A guide to commissioning cardiac surgical services

NHSNHS Improvement

NHS Improvement Heart

A guide to commissioningcardiac surgical services

HEART

LUNG

CANCER

DIAGNOSTICS

STROKE

Contents

Foreword 3

Introduction 4

Improvement to the patient pathway -summary of recommendations 5

Access to surgery 7

Elective pathways 8

• Redesign of the cardiac surgery patient pathway 9

• Ensuring patients are fit for surgery and reducing delays in thecardiac surgical patients pathway 15

• Process changes significantly increase 18 week performancein cardiac surgery 18

• Tackling change - the teamwork way 20

• Cardiac surgery and 18 weeks - a pan network approach 22

Cardiac surgery trends - the national picture 24

Non-elective pathways 29

• ‘Urgent or non urgent’, that is the question 32

Discharge planning 35

• Improving the patient experience for cardiacsurgery pathways 36

• Reducing length of stay of elective cardiac surgicalpatients to a one night stay post operatively 39

Quality - the current context 42

Supporting Information 49

Cardiac Data Dashboard 50

The Sustainability Toolkit 51

NHS Improvement System 52

Good planning can inspire change thatleads to improvements 53

References and supporting information 54

Acknowledgements 56

Cardiac Surgery National Project Team 57

A guide to commissioning cardiac surgical services

3

Foreword

There has been substantial progress incardiac surgery over the last ten years.Surgeons are operating in a more timelyfashion on more people with higher levelsof risk and co-morbidity, yet they aredelivering better outcomes.

The national audit has been a majordriver for success and so has the work ofNHS Improvement where a focus onsystems that deliver high quality care hasbeen pivotal.

Now we face an even bigger challenge.Over the last ten years, we have benefitedfrom higher levels of growth in NHSexpenditure than at any time in its historyand cardiac services have been substantialbeneficiaries. Today, we have to recognisethat it is inevitable that the wider financialsituation is going to impact on each andevery one of us. This challenge, to delivercontinuing high quality care while at thesame time delivering it much moreefficiently, is the biggest challenge thathas faced us in the history of the NHS.

www.improvement.nhs.uk/heart

It is a clinical challenge, since it is, in theend, clinicians that spend the money. So,every clinician is required to examine theirpractice and actively look for ways todeliver care more efficiently, removingwaste and saving money.

In my last foreword (Improving the patientexperience: Developing solutions todelivering sustainable pathways in cardiacsurgery, March 2009), I pointed out thatthere are still long delays in the non-elective pathways that lead to heartsurgery. These delays have not gone awayand still need to be addressed. Many ofthe issues regarding pre-assessment andtheatre scheduling are other exampleswhere the priority projects have addressedthe key efficiency measures over the years.Now, we cannot rest on our laurels, thereremains much to be done.

Professor Roger Boyle CBENational Director for Heart Diseaseand Stroke, Department of Health

Professor Roger Boyle CBE

A superficial view would suggest thatcardiac surgery has changed little over thelast twenty years – we still spend most ofour time in theatre grafting coronaryarteries and replacing heart valves.However, closer inspection shows markedchanges in the type of patient being seenby surgeons. The era of operating onpatients with heart valve disease onlywhen their symptoms became severe haspassed and now many patients areoperated on specifically to preventdeterioration rather than improvesymptoms. This change means thatpatients having heart valve surgery are nothaving their operations when they havebegun to slip down the slope of clinicaldeterioration when ‘risky’ surgery is theonly prospect of survival but when theyare well.

This change has occurred alongside ajustified increase in the expectationspatient have of what can be done forthem and as evidence of this we areoperating on an increasingly elderlypopulation of patients. In 2008, 25% ofall patients undergoing coronary arterybypass surgery were over 75 years of age.


4 www.improvement.nhs.uk/heart

Introduction

This has increased from 10% in 1999 andhas brought challenges in terms ofincreasing co-morbidity but resultsfollowing surgery continue to improve.Mortality following CABG has fallen from1.9% in 2004 to 1.5% in 2008. Thechanges in cardiac care set out in theNational Service Framework have also hada marked effect on the way patients aretreated we have found that we areoperating on many more patents on anurgent basis as appropriate treatments arenow available much earlier in the timecourse of patients’ disease course.

The attention focused on cardiacdiagnostics and 18 week pathways as partof the portfolio of work led by NHS HeartImprovement during 2007/08 highlighteda need to shift attention to cardiac surgeryto develop sustainable solutions. EightNHS Trusts supported by their local cardiacnetworks have been involved asdemonstration sites during 2008/09testing out new approaches to care andimprovement to frontline patient services.

Steve Livesey

The focus of work undertaken by thecurrent project sites considered to beconstraints within the management ofsmooth patient flows includes thefollowing:

• Pre-admission provision.• Referral management services.• Scheduling.• Discharge and post operative caremanagement.

This report aims to share the successeswith the wider NHS providing a range ofexcellent examples of where local teamshave delivered innovation in their serviceto improve the efficiency and experiencefor patients and staff.

Steven LiveseyNational Clinical LeadNHS Improvement - Heart

Lessons drawn from projectdemonstration sites suggest thatquality improvement to electivecardiac surgery services requiressmarter working, a data drivenapproach to understanding processperformance and process variation,the enhancement of staff roles and ashared overview of the patients’journey and patients experienceacross referring providers and thetertiary centre.

Cardiac networks continue to beuniquely placed to assist with thedelivery of the quality agenda bylinking clinicians, managers andcommissioners together in everyaspect of the patients’ journeythrough primary, secondary andtertiary care.

Networks are well positioned toreflect local relationships betweenclinicians across organisationalboundaries to further develop safeand effective surgical pathways ofcare for patients by providing anopportunity for clinicians andmanagers to work together on theredesign agenda and to gainagreement on:

Improvement to the patient pathway - summary of recommendations

1. Service priorities2. Models of care and idealised

patient pathways3. The approach to the change

initiative and the identificationof root cause issues andsolution development

4. The methods/approaches tochange management• Strategically in gainingagreement to change servicemodels and contractualarrangements;

• Operationally in the applicationof improvements including theadoption of processes that holdand sustain the gains.

This document identifies a range ofinitiatives that have been successfullyemployed in meeting the challenge of18 weeks in elective surgery whichinevitably required the focus toextend to systems and processes thatsupport the whole surgical process,elective or otherwise.

The detailed case studies within thepublication aim to share theknowledge and learning from thesepilot sites which breaks down into thefollowing four areas:

one:1. Referral management servicesThere is often an information gap between referring provider units andthe tertiary centre:• Manage variation in the referral process from provider units andin-house reducing multiple referral points through development ofagreed referral criteria to relieve pressure on waiting times for surgery.

• Develop central systems for optimising referral efficiency bystreamlining administrative process and referral management linkingclinical teams across secondary and tertiary care to triage referrals andadvise on appropriate tests/investigations.

• Introduce pooled referrals across consultants as this significantlyimpacts on waiting times.

• Use appropriate clinical staff to confirm referrals are complete anddiscusses work up criteria with referrer.

• Introduce a single point of contact at the tertiary centre for referrersand patients. The role of the trained clinical coordinator is pivotal intracking individual patients and in ensuring the consultant team keptinformed of significant events.


5www.improvement.nhs.uk/heart

two:2. Pre admission provision• Manage variation in pre assessment services.• Adopt investigation guidelines which state agreed timeframes from test to

planned date of surgery and only carry out investigations which arerelevant, indicated and likely to alter management.

• Introduce ‘one-stops’ for outpatients to avoid wasted clinics for medicalstaff and patients.

• Maximize opportunities for multidisciplinary team assessment andemphasise use of technology an example would be use of video linkbetween hospitals.

• Maximize pre assessment opportunities as they help manage patient healthand reduce risk.

• Maximize pre admission diagnostics particularly in referring district generalhospitals by establishing agreed pre operative protocols.

• Maximize patient work up prior to admission and agree the schedule foreach clinical scenario for example surgery for coronaries, mitral valve, aorticvalve and combination. This has a beneficial effect on waiting times.

• Train and support key clinical and managerial staff to deliver some of thework undertaken by junior doctors reconfigure services to developopportunities for other health care professionals to widen their skills andscope of relationship with patients. An example is the patient ‘navigator’role which benefits patients and families by providing information andsupport following attendance at outpatient and pre assessment clinic.

• Maximize the scope of extended practice for nursing roles working in preoperative assessment clinics functioning as part of the consultant led teamto streamline cardiac surgery patient care.

• Maximize inclusion of different staff groupings for example anaesthetistsinvolved in pre assessment to ensure that all patients presenting for surgerywill be adequately assessed as this can reduce cancellation rates, improveoperating theatre efficiency and increase patient satisfaction.

• Continue to provide information and support.

three:3. Scheduling• Move toward Day of Surgery admission as the standard of care forelective surgery as this can improve the patient experience considerably.

• Maximize theatre efficiency by reducing waste in the system forexample right staff in place at the right times with the right equipment.

• Optimise theatre capacity by reducing slot cancellations (clinical/nonclinical) and by scheduling procedures that assist with patient flowthrough ITU/HDU.

• Where ever possible pool lists to reduce waiting times.• Procedure complexity scores developed to assist with schedulingdeveloped as part of MDT.

four:4. Discharge and post operative care management• Manage variation in post operative clinical management practice.• Manage variation in discharge patterns reducing length of stay.• Start discharge planning at pre assessment to identify requirement for

support and home aids to reduce requirement for delayed discharge.• Involve a range of health care professionals for example occupational

therapists in discharge planning at pre assessment particularly wherepatients and in particular the elderly may have complex needs.

• Discharge assessment should form part of the central patient recordavailable throughout the patient journey to all staff groups.

• Move toward nurse led discharge.

Note: The resources developed by these pilot sites are availablethrough the web links and NHS Improvement system at:www.improvement.nhs.uk/heart/sustainability





The reductions in waiting times envisagedby the NHS Plan are now a reality and inorder to meet the expectations of shorterwaits, the way in which patients aremanaged and referred from onedepartment to another as their treatmentprogresses has had to improve.

As a result, the majority of units in thecountry have adopted a network-agreedsystem of investigating and referringpatients on for further treatment, such ascoronary artery bypass graft (CABG).The rapid progress of patients through thesystem has been greatly facilitated by theadoption of common protocols forinvestigation and agreed timelines forreferral. Many of the steps in thepathway are now overseen by specialistnurse practitioners rather than juniordoctors and this has contributed greatly tothe efficiency of the process.

Access to surgery

The need for non-medically qualified staffto play an even greater role in patients’assessment and treatment is becomingapparent as the effects of the reduction injunior doctors hours are starting to bite.It is vital that training organisations workwith trusts to ensure the workforcecontinues to develop to ensure timelydelivery of care in the future.

Elective care refers to care that ispre-arranged (planned). Managingelective and emergency patient flowsfrom decision to admit to dischargecan prove challenging fororganisations as they work to delivera number of national and localquality and performance targetsamong them 18 week referral totreatment admitted pathways, fourhour A&E target and locally agreedreduction in length of stay andinterhospital transfer times. Yetlooking at the pathway of care fromthe patient’s point of view making itsmoother, more accessible, lesscomplicated and less subject to delaysis necessary given the volume ofpatients who receive care.

With cardiac surgery often coming atthe end of a lengthy diagnosticpathway the delivery of shorterwaiting times completed within 18weeks is increasingly demanding.Specialty beds often occupied bymedical outliers and a lack ofintensive care beds due toemergencies or the clinical status ofpatients intensify the complexity ofdelivering smooth patient flows.



Elective pathways

Before cardiac surgery can be carriedout a range of resources have to bebrought together at the right timeand the right place: surgical staff,nursing staff, anaesthetist, theatretime, beds. Remove any one of thesecomponents and the operation has tobe cancelled. The sharing of staffand resources to support elective andnon-elective care treatment can placean added stress to elective work asurgent cases should take precedenceresulting in cancellation of scheduledelective surgery causing frustrationand delay felt by staff and patientsalike. However, as there is apermanent need to provide for non-elective care contingencies can bebuilt into the system.

Pre operative assessment ensures thatthe patient is as fit as possible for thesurgery and anaesthetic andminimises the risk of latecancellations by ensuring that allessential resources and dischargerequirements are identified andcoordinated. With appropriatetraining nurses can effectivelymanage the care of patients referredto the pre operative assessment clinic

in advance of cardiac surgery,including clinical examination, historytaking, arranging radiological andhaematological investigations inaccordance with Consultant ordepartmental guidelines. Thedevelopment of new roles allowsconsultant time to be effectively freedup permitting more appropriate useof surgeons’ time. (StaffingCardiothoracic Units Developing aworkforce for the 21st century.Livesey, S. Bartley, T. April 2007).

Across the country project sitesshowed wide variation in theirachievement of admitted waitingtimes and started their journeys toimprovement from differing baselinepositions based on localcircumstances. In understanding howpatients flowed through their servicewith a particular focus on referralmanagement services, pre admissionprovision, scheduling and postoperative care management theseessential facets have supportedachievement of continuousimprovements in elective carepathways.

The detailed case studies includedhere demonstrate their progress,outlining practical strategies forcontinuous improvements in thequality of care which has benefitedpatients in reducing delays, tacklingbottlenecks and enabled patients andcarers to access clearer informationalongside the achievement of targets.

