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Making it Better at Weston Park Collaborative Quality Improvement
Ian Scott, Programme Director Jackie Martin, Consultant Clinical Oncologist Milly Finch, Leadership Fellow, Pharmacy Anne Hilton, Project Manager David Nicholls, Project Manager June 2018
Delivering People Centred Cancer Care
Ian Scott, Programme Director June 2018
2
• Transformation Strategy
• Service Improvement Lead
– MCA WPH Collaborative
– Clinical Lead Service Improvement Projects
• Leadership Fellow-Pharmacy
• Estates Project Lead
• Workforce Project Lead
Overview
Rising National and Local Demand
4
Planning for Immunotherapy
5
• New attendances show a steady but small increase over time • FU activity shows stable increase in use in Melanoma until April
2016 • Rate escalated significantly since due to early impact of
immunotherapy primarily in Lung
Radiotherapy 6% vacancy rate
Nursing 10% vacancy rate
Oncologists 4% attrition 1% growth
9% increase in consultants is needed
nationally to stand still
6
The Workforce
Patient and Staff Experience
7
Patient
• “I ask about treatment but am told I’ll have to wait to see
the Consultant….but then I have to wait until next clinic
to see them”
• The experience within clinics and outpatients is chaotic
and as a patient I felt my needs were not put
first…waiting 2 hours plus for chemotherapy and
pharmacy”
• Patients get a great service from individual staff
members although it feels like we do so in spite of
systems and environment”
• “The brachytherapy suite is more akin to a prison cell”
• “There’s a shortage of space for patients waiting to be
seen “
• “I get anxious about coming to work – OPD is chaotic
with poor patient flow”
• “Parking is key for patients. Some of us have to be here
very early in the morning and if our work isn’t done, no
patients can be treated”
• Not just an outpatients refurbishment again please”
Staff
8
Our vision is to be a nationally recognised leader in the provision of Precision Oncology & People Centred Cancer Care with plans to provide a calm and therapeutic environment in which we deliver services wrapped around the needs of the patients and their families, while meeting the needs of our staff. 9
Transforming Our Network
• Delivering more chemotherapy options closer to the patient
• Maximise research potential and reduce inequity of access to trials
• Modernising and enhancing the workforce model to meet changing patient needs
• Extending the Weston Park brand across the wider region
• Improved access to Radiotherapy services in Sheffield, enabling access to cutting edge therapies and better treatment decisions
People Centred Cancer Care sets out an ambitious vision for the future of
Weston Park Cancer Centre and the South Yorkshire, Bassetlaw and
North Derbyshire network. We will improve where we work, how we work
and we’ll transform our services for our patients.
Here’s what we’re planning to deliver together:
✓ New
Inpatient
wards
✓ New
Outpatients
Department
A modern
Walkway
to RHH
New,
bigger
Pharmacy
Aseptic
Suite
An
expanded
Day Case
Modern
Brachytherapy
unit
Bigger
Car
Park
More
Office
Space
Transforming
our Hospital
Delivering
World Class
Innovation
Appoint
Education
Centre Manager
Expanded
Early Phase
Trials
Cutting Edge
Radiotherapy
Research
Nationally
Recognised
Education
Centre
✓ ✓
Investing in
our People
New
Staff
Areas
✓ Advanced
Practitioners
Right
Person,
Right Place,
Right Time
More Career
Opportunities
Investing in
Cultural
Development
Proud to
work
@Weston
Park ✓ ✓ ✓
Focus to fill
Vacancies
in the Right
Places
Co-
production
with
patients
Serv
ice
Im
pro
vem
en
t P
rog
ram
me
Equitable
Chemotherapy
Delivery
Improved
Access to
Cutting Edge
Radiotherapy
Easier
Access to
Treatments
More
Research
Undertaken
Improved
Outcomes for
Patients
Delivering the
Best for Our
Patients
✓ ✓ ✓ ✓
✓ ✓
✓ ✓
✓ ✓
The Good The Bad The Ugly
The Good The Bad The Ugly
Making it Better at Weston Park Collaborative Quality Improvement
Personal Perspective from the Clinical Service Improvement Lead
Dr Jackie Martin, Consultant Clinical Oncologist
12
13
Strategic ambitions for the SI work stream
• Leadership for change
• Build internal capability for a sustainable SI culture change
• Patient centred SI changes
• Improve team working, patient experience & flow, increase capacity for increasing demand
• Create a sustainable SI approach using data to support decision making
14
15
16
17
Day Case Services
Unit (DCSU)
Pharmacy Radiotherapy (RT)
Outpatients (OPD)
In Patients Wards
WAU (assessment
unit)
CCTC
18
Pharmacy Radiotherapy (RT)
In Patients Wards
WAU (assessment
unit)
CCTC
Joint Group Established in 2014 with MCA coaching
support
Outpatients (OPD)
Day Case Services
Unit (DCSU)
19
Pharmacy Radiotherapy (RT)
Outpatients (OPD)
In Patients Wards
WAU (assessment
unit)
CCTC
Day Case Services
Unit (DCSU)
Team Working
Chemo coordinator
DCSU communication
sheets
Staff rotation between OPD
and DCSU
Community Blood form
Team Working
Team nursing rolled out across department… Positive feedback from both staff and patients!
