Clinical Practice Groups

CPG ProgrammeTheory of Improvement

Care delivery problem:

• Variation in clinical practice and process, leads to worse patient outcomes at

higher system costs

Goal of the intervention:• To reduce unwarranted variation in clinical practice and process

Intervention:• Implementation of evidence based standardised clinical practice and

processes as core operating standard across RFL group of hospitalsRef: BMJ Qual Saf doi:10.1136/bmjqs-2014-003627

2

Reducing unwarranted variation through CPGs

Clinical Practice Groups (CPGs)

Quality Improvement

(QI)

New Model Content EPR

Reduce unwarranted

clinical variation

using standardised

pathways

Develop a continuous

improvement culture Implement a Group wide

EPR to digitise CPGs

Optimise patient

care, safety and

outcomes

Clinical Practice Groups in practice

CPG

Programme

manager

CPG

Programme

manager

Group Exec

Hospital Unit 1

Exec

Hospital Unit 2

Exec

Hospital Unit 3

Exec

Division 1

Group Board

Division 2

Division 3

Division 1

Division 2

Division 3

Division 1

Division 2

Division 3

Sh

are

d S

erv

ices

Gro

up

Clin

ical

Serv

ices

Shared Services support all hospital units

CP

Gs s

up

po

rt

all H

Us

CPG

Programme

manager

CPG

Programme

manager

CPG

chair

CPG

chair

CPG

chair

CPG

chair

4

CPG Implementation Group

Quality Strategy Board Digital Board

Change Board

Clinical Standard and

Innovation Committee

https://intermountainhealthcare.org

Activity analysis

Quality and outcome metrics

Performance Cost analysis

Pathway Prioritisation Matrix

5

Pathway Prioritisation: Admitted Patient Care: ICD Code Review:

