strategic alignment of projects v5 - looking back

Strategic Alignment of Projects

The Year 2012/13

RUH

During 2012/13 - 94 projects had been started and/or run.

42 QIPP 15 Lean 10 Qulturum (Quality) 27 CQUIN (not counting the sub-projects)

…with everyone trying to do everything – and thetrust had, in the main, been mostly successful.

EPMTxfmQulturum

Quality

QIPP

To recap – Where we were

Where we want to get to

A STRATEGIC ALIGNMENT of

• Every Patient Matters (EPM) Transformation programme• Qulturum/Quality priorities• QIPP (Quality, Innovation, Productivity, Prevention)• CQUIN

Lean/Txfm

QulturumQuality

QIPP

Where we want to get to

A STRATEGIC ALIGNMENT OF PROJECTS

Resulting in

• Strategic prioritisation of projects and focussed organisational effort• Combining of Enabling projects, Quality Initiatives and Delivery/Implementation• High focus on fewer transformational projects for (say) 8 – 25 weeks at a time• No more everyone trying to do everything all of the time – and their day jobs

Lean/Txfm

QulturumQuality

QIPP

2013/14’s Major QIPP Projects

At the November Board the Major 14 QIPP projects for 2013/14 were selected

Project Name > 250k Theatre/- Impact/- Criteria Ward Flow Trigger1. Outpatient Efficiencies Y Y Y Y2. Theatre Closures Y Y Y Y 3. Skill Mix Review/Reduction in Bank Staff Y N Y Y4. Bed Efficiency AAU Y P Y P5. Bed Efficiency DTOC & Green to Go Y P Y P6. Pathology Y N Y P7. Improving efficiency in Radiology Y N Y N8. Drugs Review Y N Y N 9. Terms & Conditions Y N N P10. Procurement Y N P N11. Energy & Water Consumption Y N N N12. Agency Recruitment Y * * *13. SLM Rollout Y * * *14. Back Office Review Y * * *

2013/14’s Strategic Projects

34 projects with a total estimated savings = £11,4m

Top 14 projects = £ 9,2m

80% of the QIPP Programme

2013/14 QIPP


EPM - LEAN1. Patient Flow – Elective2. Patient Flow - Elective. Day Surgery - Start Times3. Patient Flow - Elective - Patient Validation4. Patient Flow - Non Elective - (Front Door, EOL Pathway)5. Patient Flow - Non Elective (Ward Flow)6. Discharge Planning (TTAs)7. Patient Flow - Non Elective (Emergency Theatres)8. Accounts Payable9. Booking Review10. Cardiology11. Chemotherapy Outpatients, Booking12. Diagnostics13. IM&T Review14. Medical Records (Flow of Notes & U-Codes)15. Outpatients - Orthopaedics (Shoulder)16. Purchasing17. Recruitment18. SUIs Process19. Theatre Equipment & Resources


Qulturum - QUALITY1. Safer Clinical Systems – Parkinson’s 2. SHINE - Health Foundation3. Emergency Laparotomy pathway 4. Quality Improvement Care Bundle5. Dementia Challenge Fund project6. Improving Nutrition7. 5 year Patient Safety Programme8. Staff Engagement Quality Accounts priorities :

9. Promoting Organisational Learning10. Reducing Infections11. Improving the care of patients with COPD (reducing re-admissions) 12. Improving care for patients & carers at the End of Life (link to re-admissions audit)13. Continence

CQUIN


National Schemes1. Dementia FAIR2. Safety Thermometer (Pressure Ulcers)3. VTE4. Friends and Family Test (FFT)

Local Schemes5. End of Life Care (EOLC)6. 7/7 Working7. Acute Oncology8. Continence9. Francis Report

A Strategic Alignment of ProjectsThe 2013/14 RUH transformation projects for the 4 areas have now been mapped.

QIPP EPM QULTURUM CQUIN (13/14)TRANSFORMATION BOARD 1.11 Bed Effi ciency – AAU Patient Flow - Non Elective - (Front Door,

EOL Pathway)1.12 Bed Effi ciency. DTOC 2013 -2015 & Green to Go Plan

Patient Flow - Non Elective (Ward Flow), Discharge Planning (TTAs)

Safer Clinical Systems project - focussing on patients with Parkinson's Disease; Health Foundation SHINE project - Emergency Laparotomy pathway Quality Improvement Care Bundle; Dementia Challenge Fund project; Improving Nutrition will support reductions in LOS

7/7 working scheme

2.1d Improving Effi ciencies in Radiology Diagnostics 7/7 working scheme4.6 Outpatient Effi ciencies Outpatients - Orthopaedics (Shoulder),

Cardiology, Chemotherapy Outpatients, Booking

5.1 Theatre Scheduling & Capacity Realignment

Patient Flow - Non Elective (Emergency Theatres)