0
5
10
15
20
25
30
35
Non- team nursing pingtime average
Pilot team nursing pingtime average
Established team nursingping time average
Series1
21
Pharmacy Radiotherapy (RT)
Outpatients (OPD)
In Patients Wards
WAU (assessment
unit)
CCTC
Day Case Services
Unit (DCSU)
Team Working Group 1st
course chemo counselling
Outcome forms Chemo
coordinator DCSU
communication sheets
Staff rotation between OPD
and DCSU
Community Blood form
Patient Pagers
Patients reported they felt:
Safe
Supported
Comfortable
Reassured
Arrived early as this
was 1st treatment and
waiting room opened
up for us to sit in - very
nice
So Easy
No patients reported they felt:
Worried
Uncertain
Unhappy
Unwelcome
Was good, most helpful,
the information was
explained in detail
Very well
presented
At Ease
Very
Informative
1st Course Group Counselling
Patients reported they felt:
Safe
Supported
Comfortable
Reassured
Arrived early as this
was 1st treatment and
waiting room opened
up for us to sit in - very
nice
So Easy
No patients reported they felt:
Worried
Uncertain
Unhappy
Unwelcome
Was good, most helpful,
the information was
explained in detail
Very well
presented
At Ease
Very
Informative
1st Course Group Counselling
~ 8 NP per day (1 hr/pt = ~ 40 hrs of
nursing time saved per week)
24
Pharmacy Radiotherapy (RT)
In Patients Wards
WAU (assessment
unit)
CCTC
Day Case Services
Unit (DCSU)
Outpatients (OPD)
Reduce Waiting times Clinic Rescheduling
OPD Tidy up
Clinic Prep
25
26
27
Pharmacy Radiotherapy (RT)
In Patients Wards
WAU (assessment
unit)
CCTC
Day Case Services
Unit (DCSU)
OPD Sub-cut SACT injection
pathway
Outpatients (OPD)
Reduce Waiting times Clinic Rescheduling
Coffee Club
Outcome forms
OPD Tidy up
Re-stock of patient info
OPD TV
Nursing Clinic Coordinator
Patient Info
Folders (CSC)
Clinic Prep
28
Pharmacy
Outpatients (OPD)
In Patients Wards
WAU (assessment
unit)
CCTC
Day Case Services
Unit (DCSU) Healthier eating Mould Room –
Calls to patients pre-1st visit
Shoulder stabilising armholes
Radiotherapy (RT)
Breast Treatment on-set process
Test Patient Pagers
29
Pharmacy Radiotherapy (RT)
Outpatients (OPD)
WAU (assessment
unit)
CCTC
Day Case Services
Unit (DCSU)
E-Whiteboard
In Patients Wards
30
Radiotherapy (RT)
Outpatients (OPD)
In Patients Wards
WAU (assessment
unit)
CCTC
Day Case Services
Unit (DCSU)
Pharmacy
Specific time given to staff during shift to update the board
31
Pharmacy Radiotherapy (RT)
Outpatients (OPD)
WAU (assessment
unit)
CCTC
Day Case Services
Unit (DCSU)
Board-Rounds
E-Whiteboard
In Patients Wards
MDT Referrals Discharge planning Bed Management
32
Radiotherapy (RT)
Outpatients (OPD)
In Patients Wards
WAU (assessment
unit)
CCTC
Day Case Services
Unit (DCSU)
Pharmacy
Newsletters
34
Radiotherapy (RT)
Outpatients (OPD)
In Patients Wards
WAU (assessment
unit)
CCTC
Day Case Services
Unit (DCSU)
Patient info re pharmacy
process Pre-dispensing
chemo pre-meds
Pharmacy
Vial sharing
Newsletters
Pagers
Brain oral chemo
pathway
Vial Sharing
• Pembrolizumab therapy for lung and melanoma
• Pharmacy identified the potential to use one vial of expensive drug between two patients
• Short expiry of drug
• Moving patient appointments close together so that vial sharing is practical
36
Radiotherapy (RT)
Outpatients (OPD)
In Patients Wards
WAU (assessment
unit)
CCTC
Day Case Services