The dilemma of balancing bothelective and non elective/emergencywork led some sites to adopt a wholesystem approach to their qualityimprovement work due to theknock-on effects of the provision ofnon elective care to planned activity.



Redesign of the cardiac surgery patient pathway reduces length of staySt George’s Healthcare NHS Trust and the South London Cardiac and Stroke Networks

The problemIn December 2008, the opportunity totake part in a National Priority Projectprompted the St George’s cardiacsurgery team to address how theymight deal with some of theirlongstanding problems to help the unitperform at an optimum level, meetingboth national and internal truststandards for issues such as length ofstay, cancellations, and notice period ofsurgery date for patients.

Both the elective and non-elective adultcardiac surgical pathways had room forimprovement, particularly within the:• pre-assessment service;• management of length of stay,

theatre cancellations and slotscheduling;

• referral management processesinternally and from referring districtgeneral hospitals.

Achieving and sustaining the 18 weektarget for elective surgery and therequirement to meet the trust’s internalpriority to reduce length of stay acrossboth the cardiology and cardiac surgerycare groups felt challenging. A reviewof baseline data, gathered usingpathway mapping, demand andcapacity analysis, and interviews withstaff across their respective work area ofthe patient journey, highlighted anumber of system and process issues.

The issues included:

1.Pre-assessment• During 2007/08 fewer than 60% of

elective cardiac surgery patientsattended the pre-assessment clinic.

• Anecdotally, this was contributing todifficulties with planning patientadmission, scheduling andanticipating date of discharge.

2.Theatre scheduling• In Q3 2008/09, the average number

of non-clinical cancellations was 10%of all elective cases.

• These were commonly due to theatreoverruns and lack of beds.

• Patients were often cancelled the daybefore, or on the day of their surgery;there was no cancellations policy toprevent or support the decision.

• Analysis of the theatre diary showedcases rarely started on time and oftenoverran.

• There was no policy for theatrescheduling.

• Patients were given little notice oftheir surgery date; often less thanone week.

3.Electronic referral system,inpatients and interhospitaltransfer patients

• The electronic referral system,primarily developed for the referral ofnon-elective patients from districtgeneral hospitals into the tertiarycentre (interhospital transfers) thathad been implemented in 2006 wasnot being utilised.

• Paper referrals made from referringsites were frequently mislaid.

• Little and inconsistentcorrespondence between referringsites and St George’s was commonplace.

• Referring centres were unsure of thework-up required for surgical patientsresulting in patients often transferredinto St George’s unprepared forsurgery.

• Length of stay was longer thanoptimum for admission to referral,referral to transfer, transfer totreatment and treatment to dischargeor transfer back to DGH.

• A small number of patients treated atSt George’s travelled from Jersey –due to flight restrictions imposed bythe airline these patients were unableto fly home until at least ten daysafter their surgery. This resulted intheir stay in hospital being extendedto ten days post surgery as opposedto usual routine of five days.

4.Admission on the day• In Q3 2008/09, only 10% of elective

cases were admitted on the day.• An admission on the day project for

‘second on the day cases’ had beensuccessfully piloted in 2006, but hadnot been sustained.

5.Length of stay (LoS)• In Q3 2008/09, the average LoS for

elective patients was 8.8 days.• In Q3 2008/09, the average LoS for

non-elective patients was 15.7 days.• LoS needed to align with the trust

target of elective patients beingdischarged on day five. Non-electiveLOS should also be reduced inrecommendations with the NCEPODguidance.

• The cardiovascular division wasrequired by the trust to make a savingof 10 beds.

”

“



The solutionA project team was established andchaired by the unit’s general managerwith clinical and managerialmembership including servicemanagers, heads of nursing, matrons,clinical nurse specialists, clinical audit,transformation project manger,consultant cardiologist and cardiacsurgeon. Project management supportwas provided by the South WestLondon Cardiac and Stroke Network.

Baseline data was collected to identifyareas for improvement work. It wasclear the project had developed into awhole pathway redesign and wassubdivided into five key workstreams.Project team meetings were held everyfortnight and leads were nominated foreach work-stream to be responsible forthe work.

A set of key values that reflected thetrust’s own strategic vision were agreedand integrated within the team’s visionestablished to deliver the improvementwork across the patent pathway:

1) To ensure that all patients haveequal access to the service.

2) That the patient journey is safe andfree from complications.

3) Compliance with the national andlocal agenda including 18 weeks,cancellation on the day andreduction in length of stay.

4) That the cardiovascular service is asefficient and forward thinking as anyother tertiary centre in the country.

5) That the staff within the unit areproud to work in the unit and feelvalued and part of a team.

Highlight reports were produced foreach team meeting and provided themechanism for monitoring eachworkstream against key goals, actions,risks and progress against timeline.Analysis of the data to show evidenceof the improvements was supported bythe trust transformation manager andclinical audit staff members on theteam.

The work was also informed by theanalysis of qualitative data from patientand carer diaries which were used by anumber of patients and their familymembers from the time they attendedtheir pre-assessment, throughout theirstay in hospital, and for a few weeksafter their discharge.

Team members attended the nationalcardiac surgery priority project peersupport meetings which inspiredmembers to share existing goodpractice within the unit and to developsolutions to challenges shared acrossthe peer group.

The new pathway featured:• The pre-assessment of all elective

cardiac surgery patients by September2009.

• A theatre scheduling policyintroduced in October 2009,including improving notice to patientsof their date for surgery.

• Regular monitoring of theatrecancellations to reduce the numbernon-clinical cancellations

• Implementation of the use ofelectronic referrals for non-electivecases by January 2010.

• Implementation of admission on theday as normal practice.

• The recruitment of two additionalstaff; a pre-assessment nurse and acardiothoracic nurse practitioner:• Whilst these new posts required

funding overall the project was costneutral – as savings were gaineddue to the improvements made byeach work-stream, in particular,reductions in LoS and cancellations.

Working together on this project

has brought the team together and

I’m so proud of what we’ve

achieved. We were all sceptical

to begin with and I was

uncomfortable admitting we had

problems with our service, but

hearing from other colleagues

around the country reassured me

that we were not any different and

we all had the same issues.

Working on this project with the

Network and the Heart

Improvement Team has encouraged

us to start a similar project

addressing issues in cardiology –

we’re now looking forward to a

similar success story!

Jane FisherGeneral Manager



• Implementation of new dischargeplanning for Jersey patients.

Below is a summary of the work andachievements in each workstream:

1. Pre-assessment• Reviewed demand and capacity

within pre-assessment clinic.• Employed second clinical nurse

specialists to increase capacity.• Converted all pre-assessment clinics

to nurse only clinics.• Worked with admissions co-ordinator

to formalise process betweenacceptance onto waiting list andadmission to hospital.

• Developed patients information sheetto explain process, now sent to allpatients when added to the waitinglist.

2. Theatre scheduling• Theatre lists published weekly, ten

days in advance and with slotsavailable for emergency or inpatientcases.

• Set up weekly MDT meetings toreview lists for following week andidentify possible issues/over runs/resources.

• Implementation and enforcement ofcancellation policy.

• Locum theatre manager in post.• Annual/study leave booked a

minimum of six weeks in advance.• Consultants’ rota set at six weeks

ahead.• Improved theatre start and finish

times.• The notice period given to patients

about their surgery date increasedfrom one week to three.

• Outpatient referrals pooled for firsttime CABG to ensure equity ofwaiting times – this had an impact ongeneral 18 week waiting times.

• Implementation and enforcement oftheatre scheduling policy.

3. Electronic referral system,inpatients and interhospital transferpatients• Cardiothoracic nurse practitioner post

developed and recruited to.• Met with referring hospitals to discuss

new cardiothoracic nurse practitionerrole, established direct contact ofindividual who would takeresponsibility for each referral.

• Training sessions delivered to staff (ateach site) on how to use referralsystem.

• Electronic referral system used for in-house in-patients betweencardiologists and cardiac surgeons atSt George’s.

• Electronic referral system used for IHTnon-elective patients.

• All in house and IHT non-electivereferrals addressed to ‘dear surgeon’and managed by cardiothoracic nursepractitioner, rather than to a namedsurgeon.

• All referrals also processed throughnurse practitioner, who then contactsreferrer to confirm receipt and discusswork-up criteria.

• Nurse practitioner liaises withpathway co-ordinator to arrangedates for surgery, keeping referringhospital informed.

• The matron and nurse practitioneralso worked with the Jersey Hospitalsand staff at St George’s to developand implement a new dischargeroutine for Jerseys patients – the teamdesigned a clinically safe and practicalprotocol to discharge patients on dayfive to stay in a local hospital withregular nurse check-ups until day ten,before flying home. This was done incollaboration with the Jersey referringhospital, who were pleased with theteam’s dedication to safe practice andclinical effectiveness.

4. Admission on the day• 2006 pilot reviewed.• Admission on the day exclusion

criteria agreed.• Policy agreed and signed by all

cardiology, cardiac surgery andanaesthetic care groups.

• Commenced 31 July 2009.

5. Length of stay (LoS)• Analysis of LoS compared with peers

and national standards was used toestimate where beds could be saved.

• The transformation project managerworked closely with each workstreamto measure where LoS was saved.

• Alignment of the project to thestrategic direction of the trust tospecifically save 10 beds increasedengagement at senior level.

20

18

16

14

12

10

8

6

4

2

0

Nu

mb

ero

fca

nce

llati

on

s

Cardiac Networkproject commenced

Rota set atsix weeks

Improved start/finish times

Surgical pathwaycoordinator in place

Cancellation policy implemented

Transformationteam involved

AoD commenced

Apr08May08

Jun08Jul08

Aug08Sep08

Oct08Nov08

Dec08Jan09

Feb09Mar09

Apr09May09

Jun09Jul09

Aug09Sep09

Oct09Nov09

Dec09

Linear (non-clinical actual)

Theatre Scheduling - Cancellations (non clinical)

Non-clinical (actual) Non-clinical (target)



Baseline figures Percentage of non-clinical cancellations

Mean Median Range

April - March 2008/09

April 2009 - present

Oct - Dec 2008/09 average


8.3%

3.7%

10.1%

2.3%

9.0%

4.0%

10.3%

1.9%

3-15%

1-7%

5-15%

1-4%

The resultsThe new pathway has resulted in:The improvements have lead to anoverall increase in productivity – theatrescheduling, increased pre-assessmentand admission on the day, reducedcancellations and length of stay have allcontributed towards an increase inactivity by £103k to date.

Reduction in non clinicalcancellations from an average of10.1% of cases per month in Q32008/09, to 2.3% of cases per monthin Q3 2009/10.

Increase in admission on the dayfrom an average of 9.9% of cases permonth in Q3 2008/09, to 24.6% ofcases per month in Q3 2009/10.

This equates to 69 patients admitted onthe day in 2009/10 to date; at £200 perbed day this makes a saving of£13,800.



60

50

40

30

20

10

0

Perc

enta

ge




AoD commenced

Apr08May08

Jun08Jul08

Aug08Sep08

Oct08Nov08

Dec08Jan09

Feb09Mar09

Apr09May09

Jun09Jul09

Aug09Sep09

Oct09Nov09

Dec09

Linear (% CS AoD)

Admission on Day of Surgery

% CS AoD (actual) % TS AoD (target)

Baseline figures Percentage of admitted on the day

Mean Median Range





8.5%

20.9%

9.9%

24.6%

8.0%

21.1%

7.7%

25.0%

1-15%

10-31%

2-20%

19-30%

11

10

9

8

7

6

5

Day

s




AoD commenced

Apr08May08

Jun08Jul08

Aug08Sep08

Oct08Nov08

Dec08Jan09

Feb09Mar09

Apr09May09

Jun09Jul09

Aug09Sep09

Oct09Nov09

Dec09

Linear (Cardiac Surgery Elective LoS)

Length of Stay - Elective Cardiac Surgery

Cardiac Surgery Elective LoS

Baseline figures Length of stay for elective cardiac surgery

Mean Median Range





8.8

7.4

8.8

7.6

8.8

7.7

8.3

7.8

8-11 days

6-8 days

8-9 days

7-8 days

Reduction in length of stay for elective cardiac surgery patients, reduced froman average of 8.8 days in Q3 08/09, to 7.6 days in Q3 2009/10.

23

21

19

17

15

13

11

9

7

Day

s



Transformationteam involved AoD commenced

Apr08May08

Jun08Jul08

Aug08Sep08

Oct08Nov08

Dec08Jan09

Feb09Mar09

Apr09May09

Jun09Jul09

Aug09Sep09

Oct09Nov09

Dec09

Linear (Cardiac Surgery Non-Elective LoS)

Length of Stay - Non-Elective Cardiac Surgery

Cardiac Surgery Non-Elective LoS

Baseline figures Length of stay for non-elective cardiac surgery

Mean Median Range





15.5

13.2

15.7

13.3

15.4

13.3

16.0

13.1

10-21 days

10-16 days

14-17 days

12-15 days

Reduction in length of stay for non-elective cardiac surgery patients, from anaverage of 15.7 days in Q3 2008/09, to 13.3 days in Q3 2009/10.



Top tips1. Engagement at senior level and

alignment of the project to thestrategic direction of the trustspecifically saving 10 beds.

