Improving Quality and Reducing Cost The Role of Measurement

Carrie MarrAssociate Director Change &

InnovationTayside Centre for Organisational

Effectiveness

Integrating Finance and Quality

Context

Financial Waste

Demographic Harm

Safety & Quality Variation

Demographic change for population aged 65+ ScotlandPotential impact on emergency bed numbers 2007-2031

0

2000

4000

6000

8000

10000

12000

14000

16000

Y/E Mar 2007 Projected2011

Projected2016

Projected2021

Projected2026

Projected2031

Year

Be

ds

9%24%

41%61%

84%

NHS Tayside+148 beds 2016+517 beds 2031

Healthcare demand is growing

A new NinewellsHospital by 2031!

Evidence of Waste in Healthcare Systems

• 27% of New Outpatient appointments are being wasted!

Question 1 – Are there significant Outpatient Capacity losses?

Increase Capacity of Outpatient Clinics?

Opportunity?

0.0

5.0

10.0

15.0

20.0

25.0

Discharged AWAITING TESTRESULT

REFD OTHERCLIN/HOSP

DNA-Total Could Not Wait - FA REFER TO OTHERHOSP

%

New

Return

» There are approx 430,000 District Nurse Visits in a year (56% of District Nurse time was non-patient facing)

District NursingDistrict Nursing

Comparison of band 6 and band 5 activity

0%5%

10%15%20%25%30%35%40%45%50%

Band 6

Band 5

Evidence of Clinical Variation in Healthcare Systems

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200

400

600

800

1000

1200

1400

1600

GP Practices

Cost per Head by GP Practice 2006/07 (incl. GMS)

Examples of Variation in Clinical Practice

• Poly pharmacy• Rates of admissions in over 65 years• Lengths of stay in over 65 years• Referral patterns into acute specialist care

Achieving Quality Improvement and cost reductionDeveloping and Improving Services

QUALITY INITIATIVES COST REDUCTION PROGRAMMESNEW DEVELOPMENTS EFFICIENCY SAVINGS

1 2 3 4 5

Costs more Cost neutral Improves quality Quality neutral Reduces & reduces costs quality

Improving Quality and Reducing Costs

Our Choice

Surviving – the 5%

Thrive – the 95%

TACTICAL STRATEGIC

DEALING WITH THE 5%

SPENDING THE 95% BETTER

PRODUCTIVITY & EFFICIENCY

CRES

SERVICE OPTIMISATION

TRANSFORMATION

2009 - 2011

2010 - 2013

TACTICAL STRATEGIC

DEALING WITH THE 5%

SPENDING THE 95% BETTER

PRODUCTIVITY & EFFICIENCY

CRES

SERVICE OPTIMISATION

TRANSFORMATION

Steps to Better Healthcare

Mental Health

OutPatients

Theatre Capacity / Planned

Care

Workforce Older people

Shifting the

Balance of Care

Optimisation of Health Facilities across Tayside

Prescribing and

Medicines

Finance Support

Workforce Support

Scenario Planning, Financial Baselines, Benefits Tracking, Business Cases

Workforce Modelling, Engagement & Communications with staff

Comms SupportCommunications with public and staff

Other

OE SupportOrganisational Effectiveness support

Labs

Maternity

How I engage with the centre:

Technology Enabling Health

ImprovementAcademy

Improvement &

Development Support

Real time information resource to

support quality improvement of

clinical services

Enhance spread and share of

good practice through use of technology

ie web portal Develop a innovative education

and training resource to assist in

our quality improvement needs

through improvement science

and optimising e health resources.

To develop trained experts in quality

improvement organisational development

and leadership to support improvement

work prioritised by our joint clinical boards.

The focus of this expertise will be mobilised

to support front line staff and clinicians to

build capability in improvement methodology

and support key improvement programmes

Business Support Real time information and measurement

systems

NHS Tayside Clinical Portal:

CHKS

• Annual and Bi annual reports which will take a high level organisational perspective

• Specific reports designed to address issues identified within the organisational reports or at the request of the organisation when internal review may have identified issues which need further clarification

• Continuous review of data quality and feed back to the organisation to support audit and development

Average Length of Stay : General Surgery

Approaching length of stay either at specialty level as part of other indicatorsor specifically length of stay within the hierarchy by specialty 3.3 days (peer 2.6 )

Consultant Level Average Length of Stay (GS)

• The table identifies the consultants involved in the management of cases in General Surgery

• Most individuals have a greater average length of stay than the peer

• Bed day opportunity is derived from average length of stay and volume of activity

• Some individuals have very small volumes of cases

Length of Stay by Condition (HRG)

• The table above illustrates the 8 HRGs with the greatest potential for bed day improvement based on volume and comparative length of stay to peer average.

• Off note is the number of cases with no associated procedure for some of these condition groupings

Outpatients

• The outpatient indicators concentrate on new to review ratios and DNA rates

• At organisational level new to review – 1 to 0.5 (peer 1 to 2.1)

• At organisational level DNA rates 8.2% (peer 7.9%)

Business Support Hub• Collect once use for many purposes• Collect from a wide range of

sources NHS, Local government, Public health

• High Data Quality Standards applied

• Systems to support business requirements

• Training & education• Predictive modelling

Clinical Quality

Organisational Effectiveness

Financial Planning

Development of 2 tiers:

Production – automating regular reports as much as possible using IT solutions eg. BO and VBA

Health Intelligence / Innovation

Waiting list reporting Full patient tracking Weekly position summary Bed statistics / utilisation A&E submissions others...

Unique Patient Tracking Clinical Dashboards+ Quality Metrics Statistical Process Control + Variation reporting Strategic improvement data

analysis (variation and waste Data)+ Service Improvement Patient Pathways Predictive Risk Score Modelling

To build capability within the Business Support Unit

Clinical Dashboards – Pilot Metrics

• Real-time Bed Management, e.g. available / occupied beds

• Service / Resource Utilisation, e.g. boarding patients, same day surgery rate, outpatient dna rates

• Waiting Times & Access, e.g. 18 weeks RTT, inpatient / daycase / new outpatient • Infection Control, e.g. hospital acquired infection, handwashing, cleanliness

• Patient Safety, e.g. anti-biotic policy, early warning scores,

compliance with central line insertion,

daily safety briefings compliance

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Patient Safety

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Click to view trend

line

30

Hover over data point for

detail

Click for more details

Data Table

• Data for discussion, not judgement supports a shift in culture

• Education programmes that build capacity and capability in data and analysis

• Supporting staff to build confidence in handling data and align to real time delivery of services

• real-time information and measurement systems that connect whole systems – clinical and non-clinical

• Prospective capacity management• Dashboards for clinical quality, business

information and governance

The Current Challenge facingNHS Tayside