Unit (DCSU)
Patient info re pharmacy
process Pre-dispensing
chemo pre-meds
Pharmacy
Vial sharing
Oral chemo 1st course counselling
Newsletters
Pagers
Pharmacy tracking IV chemo
Brain oral chemo
pathway
37
Pharmacy Radiotherapy (RT)
Outpatients (OPD)
In Patients Wards
WAU (assessment
unit)
Day Case Services
Unit (DCSU)
CCTC
Trial set-up re-design
38
Pharmacy Radiotherapy (RT)
Outpatients (OPD)
In Patients Wards
CCTC
Day Case Services
Unit (DCSU)
WAU (assessment
unit)
Communication to ED in network
39
Pharmacy Radiotherapy (RT)
Outpatients (OPD)
In Patients Wards
WAU (assessment
unit)
CCTC
Day Case Services
Unit (DCSU) Learning MCA
methodology
Celebrate success
Weston Park Service
Improvement EXPO
March 2017
OUTPATIENTS
IN PATIENTS
PHARMACY
NEWSLETTERS
Loved hearing about all the success – we need this
positivity
Sharing ideas - what other areas are doing
As new staff member great overview of all the projects
Our clinical lead
Chance for people to ‘show off and shine’
I thoroughly enjoyed it, very proud to work at WPH
Presentations were fantastic
Great celebration – thanks everyone
Opportunity to be honest about successes and failures
Interesting variation in improvement stories
5- teams together, Empowered , Enthusiastic staff
Newsletters
Opportunity to understand each other’s pressures
Let’s make it bigger next time
More people to attend to see the excellent work
More representation but difficult due to work
pressures
Lack of clinician in each team
Patient involvement not easy
Staff Capability to interpret data
Slow process at times
47
48
Pharmacy Radiotherapy (RT)
Outpatients (OPD)
In Patients Wards
WAU (assessment
unit)
CCTC
Day Case Services
Unit (DCSU) Learning MCA
methodology
Celebrate success
Overcome challenges
BARRIERS
49
Poor morale
No engagement / buy-in of key stakeholders
Belief that others should change first
Lack of opportunity / lack of time to attend meetings and work on projects
Complexity of service / Making changes that may affect other departments.
Lots of enthusiasm generating many ideas can make focussing on one area difficult
50
Leadership for change
• Maintain visible leadership
• Recognise and celebrate success
• Communication to keep engagement high
• Change is very tiring and often requires extra time and effort
• Staff need to know their contribution is valuable
• Address peoples barriers to change to prevent a fast return to “the old ways”
51
Lessons for Moving Forward
52
Now for……..
…….. Leading by
example
53
…….. Juggling!!!
Chemotherapy Capacity & Demand
Modelling
54
Long patient waiting times
55
Increasing Treatments
& Complexity
0
20
40
60
80
100
120
140
160
Mon
Wed
sF
riT
ues
Thu
rsM
on
Wed
sF
riT
ues
Thu
rsM
on
Wed
sF
riT
ues
Thu
rsM
on
Wed
sF
riT
ues
Thu
rsM
on
Wed
sF
riT
ues
Thu
rsM
on
Wed
sF
riT
ues
Thu
rsM
on
Wed
sF
riT
ues
Thu
rsM
on
Wed
sF
riT
ues
Thu
rs
WPH cyto unit daily IV chemo workloadMon 5th Sept to Fri 23rd Dec
In-house production
Pre-mades bought in
Capacity limit
Safe upper limit
56
Absorbing work pressures from
DGH’s
57
Multiple changes – complementing MCA work
Booking Rules & Staffing
58
Clinic and prescribing patterns
59
Results
61
Development of Chemotherapy Capacity Modelling Tool
62
63
64
65
66
67
Supervise Junior Doctors QIP’s
Supervise Junior Doctors QIP’s
…….I need a break from Juggling!
