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Reducing Unwarranted Variation By Kam Kalirai Associate Director , Clinical Pathways
Gillian Smith, Consultant Urologist, Divisional Director , CPG Chair , TASS
Lila Dinner, Consultant Anaesthetist, Divisional Director, CPG Chair, SaS
Moving from Volume to Value
ML12: Reducing Variation in Care
Delivery While Improving
10th December 2018
#IHIFORUM
Nothing to Disclose
Kam Kalirai, Lila Dinner, and Gillian Smith today have no
relevant financial or nonfinancial relationship(s) within
the services described, reviewed, evaluated, or
compared in this presentation.
P1
Session Objectives
P2
#IHIFORUM
1. To understand the theory of reducing unwarranted variation
2. To outline methodology to deliver value at the RFL group of
hospitals
3. To share working example of methodology in action to reduce
unwarranted variation in the Prostate Pathway
4. To share the experience of digitisation process by the
Elective Hip and Knee pathway
CPG Theory and Methodology
3
CPG Programme Theory 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 hospitals
Ref: BMJ Qual Saf doi:10.1136/bmjqs-
2014-003627
4
Methodology
5
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)
Step 5
Continuously improve/ sustain
Plan Do Study Act
Clinical Practice Groups in practice
6
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 S
erv
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
CPG Implementation Group
CPG and Quality
Improvement Board Digital Board
Change Board
Clinical Standard and
Innovation Committee
Activity analysis
- Volume
- Secondary effects e.g. reduction in C section, non-elective
admissions
Quality and outcome metrics
- National clinical audit
Local Audit
- Pathway defined outcomes
- PROMS
Performance
- Waiting time performance
- Compliance (cancer, A&E, RTT)
- Pathway compliance
Cost benefit analysis
- Standardised framework
- Focus on cost not income
- PLICS
Prioritisation Matrix
7
CPG Pathways
8
Womens and Children
CPG
Better Birth
Induction of Labour
Early Pregnancy
Keeping Mothers and babies together
Wheeze and Difficulty in breathing
Transplant and Specialist Services
CPG
Right Upper Quadrant Pain
Liver Resection
Prostate Pathway
Haematuria
Acute Kidney Injury
Dermatology – cancer and non cancer
Anaemia
Inflammatory Bowel Disease
Dyspepsia
Surgery and Associated
Services
CPG
Acute Tonsillitis
Epistaxis
Cataracts
Elective Hip
Medical Retina
Elective Knee
Knee Acute Haematosis
Foot Ankle Injury
Fractured Neck Femur
Fractured Wrist
Shoulder Pain
Plastics Breast- Benign
Hand Trauma
Pre-operative assessment
Acute Lower Limb
Lower GI Cancer
Painless Rectal Bleeding
Medical and Urgent Care
CPG
Pneumonia
COPD
Heart Failure
Lung Cancer
Chest Pain
Pulmonary Embolism
Emergency Care Department
Frailty
Current State:
9
Presenta
tion of
SOB or
Wheeze
In hours
07.00-19.00
Out of hours
19.00- 07.00
Need a PGD
15 min target
time
Pt.
Present
Register
Start o2
therapy
by nurse
GP
Referrals
Does child
need
immediate
O2
Wait in
paediatric
waiting room
Does
child
nebuliser
inhaler
Immediate
chest
assessment
by
SHO/Medical
/ A&E DR /
senior nurse
Child seen
by
paediatrician
clinic
Doctor
prescribes
medication
Yes Walk
in
Paediatric
assessme
nt co-
located
with A&E
A&E
• Staff grade
• Time of
day
• Weekend
Great Variation.
Had ED medics
assess Paeds
ED Nurses (ooh (may
not be paed
trained) Triage
/obs child etc
Ambulance RAT by
consultant
99% Paediatric
trained will
triage child
Does child
need
immediate
medical
assessme
nt
Are you
6/12 or
GP
referral /
clinic
No
Child seen by ED
medic
Most days Paeds
called support
paediatric AD Paeds
OOHs.
