1. Enhanced Recovery Getting Started

2.  Introductions  Housekeeping  Objectives for the session

3. This Session Practical activities to get you started Based on the Implementation Guide Access to advice, guidance and support Discuss the key elements of your local implementation plan

4. Overview This Session:  Principles, elements and benefits of ERP  Drivers for Implementation  Current and future pathway  Action Planning:  Stakeholder Analysis  Testing changes for improvement  Measuring Outcomes

5. Principles, elements and benefits of Enhanced Recovery

6. What is it?  Enhanced Recovery is a new way of improving the experience and well-being of patients who need major surgery  It helps people to recover sooner so that life can return to normal as quickly as possible  It gives people a better overall experience due to higher quality care and services  It lets people choose what’s best for them throughout the course of their treatment with help from their GP and the wider healthcare team (“No decision about me without me.”)  Many people who have experienced Enhanced Recovery say that it makes a hospital stay much less stressful Your Better Sooner!!!

7. The Principles of ER  Getting the patient in to the best possible condition for surgery  Ensuring the patient has the best possible management during their operation  Ensuring the patient has the best post- operative rehabilitation

8. Kehlets theory – 1980s

9. 9 Referral from Primary Care Pre- Operative Admission Intra- Operative Post- Operative Follow Up Optimised health / medical condition Informed decision making Pre operative health & risk assessment - CPEX PT information and expectation managed DX planning (EDD) Minimally invasive surgery Use of transverse incisions No NG tube (bowel surgery) Use of LA with sedation Epidural management (inc thoracic) Optimised fluid management Planned mobilisation Rapid hydration & nourishment Appropriate IV therapy No wound drains No NG (bowel surgery) Catheters removed early Regular oral analgesia Paracetamol and NSAIDS Avoidance of opiate- based analgesia where possible or administered topically Optimised Fluid Hydration Reduced starvation No / reduced bowel preparation ( bowel surgery) DX on planned day Therapy support (stoma, physio) 24hr telephone follow up Optimising pre operative haemoglobin levels Managing pre existing co morbidities e.g. diabetes Audit & outcome measures Example of ER elements

10. Physical impact

11. Clinical evidence compelling!

12. Colorectal Surgery: Length of stay Large Intestine: Major Procedures

13. Benefits being realised...

14. Multi-Disciplinary Teams?  It give patients a better overall experience through higher quality care and services  It introduces innovative best practices that empower and motivate staff  It accelerates the clinical decision-making process by empowering MDTs  It doesn’t increase MDT workload  It ensures the most-efficient use of healthcare resources  Best-practice is day surgery or an Enhanced Recovery pathway

15. What does it mean for providers?  It improves patient safety and involvement and meets Care Quality Commission requirements  It reduces demand on resources such as critical care, surgical beds and patient uptake of procedures  It increases job satisfaction of Multi-disciplinary Teams through better ways of working and improved patient outcomes  It improves the reputation of the healthcare provider  Best-practice is day surgery or an Enhanced Recovery pathway

16. Process & capacity impact

17. Commissioners?  It enhances the reputation of the healthcare provider  It helps patients recover sooner from surgery  Best-practice is day surgery or an Enhanced Recovery pathway  It improves patient experiences through increased partnership and empowerment (“No decision about me without me.”)  It motivates medical teams through best practice, empowerment and innovation  It reduces demand on resources such as critical care, surgical beds and patient uptake of procedures