2. Regular reporting to seniormanagement supported by robustdata across a defined set ofmeasures agreed early on in theproject to ensure focus.

3. Access to data. A member of theteam with access to data was vital tomeasuring improvement as thenetwork project manager struggledto gain access to data, beingperceived as an ‘outsider’. Theinternal data manager was able toretrieve and analyse data sharedacross the project team to drive thework.

4. Interdisciplinary core project teamwas reflective of the key staff vital toimplementing and maintainingchanges being tested.a.The core team consisted of the

lead for each work stream; theseindividuals were the people whowould plan and measure thechanges – they were the peoplewho could really make adifference.

b.The core team held the five pointsoutlined as a shared vision ofchange, and worked together toachieve these goals.

c. As well as for planning purposes,the team meetings were importantfor boosting morale for when thework was facing opposition ordifficulties.

d.As a result of the project,relationships and communicationsthroughout the team and acrossthe pathway boundaries havebeen improved.

5. Keep in the forefront thatimprovement does not need to comeat a financial cost – but that byworking more efficiently and moreproductively, patients can receivebetter care that is value for money.

Contact details:Jane Fisher,General Manager, Cardiovascular,St George’s Healthcare NHS [email protected]

Laura Gillam,Senior Project Manager, South LondonCardiac and Stroke [email protected]



Ensuring patients are fit for surgery and reducing delays in the cardiac surgical patients pathway

University Hospitals Birmingham NHS Foundation Trust, Heart of England NHS Foundation Trustand Birmingham, Sandwell and Solihull Cardiac and Stroke Network

The problemAchieving the national target of 90% ofadmitted cardiac surgery patientpathways being completed within 18weeks was proving a challenge acrossorganisations within the Birmingham,Sandwell and Solihull Cardiac andStroke Network. One of the mostcommon delays in the patients’pathway at Good Hope Hospital wasthe time between angiography and casereview by the multidisciplinary team(MDT). On average the wait was fourweeks but at it’s longest nine weeks,particularly if the MDTs were cancelled.Surgeons from the tertiary centre wererequired to travel across the city toattend the MDT meetings held at thereferring provider centre to reviewindividual cases requiring surgicalopinion. Clinical commitments oftenmeant that attendance at these MDTswas not possible. Not all patients werediscussed at MDT and the process ofensuring that patients were fullyworked up for surgery prior to referralto the MDT was not supported by anagreed protocol.

The system of ensuring patients werefit for surgery was characterised byinconsistency and variation across thesurgical teams with pre-screening notcarried out in all surgeons’ outpatient

clinics and with some patients attendinga further appointment at pre-assessment clinic. The pre-assessmentclinic workforce did not have therequired skills to support a fullassessment, including history taking,patient examination and assessment.Therefore, an SHO was required toreview all patients.

Attendance at pre-assessment clinic wasoften more than four weeks before thedate of surgery which resulted in theneed to duplicate chest x-rays andblood tests on admission. This createdunnecessary expense to the Trust andinconvenience to the patient

There was no anaesthetic service in thepre-assessment clinic, resulting inclinical problems often identified late inthe patient pathway; on admission tothe tertiary centre problems had beenidentified following assessment by theanaesthetist. This often resulted in thepatient being declared unfit for surgeryand the operation cancelled. The clinicwas not working to full capacity, flow ofpatients through the clinic was low anda review of the pre assessment servicesillustrated that not all slots were beingfully utilised.

There was also some pressure to reducethe overall length of stay and improveefficiencies in the patient pathway, asthe tertiary centre is reducing its overallnumber of beds on the cardiac surgicalward from 39 to 32.

The solutionA surgical steering group was set upwhich included cardiologistsrepresenting the tertiary centre anddistrict general hospital, a cardiacsurgeon, an anaesthetist, managementrepresentation from both trusts, acardiothoracic nurse practitioner andtertiary centre cardiac audit clerk. TheBirmingham, Sandwell and SolihullCardiac and Stroke Network providedproject management support.

A patient progress tracker wasappointed by the network to track thepatients through their journeys using alive database to help map the pathwayand identify delays in the journey.Tracking patient pathways also helpedto demonstrate that patients sometimesattended more than one surgical/cardiology appointment.

A new pathway to support theachievement of 18 weeks wasdeveloped and agreed by all keystakeholders. Baseline data wascollected to help define the problemand scope of the project.



The project objectives were:• Introduction of weekly electronic

MDTs using:• telemedicine to allow the transfer

of images between referring unitsand the tertiary centre;

• teleconferencing between thereferring consultant cardiologistsand tertiary centre surgical teamsfor the purpose of weekly MDTcase review. Use of technology wasthought capable of reducing MDTcancellations and increasing thenumber of patients discussed atMDT;

• introduction of a pre-referralprotocol to ensure patients are fullyworked up prior to referral to thetertiary centre.

• Redesign of the pre-assessmentprocess with patients:• attending the clinic no more than

four weeks before the date ofadmission for surgery at the tertiarycentre;

• being assessed in pre-assessmentclinic by a cardiothoracic advancednurse practitioner and ananaesthetist to ensure they are fitfor surgery on admission to thetertiary centre, with a view toreducing the cancellation rate andoptimising use of inpatient beds.

ProgressThe tertiary centre has four corepurposes. Therefore, it was imperativethat any project undertaken to improveservices should be underpinned by thefollowing four principles.

i) Excellent patient careii) Clinical quality outcomesiii) Research and innovationiv) Education and training.

These have been achieved in thefollowing ways:

• Development of the pre-referralprotocol to support the referringcardiologist. This will ensure that allthe required information is availableat the point of referral includingpresenting history, past medicalhistory and a summary ofinvestigations and outstandingresults. It also specifies the indicationsfor undertaking core investigationssuch as trans-thoracic echo, carotidduplex scans and lung function tests.Implementation of this protocol willensure all necessary investigations arecompleted before referral to thetertiary centre, reducing the risk ofthe patient being referred back to theDGH for the tests to be undertaken,

potentially adding weeks to thepathway and unnecessary waits forthe patient.

• An increase from 0% of patientspreviously reviewed by an anaesthetistin pre-assessment to72% over a shortperiod of time. We are workingtowards 100% of patients beingassessed by an anaesthetist in preassessment clinic.

• Clinic nurses undergoing practitionertraining to enable implementation ofa cardiothoracic advanced nursepractitioner role in the pre-assessmentclinic and to help address demandson clinical service brought about byEWTD.

• Capacity at pre-assessment clinic hasincreased from approximately 12 to30 available slots per week, resultingin increased activity. This has beenachieved by increasing the number ofappointments, and reducing time pre-assessment staff spent onadministration duties, to enable themto focus on clinical duties.

• Telemedicine system is in the processof being installed.

• Development of a patientquestionnaire survey to gather anunderstanding of the patients’experience from referral for cardiacsurgery to admission for surgery.

Cardiac Surgery Pathway - RTT 18 Weeks

Referral Received inRapid Access ChestPain Clinic

SurgicalOutpatientAppointment

Rapid AccessChest Pain ClinicAppointment

DiagnosticTests

MDT (referralto tertiarycentre)

2 WEEKS 5 WEEKS

9 WEEKS

2 WEEKS

DiagnosticTests

Pre-AssessmentClinic

Cardiac Surgery

Secondary care to tertiary care - 9 weeksTertiary care to definitive treatment - 9 weeks



Top tips• Mapping the existing pathway is

essential in understanding timelinesand delays in the system.

• Strong clinical leadership (cardiologyand cardiac surgeons).

• Obtain baseline data to identify if aproblem exists and build in robustdata collection mechanisms tosupport improvement work.

• Understanding the fundingimplications and identifying who isgoing to fund what (things likeannual service costs for a piece of kitetc) as early as possible in the projectto avoid issues later on.

• Develop a communication plan tofacilitate the dissemination of projectinformation to all admin andclerical/managerial and clinical staffinvolved in the pathway as this helpsto foster support and buy in to theimprovement work making iteverybody’s business.

• Bringing together key stakeholdersfrom the referring provider unit andtertiary centre together to identifyissues and problems and develop jointsolutions.

• Understanding the patient/carerexperience is fundamental to thesuccess of any quality improvementwork.

Contact details:Emma BillinghamGroup ManagerUniversity Hospitals BirminghamNHS Foundation [email protected]

University Hospitals Birmingham is still in the process of fully rolling out

the project. However, we have already seen benefits to patients with the

expansion of pre-assessment and pre-screening clinics as well as the

development of anaesthetic-led pre-assessment clinics. We look forward

to receiving comments from patients about their pre-operative pathway

so that we can evaluate our success so far and identify any further

improvements to be made. We also welcomed the opportunity to work

with a local referring cardiology centre to identify bottlenecks in the

patient pathway and are currently working to resolve these.

I feel the project group has benefitted from networking with other

centres who have identified similar issues and we have learnt from

their experiences how to overcome these to ensure the overall

success of the project.

Emma Billingham, Group Manager”

“

Process changes significantly increase 18 week performance in cardiac surgeryRoyal Brompton & Harefield NHS Foundation Trust in collaboration with North West London Cardiac and Stroke Network

The problemThe trust performance for referral totreatment pathways for cardiothoracicsurgery, within 18 weeks betweenApril - August 2008 had remainedconsistently below the 90% nationaltarget, sitting in the low 30-50%. Areview of the elective surgical pathwayfor planned care illustrated the followingissues:

• Patients were typically added to thesurgical waiting list before they hadbeen assessed and declared ‘fit forsurgery’ which resulted in extendedwait times for definitive treatmentwell beyond 18 weeks.

• The understanding and application ofthe 18 week suite of rules variedamong staff within administrative,clinical and managerial roles at thetertiary centre and referring providers.

• Clinic outcomes were often notdocumented following the patientsattendance at the pre operativeassessment clinic (POAC), a crib sheetwas developed for the clinic staff toshow what rules can/cannot beapplied in different situations.

• 18 week clock stops were not alwaysused appropriately, for examplepatients requiring referral forconditions on a new clinical pathwaysuch as haematology often resulted inan inappropriate continuation of the18 week clock.

• These patients were not recorded ona central list and were at risk ofgetting lost ‘in the system’.

• A number of patients had alreadybreached their 18 week pathway bythe time the referral was received bythe tertiary centre, this was partly dueto the accompanying Inter ProviderTransfer Minimum Data Set (IPTMDS)form being incomplete or incorrect.

Overall there was a considerable amountof incomplete data on the inpatientwaiting list (KH07). The position ofpatients along their 18 week pathwaywas not known due to clock starts beingfound/given/used too late. Data flow ofpatients after going on KH07 was notrecorded accurately. Theseinconsistencies meant that RoyalBrompton & Harefield NHS FoundationTrust had little chance of achieving the18 week admitted referral to treatmentpathway target.

The solutionThe trust employed 18 weekco-ordinators to assist the 18 weekproject manager and received projectmanagement support from the NorthWest London Cardiac and StrokeNetwork to focus on the cardiac surgerypathway.

The surgical pathways were mappedfrom the point of referral made by thesecondary care provider through receiptof referral to treatment by tertiary carecentre which helped to identifybottlenecks in the surgical pathway.

A series of meetings with the referringtrusts and the tertiary centre helped gaina common understanding of how toapply the 18 week rules suite anddevelop a shared agreement for applyingclock-starts and stops across providers.

These meetings also highlightedconcerns around how the IPTMDS formswere being completed. Thesediscussions resulted in a revised surgicalpatient pathway and process changesfeaturing:

• Patients seen at the pre-operativeassessment clinic (POAC) beingdeclared ‘fit for surgery’ before beingadded to the surgical waiting list.

• Agreed and standardised use of the18 week suite of rules across referringproviders and the tertiary centre.

• Inter-trust contacts for administrative,clerical and nursing staff wereexchanged so that in future clockstart requests were sent to the rightpeople.

• Support and training on applicationof the 18 week rules for key adminpersonnel and nursing leads of thepre-assessment service to help reducevariation and ambiguity in theirapplication.

• Patients at other trusts who wereunder investigation were recorded onRBHfT PAS as ‘active monitoring’,effectively stopping the clock on theircardiac surgery pathway. The cardiacnurse practitioners would follow theprogress of the patient through theirappointments and tests ensuring thatthere were no unnecessary delays,once declared fit for surgery theywould be added to the waiting list.





• Redesign of the clinic outcome formwith fields developed to show a rangeof scenarios and how the clock rulesapply.

• The integrity of data on KH07 wasclosely monitored. Appropriate andeffective data management andcommunication significantly improvedthe accuracy of the data used tomonitor performance.

• Where possible clock starts werefound prior to booking POAC. The18 week database was used by pre-operative administrative staff to planthe patients clinic attendance date inline with trust targets and appropriateto breach date.

• Through discussion over the 18week rules and the use of medicalmanagement it transpired thatreferring trusts treat the majority oftheir patients before referringthem on.

Results• By December 2008, the trusts 18

week admitted performance met theminimum 90% which continues to besustained, often peaking above the95% target. Pro-active tracking ofpatients along their pathway hasensured there have been nounwarranted delays.

• There has been a far greaterunderstanding within the hospital staffand between referring trusts of the 18

week rules and how to apply themeffectively.

• There has been an improvement inboth the number of IPTMDS formssent through and their datacompleteness.