10pm onwards
O2 should be
prescribed not on
drug chart
Variation in
practice when
Sao” 92%
Variation
in
practice
Yes
RISK Child waits
in waiting room
area but no
regular monitoring
Variation
Dose/route/quanti
ty/methods
/drugs/sterioids
Monitoring of
child's response
to treatment
Escalation of
process
understanding
No
Yes
No
Yes
Does
Child
need
resus
Yes
No No
Child placed in
bed space for
treatment
Has child
been fully
assessed
No
Co-design
input for
patient
planning
Nurse variation
in what child
needs
EDUCATION
Variation in child
discharge
Medic/Paediatrician
Child in
resus,
immediate
response
from paeds
Paeds Obs RFH
used for breach
avoidance
PAV * used as
breach avoidance
Is child
likely to
be
admitted
Does
child
need
further
monthly
TX
Yes
Yes
Yes
No
No
DR/Nurse plan
discharge/check list
education
Admission time of day
for this group of children
Age profile of admission
Greater than 24 hours
discharge
Child needs
admission
to ITU
Has the
child
been
referred
to paeds
Child in cubicle
recovers
Yes
No
Severity of assessment
Local
responsibility
Bed requested
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/
11
Measure
Type
Measure
(Variable)
Definition
(description)
Source Frequency Responsible lead
Outcome Completed observations
on admission
Numerator = Number of children that have a completed
set of observations following admission
Denominator = Number of children that are admitted to
A&E with Wheeze
Paper proforma Monthly Analytics following
digitisation: Team
Outcome
Completed severity score
Numerator = Number of children that have a completed
severity score within 15 mins of admission
Denominator = Number of children admitted to A&E with
wheeze
Paper proforma / Monthly Analytics following
digitisation: Team
Outcome Readmission rate Numerator = Number of children readmitted at 7 & 30
days
Denominator = Number of children discharged home with
wheeze
Firstnet Monthly Analytics following
digitisation: Team
Outcome
Patient satisfaction Numerator = Number of children and parents that report
that are satisfied with the care they receive
Denominator = Number of children admitted and on the
wheezy child pathway
Questionnaires / emotional hotspot /
Focus groups / video / interviews.
To be decided Nurse / Doctor and
patient co-design team
Outcome Patient education Numerator = Number of children that are discharged with
bespoke, accurate information that will keep them well
Denominator = Number of children discharged home with
wheeze
As above / readmissions that result in
poor education re condition and
requirements to stay well and correctly
take medication / non- smoking
environment etc
Monthly Adama, Jeanette and
Charlotte and the NUMH
Process Time to first assessment by
clinician
Numerator = Number of children that are admitted with
wheeze and assessed by clinician within 15 minutes
Denominator = Time of all children admitted with wheeze
to first assessment by clinician
Firstnet Monthly Analytics following
digitisation: Team
Process Time to steroid
administration from first
medical assessment
Numerator = Number of children that receive steroid
administration within an hour from first medical
assessment
Denominator = Number of children admitted with wheeze
that receive a medical assessment and prescribed steroids
Patient medical records or pharmacy but
the actual time will be written on the
A&E Cardex or drug chart
Monthly Analytics following
digitisation: Team
Process Number of children that
received the bundle of care
Numerator= Number of children admitted with wheeze
that receive the correct bundle of care following medical
assessment
Denominator = Number of children admitted with wheeze
that are prescribed the bundle of care
Patient records Monthly Analytics following
digitisation: Team
Measurement Plan
Future State
12
Self
Referral
to ED
15 min target time
GP
Referral
s
Triage
Saturations
HR
RR
Able to speak
Work of
breathing
BP
Temp
PEWS
PEFR
LAS
Assessment
of Severity
Mild/Moderate Sa02 > 92%
RR <40
HR<140
Can talk short sentences
or feeding well
Mild- Moderate wheeze
& recession
Severe Sa02 < 92% in air
RR >40
HR>140
Unable to talk or feed
Mild- Moderate wheeze
& recession
CONSIDER MOVE TO
RESUS
Life Threatening Sa02 <92% and any of
Silent chest
Poor respiratory effort
Altered consciousness
Cyanosis
MOVE TO RESUS
CALL SENIOR HELP
Severe Sa02 < 92% in air
RR >30
HR>125
Unable to talk
Mild- Moderate wheeze
& recession
Mild/Moderate Sa02 > 92%
RR <30
HR<125
Can talk short sentences
Mild- Moderate wheeze &
recession
Life Threatening Sa02 <92% and any of
Silent chest
Poor respiratory effort
Altered consciousness
Cyanosis
02
Keep Sa02
94-98%
Salbutamol via spacer 2-10 puffs via spacer
Give one puff every min up to 10 puffs according to response
Consider 20mg prednisolone if asthmatic or atopic
Reassess within 1 hour
Repeat salbutamol if needed
Salbutamol via spacer or nebuliser Salbutamol 10 puffs if in air
