1. Whole system improvement in Forth Valley Improvement and support team meeting 15 th Jan 2009

2. Context Period of significant change and innovation National collaborative projects Integrated healthcare strategy includes new acute hospital 2010-2011 Consistent bed pressures Need for step change in results from improvement activity –Implementation –Measureable benefit –Focus and prioritisation

3. Lean improvement It’s about BALANCE and FLOW Resources (R) = Cycle Time (CT) Takt Time (TT)

4. Improvement on the ‘shop floor’ time Failure Reason 1 Failure Count Failure Reason 2Failure Reason 3Failure Reason 4Failure Reason 5Failure Reason 6 3. Routinely act on the most costly failures using: Concern Cause Countermeasure Multi-disciplinary team, according to problem Target Process performance #WhoWhenStatus 1 2 3 4 ~~~~ ~~/~~/08 Action ~~~~~~~~~~~~ 1. Measure actual v target for key processes 2. Assign reasons for process failure, and count …

5. Process 2 - 4 weeks 1 day1-2 days2 days1 - 2 weeks Phase 1Phase 3 Analyse the Forth Valley Whole System Phase 2 Top Team EventAnalyse Priority Areas Phase 4Phase 5Phase 6 1 - 2 weeks Prioritisation Event Evaluate Options Policy & Planning Event 2&3 Dec17&18 Dec 12th Nov 20th Oct start

6. Executive challenge Transition to new models of care across system £14.5m - £25m savings by Mar 2011 Maximum 18 week RTT by Dec 2011 Resilient U&E flow = 98% A&E asap Consistent, safe care: HAI down by 30% by 2010

7. Day PatientIn Patient Clinic community services – partnership model with LA Home Visit mental health; elderly care district nursing health visiting specialist nursing AHP (e.g. physio, OT) other GP referral A&E CAU amb care acute receiving unit in-patient out-patient diagnostics rehab day case acute services MIU SAS OOH OOH, urgent & emergency services (community) NHS 24 Specialist acute care tertiary services routine discharge complex discharge out-reach refer to GP refer on-going community care Local Authorities Partner & Vol organisations AHP (physio) sub-contract GDP GP Community Pharmacists family health services Optom GP direct access GP feedback Forth Valley System Map

9. Day PatientIn Patient Clinic community services – partnership model with LA Home Visit mental health; elderly care district nursing health visiting specialist nursing AHP (e.g. physio, OT) other GP referral A&E CAU amb care acute receiving unit in-patient out-patient diagnostics rehab day case acute services MIU SAS OOH OOH, urgent & emergency services (community) NHS 24 Specialist acute care tertiary services routine discharge complex discharge out-reach refer to GP refer on-going community care Local Authorities Partner & Vol organisations AHP (physio) sub-contract GDP GP Community Pharmacists family health services Optom GP direct access GP feedback 963,000 ~130,000 330k AHP 32k Nr 300,000 65,000 32,000 81,000 80% occ; 294 beds 28k DP; 17k OP 12,000 50,000 196,000 52,600 27,500 9,600 LOS=3.8 41,000 13,500 26,000 LOS=6.8 25,100 166,000 M 4,300 +12% +24% (new) -26% +1.1% +2% +3% 1,300,000 +5% Forth Valley System Map 38,000 3,000

10. Day PatientIn Patient Clinic community services – partnership model with LA Home Visit mental health; elderly care district nursing health visiting specialist nursing AHP (e.g. physio, OT) other GP referral A&E CAU amb care acute receiving unit in-patient out-patient diagnostics rehab day case acute services MIU SAS OOH OOH, urgent & emergency services (community) NHS 24 Specialist acute care tertiary services routine discharge complex discharge out-reach refer to GP refer on-going community care Local Authorities Partner & Vol organisations AHP (physio) sub-contract GDP GP Community Pharmacists family health services Optom GP direct access GP feedback Q Q T Q T Q Q Solutions to imbalance lie in whole system …

11. GP referral in-patient out-patient diagnostics day case Discharge refer on-going community care home out-patient Pre-Op Theatre Outpatients Demand 1000 Capacity 793 9.5 wks16.5 wks 1 st OP Appt Outcome Discharged 24.8% DNA 4% Failed Discharge 1.7% Awaiting Results 8.8% Waiting List DC 4% Ref other Clinics 2.7% IP wtg list 7% Blank/Other 8.8% Further Appt 38.4% OP – Lost Capacity Scheduled capacity 80% of demand Quality Losses 17-42% Losses = 29% of capacity Hips – Sept 08 Capacity363 Pts seen 255 (overtime69) DNA 13 Unfilled Appt 44 Canc Clinic 50 45 wks (83% > 18 wks) 23.4 wks 3.2 Planned Orthopaedics Outpatients

12. Discharges by day of the week 19% Sunday shortfall Approx 60 bed days a week (£1.6M p.a.)

13. Opportunity to release bed capacity 30%

14. Distribution of acute LOS Are there 3 themes here ? Generally elderly patients. Avoid admission … Reduce LOS by improved inpatient and discharge processes Avoid admission and ambulatory care …

15. District nurse diary study: conclusions Opportunities to increase productivity –Reducing lost time (eg. admin, meetings etc) –Scheduling domiciliary time more efficiently –Using lower grade staff for routine work –Shifting routine treatment room work to GP practices and phlebotomist –Improving predictive planning with acute services –Balancing nursing resource effectively to meet 7 day a week demand Opportunities for released capacity –Increased capacity in treatment rooms to support acute discharge –Increased capacity for anticipatory care –Understanding return on investment of different options

16. Urgent & Emergency Work-stream Enabling Work-streams : Leadership & Communication; Information & Metrics; Training; Programme Mgt; Elective Work-stream Primary & Community Work-stream Diagnostics Work-stream Redesign whole system U&E pathway Mainstream advanced care planning to reduce inappropriate hospital admissions Improve quality of Urgent and Emergency “front door” services Reduce avoidable unplanned admissions Systematic improvement in acute in-patient management Releasing/developing capacity in primary care and community services Systematic improvement in LA supported discharge Reduce variation in referral management Systematic improvement of Labs Increase CT (MRI) productivity / capacity Articulate the productivity benefits from 18 week programme NHS Forth Valley Priority Improvement Work-Streams Improve ‘home-to-home’ visibility of patient pathway

19. Conclusions Whole system perspective was revealing –Increased focus on primary and community care Process highlighted the need for good information –Real focus on evidence Challenged us about how we prioritise resource use Produced plans with clarity and shared understanding