71
Transforming Our Hospital
Anne Hilton, Project Manager June 2018
72
73
Modernising the Centre of the Network
• Newly built Assessment Unit and modern Inpatient Wards
• Planned New OPD and Daycase Facilities
• Interconnecting walkway to acute specialties approved
Milly Finch Leadership Fellow - Pharmacy
Leadership fellow
• 50:50 funded post between Health Education England & Sheffield Teaching Hospitals
• A year out to work on a project, develop leadership skills and complete a PGCert in management & leadership
• Dose standardisation of chemotherapy CQUIN at Sheffield and associated DGHs
Dose standardisation of chemotherapy CQUIN
• NHSE developed a dose standardisation of chemotherapy CQUIN in 2016/17 to deliver quality improvements and drive transformational change within the NHS.
• Now going into the 3rd year of the CQUIN.
• 17 drugs targeted in year 1, additional 30 drugs in year 2.
Dose standardisation of chemotherapy CQUIN
0
500
1000
1500
2000
2500
0
50000
100000
150000
200000
250000
300000
350000
400000
450000
Ap
r-1
6
May
-16
Jun
-16
Jul-
16
Au
g-1
6
Sep
-16
Oct
-16
No
v-1
6
De
c-1
6
Jan
-17
Feb
-17
Mar
-17
Ap
r-1
7
May
-17
Jun
-17
Jul-
17
Au
g-1
7
Sep
-17
Oct
-17
No
v-1
7
De
c-1
7
Jan
-18
Nu
mb
er o
f do
ses p
rescrib
ed
Co
st (
GB
P)
Time
Total Cost year 1drugs
Total number ofdoses year 1
Dose standardisation of chemotherapy CQUIN
0
100
200
300
400
500
600
700
800
0
100000
200000
300000
400000
500000
600000
Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17
Nu
mb
er o
f do
ses p
rescrib
ed
Co
st (
£)
Time
A graph to show how expenditure of the year 2 dose banded drugs related to number of doses prescribed
Total cost of year 2 drugs
Total number of year 2doses
Leadership fellow
• Usually expected to carry out projects alongside 9 to 5
• Overall cost savings of a reduction in expenditure of over £70,000 a month over the CQUIN
• By hitting CQUIN set targets STH have received £94,425 from NHS England to date
Investing in Our People:
Modernising and Developing the Workforce
David Nicholls, Project Manager June 2018
81
82
• Organisational Development interventions for leaders, managers & staff to improve capability, capacity, teamworking & coaching:
8 x Events - Working Together As Leaders 8 x Events - Working Together as Multi- Professional Teams
• Next Steps will look at Workforce Performance & Development (Competency Framework / Appraisals / Succession Planning / Talent Management)
• Further leader, manager & staff development to improve personal & team capability
Right people, right place, at right time to deliver best
service possible
Improved Processes,
Patient Pathways to support new
ways of working
Staff being able to
perform at their best
more of the time
(see Appendix One)
• Detailed Process Maps of the whole Directorate
• Calderdale skills mix Identification on each part of the pathway / process
• Skills Mix Log (57 changes identified so far) and Workforce Modeller
• Workforce Plan
Workforce Skills Mix & Service Improvement
• Microsystems Empowering Staff to Develop Service Improvement Change to existing Pathways
• Re- modelling of new pathways across the network with workstream leads & key stakeholders (including patients & front line staff)
83
Process Mapped the Directorate
84
• The workforce skills mix events identify ‘who does what tasks now’ at each stage of the process and ‘who else could do the tasks in the future’
• It might be ‘bundles of activity’ that are moved to other staff or it could be a completely new role
• Calderdale Framework supports the change taking into account risk, safety and governance
Skills Mix Log
85
• The skills mix change log and modeller allows users to explore the impact of proposed changes in workforce capacity
• The Workforce Modeller allows visual representation of workforce peer group comparison
Skills Mix Log and Workforce Modeller
86
• Possible to identify the right service delivery person at each stage of the patient pathway
• You can change the skills mix safely with task analysis and mitigating actions
• This seems the best way to identify the best workforce model based on maximising capability and increasing capacity or reducing cost
• Key is a ‘holistic approach’ involving process mapping, workforce skills mix analysis, modelling & Organisation Development interventions to lead and support change.
• Requires sustaining and embedding through a mix of PDRM (Plan / Deliver / Review / Make Sense) & Performance Management & Development linked to PROUD values
Benefits • Accurate picture of workforce skills mix requirements for current activity and provides a
good base for future predictions in workforce needs
• Provides the qualitative and quantitative data for best business case for change
• Involving different levels of staff in the process you get high levels of support and motivation for change
What have we learnt so far?
Thank you
Any Questions ?