• Improved communication betweenstaff has also helped reduce delays inreferrals, transferring and sharing ofinformation and the booking ofappointments.

Comparative data of performance for a four month period year on year

Top tips• Communication between providers

and across staff groups includingadministrative and clerical, clinical andmanagerial is key to ensuring fullunderstanding of the 18 week rulesand effectively applying them.

• Developing and strengtheningworking relationships between thecardiac nurse practitioners and thesurgical medical teams helped poolthe expertise to support a fullpre-operative assessment clinic.

• Access to the 18 week co-ordinatorcontactable by bleep increases theiraccessibility for staff to flag queriesand problems regarding interpretationof the rules.

• Meeting regularly with teams alongthe surgical pathway for example thetheatre scheduler who bookedelective and non-elective cases,helped reduce avoidable delays.

• A thorough understanding betweenhow the information systems andoperational processes correlated bythe 18 week co-ordinator had a hugeimpact on improving data quality andhence performance issues.

• Building relationships and improvingcommunication channels withreferring trusts had a considerableimpact on improving performance asthere was a sense of sharedresponsibility.

Contact detailsGemma SnellService Improvement Project ManagerNorth West London Cardiac andStroke NetworkEmail: [email protected]

April - August 2008 Performance

Apr

Wexham Park

Lister

Luton and Dunstable

71%

60%

0%

May

80%

66%

16%

Jun

79%

41%

20%

Jul

44%

46%

25%

Aug

50%

12%

21%

Average

64.8%

45%

16.4%

April - August 2009 Performance

Apr

Wexham Park

Lister

Luton and Dunstable

86%

70%

100%

May

100%

88%

92%

Jun

97%

74%

86%

Jul

100%

70%

84%

Aug

96%

86%

96%

Average

95.8%

77.6%

91.6%

Tackling change - the teamwork way

Essex Cardiothoracic Centre, Basildon and Thurrock University Hospitals NHS Foundation Trustin collaboration with Essex Cardiac and Stroke Network

The problemThe Essex Cardiothoracic Centre (CTC) isa relatively new unit which opened inJuly 2007, with many of its clinicalpathways and their supporting systemsand processes having been developedearly in the organisations history. Thetrust faced challenges with meetingthe national target of 90% admittedpathways completed within 18 weeks ofreferral to treatment with performanceoften running between 30-40%.Review of the surgical pathway wasseen as paramount to the continuedsuccess and growth of the unit,evidenced by internal audits that hadidentified areas for development andimprovement.

The elective cardiac surgery pathwaywas seen as a key area of focus toreview systems and processes in thefollowing areas of the pathway:

• Surgical collegiate system, a processof clinical review to ensure correctprocedure and surgeon determinedfor all cardiac surgery referrals, carriedout by surgeons prior to the patientattending an outpatients’ appointment.Challenges in sustaining the collegiatesystem, based on two surgeonsreviewing each referral on a bi weeklybasis, were related to ‘buy in’ andagreement from the surgical teams.

• Patients often needed to make morethan one visit in the pre operativepart of the surgical pathway as aresult of surgical outpatients andpre-operative assessment clinics(POAC) being held separately.

ECTC were able to focus on problemsseveral audits were carried out whichidentified areas where improvementswere required in order to streamline theservice, improve patient experience andimprove efficiency and effectiveness.The unit were keen to maintain highpatient satisfaction levels whilstmaximizing the use of in patient bedsand theatre utilisation.

The solutionA Surgical User Group (SUG) wasestablished with members drawn fromacross the multidisciplinary team tospearhead the development of thesurgical service. An action plan withclear timescales was produced, thecurrent service was discussed and ideasgenerated for future developments andimprovements planned. All changes tothe service were approved by the SUG.Additional project support was providedby the Essex Cardiac and StrokeNetwork.

Mapping of the current pathwayhighlighted issues with:

1.Collegiate system for review ofpatient referrals.

2.Process for allocation of ‘pooled’patients to consultant surgeonsresulting in longer waiting lists forcertain procedures.

3.Pre-assessment clinic not working toits full potential due to the skills ofstaff carrying out the clinic.

Baseline audit of the current service wascarried out in relation to theatrecancellations and theatre day/time. Anaudit tool was developed which allowedall sections of the theatre to bemeasured, for example time taken tocall for patient, time in anaestheticroom, knife to skin time. This audithelped to identify timing delays andidentified sections of the theatre daywhere improvements to efficiency couldbe made in order to optimize theatreusage and reduce surgical cancellationsas a result of clinical and non clinicalmatters. The picture of theatrecancellations was broken down into thefollowing:

• Interhospital transfer patientsreceived at the unit were often notfully optimised.

• Unfit elective patients.• Anaesthetic cove.r• Availability of intensive care beds.• Theatre over-runs.





A retrospective audit of 40 case noteswas carried out across six consultantsurgeons during a three month period –this illustrated the problem of delaypatients experienced between beingseen in pre operative assessment clinic(POAC) and their admission for surgerywhich often resulted in tests beingrepeated, an unnecessary expense tothe Trust. The case note audithighlighted in some cases the timeinterval was 10 weeks between POACand admission for surgery whichinvalidated the tests necessitating themto be repeated on admission.

Understanding our cardiac surgicalpathway by using service improvementtechniques and data helped us toidentify service improvements and areaswhere patient experience could beimproved.

Our overarching aim was to:• Reduce the time frame between

attendance at pre operativeassessment clinic and admission forsurgery by four weeks.

• Reduce theatre cancellations tobelow 10%.

• Reduce waiting times from nineweeks to six weeks for cardiacsurgery.

• Improve 18 week referral to treatmenttimes for admitted pathways.

• Improve efficiency within theatre day.

The new service now provides:• Same day outpatient clinic and pre-

assessment.• Dedicated lead pre-assessment nurse.• Forum for monitoring and auditing

measurables to improve service.• Same day admission for cardiac

surgery.• Super multidisciplinary team (MDT) for

review of complex cardiac surgerycases with joint cardiology and surgicalassessment of the patient presented.

Results18 week admitted pathways are nowperforming consistently at 90% as aresult of:• Improved working relationships and

MDT working have developed as aresult of the involvement of alldisciplines within ECTC as a result ofthe development of Surgical UserGroup.

• Reduction of in -hospital theatrecancellations from 20% to 10%.

• Reduction in wait from pre operativeassessment clinic (POAC to admissionfor elective cardiac surgery from nineweeks to six weeks.

• Reduction in unnecessary duplicationof tests. Tests performed at POAC,CXR, blood tests and ECGs nowremain valid from time performeduntil admission into ECTC.

• Reduced waiting times for cardiacsurgery from nine weeks to six weeks.

• Timely POAC to admission hasreduced length of stay by one day forsome groups of cardiac surgicalpatients with same day admission.

Top tips• Working together in a

multidisciplinary team andcollaborating with key stakeholderswithin ECTC and with referringDistrict General Hospitals (DGHs)meant everyone understood eachothers perspectives.

• Engagement with staff across a rangeof disciplines and at all levelsincluding consultant surgeons,anaesthetists, nurses, perfusionistsand management team.

• Strong leadership and seniormanagement support.

• Schedule meetings to meet the needsof all disciplines to ensure attendance.

• Production of robust data collectionand analysis to support the project,drive key changes and ensure thework remained focused.

Contact details:Jenni BrownMatron, Essex Cardiothoracic Centre -Basildon and Thurrock UniversityHospital NHS Foundation [email protected]

Cardiac surgery and 18 weeks – A pan network approachCardiac and Stroke Networks in Lancashire and Cumbria

The problemDuring 2008/09 the network took partin the national 18 Week DiagnosticPriority Project, which highlighted thatpatients on the cardiac surgery pathway(from the point of District GeneralHospital referral to surgery) were likelyto breach the 18 week target. Thenetwork had previously notified chiefexecutives that the 18 weeks target wasat risk of not being met due to issuessurrounding the surgical component.Work undertaken in relation todiagnostics, one-stop clinics and beddays for the cardiology part of thepathway had already been completed inJune 2008.

The surgical waiting time from referralto surgery at the start of the projectstood at up to 14 weeks and wascharacterised by variation in the surgicalreferral patterns and length of surgeonspecific waiting lists, both compromisingfactors in the delivery of 18 weeksurgical pathways.

The solutionFollowing successful recruitment to thecardiac surgery national priority project,work began in August 2008, with thesupport of all stakeholders across thenetworks constituent organisations.Management of 18 weeks across thenetwork health economies led to an

agreed standard of a nine week spiltbetween cardiology and cardiac surgeryproviders.

A project steering group, withmultidisciplinary membership, wasestablished to oversee the project andmonitor progress. Project managementsupport was provided by the network.Initial steps to baseline the projectincluded mapping the referral pathwaysto define the problem and focus of thework. This included:• Identification of the main challenges

in meeting the 18 week target foradmitted pathways.

• Mapping of all cardiac surgicalpathways in DGHs from point of GPreferral with the outcomes from themapping activity fed back to theservice.

• Collection of base line data whichincluded theatre cancellations (clinicaland non clinical) and a 12 monthreview of the number of patients onthe surgical waiting list (CABG andvalves) to establish trends.

• Mapping of the surgical pathway atLancashire Cardiac Centre (LCC) withoutcomes shared.

Monthly progress reports weresubmitted to the national team andmeasures for monitoring progress wereagreed as the number of patients on thewaiting list for CABG, the numberwaiting for valve replacement surgery,and the waiting time from referral byDGH Cardiologist to the day of surgery,and the surgical cancellation rate (clinicaland non clinical).

The aim of the project was to ensurethat the time from referral by acardiologist to the patient undergoingsurgery was limited to nine weeks.Scope of this project was confined to thesurgical element of sustaining the 18week pathway, i.e. from thecardiologist’s decision to refer for surgeryto the day the patient received surgery.Specific areas of focus agreed by theproject board were:• The interface between secondary and

tertiary care.• Subsequent scheduling of theatre cases.

The aim was to reduce the time fromDGH referral to surgery from 14 weeksto under nine weeks.

Early on in the project timeline ameeting was held with 18 week leadsfrom each of the trust’s referring theirpatients to the tertiary centre whichresulted in agreement to ensureuniformity of referral processes andcollection and transfer of RTT dataacross the network.

An electronic theatre scheduling toolwas piloted in December 2008 to allowthe booking of theatre cases to beccoordinated actively with theatreresources and capacity, with the aim ofreducing both over and under runs.

A flow tool analysis of the 20 beddedCardiothoracic Intensive Therapy Unit(CITU) was completed to help expressbed occupancy and activity on an hourlybasis, and was measured over 24 hoursfor one month. The report wassubmitted to the tertiary centre andhighlighted that the CITU runs atapproximately 80% occupancy, with thepattern across the study periodindicating that there could be capacityto accommodate extra cases at certaintimes. A repeat analysis is scheduled forMarch/April 2010 to monitor the effectof four high care beds introduced inMarch 2009.





The trust has implemented the advancednurse practitioner role into this area toassist with case management and we arehoping that the flow tool will help directthis exciting new role within the unit.

The new surgical pathway featured:• Agreed and standardised pre

operative procedures.• An increase in surgical outpatient

capacity though implementation ofsurgical satellite clinics at two of thereferring District General Hospitals.

• Multidisciplinary team review ofpatients referred for cardiac surgerycarried out via videoconferencing.

• Implementation of an electronictheatre scheduling tool.

• Pooled waiting lists fro first referralsand those patients with one and twovessel.

ResultsBy the end of the project:• The waiting time for surgery had

reduced to six weeks across theboard.

• The number of patients on thewaiting list at the start of the projectwas 120 and had reduced to 79 by9 March 2009.

• The percentage of surgical casescancelled for clinical reasons has beenreduced.

• Agreed protocol across the networkstandardising pre operative diagnosticinvestigations were in place.

• Pooled waiting lists were introducedat Lancashire Cardiac Centre for firstreferrals and those patients with oneand two vessel disease.

• Patients on the waiting list were givena date for surgery at their out[patientclinic appointment with the surgeon.

• An electronic theatre scheduling toolhas been implemented resulting in amore even spread of the intensity ofwork across the week, and throughindividual theatres.

Top tips• Engage with all staff from the outset.• It is essential to get consultant ‘buy

in’ to drive through improvements.• Scope the project fully and support

with robust data.• Projects that span more than one

organisation require sign up atexecutive level.