18. Trusts with varying experience of enhanced recovery pathways North East Gateshead NHS Foundation Trust (M) Newcastle Hospitals NHS Trust (C) City Hospitals Sunderland NHS Foundation Trust (U) Northumbira NHS Trust (MSK) South Tees Hospitals NHS Foundation Trust (C,G,U) North West Aintree University Hospitals NHS Foundation Trust (M) East Lancashire Hospitals NHS Trust (C) Hope Hospital, Salford (C) Wirral University Teaching Hospital NHS Foundation Trust (C)(M) Aintree University Hospitals NHS Foundation Trust (C,M,UPGI,Li) Yorkshire & The Humber Sheffield Teaching Hospitals NHS Foundation Trust (G) York Hospitals NHS Foundation Trust (C) Scarborough Healthcare NHS Trust (C) Leeds Teaching Hospitals NHS Trust (C,G) Calderdale and Huddersfield NHS Foundation Trust (C,G) West Midlands City Hospital NHS Trust, Birmingham (C) Good Hope Hospital (C) University Hospitals Birmingham NHS Foundation Trust (C) Birmingham Heartlands NHS Trust (C)University Hospital of North Staffordshire NHS Trust (C,U,G) Robert Jones & Agnes Hunt NHS Trust East Midlands Derby Hospitals NHS Foundation Trust (G) Queen’s Medical Centre (C) Sherwood Forest Hospitals NHS Foundation Trust (C) (G) The University Hospitals of Leicester NHS Trust (C,M,G,U) East of England Colchester Hospital University NHS Foundation Trust (C) West Suffolk Hospital NHS Trust (M) Cambridge University Hospitals NHS Foundation Trust (Addenbrookes Hospital)(G) West Hertfordshire Hospitals NHS Trust (C,M,G,U) South East Coast Brighton and Sussex University Hospital NHS Trust (C) Darent Valley Hospital (Dartford and Gravesham NHS Trust) (M) Royal Surrey County Hospital NHS Trust (C) Worthing Hospital (C) East Kent Hospitals University NHS Foundation Trust (Queen Elizabeth, the Queen Mother Hospitals)(G) Medway NHS Foundation Trust(C) Medway NHS Foundation Trust (C,M,G,U) Brighton and Sussex University Hospitals (C,M,G,U) London Barnet & Chase Farm Hospitals NHS Trust (C) Guy’s & St Thomas’ NHS Foundation Trust (C) Hillingdon Hospital NHS Trust (M) Imperial College Healthcare NHS Trust (C) South West London Elective Orthopaedic Centre (M) St George’s Healthcare NHS Trust (C)(U) St Mark’s Hospital (North West London Hospitals NHS Trust) (C) The Whittington NHS Trust (C) (M) UCLH NHS Foundation Trust (C) Whipps Cross University Hospital NHS Trust (C) The Hillingdon Hospital NHS Trust (C,G) North Middlesex University Hospital NHS Trust (C,M,G) South West North Devon Healthcare NHS Trust (C) South Devon Healthcare NHS Foundation Trust (C)(M)(G) Royal Devon and Exeter NHS Foundation Trust (U) Royal Bournemouth Hospital (M) North Bristol NHS Trust (Southmead Hospital)(U) Yeovil District Hospital NHS Foundation Trust (C)(M) Salisbury NHS Foundation Trust (C) Dorset County Hospital NHS Foundation Trust (C) Plymouth Hospitals NHS Trust (C) West Dorset NHS Trust (C) South Devon Healthcare NHS Foundation Trust (Torbay Hospital) (C,M,G,U) South Central Isle of Wight Healthcare NHS Trust (C) Milton Keynes Hospital NHS Foundation Trust (C) Royal Berkshire NHS Foundation Trust (C) Portsmouth Hospitals NHS Trust (C) Southampton University Hospitals NHS Trust (C) Oxford Ratcliffe(C) NHHT M)Winchester & Eastleigh NHS Trust (C,M,G) Royal Berkshire NHS Foundation Trust (C,M,G,U) Legend The following denotes a trust is working in this specialty: (M) Musculoskeletal (C) Colorectal (U) Urology (G) Gynaecology Enhanced Recovery Innovation Sites are shown in red Scotland NHS Lothian (M) Gold Jubilee National Hospital (M)

19. Drivers for Implementation Bella Talwar

20. Implementation Plan 1.Understanding your current service 2.Team working 3.Action planning 4.Stakeholder analysis 5.Stakeholder engagement 6.Testing and making changes to your pathway Understanding the risks 7.Understanding the investment required 8.Maintaining momentum 9.Sustaining the change

