DoN and Clinical Lead. Initial feasibility (financial and safety) of new pathway being carried out. 7
External diseases Define stage Stratification of patient pathways audit completed and analysed, findings to be presented at the next external diseases service group to determine the next steps. Clinical Administration Analysis stage Five enabling projects have been undertaken or identified to modernise existing administration systems. This will directly improve these services for patients and staff as well and enabling change within other service improvement programmes. Develop administrative operational delivery/practice models for all services including outpatient booking/call centre centralisation, administrative role development and electronic referral compliance. Kiosk pilot - Analysis stage City Road Glaucoma clinics have piloted the usage of patient check in kiosks for 3 months to improve patient flow at check-in. The three month pilot of Patient self-check Kiosks has been completed, with the following results: The kiosk improved the waiting time to check in, therefore reducing the queues, however it did not improve the patients waiting time in clinic. 1387 glaucoma patients (15.7%) in clinics 2 and 3 at City Road used the kiosk Patient feedback questionnaires were completed by 243 patients o 62% of patient completing questionnaires used the kiosk o 94% of these patients found it useful and would use it again. o 44% said staff directed them to the kiosk o 19% we curious, intrigued or used kiosks before in other hospitals or at their GP. Patients that did not use the kiosk: o 65% said they did not notice it. o 1% said they were visually impaired and not able to use it. o 20% said they preferred to speak to the clerical officer. The data collected from patients relating to contact telephone number and email address showed an improvement in demographic data capture, 74 patients (5%) highlighted stated that there was an error 8
with their demographic data. Correct patient demographic will reduce did not attend and outpatient cancellation rates. Staff were provided with access to the Enlighten system. This enabled them to see when patients checked in. This also alerted them to patients that also had a visual fields appointment, transport patient, interpreter required, post op and new patients. An options appraisal for the kiosk will be presented to the SIS board at the end of July, followed by a business case to support the preferred agreed option. Directory of Services (DoS) - Analysis stage The DoS is a comprehensive list of all services MEH deliver that can be accessed by primary care. The DoS is undergoing a refresh to match demand of users with capacity needed, to enable timely access to our services. This is required to be undertaken as this supports the booking function of the Trust hence is a key enabler to reduce overbooking of clinics as well as patients being booked into the wrong service and therefore being cancelled and rebooked. Clinics that were identified as inactive have now been disabled, preventing patients being booked in ghost clinics. Clinical terms have been reviewed within the DoS. This consists of a review of 50 documents for each service. Updating this is essential to enable primary care GP s and optometrists to choose the clinically appropriate service to refer into. This will reduce the number of e-referrals being booked into the wrong clinics; reduce Referral to treatment times and ensuring patients at seen and treated appropriately. A review of the DoS with local GP s has been carried out to understand DoS requirements from primary care perspective, and is currently being implemented. E-Referral Analysis stage KPIs: GP electronic referrals 80% by Q2, 90% by Q3 and 100% by Q4 2017/18 E-Referral project is now established for Paper switch off and preparation for October 2018. Action plan has been submitted to NHS digital as part of CQUIN requirements. Glaucoma visual fields linkage - linked to outpatient project Scoping of changes required for Visual Fields and dependencies for Glaucoma and all other services is underway. A plan has been put together for visual fields patients to be managed in a slightly different way. Some patients will be taken to GIS prior to having fields tests to reduce the bottle neck for OCT machines. e-scrutiny All services are now on WinDip for referral scrutiny purposes. Next stage is to develop internal referral process within emr. 3. Theatre Efficiency Define stage moving to measurement 9
To streamline all elective patient pathways to maximise theatre utilisation, through process and workforce redesign and development. Enable maximum utilisation of new builds/ refurbished theatres through introducing best practice. Initial patient flow and floor mapping of the 5 sites has shown variation in process, layout, and patient flow. Data from PAS, OE and Galaxy have been pooled to enable baseline data to be established Pilots to improve session start times has commenced at City Road, these include staggering patient arrival times thereby starting theatre on time, reducing patient journey times, and supporting the operational teams in driving the identification and delivery of the Golden patient. Start times target in theatres has been delivered at City Road in June 2016 4. Urgent Care - Measurement stage To streamline patients through the urgent care pathways. Reviewing demand to enable patients to be treated in appropriate services, and exploring/realising opportunities with the primary and secondary care interface. KPI: 95% patients been treated within four-hour of arrival in A&E Value stream mapping has been completed for adult and children attending A&E. Analysis of patient journey times from arrival to discharge has been completed, included additional manual audits to enable robust measurement of key stages in the patient s journey, identifying times of value added and non-value added steps in the patient journey. These are being presented at the Urgent Care programme board. Baseline data for evaluation of workforce requirements to deliver as sustainable service model has commenced. Project management support for the Trust-wide deployment of the new Emergency Care Data Set (ECDS) in October 2017. This supports the delivery of the ECDS CQUIN. Next Steps Report on progress of the commitment to reduce glaucoma travelling times by 5%. A full report of the outcomes of the baseline patient experience questionnaires carried in June 2017, for Glaucoma patients at City Road will be presented along with interventions put in place to improve patient experience. An update on the development of the new workforce model to enable the five new stratified pathways will to be implemented across the organisation will be given in the next board update along with the predicted impact on the reduction in patient journey times The agreed option and roll-out plan for the patient check in kiosks at City Road and potential Trustwide Progress on delivery of the e-referral CQUIN at Q2 towards Q4. Outcome of theatre pilot to improve session start times at City Road and identification and delivery of the Golden patient. Update on the Trust-wide deployment of the new Emergency Care Data Set (ECDS) ready for October 2017. With the launch of the Trust strategy the SIS programme is realigning its overarching objectives and projects to delivering the strategy between now and the next 5 years. 10