Contact details:Jennifer WattsAssociate Programme Director –Service ImprovementCardiac and Stroke NetworksLancashire and [email protected]

140

120

100

80

60

40

20

0

Coun

tof

Hos

pita

lNum

ber

Number of Patients on Cardiothoracic Waiting Listsby Intended Procedure Type - April 2008 to January 2010

Apr 08

Date Elective Admission List Census

OtherValveCABG

May 08Jun 08

Jul 08Aug 08

Sep 08Oct 08

Nov 08Dec 08

Jan 09Feb 09

Mar 09Apr 09

May 09Jun 09

Jul 09Aug 09

Sep 09Oct 09

Nov 09Dec 09

Jan 10

250

200

150

100

50

0

Activity Versus Cancellations - February 2009 to January 2010

Feb 09

Month

CancellationsActivity

Mar 09 Apr 09 May 09 Jun 09 Jul 09 Aug 09 Sep 09 Oct 09 Nov 09 Dec 09 Jan 10

Cardiac surgery trends - the national picture



100

90

80

70

60

50

40

30

20

10

0

Key Performance Indicator

Apr 08

Month

National

Jun 08 Aug 08 Oct 08 Dec 00 Feb 09 Apr 09 Jun 09 Aug 09 Oct 09 Dec 09 Feb 10

Perc

enta

ge

100

95

90

85

80

75

Referral to Treatment - Cardiothoracic admittedby Strategic Health Authority

NorthEast

SouthWest

London EastMidlands

WestMidlands

East ofEngland

SouthCentral

SouthEast

NorthWest

Yorkshire andthe Humber

Strategic Health Authority

National Average

Stan

dar

d:9

0%

Referral to treatment times cardiothoracic admitted 18 week pathways

Referral to treatment times cardiothoracic admitted pathways.Standard: 90%. National position (data November 2009)

Referral to treatment times for cardiothoracic surgery admitted.Standard: 90%. Position by Strategic Health Authority (SHA)(data November 2009)

Source: NHS Improvement Data Dashboard, January 2010 (data from November 2009)

Source: NHS Improvement Data Dashboard, January 2010 (data from November 2009)



Coronary Artery Bypass Graft (CABG) - England - Total Waiters by Strategic Health Authority - April 2004 to December 2009

Overview of waiting list numbers for CABG since April 2004



Valves - England - Total Waiters by Strategic Health Authority - April 2004 to December 2009

Overview of waiting list numbers for valves since April 2004



Coronary Artery Bypass Graft (CABG) - England - Waiters by Time Band - April 2004 to December 2009

Waiting times for CABG since April 2004



Valves - England - Waiters by Time Band - April 2004 to December 2009

Waiting times for valves since April 2004

The care of patients with acutecoronary syndromes has changeddramatically over the last ten years asa result of the improvementsintroduced by the Coronary HeartDisease National Service Framework.As a result, many more patients arebeing referred for surgicalrevascularisation whilst hospitalisedfollowing an acute coronarysyndrome. In many units thiscomprises up to 40% of theworkload and in order for thesepatients to be accommodated withinoperating schedules effective systemsneed to be in place.

As many of these patients are initiallyadmitted to DGHs and have coronaryangiography there they then wait fortransfer to a surgical centre and arecommonly referred to as interhospitaltransfers. These patients areconsidered high risk, assessed asbeing too ill to be discharged home,so wait for treatment on an inpatientwaiting list for transfer for diagnosticangiogram, angioplasty, heart surgeryor other procedures such aspacemakers or electrophysiologicalmanagement.



Non-elective pathways

Options to consider before transferSignposting to Improving Cardiac Interhospital Transfers (September 2007)



In order to minimise delays for thepatient and to maximise efficiencywe recommend the following:

• Use of network-wide agreed clinicalprotocols, to establish the need forsurgery and referral.

• Use of a risk stratification system todetermine priority for treatment.

• Use of existing electronic referralsystems to refer and transferpatients for urgent cardiac surgery.

• Network standards for waitingtimes.

So far, improvements in the pathway and transfer arrangements have

saved the equivalent of some 959 NHS beds each year across England.

We know that there is a lot more that can be done to take this further

saving the NHS a great deal of money and patients a great deal of stress

and worry.

Professor Roger Boyle CBE, National Director for Heart Disease and StrokeSignpost to Improving Cardiac Inter Hospital Transfers,Heart Improvement Programme, (2007)

”“Considerable work led by cardiac

networks in local health economiesundertaken across each part of thepatient journey to improve theexperience and outcomes for thisgroup of patients and staff; to reducethe impact of avoidable bed days andassociated challenges for trusts andambulance services around accidentand emergency (A&E) waits andachieving category ‘A’ targets hasbeen captured within Signposts toImproving Cardiac InterhospitalTransfers (HIP 2007).

Escalation policies to help managewaiting times across a local healtheconomy and to accelerate patientflow have been developed by severalnetworks and are aimed at settinglocally agreed performance targetswhich are monitored and if exceededallow for alternative arrangements tobe made to treat patients. The EssexCardiac and Stroke Networksummarise the benefits of developinga network wide policy as providing:

• A framework to ensure thatnumbers of patients waiting,waiting times and disruption totrusts is kept at a minimum.

• Reassurance for patients onanticipated waits for theirprocedure.

Delays in the patients journey canoccur if the patient is not fit forsurgery following their transfer. Thesedelays can be caused by a number ofreasons including absence of MRSAand dental screening, or completionand availability of pre operativeinvestigations and tests. These delayscan be addressed through jointpolicies on issues such as MRSAscreening, anticoagulant treatmentand pre operative tests and

investigations. Clarity is needed aboutwhich tests should be carried outprior to transfer, where they shouldbe carried out and whatdocumentation should accompanythe patient on transfer (MakingMoves, Heart ImprovementProgramme, 2006).



Transferco-ordinator

Makingthe referral

systemwork

Agree localescalation policy

to managewaiting times

Assesspatient needsand match totransfer type

Communicationwith

AmbulanceService

Information

Fit forprocedure?

InterhospitalTransfers: Making

Connections

• This can improve communication forreferring centres and help manage:• Numbers waiting• Waiting times• Disruption• Identification of anticipated waits forprocedure

• Electronic referral systems.• Standardised referral method• Central management of referral• Minimum dataset• Image transfer.(Angiogram)• PACS• Medcon

• Referral pack for patients awaiting transfer:• Physical/psychological preparation• Discharge requirements• Video

• Agreed pathway for high-risk patients• Network-wide policy agreed. Includesemergency transfers/balloon pump transfers

• Standardised documentation between units

• Single point of contact• Robust communication links• Ownership of the problem• List scheduling• Ensure treatment according to clinical priority• Provide timely and accurate information

• Ambulance crew type• Paramedic crew• Technician crew• Intermediate crew• Transfer crew• PTS crew

• Skill-mix appropriate to patient needs.• Escort required.• Type of vehicle

• Dedicated transfer code agreed withAmbulance service

• Time ready agreed with Ambulanceservice

• Emergency or Urgent? Blue light – 8mins/ or longer.

• Agreeing pre-transfer patient work-upto ensure patient is fit for procedure.This should include guidance on:• MRSA• Dental screening• Medication• Anticoagulation• Tests• Documentation

Improving interhospital transfers



‘Urgent or non urgent’, that is the question

Glenfield Hospital, University Hospitals of Leicester NHS Trustin collaboration with East Midlands Cardiac and Stroke Network

The problemGlenfield Hospital is a tertiary centreproviding specialist investigations andtreatment. More specifically thedepartment performs approximately1,200 cardiothoracic cases per year.For some time now the department hasworked towards a balance of meetingnational targets such as 18 weeksreferral to treatment and 13 weeks forcoronary artery bypass surgery (CABG).Local targets such as 11 week CABGand seven days for urgent inpatientsurgery and an internal standard toaccept patients within 48 hours ofreferral for inter hospital transfers. Thishas had to balance with the increasingnumbers of non-elective referrals whichare both in-house and interhospitaltransfers from referring district generalhospitals (DGHs). Non elective referralshave averaged approximately 30% of alladult cardiac surgery activity during theperiod 2008-09.

With the assistance of the East MidlandsCardiac and Stroke Network a numberof key areas were identified within thecurrent non-elective care pathwayresulting in a higher than average pre-operative length of stay. A review ofdata extracted from a local data baseidentified a median pre operativelength of stay (LOS) of 19 days and amean of 23.

Additional data illustrated the total LOSfor all urgent inpatient (non emergency)surgical referrals as 33 days whichincluded a 10 day post operative LOS.

Inter hospital transfer patients cominginto the department were also exposedto these delays as the majority arereferred directly to cardiology withoutbeing fully assessed and the appropriateinvestigations being completed.

The solutionA steering group was established fromthe project outset with multidisciplinaryteam membership drawn from staffworking across the pathway of care.Staff not directly involved in thepathway were also invited to contribute.

The project steering group included:• General/service and operational

management.• Heads of service for cardiothoracics

and cardiology.• Clinical leads from both

cardiothoracics and cardiology.• Heads of nursing and matron for

department.• Service improvement manager from

the East Midlands Cardiac and StrokeNetwork.

• Members of Leicester City PCT.• Consultant cardiologists from

referring centres.

Regular steering group meetings wereheld to discuss the progress of theproject and to table products such asrevised pathway algorithms. The role ofthe group was to agree an action plan,oversee changes to current practice andagree newly designed pathways anddocuments.

Agreed solutions to our identifiedproblems included the following:• Learning from patient and carer

experience of the current service byfacilitating a patient forum. Patientsand relatives were invited to sharetheir experiences of Glenfield Hospitaland what it was like to wait forcardiac surgery as an inpatient. Anemergent common theme identified

from this forum centred on length ofwait and communication.

• ‘Better communication is needed’.• ‘seemed to be a lot of waiting around

with nothing happening’.• ‘Why couldn’t they have waited at

their referring hospital’.• ‘Why have I been waiting so long?’

Themes from the patient and carerfocus group were discussed within thesteering group and helped us to shapethe direction of some of our work.

An initial task was to look in detail atthe current processes and establishwhere problems and bottlenecks werein addition to understanding aspects ofthe process we were doing well. Usinginformation gathered from a localdatabase helped establish evidencearound the size of the problem for thenon elective patient group length ofstay highlighting a median pre-operativelength of stay of 19 and a mean of 23days.



Detailed process mapping of both thein-house urgent and interhospitaltransfer pathways of care was carriedout. The mapping exercise helpedidentify the following areas as potentialbottlenecks within the current system:• Admin and clerical delays (three days

from dictation to receipt of letter)• Decision making process, PCI vs

surgery. If surgery, then how urgent?• Inequity of access to surgical care and

treatment in both pathways wasevident with variations in referralsprocesses occurring withoutconsideration of constraints uponthe service such as waiting listcommitments and availability.

• Inconsistent pre-operative assessmentprocesses across consultant surgicalteams with variation in the pre-operative requirements of individualcardio-thoracic surgeons.

• Delays in obtaining some diagnosticinvestigations due to uncertainty ofrequirements.

• Referring district general hospitalswere unclear about GlenfieldHospitals referral assessment criteriaand medical staff at these centreswere also uncertain of the timing ofsurgical referrals, who and where torefer them to.

• Complexity of the referrals processdue to variations in practice, referralpatterns and relationships formedbetween clinicians.

The following were identified at all levelsacross the unit as being a requisite of anyservice redesign within our department.

Referral proforma’s• To streamline admin and clerical delays

caused by traditional dictated andtyped referral process:• Referral proforma’s were developed

and designed to be available toclinical staff on each of the wards.The proformas provided guidanceabout the type of clinical informationrequired by the surgeons at the pointof referral and went through aperiod of piloting and refinement.Their use enabled the operationalmanager to audit the referral processwith regard to the level ofinformation available on referral ofthe patient to the surgical team;

• Proforma’s also enabled the team tore-direct surgical referrals to thesurgical team with the necessaryclinical skills and theatre availabilityreducing the inequity that previouslyexisted.

Referral pathwaysReferral pathways were redesigned toreduce variation. A central point ofreferral was agreed whereby all surgicalreferrals with the exception of trueemergencies arrived via this point.Initially hand delivery for in-housereferrals, faxed by referring DGHs thenwith a view to electronic referrals. Thecentral referral point also gave theopportunity to provide referringclinicians with waiting list/timeinformation before making the referral.

• Two referral pathways were designed;one for external referrals and anotherfor internal ones. Both providing clearguidelines about how and when torefer patients to a cardiothoracicsurgeon. Each of these also providedtwo arms by which guidance wasoffered for both urgent and unstablereferrals and those urgent butunstable.

• Referral pathways aimed to provideclarity for referring clinicians withregards to whether patients aretransferred directly under the care ofa consultant cardiac surgeon with aprovisional date for surgery. Orwhether they are transferred underthe care of a cardiologist for furtherassessment then referral internally.

• A formally agreed set of criteria wasdeveloped to provide guidance onwhy some patients would not receivesurgery within the agreed seven daypathway. This includes those patientsawaiting multiple dental extractions,patients admitted with extensiveMyocardial Infarction where surgeryhas not been performed as anemergency and require a period ofrecovery, failed PCI.

Algorithms• Following a number of steering group

meetings and discussions withGlenfield Hospital cardiologists andDGH consultants, the generalconsensus was that they did knowwhat information the surgical teamsrequired from them when making asurgical assessment.

• Likewise the cardiac surgicalconsultants also felt that the pre-operative assessment was ofteninadequate for the purpose ofdeciding the course of treatment. Thisoften proved to be costly in terms ofdelays in the decision making process.



ResultsMany aspects of this project have beendrafted and agreed at steering groupand cardiothoracic board level.

• MDTs, surgical referral proforma’s andthe central referral point haveprovided a more successful forum forthe discussion of surgical referrals.They have promoted bettercommunication between DGHconsultants wishing to make referralsinto Glenfield Hospital as they areprovided with referral data, timeframes and waiting list information.The central referral point also providesa means of advice pertaining tosurgical specialities within thedepartment.

• The surgical referral pathways havebeen drafted, redesigned and agreedacross the clinical and managerialteams within the department andwith external referring centres.