Nebulised salbutamol 2.5mg if in O2
Prednisolone 20mg within 1 hour of arrival
IV hydrocortisone if vomiting 4mg/kg (100mg max)
If poor response
3x back to back nebulised Salbutamol 2.5mg and Ipratropium 250mcg
Repeat nebulised salbutamol & ipratropium every 20 mins for 2hours as
needed
Salbutamol via spacer or nebuliser 3x back to back nebulised Salbutamol 2.5mg and Ipratropium 250 mcg
Prednisolone 20mg
IV hydrocortisone if vomiting 4mg/kg (100mg max)
Discuss with consultant/SpR
Repeat nebulised salbutamol & ipratropium every 20-30 mins
Consider IV therapy if not improving
Continuous saturation monitor
Hourly documentation
Medical review if deterioration
Review every 15 mins
Continuous re-assessment
Salbutamol via spacer 2-10 puffs via spacer
Give one puff every min up to 10 puffs according to response
30-40mg prednisolone within 1 hour of arrival
Reassess within 1 hour
Repeat salbutamol if needed
Salbutamol via spacer or nebuliser Salbutamol 10 puffs if in air
Nebulised salbutamol 5mg if in O2
Prednisolone 30-40mg within 1 hour of arrival
IV hydrocortisone if vomiting 4mg/kg (100mg max)
If poor response
3x back to back nebulised Salbutamol 5mg and Ipratropium 250mcg
Repeat nebulised salbutamol & ipratropium every 20 mins for 2hours as
needed
Continuous saturation monitor
Hourly documentation
Medical review if deterioration
Age
below 5
years
Age above
5 years
Salbutamol via spacer or nebuliser
3x back to back nebulised Salbutamol 5mg and Ipratropium 250 mcg
Prednisolone 20mg
IV hydrocortisone if vomiting 4mg/kg (100mg max)
Discuss with consultant/SpR
Repeat nebulised salbutamol & ipratropium every 20-30 mins
Consider IV therapy if not improving
Review every 15 mins
Continuous re-assessment
History
Atopic
Previous PICU?HDU
Number of exacerbations
Number of ED/Admission
Steroid courses in year
Interval symptoms/triggers
Smoking
Missed school
Assessment
Airway
Sao2
RR
Work of breathing
PEWS
Wheeze
Severity
Progress
0
20
40
60
80
100
120
140
160
Apri…
May…
June…
July…
Aug…
Sept…
Oct…
Nov…
Dec…
Janu…
Febr…
Mar…
Apri…
May…
June…
July…
Aug…
Sept…
Oct…
Nov…
Dec…
Janu…
Febr…
Mar…
Apri…
May…
June…
July…
Aug…
Sept…
Oct…
CPG Paediatric Difficulty in Breathing; volume of AE arrivals - Site: BH Site Series4 Mean Value
Trend Shift Outlier
0
10
20
30
40
50
60
70
80
90
100
Apri…
Ma…
Jun…
July…
Aug…
Sep…
Oct…
Nov…
Dec…
Jan…
Feb…
Mar…
Apri…
Ma…
Jun…
July…
Aug…
Sep…
Oct…
Nov…
Dec…
Jan…
Feb…
Mar…
Apri…
Ma…
Jun…
July…
Aug…
Sep…
Oct…
CPG Paediatric Difficulty in Breathing; volume of AE arrivals - Site: RFH Site
Series4 Mean
0
10
20
30
40
50
60
70
80
90
Apr…
Ma…
Jun…
July…
Aug…
Sep…
Oct…
Nov…
Dec…
Jan…
Feb…
Ma…
Apr…
Ma…
Jun…
July…
Aug…
Sep…
Oct…
Nov…
Dec…
Jan…
Feb…
Ma…
Apr…
Ma…
Jun…
July…
Aug…
Sep…
CPG Paediatric Difficulty in Breathing; time to initial assessment (mins) Site: BH Site
Control Limit MeanValue Trend
0
10
20
30
40
50
60
70
Ap
ril 1
617
May
16
17
Jun
e 1
617
July
161
7
Au
gust
16
17
September…
Oct
ob
er 1
617
November…
Decem
ber…
Jan
uar
y 1
61
7
Feb
ruar
y 1
617
Mar
ch 1
617
Ap
ril 1
718
May
17
18
Jun
e 1
718
July
171
8
Au
gust
17
18
September…
Oct
ob
er 1
718
November…
Decem
ber…
Jan
uar
y 1
71
8
Feb
ruar
y 1
718
Mar
ch 1
718
Ap
ril 1
819
May
18
19
Jun
e 1
819
July
181
9
Au
gust
18
19
September…
CPG Paediatric Difficulty in Breathing; time to initial assessment (mins) Site: RFH Site
Control Limit MeanValue Trend
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%Ap…
Ma… Ju…
Jul…
Au…
Se…
Oc…
No…
De…
Jan…
Fe…
Ma…
Ap…
Ma… Ju…
Jul…
Au…
Se…
Oc…
No…
De…
Jan…
Fe…
Ma…
Ap…
Ma… Ju…
Jul…
Au…
Se…
CPG Paediatric Difficulty in Breathing; % of patients reattending AE within 7 days): BH Site
Series4 Mean
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
April…
May…
June…
July…
Augu
…
Septe…
Octo…
Nove…
Dece…
Janu…
Febr…
Marc…
April…
May…
June…
July…
Augu
…
Septe…
Octo…
Nove…
Dece…
Janu…
Febr…
Marc…
April…
May…
June…
July…
Augu
…
Septe…
CPG Paediatric Difficulty in Breathing; % of patients reattending AE within 7 days): RFH Site
Series4 Mean ValueTrend Shift Outlier
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
18.0%
April…
May…
June…
July…
Aug…
Sept…
Oct…
Nov…
Dec…
Janu…
Febr…
Mar…
April…
May…
June…
July…
Aug…
Sept…
Oct…
Nov…
Dec…
Janu…
Febr…
Mar…
April…
May…
June…
July…
Aug…
Sept…
Oct…
CPG Paediatric Difficulty in Breathing; % of patients reattending AE within 30 days): BH Site
Series4 Mean ValueTrend Shift Outlier
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
April…
May…
June…
July…
Aug…
Sept…
Oct…
Nov…
Dec…
Janu…
Febr…
Mar…
April…
May…
June…
July…
Aug…
Sept…
Oct…
Nov…
Dec…
Janu…
Febr…
Mar…
April…
May…
June…
July…
Aug…
Sept…
Oct…
CPG Paediatric Difficulty in Breathing; % of patients reattending AE within 30 days): RFH Site
Series4 Mean ValueTrend Shift Outlier
Gateway review
Digitising 20 clinical pathways in EPR
Pathway Reporting – Based on Measurement
Plan
19 © Cerner Corporation. All rights reserved.
