1. From Zero to FLS: Implementation & Beyond National Osteoporosis Society FLS Education Programme October 2010

2. Previous fracture Non-vertebral & Vertebral Size Matters! Determinants of the scale of your service The FLS’ target population -which fracture groups? -what age group? New Fracture Non-vertebral & Vertebral

3. Previous fracture Non-vertebral & Vertebral New Fracture Non-vertebral & Vertebral Size Matters! Determinants of the scale of your service ~650 new non-vertebral fractures & ~120 new vertebral fractures age 50+ per 100K, per year ~70 previous non-vertebral & Vertebral fractures age 50+ per 100K, per year

4. NEW FRACTURE PRESENTING TO A&E / ORTHO / TRAUMA EDUCATION PROGRAMME EXERCISE CLASSES FALLS RISK ASSESSMENT NEW RADIOLOGY REPORT OF FRACTURE PRESCRIPTION ISSUED BY GP Rx FOR FRACTURE 2 Y PREVENTION McLellan et al. Osteporos Int 2003;14:1028–1034 PREVIOUS FRACTURE

5. Project Management From Zero to FLS: Implementation & Beyond

6. The first steps Appointment of project management team & Chair

7. Membership of FLS implementation project team NumberPost x2Local champion / lead clinician x1Chair GG&CHB Osteoporosis Subgroup (clinician) x3-4Other HB lead clinician & secondary care clinicians from involved sites x1-3CHP GP lead x2Osteoporosis Nurse Specialists x1General Manager – Medical Services x1GG&C osteoporosis exercise service lead physio x1Superintendent Radiographer x1Assistant General Manager, Radiology x1Consultant radiologist (DXA) – local imaging lead x1Estates manager x1NOS patient representative

8. From Zero to FLS: Implementation & Beyond The first steps Appointment of project management team & Chair Redefine & agree with providers of funding remit of group & scope of service

9. 1.To roll out an FLS, to provide systematic post-fracture assessment to all men & women age 50+ with new fracture presentations or with new report of vertebral fracture or with previous fracture age 50+ 2.To ensure equitable access of all relevant patients in the region 3.To implement these services within the constraints of the proposed funding 4.Case-finding for new fracture presentations & for new reports of vertebral fracture – by the FLS ONS Remit of group & scope of planned service

10. 5.Case-finding for previous fractures – by primary care 6.Post-fracture, risk assessment based on one-stop consultation with FLS-ONS incorporating DXA, where appropriate 7.All episodes of FLS-patient care recorded in database 8.To provide this for population of x over y sites and covering fracture patients from z hospitals Remit of group & scope of planned service

11. From Zero to FLS: Implementation & Beyond The first steps Appointment of project management team & Chair Redefine & agree with providers of funding remit of group & scope of service Work breakdown

12. Project Management DXA PersonnelLogistics Work Breakdown From Zero to FLS: Implementation & Beyond

13. Project Management DXA PersonnelLogistics Work Breakdown From Zero to FLS: Implementation & Beyond

14. The first steps Appointment of project management team & chair Redefine & agree with providers of funding remit of group & scope of service Work breakdown Schedule work & establish timeline for delivery of service

16. Project Management DXA PersonnelLogistics Work Breakdown From Zero to FLS: Implementation & Beyond

17. What do you need to provide a DXA for a FLS service ? Space for DXA (may require building works!) DXA scanner/s –DXA (VFA) site visit to inform choice –DXA procurement Radiographer/s ONS clinic space - near DXA Database - reporting system Patient transport issues

18. Project Management DXA PersonnelLogistics Work Breakdown From Zero to FLS: Implementation & Beyond

19. Personnel Overview –Banding & Grades of Staff –Job descriptions –Appointments processes - job descriptions - adverts – interviews –Consultant Sessions How are Consultant sessions best deployed? Osteoporosis Nurse Specialist/s –Band 6/7 Osteoporosis Nurse Specialist –ONS line management –ONS where & how will they work?

20. Personnel Administration & Clerical Staff –Band 3 A&C Physiotherapist/s for exercise services –Band 6 Physiotherapist Radiographer/s –Band 6 Radiographers

21. Project Management DXA PersonnelLogistics Work Breakdown From Zero to FLS: Implementation & Beyond

22. Logistics Pathways of care –New fracture presentations in which hospitals & FLS in which centres –New reports of vertebral fractures in which hospitals & FLS in which centres –Past fractures from across region referred to which centres Protocol development Access to Mineral Metabolism clinic for those who don’t fit with management protocols Liaison re exercise classes Liaison with falls service

23. Logistics Communication within secondary care & with GPs Standardisation of forms Website development to facilitate communication Patient education materials Patient education classes ? Nurse telephone follow up (? Telephone BPR tariff) Training & induction Launch meeting

24. What do you need to provide exercise classes? Access to health service physio gym –Identify exercise class locations Access to leisure centre gyms –Identify exercise class locations Patient transport issues

25. If at first you don’t succeed…

26. If at first you don’t succeed… you’ve failed!

27. Pathway to success… & it will be incremental!

28. Do StudyAct Plan What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make to effect improvement? Pathway to success… & it will be incremental!

29. Cycle 1 Objective 1Case-finding all new fx F&M age 50+ by GP Objective 2Fracture risk assessment by ONS at one-stop clinic with DXA Outcomes audit Only 5% wrist fx & 11% hip fx identified / referred for assessment Essential change Case-finding must be by ONS in secondary care PDSA & the Evolution of the Glasgow FLS for new fractures

30. Cycle 1Cycle 2 Objective 1Case-finding all new fx F&M age 50+ by GP Case-finding all new fx F&M age 50+ by ONS in secondary care Objective 2Fracture risk assessment by ONS at one-stop clinic with DXA Outcomes audit Only 5% wrist fx & 11% hip fx identified / referred for assessment ~all fx patients identified & assessed – but only 4% of fx were vertebral Essential change Case-finding must be by ONS in secondary care Need for new approach to identify vertebral fx PDSA & the Evolution of the Glasgow FLS for new fractures

31. Cycle 1Cycle 2Cycle 3 Objective 1Case-finding all new fx F&M age 50+ by GP Case-finding all new fx F&M age 50+ by ONS in secondary care & all new radiology reports of vertebral fx Objective 2Fracture risk assessment by ONS at one-stop clinic with DXA Outcomes audit Only 5% wrist fx & 11% hip fx identified / referred for assessment ~all fx patients identified & assessed – but only 4% of fx were vertebral ~all fx patients identified & assessed – now 12% of fx are new vertebral fx Essential change Case-finding must be by ONS in secondary care Need for new approach to identify vertebral fx PDSA & the Evolution of the Glasgow FLS for new fractures

32. ‘The only place success comes before work is in a dictionary!’