Care Redesign Realising the opportunities

Transcription

1 Care Redesign Realising the opportunities January 2017

2 With over 16 million hospital admissions, 23 million attendances at Accident & Emergency Departments and 86 million outpatient attendances, NHS acute trusts provide a huge number of different clinical services to patients every year. This paper draws on recent care redesigns at NHS trusts, to share an approach to improving quality, financial efficiency and patient access to care. Clinical service in many acute trusts has evolved organically over the years. Services are shaped by expertise, experience and patient need, as well as physical, staffing and technological developments and constraints. Clinical teams see examples of waste within their own services, but frequently struggle to implement improvements. They are inhibited by interdependencies between different services, the numbers of people who need to be involved in any change, and a lack of time to make changes happen. However, the opportunities for improvement through redesign are real, not least because of the current pace of change in technology and clinical practice. This paper provides an approach that helps clinical teams to redesign their services, implement improvements, and overcome the additional challenges caused by interdependencies and complexity. The Opportunity for the NHS Current services, including elective orthopaedics, cancer pathways and emergency pathways, as well as functions including pharmacy, diagnostics, theatres, wards and outpatients, can be redesigned to be safer, more consistent and 9-30% more efficient, and to have radically shorter access times for patients. Clinicians and managers who run services point to significant waste and frustrations, including delays to ward assessment processes, slow turnaround times in diagnostics, and late starts in theatres. Analyses led by Lord Carter have also identified significant efficiency opportunities 1. The Challenge While the prize is large, the obstacles are too. The same clinicians who can see the opportunities typically have little time to re-think the service, and often lack the organisational overview needed to navigate the numerous and complex interconnections between services. Furthermore, care redesign requires significant behavioural change from large numbers of people, some of whom will have been used to working in the established ways for many years. 1 Operational productivity and performance in English NHS acute hospitals: Unwarranted variations, an independent report for the Department of Health by Lord Carter of Coles: unwarranted variation is worth 5bn in terms of efficiency opportunity a potential contribution of at least 9% on the 55.6bn spent by our acute hospitals, p6. Page 1

3 A Solution: Care redesign that acknowledges interdependencies Instead of trying to unpick and gradually improve one service in isolation from others, this paper shares an alternative approach that starts from scratch. This means supporting clinicians and managers to design an approach that meets your quality, financial and access targets: i) without being constrained by how the service is currently designed; ii) with an understanding and acknowledgement of key interdependencies; and iii) in a way that is based on recognised best practice. This exciting and engaging approach requires a set of principles that people can collaborate around: What does care redesign involve? Start by defining the key threads of your organisation: what are the top 20 patient conditions that you are caring for (e.g., by numbers of patients, by income, or by strategic importance)? And what are the core clinical supporting functions for these conditions (e.g., outpatients, pharmacy, A&E, diagnostics, wards, therapies, theatres, transport)? The redesign process requires a multi-disciplinary team with clinical leadership from the profession that has the greatest influence on how the service is delivered, e.g., medical leadership for outpatients redesign. Clinical teams need to be established with the expectation that they will be ongoing improvement engines for the service. Teams need to include patients, service partners (e.g., from the community) and commissioners so that they have a shared understanding of the purpose of the resign and develop the new design together. Page 2

4 Each clinical team generates the future state design that they can align themselves behind and iterate towards over the next 3-5 years. The following five steps are used to generate the future state design: 1. Define: Agree what the question is that the team are answering; set the scope and how success will be measured; plan the work; engage with patients, colleagues and other stakeholders; and set up the team to do the work. For example, for the radiology service, define which modalities are in scope and whether or not interventional services are included. 2. Discover: Find out what has already happened by analysing data; observing current practices; quantifying and prioritising pain points and root causes for these; and discovering best practice examples inside the trust and outside. Then set out the scale of the potential improvement opportunity, and agree with the Executive team and clinicians the growth assumptions to use in the design phase, and the key interdependencies. 3. Design: Start with a set of hypotheses for the potential future state design, using findings from the discover phase. Iterate with the team and with key interdependent services. Describe what this future service would look and feel like (flow, size, key roles, technologies, processes), and what quality, financial and access benefits would be achieved from it. The focus here should be on usercentred design and transformative developments. 4. Deliver: Create a delivery plan that prioritises the key design initiatives and sets out the journey towards the future state. Use rapid improvement cycles to implement and test changes, getting everyone involved in working towards the future state design. 5. Digest: Review frequently what s working and what lessons are being learned. Engage people widely and celebrate successes. Managing interdependencies between services The redesign work will have knock on-effects for other services. For example, the redesign of a surgical pathway may result in a recommendation for a one-stop diagnostic service and dedicated theatre and bed capacity, which in turn could conflict with theatre and Page 3