• Baselines
• Adoption & Pathway Compliance
• Outcome variance
How CPGs, QI and Digital interrelate
Clinical Practice Groups (CPGs)
Quality Improvement
(QI)
New Model Experience
Reduce
unwarranted
clinical variation
using standardised
pathways
Develop a
continuous
improvement
culture
Implement a
Group wide
EPR to
digitise
CPGs
Transform patient
care, safety and
outcomes
Benefits Realisation: Finance
Step 2
Current Pathway
Moments of Care
Pathway A and B
Step 1.
Identify Patient Cohort
Step 3.
Resources clinical and non-clinical resources to deliver moments of
care
Pathway A and B
Step 4.1
Identify Income based on current encounter data sets pathway A
(SLAM)
Step 5.1
Identify and describe encounter data set
Income for new pathway B
Step 4.2
Identify Costs
Based on moments of Care
Use traditional costing or PLICS
Step 5.2
Identify potential costs for new
pathway B
Step 6
Identification of contribution based on changes pathway A to
pathway B and reduction in variation
Step 7
Potential benefit realised
for plan
CPG 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 -
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 -
Moments of
care
R
e
s
o
u
r
c
e
Current State Future State
CPGs in Practice
22
Transplant and Specialist Services CPG Governance
Gillian Smith CPG Chair
Dinesh Sharma Deputy CPG Chair
23
CPG implementation process
Define
•Analysis and design of what is important to the Group, high value pathways both clinically and cost
•Clinical Pathways and Processes (service line mapping)
•Current programmes of work
Measure
•Quality Metrics (outcomes, safety, learning from patients and staff)
•Activity and Process Measures (RTT, Cancer PTL, external compliance, productivity)
•Finance and Cost analysis (PLICS, Potential Efficiencies, Planning)
Analysis
•Pareto analysis major pathways and processes suggest pathways approved by GEC
•Value stream map major pathways and processes for Clinical Practice Groups (CPG) development
•Random sample of the specific pathway cohort to understand degree of unwarranted variation
•Patient and Staff feedback (patient co-design)
Improve
•Based on evidence based practice, outcome data understand the degree of unwarranted variation
•Redesign pathways and develop prototype pathways for testing using model for improvement
•PDSA cycles QI improvement aligned to CPG development
•Benefits realisation
•Planning implementation of improvement
Continuous Improvement
•Agree standard, develop standard operating procedures and clear measures for monitoring performance
•Continuous monitoring on agreed standards and regular review
•Sustainability and continuous improvement
24
Workshop 1
Workshops 2-4
Workshops 7
This is where
we are.
CPG Core Team Support Structure
Chris Streather
Group Medical Director
John Connolly Group Programme Director CPG
Core CPG Team:
Kam Kalirai: Associate Director, CPGs
Scott Wilson: CPG Senior Analyst: CPG
Shuang Yang: CPG Analyst
Head of Finance: Neil Corless
Lorraine Gallagher
CPG Programme Manager – WC&I
Ann Woodward CPG Programme Manager - TASS
Rachel Brady
CPG Programme Manager – M&UC
Helen Wark
CPG Programme Manager – SaS
Gillian Smith: CPG Chair Transplant and Specialist Services (TASS)
Dinesh Sharma: Deputy CPG Chair
Beth Foley: Director of Operations:
Anne McReynolds: Divisional Director of Nursing
Hospital
Executive Team
Transplant and Specialist Services (TASS) CPG: Pathway Development Teams Group Wide
Right Upper Quadrant Pain Anaemia
HPB Prostate Pathway
Dermatology Non-Cancer Haematuria Pathway
Dermatology Cancer Inflammatory Bowel Disease
Hospital
Executive Team
Hospital
Executive Team
Divisional Analysts
Ashkan Sorour
Divisional Business Analyst
Define measure, analyse and Test…
Multidisciplinary team and patient involvement
Map current pathway
Goals and measures
Identify your specific patient cohort
Evidence base, national clinical audit
Redesign pathway
Test pathway (PDSAs)
Understand the degree of unwarranted variation quality outcomes
Benefits realisation
Planning for implementation
• Spread and sustainability of improvement
Pathway Team:
Prostate
Aim:
“We will provide an expert opinion with quick access to
tests to tell you if you have cancer and give you a
personalised plan of care”
The Team
28
Site
Ashoke Roy Consultant and Pathway Lead RFL
Dan Cohen Urology Consultant RFL
Fionnuala McCarthy CNS RFL
Jenny Reid CNS RFL
Lizzi Parsons Senior Ops Manager, Nephrology,
Urology and Renal
RFL
Emma Davidson Assistant Ops Manager, Urology RFL
Gopal Nair Consultant NMUH
Paras Singh Consultant Royal Free
Chris Heman-Acke Associate Specialist Royal Free
Jeevan Reddy Staff grade Royal Free
Akhtar Hussein, Locum Consultant Royal Free
Kimberly Ellis Service Manager NMUH
Current State: Prostate Cancer pathway
Patient called
by OAC to
confirm
appointment
Patient
informed and
letter sent by
OAC
Patient booked
into Tuesday
clinic
(5 slots)
OAC book
patients into
clinic
No
Has the
patient
confirmed the
appointment?
