1. Surgical equipment slide Green Ward slide Think of secondary drivers
To do:
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.

2. 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
Ben Whittaker (Occupational Therapy Programme Lead, CSH)
Camilla Cox (Occupational Therapist, Eating Disorders Service, BEHMHT)

3. 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

4. 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

5. 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.

6. 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.

7. Ben

8. NHS CARBON FOOTPRINT
Ben

10. Ben

11. 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
Royal College of Physicians (2011). A strategy for quality: 2011 and beyond.

12. 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.

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

14. 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.

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

16. CARBON HOTSPOTS

17. CARBON HOTSPOTS
Sustainable
Development Unit (2012)

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

19. 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)

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

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

22. How will 80% carbon reduction be achieved?

23. 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

24. 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

25. 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

26. 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

27. 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

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

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

30. 4. Measuring environmental and social costs/impacts

31. 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)

32. 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).

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

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

35. 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

36. “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

37. REFERENCES
Atkinson, S. et al (2010). Defining Quality and Quality Improvement. Clin Med. 10(6),
COT (2013) Briefing paper on sustainable development. London: COT
COT (2017). Saving Money, Improving Lives. Available at: [Accessed: ]
Kings Fund (2016). Improving quality in the English NHS. London: Kings Fund.
Mortimer F (2010) The sustainable physician. Clinical Medicine, 10(2),
Mortimer F (2013) Transforming models of care: Sustainable clinical practice. CleanMed Europe, Oxford, Available at: Accessed on:
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.

38. REFERENCES
Pett J (2010) “What if it’s a big hoax and we create a better world…?” editorial cartoon. USA Today, , 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: Accessed on:
UCL Lancet Commission (2009) Managing the health effects of climate change. The Lancet, 373(9676),
WCED (1987) Our Common Future: Brundtland Report. Oxford: Oxford University Press. Available at: worldinbalance.net/pdf/1987-brundtland.pdf Accessed on:

39. websites www.carbonaddict.org www.climateandhealth.org