Top 30 by Cost

ICD Code Cost

Patient

Encounters

Average

Encounter

Cost Beds ITU Theatres Radiology Pathology Endoscopy

£

# of

encounters £ LoS Days LoS Days

Cutting

Minutes

# of scans or

investig # of tests

# of

encounters

A419-SEPTICAEMIA, UNSPECIFIED 7,189,470 2,360 3,046 13,274 1,309 5,717 2,873 62,477 70

J181-LOBAR PNEUMONIA, UNSPECIFIED 6,457,347 2,979 2,168 12,259 1,088 550 2,305 49,692 51

S720-FRACTURE OF NECK OF FEMUR 5,237,450 1,075 4,872 6,943 193 38,883 1,220 18,468 -

N390-URINARY TRACT INFECTION, SITE NOT SPECIFIED 4,806,933 2,738 1,756 9,532 51 1,048 1,359 32,786 12

O701-SECOND DEGREE PERINEAL LACERATION DURING DELIVERY 4,452,665 1,165 3,822 767 - 1,339 31 5,822 -

O342-MATERNAL CARE DUE TO UTERINE SCAR FROM PREVIOUS SURGERY 4,451,990 693 6,424 571 - 25,275 49 4,482 -

I500-CONGESTIVE HEART FAILURE 4,255,506 1,775 2,397 8,389 120 109 1,283 39,600 19

N185-CHRONIC KIDNEY DISEASE, STAGE 5 3,890,897 2,049 1,899 3,017 241 40,033 1,076 22,517 7

J690-PNEUMONITIS DUE TO FOOD AND VOMIT 3,526,427 1,339 2,634 7,792 318 738 1,131 24,303 38

C509-MALIGNANT NEOPLASM, BREAST, UNSPECIFIED 3,353,782 2,598 1,291 1,098 6 46,746 679 9,128 5

O688-LABOUR AND DELIVERY COMPLICATED BY OTHER EVIDENCE OF FETAL S 3,216,820 513 6,271 470 1 11,204 57 8,143 -

Z369-ANTENATAL SCREENING, UNSPECIFIED 3,028,364 12,062 251 - - 1,009 4,509 30,665 -

J189-PNEUMONIA, UNSPECIFIED 2,949,607 1,566 1,884 5,599 205 180 972 23,645 14

N179-ACUTE RENAL FAILURE, UNSPECIFIED 2,916,570 1,265 2,306 5,089 276 1,288 1,141 29,332 11

O628-OTHER ABNORMALITIES OF FORCES OF LABOUR 2,811,162 441 6,375 - - 15,676 46 8,272 -

H269-CATARACT, UNSPECIFIED 2,607,599 3,131 833 602 - 61,763 6 69 1

O680-LABOUR AND DELIVERY COMPLICATED BY FETAL HEART RATE ANOMALY 2,554,656 409 6,246 269 2 10,325 50 5,978 -

C64X-MALIGNANT NEOPLASM OF KIDNEY, EXCEPT RENAL PELVIS 2,531,053 724 3,496 1,252 59 44,590 364 6,601 7

O700-FIRST DEGREE PERINEAL LACERATION DURING DELIVERY 2,498,164 659 3,791 253 - 1,241 28 3,137 -

I639-CEREBRAL INFARCTION, UNSPECIFIED 2,493,860 480 5,196 5,289 100 307 629 9,411 12

M179-GONARTHROSIS, UNSPECIFIED 2,450,092 623 3,933 2,796 125 50,436 654 5,966 1

O800-SPONTANEOUS VERTEX DELIVERY 2,289,215 586 3,907 491 - - 5 1,416 -

L031-CELLULITIS OF OTHER PARTS OF LIMB 2,040,823 1,668 1,224 2,695 14 1,896 580 12,674 6

C787-SECONDARY MALIGNANT NEOPLASM OF LIVER 2,003,680 783 2,559 1,262 311 22,804 618 7,054 12

I214-ACUTE SUBENDOCARDIAL MYOCARDIAL INFARCTION 1,948,776 723 2,695 2,676 126 135 749 12,892 6

O420-PREMATURE RUPTURE OF MEMBRANES, ONSET OF LABOUR WITHIN 24 HO 1,920,897 538 3,570 111 - 744 9 3,430 -

R296-TENDENCY TO FALL, NOT ELSEWHERE CLASSIFIED 1,899,828 1,280 1,484 4,283 - 50 584 9,038 7

I702-ATHEROSCLEROSIS OF ARTERIES OF EXTREMITIES 1,851,607 237 7,813 2,189 58 12,973 407 6,534 -

J440-CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH ACUTE LOWER RESPI 1,840,843 1,126 1,635 3,212 297 159 468 10,879 7

O321-MATERNAL CARE FOR BREECH PRESENTATION 1,828,425 301 6,075 244 - 8,567 34 2,519 -

• Top 30 Admitted Patient Care ICDs are 10% of Trust total costs

• Most of these encounters and those under linked ICDs have been corralled into the first two sets of

pathways

Key Clinical ProcessesHigh total cost, and review

total encounters, and av.

cost

CPG Pathways

7

Methodology

8

Agree scope of

service

• Clinical pathways

• Clinical guidelines

• Patient experience

• Current Value

stream map

Quality metrics

• Clinical outcomes

• Patient

experience

• Activity

• Performance

• Cost Data

• Patient Safety

Data analysis

• Pareto analysis

• Gap analysis

• Value

assessment

• Clinical

grouping s and

outcomes

• Pathway

selection

Improve

• Agree future

state

• Model future

state

• Test pathways

• Develop IT

data collection

systems for

pathways

Sustain

• Chart analysis

of CPG impact

• Continuous

monitoring of

performance

• Continuous

Improvement

• Benefits

realisation

Step 1

Define

Step 2

Measure

Step 3

Analyse

Step 4

Design

(test PDSA)

Step 5

Continuously improve/ sustain

Patient Co-Design

Experience-Based Co-Design

Patient and Family Centred Care

(PFCC)

• Feedback questionnaires using Survey

Monkey

• Patient Shadowing

• Patient co-design panels

https://www.pointofcarefoundation.org.uk/

Example: Pre-Operative Assessment:

POA at the Barnet & Chase Hospital Sites - Current value stream map

CPG version 0.6

GP makes

referral to

surgical

specialty

Patient

attends

OPA with

decision to

treat

Admission

books TCI

and POA

Nurse-led

appointment

Book

anaesthetic

appointment

Obs, swabs

Happy

to

proceed

?