From August 2009 to January 2010,Glenfield Hospital was identified as theNational Centre for Extra CorporealMembrane Oxygenation (ECMO)treatment for the H1N1 Virus resultingin a large proportion of ourcardiothoracic surgery/intensive careservice being consumed by ECMO. Thismeant an increase in the length of stay

for urgent in-house surgery. To maintainpatient’s safety a number of thesereferrals were outsourced to othercardiothoracic centres across themidlands region. Despite this situationthe work currently undertaken has beenin everyday use, i.e.; the referralproforma’s, algorithms, and referralpoint.

The new referral pathways willcommence following discussion atboard level and are likely to be ingeneral use by the end of February2010. This delay has been largely toensure we sustain a balance betweenpatient safety and our national andlocal targets.

Top tips• Develop a project steering group from

the outset of the project with therelevant members.

• Agree clear aims and objectives,retain some flexibility as events canchange.

• Map processes at the beginning ofany project involving the review ofcurrent processes.

• Carry out a demand and capacityexercise to support the project withrobust data as this will provide thesteering group with the informationthey need to direct potential changes

• Build in the overall strategic directionof the department to the projectwork.

• Define a clear set of measures, inthese circumstances length of stay,administrative delays, quality ofpatients’ experiences.

• Engaging with stakeholders at anearly stage to form and strengthenrelationships across secondary andtertiary care as this helps tomanage the internal dynamics of adepartment which may be challengedduring the project work.

Contact details:Steven PeckOperational Manager,Department of Cardiothoracic Surgery,Glenfield Hospital,University Hospitals Of [email protected]

• Three algorithms were developedproviding advice regarding theassessment and investigationsrequired to make a safe decisionregarding the eligibility and readinessof a patient for:1. Coronary Artery Bypass Grafting

(C.A.B.G).2. Heart Valve Surgery.3. Patients admitted with Acute

Coronary Syndrome (ACS).

Multidisciplinary team meetingsA weekly multidisciplinary teammeeting (MDT) to review patients withtreatment choices and complextreatment decisions was already inexistence at Glenfield Hospital forurgent and elective referrals.However, this takes place weekly andwith the number of potential urgentreferrals we as a steering group believedit would be prudent to start a secondMDT. This would largely discuss internaland DGH referrals and so we aimed toinvite DGH consultants, anaesthetistsand other clinical staff.

Discharge planning



Managing and maintaining patientflow within the acute setting requiresa focus on discharge whilstmaintaining an approach that isfocussed on the individuals dischargeneeds. Assessing the patientsdischarge needs pre operatively,educating patient and family aboutrecovery at home and informingthem about care they receive oncedischarged is important to includewithin the pre operative assessmentclinic service. Optimising the patientsdischarge can help improve thepatients’ experience, reduce theoverall inpatients length of stay;improve patient flow and efficiency inuse of beds.

Delayed discharges are a frustrationfor patients and staff alike.Establishing the cause of delay andhow to overcome issues preventingdischarge is important to understandand recognises the need forcollaborative working across thehealth professions if you are toimprove patient experience andpatient flow. An important part ofthe discharge process is to discuss thepossible options before the patientsadmission for surgery, encouraging

them together with their family (ifappropriate) to consider theirdischarge plans and place of care.Discharge planning should embracephysical, psychological and socialaspects of the patients care.

All of the case studies within thisdocument contain elements ofdischarge planning and address theimportance of:

• Securing admission/dischargeprotocols between providers.

• Providing information packs forpatients and carers.

• Establishing intermediate careprocesses.

• Seeking the patients and carersviews and involving them indiscussions to inform change.

The following two case studiesillustrate an interesting approach todischarge planning.

The case study presented by TrentCardiac Centre illustrates howrecognising the need for collaborativeworking with physiotherapists,intensive care practitioners, cardiacrehabilitation nurses, pharmacists,

medical and anaesthetic staff hugelyimproves the process as together theywere able to identify patients suitablefor early discharge home. Theircombined knowledge and expertisewas used to jointly assess the patientpre and post operatively to identifyany specific needs or issues to beaddressed. The multidisciplinaryteam developed a range of decisionsupport tools to complement thepatient assessment process supportedby a series of home visits by thespecialist nursing team.

One mechanism for optimisingdischarge planning is to improveward efficiency by reducing andeliminating unnecessary avoidabledelays by using visual managementsystems (VMS) to track patientprogress, trouble-shoot and progresschase. An example of this approach isdemonstrated within the Papworthcase study. VSMs bring together themultidisciplinary team to plandischarge/transfer focussing the teamon the steps required to supporttimely and safe discharge/transfer.They help improve the knowledgeamong the multidisciplinary team ofthe wider health and social care

aspects that impact on the individualpatients discharge and therequirement for advance planning toensure that services and support areavailable on discharge.

The case study presented byPapworth Hospital NHS FoundationTrust outlines how they reduced theirtotal inpatients length of staythrough using audit of delayeddischarges to reduce variation in postoperative practice and addresspatient focussed discharge at preoperative assessment clinic.



Improving the patient experience for cardiac surgery pathwaysPapworth Hospital NHS Foundation Trust in collaboration with Anglia Cardiac and Stroke Network

The problemMaking sure that patients aredischarged home when they aremedically ready to go and avoiding anyunnecessary system delays, was thepurpose of a project undertaken atPapworth Hospital in July 2009.

Achieving the challenging 18 weektarget in cardiac surgery requiresinefficiencies to be removed from thepatient pathway. Papworth Hospital hasan older and more complex case mixthan most cardiac surgery units andtherefore had a greater challenge.

The Papworth Team undertook a projectto streamline the cardiac surgerypathway and began with an audit of220 patients. Patient and carersatisfaction are high among cardiacsurgery patients at Papworth and workwith a focus group showed thatappropriate, early discharge and thereduction of health acquired infectionrisk were important issues for patients.Add this to the fact that patients cantravel long distances to Papworth, anddischarge nearer home was also animportant patient driver.

The audit identified that up to 45% ofpatients experienced delays in theirdischarge (discharged after their 8th

post operative day, which is Papworth’scoronary artery bypass graft standard).A number of areas where the pathwaycould be improved and a higher qualitypatient experience could be achievedwas identified and focused on theprocesses related to:

• Variation in practice across thesurgical team with regards to:• Removal of pacing wire, central

venous catheter and urinarycatheter;

• Post operative checks (sternalstability, bowel movement, woundand stair assessments).

• Repatriation process to districtgeneral hospitals and liaison withlocal services for discharge e.g.intermediate care.

• Multidisciplinary team communicationand co-ordination regarding dischargeand expected discharge date.

As part of the audit we calculated thata reduction in length of stay by one dayper patient would result in cost savingof £530,000/year (based on a bed daycosting £250).

The solutionTo streamline the adult cardiac surgerypathway for patients prior to admissionand at discharge; thereby usinginpatient beds more appropriately andefficiently to maximinise available bedcapacity for admissions, sustain theachievement of 18 week referral totreatment times for admitted patientpathways and improve the patientsexperience.

The Anglia Cardiac Network funded aproject manager to review the adultelective cardiac surgical pathway for preadmission and discharge. A projectsteering group was set up, an actionplan produced identifying severalstreams of work, baseline measurementcarried out and the current pathwaymapped and a new pathway developedand agreed.

This work helped to identify processescarried out prior to admission whichcould be done either in a morestreamlined way, e.g. combining preadmission and outpatient’s clinic, orcarried out in alternative locations.

Overall we wanted to identifysustainable solutions to reducingunnecessary delayed discharges:• To ensure the appropriate and safe

early discharge of patients either totheir own home, referring provider orprovider unit nearer to their homewithout reducing the quality ofpatient care.

• To maximise the use of beds atPapworth, increasing throughput forboth elective and non-electiveadmissions for cardiac surgery.



The new pathway was approved andpiloted and now features:• Initiation of discharge planning at pre

admission (or within 24 hours ofadmission):• Comprehensive discharge

assessment documentation withinthe surgical integrated carepathway;

• Outlining options and theavailability of support services topatients;

• Patient referral to intermediate careservices from pre admission clinic.

• Same day admission for routineelective adult surgical patients , toinclude those patients who aresecond on the list, single procedure,non diabetic with no co-morbiditieswith a plan to extend to a greaterpatient population.

• Standardisation of surgical dischargecriteria. Agreement of thepost-operative process in terms ofremoval of pacing wire, centralvenous catheter and urinary catheterand completing post operative checksearlier in the patients post operativerecovery period.

• A traffic light visual managementsystem to identify an estimateddischarge date on the third postoperative day.

• Multi disciplinary team involvement inthe admission and dischargeprocesses.

• Information for patients, relatives andcarers about discharge from hospitalin the form of leaflets and DVDs.

On going workIn addition to work completed arounddelayed discharge, there were severalother areas identified which are beingaddressed:• Reviewing and updating discharge

policy.• Piloting an improved intermediate

care referral system.• Trialing nurse led discharge within

cardiology.• Preparing a business case for a

discharge co-ordinator role.

ResultsImprovements to the pathway have thepotential for improving the patientexperience for 2,300 patients per year.This new pathway has meant patientswill benefit from:• New information on discharge, which

is discussed early in the patients’pathway. Documentation wasdeveloped and given to all patients.

• Appropriate and safe early access tointermediate care nearer to patients’homes, due to an improved referralsystem.

• Improved patient participation andcommunication regarding estimateddischarge date and schedule for postoperative procedures and checks.

• Improving the quality of the patientexperience has also identifiedproductivity gains, which include (costsavings are based on a bed daycosting £250):• Total length of stay from 9.98 days

to 8.5 days for all elective cardiacsurgery equating to a potential costsaving of £741,480 (based on2007/08 activity figures);

• Length of stay from 9.01 days to8.0 days for elective coronary arterybypass graft, equating to apotential cost saving of £506,010(based on 2007/08 activity figures);

• Length of stay reduced from 10.74days to 9.7 days for elective valves,equating to a potential cost savingof £521,040 (based on 2007/08activity figures).

14

13

12

11

10

9

8

7

6

5

LOS

(Day

s)

Cardiac Surgery: Post Operative Length of Stay

Jul 09 Aug 09 Sep 09 Oct09 Nov09 Dec09

Month

Elective LoS post op (CABG)

Elective LoS post op (AVR)Elective LoS post op (MVR)

Elective LoS post op (CABG & Valve)



• A 52% reduction in the number ofbed days lost due to delays inrepatriation (n = 107 to 51) a costsaving of £14,000 during the life ofthe project (non inclusive of costsassociated with loss of activity).

Top tipsKey to the service re-design wasworking in collaboration with theCardiac Network, NHS Improvement -Heart and other key stakeholders toidentify and implement the necessaryimprovements.

• Working with patients, carers andstaff to seek their views on thedischarge process.

• Agree data set and communicatebaseline measurement early in theproject.

• Strong leadership both clinical andmanagerial.

• Aligning the work within theorganisations priorities.

• Setting out project aims and assigningresponsibilities.

• Collecting, and analysing robust datamonthly, and making necessaryadjustments to the new process.

• Having pre-set meetings withclinical representation.

• The reduction in length of stay isbeing achieved by increasedcommunication between professionsand implementing small changeswhich are easily sustainable.

Contact details:Nadine HazelwoodAssistant Directorate Manager (Pathways)Papworth Hospital NHS Foundation [email protected]



Reducing length of stay of elective cardiac surgical patients to a one night stay post operativelyTrent Cardiac Centre, Nottingham University Hospitals NHS Trust in collaboration with East Midlands Cardiac and Stroke Network

The ideaThe average length of stay for peopleundergoing cardiac surgery at the TrentCardiac Centre is around five to sevendays. The typical elective surgerypathway includes review of the patientin outpatients by the cardiac surgeonwhere the decision to undertake surgeryis made and the patients added to thewaiting list. A week before surgerypatients are invited to attend the pre-operative assessment clinic where theyare seen by the surgeon, anaesthetistand cardiac rehabilitation nurse. At thisappointment the full range of pre-operative tests are undertaken.

Patient and carer satisfaction levels arehigh at the Trent Cardiac Centre andfeedback from patients had indicatedthat some were keen to leave hospitalearlier and return to their usualresidence. We decided to test outwhether we could send selected lowrisk elective adult cardiac surgicalpatients home after a one night staypost operatively following coronaryartery bypass surgery, valve surgery orrepair of atrial septal defect. An audit ofpatients stratified as having a low riskprofile for cardiac surgery whoseoperation was performed in theprevious 12 months highlighted thatapproximately 10 percent (80 patients)of all elective referrals may be eligible

for a shorter spell in hospital postoperatively potentially being dischargedhome following a one night stay inhospital. A shorter length of stay wouldequate to saving four post operativebed days per patient stay and a total of320 acute beds per year.

The solutionThe Trent Cardiac Centre at NottinghamUniversity Hospitals NHS Trust, set up aproject team with multi-disciplinarymembership representing the tertiaryunit, primary care and the nationalimprovement lead for cardiac surgery.This group was led by a consultantsurgeon with project managementsupport from the East Midlands Cardiacand Stroke Network.