Yes Patient sees
consultant
Mr Singh
Miss Smith
Patient checks
in to 2 week
target
appointment
(Tuesday)
Patient sent
first class letter
Patient
completes as
IPSS
questionnaire
IPSS:
International
Prostate
Symptom
Score
Flow rate
Bladder scan
Dip stick urine
Appointment
slots 20 mins
Can take 2
hours
(AM clinic)
Patients do not
like to travel
with full bladder
2 week target
Patients
Pathway
OAC
Prepared by Kam Kalirai Associate Director Service Improvement 29
Does patient
agree to
investigations?
Patient discharged
with advice or
routine follow in 6
months
Is patient
suitable for
MRI??
Clinician decides
on bone scan or
CT
Patient has MRI MRI report
generated
Takes up to 10
days
Will be ready for
MDT
Within 7 days
(moving to same
day)
Patient
discussed at the
MDT and
outcome agreed
Yes
No
Yes
MDT
Every Friday
CNS will action
the outcomes
Other CNS try
and cover A/L
(delays)
Patient
telephoned and
outcomes
explained
CNS/Dr
Letter sent to
patient and GP
by CNS
(Dictate IT)
No
Clinician decides
on bone scan or
CT
No
Is it a day
case?
Patient offered a
Template biopsy
Patient booked
into 2 week OPD
Patient booked
for a TRUS
biopsy
Wed PM
No Patient choice
7 – 10 days
2 weeks later
Histopathology
variation in
results
turnaround
CNS leads clinic
to discuss
outcomes
Patient checks
into CNS clinic
Patients sees
CNS to discuss
results
Does
patient
have Ca?
Back to MDT
F/up in 6 months
PSA levels
Is it High/
Intermediate
?
Patient booked
for a bone scan
Is it low?
No No
Yes Yes Yes
Yes
Does patient
require
investigations?
Patient
discussed at MDT
Treatment options
discussed SMDT
Options reviewed Options given to
patient Radiotherapy
(RFH)
Radical Surgery
(UCLH)
Brachytherapy
(Barts)
Focal Therapy
(UCLH)
Localised
Disease Therapy
Patient Codesign: Patient Shadowing
Pre clinic preparation
• Information prior to appointment √
• Additional information from nurse √
30
1st consultation
• All tests on same day √
• Clear about what was happening √
• No-one available to help patient with
finding MRI room X
MRI scan
• Patient expected √
• MRI delayed as patients needed to
urinate X
• No family or friends present during MRI X
Pre clinic preparation
• Copy of prostate cancer charity booklet on
PSA be sent to all patient pre clinic
• Inform patients that they can bring a family
of friend / bring a book as it’s a long
appointment
• Provide written information on MRI scan in
advance of appointment
• Timeline is very tight and requires strict
planning. Administrative support is key
• Further planning on when to test flow rate to
avoid MRI delay. 2 early slots and 2 late
slots, early patients could just do MSU and
then flow rate after MRI.
Dashboard Display of Measurement Plan Qlikview cancer metrics – 7 days, 38 days and 62 days + PTL
31
Prostate 2WW diagnostic pathway
‘I saw a consultant within four days of referral. He
immediately after investigation sent me for an
MRI scan which followed the consultation within
minutes. He had the results within 1.5 hours
which he followed up with a set of biopsies all
within 4 hours, which I and my doctor found to be
exceptional. Everyone was very courteous and
sympathetic. Everything was very efficient. Three
cheers for the NHS thank you very much’.
32
Context of increasing demand for prostate 2WW appointments
Latest figures show that from April to
July 2018, 14,479 patients received
treatment for a urological cancer - an
increase of 3,929 (36%) compared to
the same period in 2017 (BBC website Sept 18)
33
London Cancer Network Jan 16 – Feb 18
34
100 % of patients
referred before
Day 38 at
February 18
Impact of increasing referrals on prostate 2WW pathway
•Pathway built to manage up to 36 referrals a week until May, then increased to 42 referrals •80% will require an MRI with hot reporting
•Many of these will need a same day TRUS biopsy or a template biopsy on another day
•Whole system needs to be able to adjust to changes in demand
35
Objective of the pathway are…
• All patients seen within 7 days of referral
• All patients have same day review with MRI result
• All patients have same day biopsy if appropriate (depending on type of biopsy and site)
• Diagnosis given within 28 days
• All patients who require definitive treatment (surgical) are referred before day 38 (ITR)
• All patients have access to dedicated CNS and administrative support
36
Dashboard Display of Measurement Plan
37
Decline in 38 day ITR
performance partly due
to increased demand
post Feb 18
Variation from the pathway – Where do we need to improve?