Y

Document on

Cerner

N

Obs, swabs, ?ECG,

medical and

physical history,

bloods, peak flow,

blood glucose

Bloods

normal?

Y

N

Renal impairment –

A&E

IV irons

Referral to anti-coag

Rebook for another

F2F appt

Happy

to

proceed

?

Y

N

Document on

Cerner

Further

investigation

s requested

More

information

required

from GP,

records etc.

Risk vs

benefits

discussion

Happy

to

proceed

?

N

Y

Document on

Cerner

Happy

to

proceed

?

N

Y

Document on

Cerner

Patient

happy

to

proceed

?

N

Y

Document on

Cerner

Document

on Cerner

Document on

Cerner

Nurse-led

50% POA clinics

have

anaesthetic

cover

Clinical Algorithm

For appointment face to

face or telephone

assessment

Example: Pre-Operative Assessment

Brown Paper and Gateway Documents

Bespoke Clinical Workflow Views

Message Centre Pools

Worklist Reports

Discern Alerts

Powerforms

Patient Portal - Clipboards

Dashboard – CPG pathway measures

12

POA – Orders eligible for same day POA and triage not completed

Chase Farm Hospital

Improvement period 1

(additional support for go-live)Improvement period 2

(change in staffing resource)

Pathways: Approach to Financial Benefits

Cohort

Moments of Care

Current and Future

Income, Resources, and

Costs

Current and Future

Metrics and profiling

Decision to proceed

Business Units embed in

financial plans

Implement, monitor

CPG SAS

Pathway Lower GI

# of pathways 100

Total Annual Cohort size 7100

Future State

For # of

pathways

For Total

Cohort

Moment of care & Setting Total Total

Resource

Additional Detail Units OP FA F2F OP STT

Colonscopy

(Endo)

Virtual

colonoscop

y

CT

Abdomen/

Pelvis

Results

review

Unit

Cost Cost Cost

Clinical Income

# of moments of care 25 100 52 20 16 100

# of pathways 100 100 100 100 100 100

Direct Clinical Delivery Service

Pay

Consultant Hours 11 28 21 10 100 6,930 492,030

Senior Fellow Hours 34 - -

Nurse Endoscopist Hours 14 34 471 33,474

Nurse Hours 27 - -

Therapist Hours 27 - -

A&C - Navigator Hours 8 5 15 180 12,788

Non-Pay

Drugs £ 100 3 300 21,300

Hotel £ 1 - -

Outsourced £ 1 - -

Clinical Non Pay £ 100 8 800 56,800

Clinical Support Services

Radiology Virtual colonoscopy Count 20 107 2,133 151,475

CT Abdomen/Pelvis Count 16 93 1,493 106,031

Pathology Biopsy Count 42 60 2,496 177,216

Other Pathology Days 100 8 800 56,800

Ward - Surgical Days 250 - -

POA Count 69 - -

Endoscopy Hours 35 300 10,400 738,400

Total Cost per 100 Pathways 1,163 4,768 15,447 2,133 1,493 1,000 26,004 1,846,314

Cost per moment of care 47 48 297 107 93 10

# of moments of care (Total 1,775 7,100 3,692 1,420 1,136 7,100

Annual Total Cost (Total Cohort) 82,538 338,500 1,096,770 151,475 106,031 71,000 1,846,314 -

Future StateCPG SAS

Pathway Elective Knee

# of pathways 100

Total Annual Cohort size 7100

Current State

For # of

pathways

For Total

Cohort

Moment of care & Setting Total Total

Resource

Additional Detail Units OP FA F2F OP STT

Colonscopy

(Endo)