5 diagnostic service redesigns. To help manage these interdependencies, we recommend distinguishing between speciality services, which are focused on caring for specific conditions (e.g., elective orthopaedics), and clinical service functions, which provide services across many patient conditions (e.g., diagnostics). Speciality clinical teams set out the care pathways for their patients, defining which functions are required, in what sequence, and within what performance parameters. Clinical support service teams design the functional service modules needed to meet the speciality service parameters. In the example set out below, the elective orthopaedics clinical team has determined that a one-stop-shop is needed and defined the diagnostic turnaround time it will require. The diagnostics and elective orthopaedics teams have agreed that some of the images can be reported by the requester. The diagnostics team are then responsible for designing the service to meet the one-stop-shop requirements. By meeting the speciality requirements, this approach reduces the need for less efficient, ring-fenced clinical functions. Organising and sequencing the redesign work The trust needs to consider how much redesign work can be done at once, and which areas to start with first. It is useful to have multiple services redesigning in parallel, as this encourages sharing of ideas, consistency of approach, and an element of competition to provide momentum. Selected teams must: Have the potential to produce a clear and sizable positive impact for patients Page 4

6 Be aligned with the trust s ambitions and strategic priorities (e.g., Carter, Vanguards, STP) Have a strong clinical lead, committed to making time for the project and able to generate enthusiasm among the team It is sensible to start with a mix of teams: one small speciality that can run faster (to develop and test the approach); one larger speciality to build credibility and achieve impact; and a clinical functional service, to demonstrate the application of the approach to functions and for managing intersections between specialities and clinical functions. Balancing quality and financial objectives Trusts have been running Cost Improvement Programmes for many years, and if staff see a service redesign programme as being driven only by efficiency savings, it is likely to be difficult to engage them broadly. In contrast, when staff see patient quality as being at the heart of the programme, it can represent an opportunity to reconnect them powerfully with their own commitment to delivering healthcare. We recommend establishing an open dialogue throughout the programme between clinicians and managers, to ensure that an acceptable balance is being achieved between meeting quality and financial objectives in the near and longer term. The care redesign approach aims to find creative and innovative ways to deliver both better quality and greater efficiency, by focusing on the needs of users and on reducing unwarranted variation. For example, using existing web-based approaches can give patients greater Practical tips Effective clinical leadership requires practical thought and planning to be successful: Invest in clinical PAs and backfill during the design phase Ensure the chief executive, board members and clinical leaders spend time generating a shared vision for transformation Clinical leaders will benefit from working alongside their operational colleagues throughout the programme Big changes, such as estates changes, can be a major sticking point for clinicians who have set up their professional and personal lives around the current location think about how to discuss this in a sensitive and collaborative manner ownership of care, access to advice, and support when booking appointments and accessing results, meaning that self-service can become the norm. Resourcing the redesign The success of the redesign relies on clinicians designing and implementing the new approach. However, they also have clinical, and possibly research and education, commitments. When embarking on a care redesign project, you need to be clear what roles are required and how much time is needed. Key roles include clinical leadership, analytics, administration, IT, operations and finance. Identify suitable individuals for the roles for example, the clinical leaders need to be individuals who have the respect of their clinical colleagues. Support these individuals to work out what they can stop doing, where other colleagues can step up with guidance, and where any backfill is required. Page 5

7 Integrating the redesign with development The redesign process is particularly effective when run with an integrated development programme to provide the clinical teams with the skills and environment needed to manage the redesign. This would include coaching and training on redesign principles, behaviours and tools. This makes the redesign approach more sustainable (by reducing reliance on external resource) and staff (clinicians and managers) value the investment in their personal development. In one of the most successful examples we have seen, the trust strategy, redesign, cost improvement and development programmes were fully joined up: the trust strategy set the redesign priorities; the redesign work provided the high-level future state for each service; the development programme provided training and support to clinical teams to deliver the improvements and to lead the next wave of design; and the trust managed the process, quality, capability and cost improvements through a joined up governance process. As a result, the trust harnessed the skills and energy of tens of thousands of staff members in a fully aligned effort that resulted in significant quality improvements and more than 30m of efficiency savings. Conclusion Care Redesign is a major undertaking that is often avoided because of the complexity associated with it. However, very significant quality and efficiency benefits can be realised with a clear set of principles to navigate the interdependencies between services, and by integrating strategy, redesign and staff development into a coherent approach. This approach requires sustained senior leadership from the whole Executive Team, and time investment from clinical leaders within each service. It is not to be entered into lightly. In our experience, this approach should only be pursued if the Chief Executive and wider Executive Team make care redesign one of their top three priorities for the next three years. With this commitment, a clear vision and strong, collaborative leadership, care redesign is an exciting approach that can substantially improve performance in terms of outcomes, consistency, lead times and resource utilisation, and reinvigorate the whole organisation. About 2020 Delivery 2020 Delivery is a specialist public service consultancy. Our staff are committed to improving public services and delivering lasting change for service users and taxpayers. Further details about the company can be found at Authors: Caroline Cake, Director carolinecake@2020delivery.com, Chris Bradley, Director chrisbradley@2020delivery.com Kate Ford, Principal Consultant kateford@20202delivery.com. Page 6