22. Audience: Patients Enhanced Recovery is a new way of improving the experience and well-being of patients who need major surgery. It helps people to recover sooner so that life can return to normal as quickly as possible It gives people a better overall experience due to higher quality care and services It lets people choose what’s best for them throughout the course of their treatment with help from their GP and the wider healthcare team (“No decision about me without me.”) Many people who have experienced Enhanced Recovery say that it makes a hospital stay much less stressful

23. Enhanced Recovery is a new, evidence-based pathway that creates fitter, patients who recover faster from major surgery It give patients a better overall experience through higher quality care and services It introduces innovative best practices that empower and motivate staff It accelerates the clinical decision-making process by empowering MDTs It doesn’t increase MDT workload It ensures the most-efficient use of healthcare resources Best-practice is day surgery or an Enhanced Recovery pathway Audience: Multi-Disciplinary Teams

24. Mapping your pathway against the Enhanced Recovery Elements Bella Talwar

25. Understanding your current service Identify elements in place on enhanced recovery pathway map Audit of compliance with clinical elements on an individual patient basis Process map / Walk the patient journey Track patient journeys Patient Experience Length of Stay Re-operation rates Readmission rates Complication rates CLINICAL INTERVENTIONSCLINICAL SYSTEM OUTCOMES

26. Understanding your current service Referral from Primary Care Pre- Operative Admission Intra- Operative Post- Operative Follow Up Optimised health / medical condition Informed decision making Pre operative health & risk assessment PT information and expectation managed DX planning (EDD) Pre-operative therapy instruction as appropriate Minimally invasive surgery Use of transverse incisions (abdominal) No NG tube (bowel surgery) Use of regional / LA with sedation Epidural management (inc thoracic) Optimised fluid management Individualised goal directed fluid therapy Planned mobilisation Rapid hydration & nourishment Appropriate IV therapy No wound drains No NG (bowel surgery) Catheters removed early Regular oral analgesia Paracetamol and NSAIDS Avoidance of systemic opiate-based analgesia where possible or administered topically Admission on day Optimised Fluid Hydration CHO Loading Reduced starvation No / reduced oral bowel preparation ( bowel surgery) DX when criteria met Therapy support (stoma, physio) 24hr telephone follow up Optimising pre operative haemoglobin levels Managing pre existing co morbidities e.g. diabetes

27. Care Pathway Project Plan

28. Short-term investment  Support to change the pathway (e.g. service improvement, change manager, facilitator etc)  Training – new skills e.g. pre-assessment  Equipment – invest to save  Communication/awareness Find out what is already in place & going on Make the connections

29. What investment may be required? Finance is not the only investment

30. What else is ER aligned to? ERP Pre – 11 am Discharge Productive Wards Discharge Lounge Ticket Home Protocol Led Discharge Nurse Dispensing Actual Bed Time Top Tips TCAB

31. Understanding and improving systems and processes Patient Pathway

32. Undertake mapping and tracking

33. Understanding your current service - Exercise  On the map provided: Understanding your current service - Exercise  Mark the interventions you already have in place  You should also consider when, where and how they are provided and whether there is further opportunity for improvement  Identify the interventions you need to establish and start to consider the sequence for implementation

34. Stakeholder Analysis Janine Roberts

35. Identifying the team Implementation requires a number of factors:  Changing clinical interventions  Changing care systems and processes  Creating a team to work across the patient pathway  Both require technical and behavioural change management  Lets start with thinking about who to engage and how to structure the project team

36. Essential Roles Sponsors: authority to sanction change (organisational alignment / benefit) Change Agents: facilitate change, require knowledge, skills and credibility Champions: respected opinion leaders who positively promote work Leaders: lead by example

39. Satisfy Opinion formers Keep satisfied Review regularly Manage Key Stakeholders need to be fully engaged through full communication & consultation Inform / Monitor Not crucial to the process but useful to keep informed Involve Voices that need to be heard Need to be proactive High Influence Little / No Influence Little / No Interest High interest Stakeholder Analysis