Virtual

colonoscop

y

CT

Abdomen/

Pelvis

Results

review

Unit

Cost Cost Cost

Clinical Income

# of moments of care 100 100 52 20 16 100

# of pathways 100 100 100 100 100 100

Direct Clinical Delivery Service

Pay

Consultant Hours 42 28 10 100 7,973 566,107

Senior Fellow Hours 34 - -

Nurse Endoscopist Hours 7 34 236 16,737

Nurse Hours 27 - -

Therapist Hours 27 - -

A&C - Navigator Hours 30 15 450 31,950

Non-Pay

Drugs £ 100 3 300 21,300

Hotel £ 1 - -

Outsourced £ 1 - -

Clinical Non Pay £ 100 8 800 56,800

Clinical Support Services

Radiology Virtual colonoscopy Count 20 107 2,133 151,475

CT Abdomen/Pelvis Count 16 93 1,493 106,031

Pathology Biopsy Count 42 60 2,496 177,216

Pathology Other Days 100 8 800 56,800

Ward - Surgical Days 250 - -

POA Count 69 - -

Endoscopy Hours 35 300 10,400 738,400

Total Cost per 100 Pathways 6,550 - 15,905 2,133 1,493 1,000 27,082 1,922,816

Cost per moment of care 66 - 306 107 93 10

# of moments of care (Total 7,100 7,100 3,692 1,420 1,136 7,100

Annual Total Cost (Total Cohort) 465,050 - 1,129,260 151,475 106,031 71,000 1,922,816 -

Moments of care R

e

s

o

u

r

c

e

Current State

C

o

s

t

sCosts and

Income

Governance: Financial Benefits Realisation Group Chaired By CFO broke

this summary arrow into 12 steps and applied RAPID Decision Tool

• Pathways:• Complexity

• Multiple people/services

responsible for parts of the

pathway

• Costs:• Strong modelling assumptions

• Sticky costs: fixed versus variable

• GL Structure not fit pathways

• Patient encounters not easily

linked to pathways

• Complexity of costs

Key risks

• Internal:• IT analytics and systems not set

up for pathway analysis

• Multiple potential owners of

change

• Focus on short term hard cash

out not long term reorganisation

• Service Line profitability may be

differentially affected

• External:• Distribution of benefits across

the health economy

• Inability to control the whole

pathway

Board Goal: 20 Million cost reduction through CPGs

CPG Pathways embedded, monitored and digitised

15

Pathway A (‘Current state’)

◼ Patient seen in OP with a decision to list for surgery (variation in conversion)

◼ Average length of inpatient stay ~4 days

◼ Full hip precautions being applied to all THR patients

◼ Variation in follow-up procedures by consultant

Pathway B (‘Future state’)

◼ Standardised means of listing patients for surgery

◼ Anaesthetic protocol now spinal +/- sedation

◼ Structured phases of recovery during inpatient stay – built into digital pathway

◼ Hip precautions no longer in place following literature review

◼ Discharge summary completed at phase 2 to remove delays

◼ Virtual follow-up clinics being developed

Key measures to deliver benefit realisation

Length of stay PROMS outcomes (patient experience)

RTT performance NJR outcomes (Clinical effectiveness)

Key enablers to realise benefits

Adoption of digitised pathway, Clinical agreement re. no hip precautions, no stockings, spinal anaesthetic,

physio resource to support early mobilisation

Aim

Excellence in clinical outcomes whilst offering value to the tax payer with an average length of stay of 3

days or less

Income implications

◼ Reduction in OP attendances although expect to be populated with existing unmet demand

◼ Expect average IP spell income remains the same

CPG: Elective joint replacement, SaS CPG Chair: Lila Dinner

CPG Pathway Lead; Philip Ahrens

CPG Programme Manager: Helen Wark / Rachel Luker

Risks / Barriers

▪ Potential Risks:

Lack of adoption from all staff with newly designed pathway – some areas not yet agreed complete clinical

consensus

▪ Potential Barriers:

Long waiting times for many orthopaedic procedures, physio resource to support regular mobilisation

Critical Milestones Time line

Current state pathway mapped Sept 17 - Nov ’17

Literature reviews, shared learning with other providers Jan ‘18 – Jul ‘18

Agree key measures and understand current performance May ‘18 – Jul ‘18

Digitisation design sessions Feb ‘18 - May ’18

Joint schools harmonised Mar ’18 - Jul ’18

Agreement re. hip precautions and f/up protocol Sept ’18

Patient co-design event Oct ‘18

Digitisation training and launch Oct ‘18 – Nov ‘18

Benefits

◼ Activity/volumes

Moving activity to cold elective site – CFH,

increased efficiency for IP and OP

◼ Patient and Clinical Outcomes

Reduced LoS, improved patient experience

◼ Performance

Improved RTT, PROMS and NJR performance

◼ Cost

Reduced LoS with less resource input

Step 1

Decide the patient cohort

In determining the scope of the elective joint pathway, the

cohort of patients was defined by the pathway team:

• Patients over the age of 50

• Who are suitable for Chase Farm Hospital, and

• Having total hip replacements or a total knee

replacement

Chase Farm theatres elective hip patient population

Barbara’s story

Barbara is 81 years old, lives in East

Barnet and is typical of the patient

cohort for this pathway. She visited her

local GP in late 2018 and was referred

to an outpatient clinic at Barnet

Hospital to discuss a right total hip

replacement

Step 2Decide the moments of

care that make up Pathway A and B

Each pathway that the team has mapped (current state /

pathway A and future state / pathway B) can be broken

down into moments of care, that require some resource

Pathway A

Pathway B

Barbara’s story

Barbara’s first ‘moment of care’ in

the pathway was when she

attended Barnet Hospital to see

a consultant on 14 January 2019,

where she and her consultant

decided she would have a right

total hip replacement

Moments of care summary

-

1,000

2,000

3,000

4,000

Pathway A Pathway B

RFH 1,193 1,060

CFH 2,426 2,156

Nu

mb

er

of

OP

ap

po

intm

en

ts

Decrease in OP appointments

3,618

804 804 804

3,216

804 804 804

OP IP DI Therapy

Moments of care

Changes in moments of care

Pathway A Pathway B

Reducing the number of pre and post follow up appointments will reduce the moments of

care needed in the pathway. The reduction in outpatient appointments is due to

• No pre-operative OP follow up appointments following imaging

• Post-operative OP follow up appointments reducing from median of 1.5 to 1.0

The number of moments care along the rest of the pathway remain the same.

Imaging

Step 3

Decide the clinical and non-

clinical resources needed to

deliver the moments of care

in Pathways A and B

For example, in pathways A and B, all patients are

invited to attend Joint School before their

operation. This ‘moment of care’ needs the resource

of the staff members who run the session:

Barbara went to Joint School

at Chase Farm Hospital on 2

April 2019 and said:

“It was useful and informative. I have had my knee

done before and when I woke up shivering I felt

worried because I thought there was something

wrong with me, but [at joint school] they explained

that this is how your body warms up after surgery,

so I wasn’t worried this time”

Barbara’s story

Resource required Time required

per week

Cost (in A and B) per

annum

Anaesthetist 15 minutes £3.4k

Nurse 90 minutes £5.0k

Therapist 90 minutes £5.0k

TOTAL £13.4k

Step 4Decide the income and cost for

Pathway A (based on current

encounter data set)

Pathways A and B can then be looked at in terms of

cost and income. For example, in Pathway B there

are fewer outpatient appointments before surgery,

therefore both cost and income will be impacted:Step 5

Decide the cost of resources for

Pathway B and estimate income

Barbara only had to attend one

outpatient appointment before

her operation, and had had an

x-ray on the same day. She also

walked round to pre-operative

assessment at Barnet Hospital,

was triaged same day and then

returned on 5 March 2019 for a

face to face assessment

Average no. of pre-operative outpatient appointments per

patient (hips and knees) Apr 2016 – Mar 2019

Barbara’s story

Pathway

A

Pathway

B Variance

Total number of pre-op follow up

appointments 402 - - 402

Percentage of total OP

appointments 11% 0% -11%

Total income 28,927 - - 28,927

Total cost 10,050 - - 10,050

Step 6

Decide the contribution of Pathway A and

estimate the contribution of Pathway B

Once total income and cost per pathway are

understood, contribution (the difference

between the two as a percentage of income)

can be calculated.

Pathway A contribution = 45%

Estimated Pathway B contribution = 51%

Change in contribution is due to lower length

of stay. Time, resources and experience in

theatre will remain unchanged, so contribution

of moment of care in theatre is unchanged.