38
• Audit carried out of 114 patients on prostate PTL in September. Excluded all on PTL < 21
days, n = 72
• Of these, 21 had a fusion or template biopsy; 4 had a same day TRUS biopsy and 27 had a
TRUS biopsy, but not on the day (variation from the pathway)
Support colleagues to
make decision re
biopsy in clinic where
possible
Move to template
biopsies under local
anaesthetic is future
aspiration
Work with colleagues
in radiology to align
MRI reporting with
clinic cut-off times
Review pathway via
Chase Farm clinic
39
55%
65%
75%
85%
95%
105%
2017/
18
Q1
Ap
r
2017/
18
Q1
Ma
y
2017/
18
Q1
Ju
n
2017/
18
Q2
Ju
l
2017/
18
Q2
Au
g
2017/
18
Q2
Se
p
2017/
18
Q3
Oct
2017/
18
Q3
Nov
2017/
18
Q3
Dec
2017/
18
Q4
Ja
n
2017/
18
Q4
Fe
b
2017/
18
Q4
Ma
r
2018/
19
Q1
Ap
r
2018/
19
Q1
Ma
y
2018/
19
Q1
Ju
ne
2018/
19
Q2
Ju
ly
2018/
19
Q2
Au
g
2018/
19
Q2
Se
p
62-day wait for first definitive treatment following urgent GP referral - Prostate Reporting Period: April 17 - September 18 Target: 85%
Dashboard Display of Measurement Plan Qlikview cancer metrics – 7 days, 38 days and 62 days + PTL
Same day MRI metrics from Infoflex
40
Digitisation of Prostate Pathway
41
Cost Benefit Analysis - prostate
42
Pathway Current Future Diff Diff (%)
Prostate 380 380 - 0%
Costs of pathway (£k)
• Notes on Income and Commissioning effects:
• Anomaly in coding of MRI at BH as Without Contrast
• Same day activity that happens in an OP setting is significantly under-recorded
which should be corrected through digitisation (e.g. OP First, Uroflowmetry, MRI,
OP Follow Up and, for some, OP TRUS Biopsy can all happen on the same day but
often only an OP First is billed to the Commissioners) – possibly an opportunity to
review a pathway tariff to incentivise same day activity
• Cost effects:
• Substantial changes to delivery costs per referral occurred before the
introduction of the Pathway Development Team
• Future state is under review to ensure staff across the service are working
at the top of licence
Implementation Plan
• MDT working across disciplines to implement changes
• Ongoing liaison with colleagues in radiology around building resilience into
prostate pathway
• Reintroduce phone call to patients with the appropriate script to prepare them
for an all day consultation – OAC?
• New pathway vulnerable to increases in demand – capacity needs to flex
across the whole system: MRIs / biopsies etc. Contributed to reduced
performance February 18 onwards, along with other factors
• Apply learning from Patient Shadowing and audit of PTL (pathway variance)
• Applying learning to NMUH. Issues around consultant capacity and access to
MRI scans, but progress is being made
• Continue with pathway digitisation October / November 18
43
Surgery and Associated Services (SAS)
CPG Governance
CPG Chair Lila Dinner, Consultant Anaesthetist
CPG Deputy Chair Susanne Althauser, Consultant Ophthalmologist
44
CPG implementation process
Define
•Analysis and design of what is important to the Group, high value pathways both clinically and cost
•Clinical Pathways and Processes (service line mapping)
•Current programmes of work
Measure
•Quality Metrics (outcomes, safety, learning from patients and staff)
•Activity and Process Measures (RTT, Cancer PTL, external compliance, productivity)
•Finance and Cost analysis (PLICS, Potential Efficiencies, Planning)
Analysis
•Pareto analysis major pathways and processes suggest pathways approved by GEC
•Value stream map major pathways and processes for Clinical Practice Groups (CPG) development
•Random sample of the specific pathway cohort to understand degree of unwarranted variation
•Patient and Staff feedback (patient co-design)
Improve
•Based on evidence based practice, outcome data understand the degree of unwarranted variation
•Redesign pathways and develop prototype pathways for testing using model for improvement
•PDSA cycles QI improvement aligned to CPG development
•Benefits realisation
•Planning implementation of improvement
Continuous Improvement
•Agree standard, develop standard operating procedures and clear measures for monitoring performance
•Continuous monitoring on agreed standards and regular review
•Sustainability and continuous improvement
45
Workshop 1
Workshops 2-4
Workshops 7
This is where
we are.