We employed service improvementtechniques to look at the currentpatient process by undertaking processmapping and asking patient and carersto share their views on the currentpatient experience along the usualpathway of care. A new patient pathwaywas agreed detailing what tasks, supportand mechanisms would need to be inplace and delivered by who for patientsto be safely and appropriately dischargedhome. The project team agreed to worktoward testing out a one night postoperative stay with 10 patients selectedagainst criteria.

Potential risks to patient safety werehighlighted through a risk assessmentprocess which helped us to considereach of the identified risks and stepsrequired to mitigate these. To help usunderstand the concerns patients andcarers may have regarding earlydischarge from hospital we held aworkshop to identify their views andexperiences of the current service andto gather views of the proposed shorterpathway.

Having identified the potential risks toearly discharge and the changesrequired to ensure patient safety in thepre and post operative surgicalpathway we:

• Developed a set of inclusion andexclusion criteria used to select theappropriate patients.

• Produced staff handbooks assembledto contain the full set of protocols,information and processes to supportstaff training in the pilot.



• Constructed a rating system to scorethe confidence of patients and carersselected to take part in the one nightstay pilot which formed part of thepre assessment process.

• Produced a DVD ‘Moving rightalong’ aimed at informing patients’and carers about the post operativeexperience which included instructionon using equipment for homemonitoring of blood pressure, pulseand temperature, pre-operativeadvice of what happens within eachstage of the patient pathway,exercises to be undertaken and howto safely move and information onhow to record results and progress inthe self management recovery plan.

• Devised a patient/carer selfmanagement tool to help themmonitor recovery at home.

• Created competency documentationto test the carers use of simple homemonitoring equipment.

• Initiated the use of the patient hotelfacility situated on site for the patientand carer to stay one day beforesurgery rather than admitting them toan acute ward bed.

• Extended the role of the cardiac rehabnurse as ‘the nurse navigator’ toensure robust communication andadherence to protocols and processes.

• Instigated a series of pre-operativehome visits to assess the patientshome environment and carercircumstances and built in one to oneeducation on use of the recovery athome plan and home monitoringequipment.

• Put in place a series of three postoperative home visits which helped tosupport the processes aimed atensuring patient recovery, safety andcarer support.

• Implemented early system of patientreview and assessment with thesurgical team at the Trent CardiacCentre on the seventh post operativeday and then the patient wasdischarged.

• Composed a process for continuouspatient and carer feedback usingtelephone interviews and an in-depthDiscovery Interview.

ResultsAt the point of publication, twopatients have completed the one nightstay initiative following elective cardiacsurgery and results have demonstratedthe following:• Whilst the work was focussed on a

sub set of the elective patientpopulation, the downstream effecthas been that several of the processesand products developed to support

early discharge and patient selfmanagement have been applied topatients on the traditional carepathway, for example, the patienttools developed for breathing,coughing and mobilisation exercisesand advice designed by thephysiotherapists.

• Enhanced skill set for cardiacrehabilitation nurses using theconfidence rating to help assesspatient and carer confidence whenexploring participation in a one nightstay pathway. These results helpedestablish if there was a link betweenthe patient’s pre admissionconfidence scores and theirexperience post operatively forexample did high scores ofconfidencecorrelate to being discharged on oneday after surgery.

• Feedback from patients and carerswho have completed the one nightstay pathway highlight the benefitsfrom their perspective as:• The peace and quiet at home in

comparison to usual care in thehospital environment;

• Opportunity to eat and drink whathe wanted and when he wanted to;

• Access to own bathroom and toiletfacilities;

• The added bonus of being able towalk in the garden and outside;

• The carer reported the back upsystem and emergency telephonecontact number to seek advice wasused and worked extremely well.

• The second patient went home aftera two night stay returning on thethird night and was subsequentlydischarged on the fourth night post-operatively. Whilst the patient didwell, his oxygen saturation levels werelower than the set criteria, this wasthe only reason for his re-admission.The protocol has been adapted toreflect checking the patients oxygensaturations pre operatively as part ofthe assessment criteria at rest and oncompletion of climbing the stairs inorder to gain a better assessment ofnormal values for the patient.

• A DVD has been produced forpatients and carers to supportinformation contained within therecovery at home self managementwork book. The DVD features videoof former patients and carersperforming a range of routine postoperative activities includingbreathing exercises, recording coretemperature, blood pressure andoxygen saturation levels and moregeneral activities designed to supporttheir recovery.



• Stair assessments performed by thephysiotherapists are now routinelycarried out for all patients on theirthird post operative day (whereappropriate) rather than the fourthpost operative day.

• A consequence of the one night staypilot appears to have resulted in anoverall reduction in the post operativelength of stay for cardiac surgicalpatients in general regardless ofwhether or not they were part of thispilot study. Typical established postoperative pathways resulted inpatients being discharged betweenfive to seven days post operativelyand since commencement of theproject we have seen an increase inthe number of patients dischargedwithin three days of their surgery with15 patients discharged within threedays between January to December2009 in comparison with two patientsbetween January to December 2008.We note there is a difference ofearlier discharge of more patients in2009 with a subsequent 24 bed dayssaved with equivalent cost saving of£6000 and are assuming this hasresulted from dissemination of thelocal learning from the one night stayproject.

• A further knock - on effect is areduced risk of gaining a hospitalacquired infection if patients aredischarged earlier and recover athome.

Top tips• Patients should be on a defined

inpatient pathway based on a riskprofile.

• Clinical decisions need to be made ona regular basis pre operatively andshould be part of the structure ofhome visits, pre operative assessment,in patient visits on a two to threehourly basis on day of operation andfirst post-operative day, daily homevisits with patient/carer selfmonitoring to promote proactive casemanagement.

• Having a dedicated project team whowork collaboratively to formulateideas and processes to test.

• Draw on the expertise and specialistknowledge of a wide range of staffand professional disciplines involvedin the care and support of patients inthe pre and post operative pathwayof care:• Cardiac rehabilitation staff were

instrumental in navigating and co-ordinating the patient process andeducation. They also were

instrumental in providing homevisits pre and post operatively notonly to the patient but to the carer;

• Physiotherapists were instrumentalin supporting the patient breathingand activity pre and post operativelyto aid recovery;

• Cardiac intensive care unit nurseswere instrumental in supportingthe patient immediately postoperatively until they weredischarged and were the point ofemergency telephone contact;

• Advanced nurse practitioners wereinstrumental in providing advancedassessment of the patient afterone night post operatively at home.

• Patient and carers need help todevelop their understanding ofsymptoms in order to encourage theirself-management and to know whoto contact when needed.

• Having strong leadership from aconsultant clinical lead.

• Using the Trusts patient and publicreader panel to help gather thepatients perspective on informationproduced for patients and carers.

• Working with patients and carers tounderstand their experiences.

• Don’t underestimate the knock-oneffects from the work and howsharing works with the wider team

not directly involved can result in theiradoption of several of the patienttools, for example the recovery athome plan for use with patients onthe ward.

• Developing a peer supportmechanism to help staff recogniseand pick up new things from othersites external to the organisation inwhich they work and in appreciatingtheir own good practice.

Contact details:Mr David RichensConsultant Surgeon andHead of Service,Trent Cardiac [email protected]

Atiya Chaudhry-GreenService Improvement Manager,East Midlands Cardiac andStroke [email protected]



The document ‘High Quality Care ForAll’ next stage review published in2008 set quality as the keyorganising principle of the NHS with‘quality’ being defined under thethree domains of patient safety,clinical effectiveness and patientexperience.

Since 2008, these domains havebegun to help define the way theNHS drives forward qualityimprovement and now feature asunderpinning principles within allcurrent NHS strategy including TheOperating Framework 2010/11 (andquality framework see below), WorldClass Commissioning and the NHSPerformance Framework (2009).

Measuring quality using thesedomains is emerging with thedevelopment of the ImprovingQuality Indicators (IQIs) by the NHSInformation Centre. Additionallymany of the emergentCommissioning for Quality andInnovation schemes (CQUINN) areusing these domains to define,manage and reward qualityimprovement within healthcarecontracts.

Quality - the current context

Complementing this approach is the‘Quality and Productivity Challenge’which builds on the above domainsby extending the quality focus toinclude innovation, productivity andprevention. Also described by theacronym ‘QIPP’ the intention is toprovide a mechanism through whichbetter care and better value can beachieved through the reduction ofwaste and in the prioritisation ofeffective treatments.

With the above in mind it is useful tosummarise the learning from thesurgical project sites aligned to theseprinciples. (Note: The author hasomitted ‘prevention’ as this wasn’tconsidered a primary focus of theinitiative).

The Quality Framework

Quality is our organising principle - the full nationalenabling framework will be in place from 2010/11

Bringing clarity to qualityFirst four NICE quality standards by April 2010 on strokecare,VTE prevention, dementia and neonatal care

Measuring qualityOver 200 quality indicators now available on theInformation Centre website

Publishing on qualityFirst Quality Accounts to be published in 2010

Rewarding qualityNational CQUIN goals on VTE, patient-reportedoutcome measures and patients’ experience

Raising standardsNational Quality Board review of system alignment

Safeguarding qualityFull CQC registration against essential levels of safetyand quality in place from April 2010

Staying aheadConnecting innovation to our core purpose - thequality and productivity challenge

Source: Operating Framework 2010\11



Same day outpatient clinic and pre-assessment

Standardisation of network wide pre operative investigations

Dedicated lead pre-assessment nurse

Pre assessment processes / protocols

Anaesthetic assessment at pre assessment.

Implementation of cardiac advanced nurse practitioner

Revised pre – assessment algorithm’s (CABG , Valve , ACS)

Nurse led pre – assessment clinics

Patient information sheets

Safety EffectivenessPatientExperience Innovation Productivity Page No.

Initiative:

Pre-operative assessment

20

22

20

9, 18

15

15

32

9

9



Pooling of surgical waiting lists (first time graft)

Surgical pooling ‘Dear Surgeon’

Standardisation of pre-referral/pre-assessment protocols


Initiative:

Referral management

Revised inter provider transfer minimum data set (IPTMDS)information capture and consistent application of 18 week rulesacross pathway

Implementation of cardiothoracic advanced/nurse practitioner

Pro active patient tracking

Revised multidisciplinary team processes incorporating telemedicineand teleconferencing

Proactively manage inter hospital transfer - role of the nursepractitioner

Interhospital transfer admission/discharge protocols

Revised surgical pathway

Increased surgical satellite clinics

Revised referral processes

Electronic referral system

Electronic referral system for inter hospital transfers

Role of the pathway coordinator

9,22

9

15

18

9,15

18

15

9

9, 36

9

22

32

9

9

9



Admission on day of surgery

Inter hospital transfer non elective referral systems

Improved theatre scheduling and associated policies

Implementation of electronic theatre scheduling tool


Initiative:

Scheduling

9, 36

9

9

22



Interhospital transfer admission/discharge protocols

Comprehensive discharge planning

Implementation of visual management system for patient discharge

Patient information packs

Intermediate care referral system

Revised post operative procedures

One night stay for appropriate elective patients

Patient experience questionnaire

Development of a patient forum

Discharge protocol for Jersey Hospitals


Initiative:

Discharge and post operative care management

9, 36

36

36

36

36

36, 39

39

15

32



Reduced waiting times

Improved multi disciplinary team

Improved audit

Reduction in theatre cancellations

Reduction in wait from pre–assessment to admission for elective surgery

Reduction in unnecessary tests

Reduction in length of stay for non elective surgery

Reduction in length of stay for elective surgery

Reduction in elective length of stay

Reduction in elective length of stay - CABG

Reduction in elective length of stay - Valves

Reduction in interhospital transfer repatriation times

Reduction in non clinical theatre cancellations

Improved theatre utilisation

Achieved and sustained 18 week target for admitted pathway

Improved pre assessment clinic capacity and activity

Increased anaesthetic input to pre assessment clinic


Initiative:

Key results

20, 22

22

22

9, 22

20

15,22

9

9, 39

36

36

36

36

9

9

15, 18, 22

15

15



The commissioning of world classhealth services will require anagreement between the purchasersand providers of cardiac surgicalservices to agree both:

• The quantity of services to beprovided.

• The quality of care to be delivered.

The formal introduction ofmeasurement for quality throughinitiatives such as IQIs and the CQUINprogramme (as a sub set of thequality framework) help to removethe often subjective nature of‘quality’ by defining metrics throughconsultation with a wide range ofstakeholders, service users, providers.purchasers and the public. Thistogether with a levelling up offinancial risk across healtheconomies, changes in tariff and theintroduction of the revisedPerformance Framework will providethe environment for qualityimprovement to flourish.

In respect to this, Cardiac (andStroke) Networks, working withclinical teams, managerscommissioners, patients and carersacross the entire patient pathwaycontinue to be uniquely placed tosupport and drive this agenda. Thenetworks ability to work impartiallyand objectively across organisationaland departmental boundaries hasbeen key to delivering therequirements of the Coronary HeartDisease National Service Framework(and other key cardiac strategies),with the case studies andachievements in this documentproviding a mere snap shot of theadded value that these organisationsbring.

NHS Performance Framework2010/11



NHS Improvement and specifically theHeart Improvement Programme havecollated a bank of useful resourcesaimed at providing local teams withsolutions to problems to support localimprovement work.

The following pages highlight someof these practical tools, products,web links and references to help youin your quality improvement work.