• Barbara had her operation (right total hip

replacement) at Chase Farm Hospital

on 16 April 2019

• Barbara arrived on the ward at 6.30pm

that evening and the first nursing

checklist within the elective hip care

pathway an hour later

• Barbara was first mobilised by a

physiotherapist at 9.30am the following

morning, and the first physio checklist

was also completed

Barbara’s story

Step 7

Decide the financial and non-financial

measures describing the benefits and

include in measurement plans

The primary outcome measure in the elective

hip and knee pathway is length of stay, this

describes a key outcome and is captured in the

measurement plan for the pathway.

Step 8

Decide the expected change in financial profile from

Pathway A to Pathway B from expected changes in

measures

Change in average length of stayLength of stay (elective hip)

Apr 2016 – Mar 2019Hip Knee

Before go-live (Apr-

Oct 2018)4.5 days 4.0 days

Since go-live (Nov 2018-Mar 2019)

3.7 days 3.6 days

Change so far 0.8 days 0.4 days

Dashboard – CPG pathway measures

23

Elective hip - Variation in length of stay by consultant (anon.) at Chase Farm Hospital

• After spending three nights at Chase Farm Hospital,

Barbara’s final nursing and physiotherapy checklists

were completed and she was confirmed ready for

discharge on 19 April 2019

• Barbara’s length of stay was 3.14 days

• Barbara’s GP discharge letter confirmed a follow up

outpatient appointment 6 weeks post-discharge, as her

final moment of care on the pathway

Barbara’s story

2,600 2,700 2,800 2,900 3,000 3,100 3,200 3,300

4.6 4.5 4.4 4.3 4.2 4.1 4.0 3.9 3.8 3.7 3.6 3.5 3.4 3.3 3.2 3.1 3.0

LOS (Days)

Cost and length of stay (LOS)

Cost (£k)

LOS

(Days) Cost (£k)

Pathway A 4.6 3,192

Pathway B 3.0 2,835 - 358

Reducing length of stay (LOS)

will result in a reduction in cost.

This will release both consultant

time and beds in the surgical ward

Cost reduces with

length of stay

Summary of financial benefits realisationDeciding Factor for

Change

Effect of

Change CPG Benefits

CPG

Benefits

£k

Reduced Length of

Stay

Reducing LOS

from 4.6 to 3.0

days

Ward LOS -

Reduction

358-

No follow up

appointment after

imaging

Removal of

staff costs as

patient has one

less OP

appointment

F2F Follow ups -

Reduction in Vol

10-

Reduced Follow up

appointments

Reduction in

the number of

follow up

appointments

after being

discharged

F2F Follow ups -

Reduction in Vol

9-

Income Associated

income with

cost saving

measures

Income Redt'n -

Standardisation

Methodology

across sites

58

319-

This table shows the key drivers of

change and the financial impact of

the change.

• The biggest financial gain can be

achieved by reducing length of

stay from 4.6 to 3.0 days for

elective hip and knee patients.

• Further cost reduction comes

from reducing outpatient

appointments

Pathway: Elective Hip & KneePathway A

£KPathway B

£KDiff£k

Diff (%)

Income 6,172 6,114 (58) (1%)Expenditure 3,377 3,000 (377) (11%)Contribution 2,795 3,114 319 11%Contribution % 45% 51%

This summary of income and

expenditure in pathway A and

pathway B demonstrates an

opportunity to remove £377k cost

from the pathway which can free

up capacity

Income Expenditure Contribution

Pathway A 7,677 4,200 3,476

Pathway B 7,605 3,732 3,873

(72) (469) 397

Average per patient (£)Similarly looking at the average

cost per patient, we can see

opportunity to remove further cost

from both the hip and knee pathways

Step 9

Whether to

proceed with

the financial

case

(“Gateway

review”)

Step 10

Decide the ownership

of the realisation of

expected benefits

within the business

units and pathway

development team

Step 11

Decide the infrastructure

that is appropriate to

deliver, monitor and report

on the financial effects

within the business units

and pathway development

team

Step 12

Decide on

reconciliation

between the

business unit

and pathway

development

team benefits

realisation

• After Barbara had gone home, the ward team at

Chase Farm did their weekly dashboard

review to see all of the patients who had a

length of stay longer than 3 days

• The team then reviewed these patients’ records,

including Barbara’s, to understand and record

the drivers behind a longer length of stay,

and to take action accordingly

Barbara’s story