CPG Core Team Support Structure
Chris Streather
Group Medical Director
John Connolly Group Programme Director CPG
Core CPG Team:
Kam Kalirai: Associate Director, CPGs
Scott Wilson: CPG Senior Analyst: CPG
Shuang Yang: CPG Analyst
Head of Finance: Neil Corless
Lorraine Gallagher
CPG Programme Manager – WC&I
Helen Wark CPG Programme Manager – SaS
Rachel Brady
CPG Programme Manager – M&UC
Ann Woodward
CPG Programme Manager – TaSS
Lila Dinner: CPG Chair Womens and Children
Susanne Althauser: Deputy CPG Chair Womens and Children
Kate Cox/Linda McGurrin: Director of Operations:
Susanne Tierney / Jacqueline Sinclair: Divisional Director of Nursing
Hospital
Executive Team
Surgery and Associated Services CPG:
Pathway Development Teams Group Wide
Elective Hip / Knee Cataracts
Vascular Acute tonsillitis
Epistaxis Benign breast
Pre-operative assessment Lower GI Cancer
RUQP - Simple
Hospital
Executive Team
Hospital
Executive Team
Divisional Analysts
Chiara Mauri
Divisional Business Analyst
Chase Farm Hospital Executive Team
Natalie Forrest, Managing Director
Alan McGlennan, Medical Director
CPGs in practice
The total joint replacement pathway
Why did we prioritise total joints?
ACTIVITY
• Over 1,000 joint replacements / year
• Avg. LoS 4.8 days
• Moving all non-complex activity to CFH
QUALITY AND OUTCOMES
• Average mortality rate average
• 1 year and 5 year revisions average
• Patient reported outcomes average
PERFORMANCE
• LoS high compared to others
• Waiting time 18.6 weeks in OP
• Low submission rate for the total joint
national reporting requirements
COST BENEFITS
• Yearly spend of >£5.4m
• Average cost of THR differs by £755 across
site and by £550 for TKR
Define Measure Analyse Design &
test Sustain & improve
• Current pathway
• Clinical
guidelines
• Patient
experience
• Value stream
map
• Clinical
outcomes
• Activity
• Performance
• Cost / efficiency
• Patient safety
• Pareto analysis
• Gap analysis
• Value
assessment
• Understand
clinical variation
• Design ideal
pathway
• Model future
pathway
• Test pathway
• Measures for
tracking success
• Track impact
• Continuous
monitoring to
drive
improvement
• New guidelines /
research
Define Measure Analyse Design & test Sustain & improve
Understanding variation within the current pathway
Define Measure Analyse Design & test Sustain & improve
Understanding variation within the current pathway
15%
20%
25%
30%
35%
40%
45%
Ap
r-16
Ma
y-1
6
Jun
-16
Jul-
16
Au
g-1
6
Se
p-1
6
Oct-
16
Nov-1
6
Dec-1
6
Jan
-17
Fe
b-1
7
Ma
r-1
7
Ap
r-17
Ma
y-1
7
Jun
-17
Jul-
17
Au
g-1
7
Se
p-1
7
Oct-
17
Nov-1
7
Dec-1
7
Jan
-18
Fe
b-1
8
Ma
r-1
8
Ap
r-18
Ma
y-1
8
Jun
-18
Jul-
18
Au
g-1
8
Se
p-1
8
% of patients, over 50 with hip or knee pain presenting to the outpatient clinic where surgical treatment is deemed to be necessary Control Limit Mean
Value Trend
Shift Outlier
Trajectory Goal
Define Measure Analyse Design & test Sustain & improve
Understanding variation within the current pathway
17
22 23
25
27 27 28
33 33 33 34
36 37
0
5
10
15
20
25
30
35
40
1 2 3 4 5 6 7 8 9 10 11 12 13
% o
f p
ati
en
ts b
ein
g lis
ted
fo
r su
rgery
in
ou
tpati
en
ts
% converting to surgery
Define Measure Analyse Design & test Sustain & improve
0
1
2
3
4
5
6
7
Ap
r-16
Jun
-16
Au
g-
16
Oct-
16
Dec-
16
Fe
b-
17
Ap
r-17
Jun
-17
Au
g-
17
Oct-
17
Dec-
17
Fe
b-
18
Ap
r-18
Jun
-18
Au
g-
18
Oct-
18
Days
Median length of inpatient stay - Elective Hip Control Limit Mean Value Trend
Shift Outlier Trajectory Goal
0
1
2
3
4
5
6
Ap
r-16
Jun
-16
Au
g-
16
Oct-
16
Dec-
16
Fe
b-
17
Ap
r-17
Jun
-17
Au
g-
17
Oct-
17
Dec-
17
Fe
b-
18
Ap
r-18
Jun
-18
Au
g-
18
Oct-
18
Days
Median length of inpatient stay - Elective Knee Control Limit Mean Value Trend
Shift Outlier Trajectory Goal
Define Measure Analyse Design & test Sustain & improve
Understanding variation within the current pathway
0
1
2
3
4
5
6
7
8
1 2 3 4 5 6 7 8 9 10 11 12 13
Av
era
ge l
en
gth
of
sta
y (
days)
Consultant
Average length of stay for hip and knee patients in days by consultant
Average LoS (Knee)
Average LoS (Hip)
Define Measure Analyse Design & test Sustain & improve
Deciding on the
future state
Patient forum
Feedback at each pathway step