40. Stakeholder Engagement  Full guide to stakeholder analysis and management: NHS Institute for Innovation and Improvement  ‘The Handbook of Quality and Service improvement Tools’  Section 3 Stakeholder and User Involvement

42. Activity  On the sheets you have record your stakeholders for your chosen pathway(s)  Then, if you have time - in relation to each pathway record the key actions needed to ensure effective stakeholder engagement for that workstream  Some areas will be specific to a pathway  some areas may cross all pathways  Some areas may involve the same group of stakeholders but different individuals

43. Action planning and potential challenges Sophia Mavrommatis

44. Action Planning Take time to deliberate; but when the time for action arrives, stop thinking and go in’ -Andrew Jackson quoting Napoleon Bonapart

45. Agreement amongst the key players Certainty that the change will work Just do it JDI high low high Test on a very small scale Managing Improvement

46. Just Do it!  Little risk  Minimal cost  Broad agreement  Easy to do

47. Testing Changes for Improvement Sophia Mavrommatis

50. Enhanced Recovery Action Plan ActionOwnerResources306090

51. Action Planning & Challenges  On your table provided start to fill in from the earlier work today which actions need to be completed  Who can deliver these actions  What is the timescale – 30, 60 or 90 days  Resourse – flag up what support you may need here to deliver the action – eg connection into the local PCT, facilitator to deliver a workshop Include in this the top three challenges that you think you will encounter and the actions you will put in place to work through these challenges.

52. Measuring Outcomes Bella Talwar

53. Outcomes  Patient / staff  Clinical - elements of the pathway  Financial

54. Understanding Your Current Service Identify elements in place on enhanced recovery pathway map Audit of compliance with clinical elements on an individual patient basis Process map / Walk the patient journey Track patient journeys Patient Experience Length of Stay Re-operation rates Readmission rates Complication rates CLINICAL INTERVENTIONSCLINICAL SYSTEM OUTCOMES

55. 55 Referral from Primary Care Pre- Operative Admission Intra- Operative Post- Operative Follow Up Optimised health / medical condition Informed decision making Pre operative health & risk assessment - CPEX PT information and expectation managed DX planning (EDD) Minimally invasive surgery Use of transverse incisions No NG tube (bowel surgery) Use of LA with sedation Epidural management (inc thoracic) Optimised fluid management Planned mobilisation Rapid hydration & nourishment Appropriate IV therapy No wound drains No NG (bowel surgery) Catheters removed early Regular oral analgesia Paracetamol and NSAIDS Avoidance of opiate- based analgesia where possible or administered topically Optimised Fluid Hydration Reduced starvation No / reduced bowel preparation ( bowel surgery) DX on planned day Therapy support (stoma, physio) 24hr telephone follow up Optimising pre operative haemoglobin levels Managing pre existing co morbidities e.g. diabetes Audit & outcome measures Making your baseline assessment

56. Enhanced Recovery Pathway ‘Implementation & Sustainability’ ERP implemented Robotic Surgery ERP implemented CQUINS

57. Ann’s story to the Deputy Prime Minister “ I had two hip replacements last year. One in June and one in December. The second one was much better, the service is fabulous!”

58. Benefits Realisation Janine Roberts

59. Benefits Realisation

60. Next Steps Janine Roberts

61. Next steps Making it happen? What ongoing support can we provide? Implementation plan Follow-up session

62. Next Steps What will be your first change you will test or implement? Remember the importance of a quick win as well as a plan for sustainability

63. Next Steps Advice guidance and support – to change  Implementation guide  Enhanced Recovery Toolkit  SHA support  Local Network events  UCLH Implementation team  E-learning / DVD / Top Tips  http://insight/departments/Projects/QEP/Pages/home.as px http://insight/departments/Projects/QEP/Pages/home.as px  www.improvement.nhs.uk