Surgical equipment slide Green Ward slide Think of secondary drivers To do: Email Camilla SD paper. Surgical equipment slide Green Ward slide Think of secondary drivers References Websites: add wfot website and un websites for sd goals Joel Pett/Lexington Herald-Leader. Reprinted with permission.

Quality improvement: creatively designing sustainable services Sustainability in Quality Improvement (SusQI) training materials, developed by the Centre for Sustainable Healthcare with grant funding from North Bristol NHS Trust. Quality improvement: creatively designing sustainable services I am me Camilla is…. Improving quality outcomes for service users is a core focus for a modernised NHS. It has been argued that only by adopting quality improvement as a principal strategy in a sustained and comprehensive way can the NHS meet England’s health care requirements (King’s Fund, 2016). In this workshop we’ll be looking at how front-line clinicians can get involved with quality improvement in a meaningful and manageable way. From Frances: “Sustainability can be considered a domain of quality in healthcare, extending the responsibility of health services to patients not just of today but of the future. The longer term perspective highlights the impacts of our healthcare system on our environment and communities and in turn back onto population health. A sustainable approach will therefore expand the healthcare definition of value to measure patient outcomes against environmental and social impacts alongside financial costs.” RCOT Annual Conference 08.06.2017 Ben Whittaker (Occupational Therapy Programme Lead, CSH) Camilla Cox (Occupational Therapist, Eating Disorders Service, BEHMHT)

Aims Recognise sustainability as a domain of quality in healthcare and discuss its relationship to other domains. Review the environmental, social and economic inputs to a given health system, and identify relevant carbon hotspots. Apply the principles of sustainable clinical practice in the design of a QI intervention. Consider ways of evaluating environmental, social and economic impacts. Camilla

What is quality improvement? “Designing and redesigning work processes and systems that deliver health care with better outcomes and lower cost, wherever this can be achieved.” The Kings Fund (2016) WFOT Quality Indicators project – developing set of indicators for OTs Camilla Quality indicators are a framework by which to design, audit and modify effective health and social care services. WHY? I was struggling with the concept of thinking about services with too much emphasis based on outcomes. The reasons I got interested was because the idea of designing a quality service speaks to me more than the idea of focusing on outcome. Emphasising the outcome has difficutlies because we sometimes don’t know why people won’t get better. Focusing on indicators feels more empowering. HOW? Working with WFOT… Quality assurance suggests service audit Quality outcomes doesn’t work as can have different outcomes if he Quality indicators suggest service design. uses best evidence for best service. Are you the right person to deliver the right service at the right time? Is it an OT that needs to be doing this? There’s quite a lot of shift with moving towards third sector involvement. Is the NHS the right service to deliver things? There’s something about placing services based on outcome as one of our key iindicators, it places a lot of expectiation on the service user, and some conflict because if they don’t get better then we don’t meet that outcome. If someone doesn’t meet this outcome it doesn’t mean it’s not a quality service. There are lots of others. (and sometimes poor quality services motivate people to change). Like the idea that we believe that we’ve designed the best service, and we hope that you will benefit from it. This places responsibility on the service to implemenet and design on the quality framework, We hope that people

Turn to the person next to you and say: Hello Something about how you understand quality improvement and quality indicators are being used within your service or setting. Camilla.

Sustainable healthcare WHAT IS SUSTAINABLE HEALTHCARE? Using resources to deliver healthcare today without compromising the health of current or future generations. Social Sustainable healthcare Environmental Economic Ben WHY? Tell story about working for wellbeing of people on a local level but becoming aware of the wellbeing for people on a global level. WHAT? What WFOT and COTED are doing.

Ben

NHS CARBON FOOTPRINT Ben

Ben

Sustainability as a domain of quality Timely Efficient Safe Effective Patient Centred Equitable Sustainable Camilla The Institute of Medicine identified six domains of healthcare quality, stating that it must be: safe, effective, patient-centred, timely, efficient and equitable. The Royal College of Physicians’ (2011) quality improvement strategy expanded on these to include the seventh domain of sustainability, which refers to a health service’s ability to provide healthcare over time, with acknowledgement of future generations. They recognised that sustainability must both be incorporated into and moderate other healthcare domains. Sustainability can be considered a domain of quality in healthcare, extending the responsibility of health services to patients not just of today but of the future. The longer term perspective highlights the impacts of our healthcare system on our environment and communities and in turn back onto population health. A sustainable approach will therefore expand the healthcare definition of value to measure patient outcomes against environmental and social impacts alongside financial costs. “Policy goal: Placing sustainability at the heart of NHS decision-making” Leading for Quality - the Foundation for Healthcare over the Next Decade. The Royal College of Physicians. (2010) “healthcare should be considered not only in terms of what can be delivered to an individual today, but also to the population in general and the patients of the future.” Atkinson et al (2010) Dr Donal O’Donoghue National Clinical Director for Kidney Care 2007-13 Royal College of Physicians (2011). A strategy for quality: 2011 and beyond.