For further information go to:www.improvement.nhs.uk/heart

Supporting Information

Developed by NHS Improvement, theCardiac Data Dashboard is an onlinetool that aims to provideorganisations with publicly availabledata on performance within cardiacservice delivery against the national18 week and diagnostic targets.

Transforming this data intoknowledge through the use ofmaps, graphs and tables providesorganisations with an opportunityto enable comparison andbenchmarking at a number of levels:cardiac network, SHA, provider andcommissioner. The information canalso be used as an aid to serviceimprovement as it allows the user tomonitor the effect and sustainabilityof changes made to the service.

Data currently available via theDashboard includes:• Referral to Treatment (RTT) -

• Cardiology admitted andnon-admitted;

• Cardiothoracic surgeryadmitted and non-admitted.

• Diagnostic data -• Echocardiography• Electrophysiology.

The data is grouped together togive a comprehensive view ofperformance by SHA, cardiacnetwork, provider unit andcommissioner giving monthly updateson performance against the 18 weektarget.

This online tool can be accessed via:www.improvement.nhs.uk/heart/dashboard

Cardiac Data Dashboard





This interactive resource has beendeveloped with the aim of supportingNHS staff in their work to improveexisting cardiac pathways and sustainthose improvements.

Based on a generic cardiac map theuser can ‘interact’ with the site tofind a range of resources to help planyour service transformation workbased on projects undertaken byexperienced cardiac serviceimprovement project managers andNHS Improvement national teammembers.

This pulls together resources in oneeasily accessible and useablepackage.

The information contained here ismore than just currently availabletheory. We have taken this a stepfurther. The resource provides awealth of ideas and suggestionsbased on actual servicetransformation projects undertakenby experienced cardiac serviceimprovement project managers andNHS Improvement national teammembers over the last four years.

Improving Cardiac Patient Pathways: The Sustainability Toolkit

To access the resource visit:www.improvement.nhs.uk/heart/sustainability

The environment is changing rapidlyas new information comes to thefore. This resource is not exhaustivebut does uphold the guidingprinciples of the 10 High ImpactChanges, so most ideas contained inthis package result from projectswhich are:

• Patient-centred.• Propose changes that areevidence based.

• Imply a systems view on servicetransformation.



What is it?The NHS Improvement System is acomprehensive, online tool tosupport sharing of quality serviceimprovement resources in NHSservices. Giving you direct access touseful information and stories fromaround the country, it will assist youin your own service improvementwork.

Why use it?The NHS Improvement Systemactively helps organisations toeffectively achieve their objectives inline with World Class Commissioning.It enables users to be more strategicand align long-term goals that canhelp to deliver high quality, patientfocussed health outcomes.

NHS Improvement System

Which specialties are included?The system can be used to supportsustainable service improvementin any specialty.

What does it contain?• Service improvement toolsand resources

• Practical guidance• Case studies• Useful contacts• Signposting and links.

Where can I see ademonstration of the system?Demonstrations of some of the keymodules are available on theimprovement system home page at:www.improvement.nhs.uk/improvementsystem

Who can use the system?The system is free of charge and canbe used by all staff working for NHSorganisations in England.

How can I register to use thesystem?Access to the system is controlledby user ID and password.

To request an ID [email protected]



• Identify the key people to be involved early on in the workstream.• Who are the key stakeholders?• Clinical and managerial leadership is critical to success.• Have you included data and informatics and finance,

primary care and social care?

• Establish the steering/working group.• Has the group got the people with the knowledge and skills?

Can they make the decisions?• Do they have service improvements skills?• Knowledge of heath and social care processes?• Is there service user Involvement?• Is their agreed local accountability and responsibility for delivery?• Knowledge of commissioning?• Information gathered from all perspectives (service users, staff,

commissioners, partnerships etc).

• Identify, understand and define the ‘real’ problem not thesolution.

• Review data to understand demand, activity and variation inperformance.

• How are your improvements going to be measured andmonitored? Have you included qualitative and quantitativeperformance indicators?

• Match the collection of baseline data with the scope of theproblem identified.

• Remember that no data will be perfect and beware of analysisparalysis (collecting everything that tells you nothing).

• Break the data down into sections of information to helpyou identify what needs to be collected and analysed.

• Look for the 80/20 rule (Pareto principle) this happens to 80%of our users; focus on the 80% first, look for trends inretrospective data.

• Keep clinicians, leaders and key people involved.• Identify (visioning) and design the ideas to tested.

Leadership andengagement

Knowledge andskills – the basics

Planning theimprovementworkstream

Good planning can inspire change that leads to improvements

• Seek and build continuous and meaningful engagement withthe public and service users, involve them in shaping services.

• Have an understanding of different user engagement options,including the opportunities, strengths, weaknesses and risks.

• Routinely invite service users and the public to respond to andcomment on issues.

• Ensure that users and the public understand how their views willbe used, which decisions they will be involved in, when decisionswill be made, and how they can influence improvement.

• Communicate widely about ideas being tested.• Test the idea (maybe more than one testing cycle).• Capture results, benefits and measure the impact. Match across

to your performance indicators.• Capture the learning (the things that work and those that

didn’t documenting reasons why).• Communicate regularly with the whole team and partnerships -

keep the message short and snappy.• Ensure identified ownership of action points.

• Analyse the results and quantify the impact of actual and potential.• Identify benefits- e.g. quality, cost, outcomes.• Identify risks.• Evaluate the alternatives.• Make recommendations.• Build your business case on evidence.

• Recommendations for implementation(provide the evidence that supports your testing).

• Commissioners want to see the evidence.• Celebrate your achievements.• Share the learning - publicise your work.• Prepare your spread/adoption strategy.• Include how you will measure sustainability.

Engagement withpublic and serviceusers

Test out your ideas

Evaluation

Implementation -spread and sustain



References and supporting information

Department of Health (2000) Coronary Heart Disease NSFwww.dh.gov.uk/assetRoot/04/05/75/25/04057525.pdf

Audit Commission (2003) Review of Operating TheatresCompressive assessment of NHS operating theatres.www.audit-commission.gov.uk/nationalstudies/health/other/pages/operatingtheatres.aspx

Department of Health (2003) Discharge from HospitalPathway Process and Planningwww.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4003252

Parliamentary and Health Service Ombudsman (2005) Consent in cardiacSurgery: a good practice guide to agreeing and recording consentThe issue of consent and communication of risk to patients is outined in this guide.www.ombudsman.org.uk/pdfs/informed_consent.pdf

NHS Heart Improvement Programme (April 2006). Making MovesResults of a data audit and review of service improvements in interhospital transferarrangements for cardiac patients.www.heart.nhs.uk/Heart/Portals/0/docs_2006/Making_Moves_April_2006_HIP008.pdf

NHS Heart Improvement Programme (September 2006)Web-based referral systems for interhospital transfersThis document provides a review and comparisonof systems in English cardiac networkswww.heart.nhs.uk/heart/Portals/0/docs_2007/signposts_IHT.pdf

NHS Heart Improvement Programme (2007) - Signposts to ImprovingCardiac Interhospital Transfers - ‘Get the right response to the rightpatient at the right time’This document focuses on the transport issues and signposts to potential solutionssurrounding the complexity of the booking and transfer of non-elective cardiacinpatients between hospitals for diagnosis and/or intervention.

This is an interactive pdf document, aimed at commissioners, managers andclinicians within NHS trusts, primary care trusts, cardiac networks and theambulance service and is produced by the Heart Improvement Programme workingin partnership with cardiac networks, ambulance services, ASA and the DH.www.heart.nhs.uk/heart/Portals/0/docs_2007/signposts_IHT.pdf

NHS Heart Improvement Programme (2007). Getting it Right -Improving the Consent Process for Cardiac SurgeryA range of materials to support the implementation of the Ombudsman'srecommendations for Consent in Cardiac Surgery: a good practiceguide to agreeing and recording consent.www.heart.nhs.uk/consent

NHS Heart Improvement Programme (2008)National Priority Projects 2007/08Summary documents from the Heart Improvement Programme’s 2007/08 nationalpriority projects are available to download from: NHS Heart ImprovementProgramme - 2007/08 Priority Projects:• Making Best Use of Inpatient Beds Project;• 18 Weeks Whole Pathways Project;• 18 Weeks - Focus on Cardiac Diagnostics Project;• 18 Weeks - Atrial Fibrillation in Primary Care.www.improvement.nhs.uk/Publications/tabid/56/Default.aspxThe summaries include descriptions, supporting information and key learning fromthe projects. Details of each project site are available in the summary documents,and are linked to the priority project online.

National Confidential Enquiry Patient Outcome and Death (2008)Coronary artery bypass grafts: The Heart of the MatterThis NCEPOD report analyses the care of a sample of patients who in the majoritydid not survive to leave hospital following their CABG operation. It takes a criticallook at the selection of the surgery and the strategy and the organisational factorsinvolved in its implementation. The report is available to download from: NCEPOD -CABG: The Heart of the Matter Report (2008).



Department of Health (2008). High Quality Care for All:NHS Next Stage ReviewThe final report of Lord Darzi's NHS Next Stage Review. It responds to the 10 SHAstrategic visions and sets out a vision for an NHS with quality at its heart.www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085825

Department of Health (2008). Using the Commissioning for Quality andInnovation (CQUIN) payment frameworkThis document is available to download fromFrom The Stationary Office at www.tsoshop.co.uk or download atwww.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_091443

World Health Organisation Surgical Safety Checklist (2009)This checklist describes the process which should be used for every patientundergoing a surgical procedure. Lord Darzi helped develop the checklist, which isseen by WHO as one of the best ways to improve patient safety.www.nrls.npsa.nhs.uk/resources/clinical-specialty/surgery/?entryid45=59860

Department of Health (2009). The operating framework for 2010/11 forthe NHS in England.This document sets out the specific business and financial arrangements for theNHS during 2010/11 and describes the national priorities for the year. It is availableto download fromwww.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_110107 or in hard copy from www.orderline.dh.gov.uk quoting:299522 the operating framework for the NHS in England 2010/11.

Department of Health (2009). NHS 2010-2015: from good to great.Preventative, people-centred, productive. This report describes practical measures tomeet the demands of an aging population and the increased prevalence of lifestylediseases. The document is available via The Stationary Office at www.tsoshop.co.ukor dowwnload fromwww.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_109876

Department of Health (2010). Quality Accounts Toolkit: Advisory guidance forproviders of NHS Services producing Quality Accounts for the year 2009/ 2010This toolkit is for NHS providers to assist with the production and publication of theirQuality Accounts in 2010. It features best practice guidance and useful tools basedon the findings from the Quality Reporting process in 2009 and discussions withstakeholders. It is an interactive document, designed to be used online.www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_112359

Department of Health Quality and Productivitywww.dh.gov.uk/en/Healthcare/Highqualitycareforall/QualityandproductivityMeasuring for Quality Improvement. High Quality Care for All proposed that clinicalteams should use clinical indicators to measure the quality of care they deliver,highlight areas for improvement and track the changes they implement. Indicatorsfor quality improvement (IQI) were released on the NHS Information Centre websitewith descriptive information and links to their sources and can be found NHSInformation centre website.www.ic.nhs.uk/services/measuring-for-quality-improvement

Hospital Episode Statistics (HESonline)www.hesonline.nhs.uk



Acknowledgements

The list represents the full list of organisations who participated inthe Cardiac Surgery National Priority Project:

Anglia Cardiac and Stroke Network

Basildon and Thurrock University Hospitals NHS Foundation Trust:Essex Cardiothoracic Centre

Blackpool, Flyde and Wyre Hospitals NHS Foundation Trust:Royal Victoria Hospital

Birmingham, Sandwell and Solihull Cardiac and Stroke Network

Cardiac and Stroke Networks in Lancashire and Cumbria

Essex Cardiac and Stroke Network

East Midlands Cardiac and Stroke Network

Heart of England NHS Foundation Trust: Good Hope Hospital

North West London Cardiac and Stroke Networks

Nottingham University Hospitals NHS Trust: Trent Cardiac Centre

Papworth Hospital NHS Foundation Trust

Royal Brompton and Harefield NHS Foundation Trust

South London Cardiac and Stroke Networks

St George’s Healthcare NHS Trust

University Hospitals Birmingham NHS Foundation Trust:Queen Elizabeth Hospital

University Hospitals Leicester: Glenfield Hospital

Cardiac Surgery National Project Team

NHS Improvement

Wendy GrayNational Improvement [email protected]

Garry [email protected]

Rhuari PikeNational Improvement [email protected]

Heather LockettDirector of [email protected]

Jim FarrellGraphic [email protected]

National Clinical Leads

Steve LiveseyConsultant Cardiac [email protected]

Gordon MurrayConsultant [email protected]





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NHS Improvement

With over ten years practical service improvement experience in cancer, diagnosticsand heart, NHS Improvement aims to achieve sustainable effective pathways andsystems, share improvement resources and learning, increase impact and ensure valuefor money to improve the efficiency and quality of NHS services.

Working with clinical networks and NHS organisations across England, NHSImprovement helps to transform, deliver and build sustainable improvements acrossthe entire pathway of care in cancer, diagnostics, heart, lung and stroke services.

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HEART LUNGCANCER DIAGNOSTICS STROKE

Health & Medicine

A guide to commissioning cardiac surgical services