Seeing your GP for a referral
Waiting for your hospital appointment
Your first hospital appointment
Coming to joint school
Coming to pre-operative assessment
The night before surgery
Day of surgery
Recovery
Being on the ward
“My questions were answered
and it was a good explanation”
“Reasurring, lots of information”
“Noone told me about joint
school”
“I was worried to death – there
was no need to be. Everyone
was very nice” “Worrying about whether I
would wake up”
“I stayed in for two days
waiting for a phone call and
just got a text”
“The staff have all been very nice”
“It would be better if the therapists
came more – you need the
encouragement”
“Nothing is too much trouble”
Progress
Remove full hip precautions
• Literature review on benefits of
restrictions
• Discussing practice at other NHS Trusts
• Agreeing advice given and restrictions or
full precautions for patients if required
Moving to virtual follow-up reviews
• Literature review on benefits of virtual f/up
review
• Reviewing practice at other NHS Trusts
Define Measure Analyse Design & test Sustain & improve
Standardisation starting to show improvements already
0
0.5
1
1.5
2
2.5
Ap
r-16
Ma
y-1
6
Ju
n-1
6
Jul-1
6
Au
g-1
6
Se
p-1
6
Oct-
16
Nov-1
6
Dec-1
6
Ja
n-1
7
Fe
b-1
7
Ma
r-17
Ap
r-17
Ma
y-1
7
Ju
n-1
7
Jul-1
7
Au
g-1
7
Se
p-1
7
Oct-
17
Nov-1
7
Dec-1
7
Ja
n-1
8
Fe
b-1
8
Ma
r-18
Ap
r-18
Ma
y-1
8
Ju
n-1
8
Jul-1
8
Au
g-1
8
Se
p-1
8
Nu
mb
er
of
Att
en
dan
ces
First Outpatient Attendance Date
Mean number of outpatient attendances from referral to operation
Control Limit Mean
Value Trend
Shift Outlier
Trajectory Goal
Define Measure Analyse Design & test Sustain & improve
Standardisation starting to show improvements already
0
2
4
6
8
10
12
Ap
r-1
6
Ma
y-1
6
Jun
-16
Jul-
16
Au
g-1
6
Se
p-1
6
Oct-
16
No
v-1
6
De
c-1
6
Jan
-17
Fe
b-1
7
Ma
r-17
Ap
r-1
7
Ma
y-1
7
Jun
-17
Jul-
17
Au
g-1
7
Se
p-1
7
Oct-
17
Nov-1
7
Dec-1
7
Jan
-18
Fe
b-1
8
Ma
r-18
Nu
mb
er
of
Pati
en
ts
Number of patients who attended surgery without either joint school appointment or pre-operative assessment
Control Limit Mean Value
Trend Shift Outlier
Trajectory Goal
Define Measure Analyse Design & test Sustain & improve
0
1
2
3
4
5
6
Ap
r-1
6
Jun
-1
6
Au
g-
16
Oct-
16
Dec-
16
Fe
b-
17
Ap
r-1
7
Jun
-1
7
Au
g-
17
Oct-
17
Dec-
17
Fe
b-
18
Ap
r-1
8
Jun
-1
8
Nu
mb
er
of
Att
en
dan
ces
Mean Number of outpatient attendances post-op before discharge -Elective Hip
Control Limit Mean
Value Trend
Shift Outlier
Trajectory Goal
Define Measure Analyse Design & test Sustain & improve
Clinical
leadership Measurement Governance Digitisation
SUSTAIN & IMPROVE
On-going improvement part of business as usual
The ‘digitisation’ process
6
3 © Cerner Corporation. All rights reserved.
Reduction in
unwarranted
variation
=
Quality
Improvement
Analytics Solution
Pathway digitisation
• Meeting the teams and
understanding roles
• Seek mutual understanding
of the ideal pathway
• Re-created ‘brown paper’
from a digital perspective
• 50% build complete by
workshop two
• Multiple iterations – feedback
loop
• Scenario testing
Digitised pathway
Decision tree to ensure all patients
appropriately listed for surgery and to
aid ease of documentation
Order set – order the entire pathway
from POA to 1 year virtual follow-up at
point of listing patient
Anaesthetic protocol built into Cerner
order – will report on deviations and
reasons
65
Digitised pathway
Standardised post-op note template –
removes need to handwrite repeated
information
Phased recovery – not based on days
but achieving milestones. Separate
for medical, therapies and nursing
teams. Prompts early discharge
paperwork completion.
66
Pathway Reporting - Overview
67 ©
Cerner
Corporat
ion. All
rights
reserved
.
• Baselines
• Adoption & Pathway Compliance
• Outcome variance
Making the digital system “real”
For each critical step, what are
the enablers to ensure success?
People
Process
Technology
Environment
Human factors to change
Clinical
leadership
INTERNAL DATA EXTERNAL DATA
QUALITY
EXPOSURE
OWNERSHIP
Data
driven d
ecis
ions
The test and learn approach
1 patient
1 day
1 clinic
Critical mass
Clear incentives
Questions