SUSTAINABLE QUALITY IMPROVEMENT (SusQI) SusQI goal: “Deliver care in a way that maximises positive health outcomes and avoids both financial waste and harmful environmental impacts, while adding social value at every opportunity.” SusQI framework: Setting goals Studying the system Designing the improvement effort Measuring impact/return on investment Ben Saving money, improving lives. Mention here.

Including sustainability within your project aims (how will this affect engagement with colleagues and wider stakeholders?) 1. Setting qi goals

outcomes costs value = economic social environmental Ben Slide from: Mortimer (2013). Increasingly CCGs and NHS England are seeing not only financial costs as a way of calculating value. We as OTs are Value based commissioning.

Understanding social and environmental resource use and impacts 2. STUDYING THE SYSTEM

CARBON HOTSPOTS

CARBON HOTSPOTS Sustainable Development Unit (2012)

SOCIAL IMPACTS… ON WHOM? 👤 Patient 👥 Staff 👥 Carers 👥 Dependants 👥 Local community 👥 Distant communities (e.g. supply chain workers)

Social impacts on distant communities “It would not be ethical to reduce the carbon footprint in this country and push it elsewhere, and consideration is also needed of the labour standards in equipment supply chains” “Labourers in surgical instrument manufacture are often paid less than US$1 per day, have poor job security, have woefully inadequate protection of health and safety, and many employees are children, some as young as seven years old.” Use COT briefing paper quote about. COT (2013)

Canadian Model of Occupational Performance and Engagement (CMOP-E) (Polatajko, Townsend & Craik, 2007)

3. Designing your QI intervention Applying the principles of sustainable clinical practice

How will 80% carbon reduction be achieved?

SUSTAINABLE CLINICAL PRACTICE Secondary drivers Reduce carbon without reducing health Reduce activity Prevention Self care Lean pathways Reduce carbon intensity Low carbon alternatives Sustainable estates Primary driver Outcome needed Primary driver Questions about setting based on the framework… Four groups. Each group takes one pillar of sustainable practice. CENTRE for SUSTAINABLE HEALTHCARE Mortimer-F. The Sustainable Physician Clinical Medicine 2010, Vol 10, No 2: 110–11

SUSTAINABLE CLINICAL PRACTICE Secondary drivers Reduce carbon without reducing health Reduce activity Prevention Self care Lean pathways Reduce carbon intensity Low carbon alternatives Sustainable estates Primary driver Outcome needed Primary driver Questions about setting based on the framework… Four groups. Each group takes one pillar of sustainable practice. CENTRE for SUSTAINABLE HEALTHCARE Mortimer-F. The Sustainable Physician Clinical Medicine 2010, Vol 10, No 2: 110–11

SUSTAINABLE CLINICAL PRACTICE Secondary drivers Reduce carbon without reducing health Reduce activity Prevention Self care Lean pathways Reduce carbon intensity Low carbon alternatives Sustainable estates Primary driver Sustainable clinical practice Outcome needed Primary driver Questions about setting based on the framework… Four groups. Each group takes one pillar of sustainable practice. Infrastructure & process CENTRE for SUSTAINABLE HEALTHCARE Mortimer-F. The Sustainable Physician Clinical Medicine 2010, Vol 10, No 2: 110–11

Outcome Primary Drivers Secondary Drivers Actions Improve sustainability of respiratory inhaler prescribing 1. Prevent avoidable respiratory disease Reduce smoking Review referral rates to smoking cessation service Reduce cold/mould exposure Investigate housing improvement referral scheme Reduce air pollutant exposure Input to local transport policy Ensure patients receive air quality health advice 2. Empower patients to improve disease management Co-production Ensure yearly care planning Rescue packs for acute exacerbations Social prescribing Singing/ pulmonary rehab referral forms 3. Ensure lean prescribing and dispensing systems Lean communications Introduce paperless prescribing/ repeat requests High value prescribing Introduce annual inhaler reviews 4. Switch to lower carbon alternatives Preferential use of DPI vs MDI inhalers Update prescribing guidelines Write article for local GP newsletter 5. Improve operational resource use Inhaler recycling Signpost recycling points Waste, energy, travel Relevant actions Outcome Primary Drivers Secondary Drivers Actions

Green ward competition 2017 University Hospital Southampton Eat, Drink, DRESS, Move Project 4 week period on dementia friendly Medicine for Older Persons (MOP) ward. Each morning, Therapy Assistant encourages patients to get washed and dressed in their own clothes, working alongside the HCAs. Establish a more realistic ”normal daily routine” like patients would have at home and encourage to sit out for meals and activities, interacting with each other, staff and relatives. Intention is to change hospital culture. Outcome: Reduce length of hospital stay Primary Drivers: Prevent health complications related to immobilisation Enable and increase patient engagement through activity Ensure lean prescribing of equipment and interventions Switch to lower carbon alternatives Improve operational resource use

Your service - sustainable clinical practice Principle Opportunities? 1. Prevention 2. Patient empowerment and self care 3. Lean systems 4. Low carbon alternatives

YOUR SERVICE – SUSTAINABLE CLINICAL PRACTICE Resource use Opportunities? Energy Travel (staff, patients) Medical supplies Non-medical supplies Water Waste

4. Measuring environmental and social costs/impacts

Sustainable value in healthcare: Informed by patient values outcomes (goods – harms) value = environmental + social + financial costs (the “triple bottom line”) Academy of Medical Royal Colleges, 2016 (with CSH)

Environmental Costs Carbon footprint - the sum of greenhouse gas emissions released in relation to an organisation, product or service, expressed as carbon dioxide equivalents (CO2e).

Goods and services carbon hotspots, Sustainable Development Unit (2012)

Measuring social impacts? Patients Carers Community Supply chain Staff Housing Poverty Health Education Employment Safety/security Satisfaction Participation Social gradient Include OSA

Sustainable QI Apply sustainability approach at the different stages of ANY project Choose a project area that relates closely to sustainability, e.g. Prevention, patient empowerment, etc. Reducing pharmaceutical waste Reducing over-investigation/ over-treatment

“We need to develop a health and care system that is financially, socially and environmentally sustainable; that does not simply mean that we must make the best use of resources; it also means that we must improve both the quality of life and quality of care, experienced by all users of health and care services.” Stephen Dorrell (SDU 2014) Camilla

REFERENCES Atkinson, S. et al (2010). Defining Quality and Quality Improvement. Clin Med. 10(6), 537-539 COT (2013) Briefing paper on sustainable development. London: COT COT (2017). Saving Money, Improving Lives. Available at: www.cotimprovinglives.com [Accessed: 22.01.2017] Kings Fund (2016). Improving quality in the English NHS. London: Kings Fund. Mortimer F (2010) The sustainable physician. Clinical Medicine, 10(2), 110-111 Mortimer F (2013) Transforming models of care: Sustainable clinical practice. CleanMed Europe, Oxford, 18.09.2013. Available at: http://cleanmedeurope.org/speakers/plenary-speakers-slides Accessed on: 12.03.2014 Mortimer F (2017) Sustainability in Quality Improvement. February 2017 presentation. Mortimer F, Isherwood J, Vaux E, Pearce M, Kenward C & Wilkinson A (in press). Sustainability in Quality Improvement: Redefining Value.

REFERENCES Pett J (2010) “What if it’s a big hoax and we create a better world…?” editorial cartoon. USA Today, 07.12.2009, A.8 Polatajko HJ, Townsend EA & Craik J (2007) Canadian Model of Occupational Performance and Engagement (CMOP-E). In: Townsend EA & Polatajko HJ (2007) Enabling Occupation II: Advancing an Occupational Therapy Vision for Health, Well-being & Justice through Occupation. Ottawa, ON: CAOT ACE Royal College of Physicians (2011). A strategy for quality: 2011 and beyond. London: Royal College of Physicians. Sustainable Development Unit (2012) Goods and Services Carbon Hotspots. Sustainable Development Unit (2014) Sustainable, Resilient, Healthy People & Places: A Sustainable Development Strategy for the NHS, Public Health and Social Care System. Cambridge: SDU. Available at: http://www.sduhealth.org.uk/policy-strategy/engagement-resources.aspx Accessed on: 09.02.2015 UCL Lancet Commission (2009) Managing the health effects of climate change. The Lancet, 373(9676), 1693-1733 WCED (1987) Our Common Future: Brundtland Report. Oxford: Oxford University Press. Available at: worldinbalance.net/pdf/1987-brundtland.pdf Accessed on: 06.12.2009

websites www.carbonaddict.org www.climateandhealth.org www.climateandhealthalliance.org www.theclimateconnection.org www.nhsforest.org www.networks.sustainablehealthcare.org.uk www.sap.sustainablehealthcare.org.uk www.sd-commission.org.uk www.sduhealth.org.uk www.sustainabilityforhealth.org www.un.org/sustainabledevelopment/sustainable-development-goals/ www.wfot.org

ben.whittaker@sustainablehealthcare.org.uk