5.1 Theatre Scheduling & Capacity Realignment

Patient Flow - Elective

Patient Flow - Elective. Booking ReviewPatient Flow - Elective. Day Surgery - Start TimesTheatre Equipment & ResourcesPatient Flow - Elective - Patient Validation

1.2 Reduction in Infection & Harm 5 year Patient Safety Programme; Quality Accounts priority 'Promoting Organisational Learning'- aim to reduce harm events by increasign learning from incidents; Quality Accounts priority - reducing infections;

VTE SchemeStafety Thermometer Scheme (Pressure Ulcers)

1.3 Reduction in Readmissions Quality Accounts priorities - Improving the care of patients with COPD (reducing re-admissions) and Improving care for patients & carers at the End of Life (link to re-admissions audit)

EOLC scheme

1.4 ED attendance avoidance project 5.4 INNF Compliance 1.6 Acute Oncology Acute Oncology Scheme2.5 Pathology Effi ciency

Theatre RecoveryEFFICIENCY BOARD 3.1 Back Offi ce Review IM&T Review, Recruitment, Medical

Records (Flow of Notes & U-Codes), Accounts Payable, SUIs Process

3.10b Agency Recruitment Recruitment 3.2 Procurement Purchasing3.3 R&D/Commercial Research3.6 Energy & Water Consumption3.12 Terms & Conditions Qulturum links to Staff Engagement

group3.10a Skill Mix Review / Reduction in Bank 2.9 Drugs ReviewSLM 2.4a SLM Urology (v4)2.4b SLM Gastro (v9)2.4c SLM OPU (v9)


But Wait -

Theres More!

MORE?


Information Technology±75 Projects

IT Infrastructure

Change Requests

E.P.R.


+ PLUS +

14 Commercial Development Projects

2013/14 - The Year Ahead

RUH

Transformation Projects for 2013/14

34 QIPP 19 Lean 13 Qulturum 9 CQUIN# 75

+ PLUS + 75 IT Projects 14 Commercial Development Projects# 89

Total 172 discreet pieces of work

Not Incl. Replacement PACS, Pathology Build etc.

A Strategic Alignment of Projects

OK. So what now?

Which do we do first?

How do we make informed decisions?

FIRST…….Things we must be aware of – like Relationships & Interdependencies

Relationships & Interdependencies - LOS

SLM OPU

SLM Urology

Reduction in infection

& Harm

Non Face-to-Face

Ophthalmology

PSA Tracker

Theatre Schedulin

g

ED Attendanc

e Avoidance

Ambulatory Care

FOCUS Unit

Hip Fracture Pathway

Acute Oncology

Paediadtric Pilot

Best Practice

Tariff

Outpatient Efficiencie

s

Green to Go

Increasing Day Case

Rates

Reducing Readmissi

ons

Back Office

Review

INNF

R&D Income

E-Rostering

Reduction in Agency

PACs System

Diagnostic Efficiencie

s

Medical Workforce

- Med

Drugs Review

Medical Workforce

- Surg

SLM Gastro

Procurement

Terms & Conditions

Energy & Water

Patholgy

SAU/ Non-Elective Surgery

7/25/2013

LOS Work Stream

LOS

Outpatients

Theatres

Medicine Other

Surgery Other

Efficiency

Relationships & Interdependencies - OP

SLM OPU

SLM Urology


& Harm

Non Face-to-Face

Ophthalmology

PSA Tracker

Theatre Schedulin

g

ED Attendanc

e Avoidance

Ambulatory Care

FOCUS Unit


Acute Oncology

Paediadtric Pilot

Best Practice

Tariff


s

Green to Go

Increasing Day Case

Rates

Reducing Readmissi

ons

Back Office

Review

INNF

R&D Income

E-Rostering

Reduction in Agency

PACs System


s

Medical Workforce

- Med

Drugs Review

Medical Workforce

- Surg

SLM Gastro

Procurement

Terms & Conditions

Energy & Water

Patholgy


7/25/2013

Outpatients Work Stream

LOS

Outpatients

Theatres

Medicine Other

Surgery Other

Efficiency

SLM OPU

SLM Urology


& Harm

Non Face-to-Face

Ophthalmology

PSA Tracker

Theatre Schedulin

g

ED Attendanc

e Avoidance

Ambulatory Care

FOCUS Unit


Acute Oncology

Paediadtric Pilot

Best Practice

Tariff


s

Green to Go

Increasing Day Case

Rates

Reducing Readmissi

ons

Back Office

Review

INNF

R&D Income

E-Rostering

Reduction in Agency

PACs System


s

Medical Workforce

- Med

Drugs Review

Medical Workforce

- Surg

SLM Gastro

Procurement

Terms & Conditions

Energy & Water

Patholgy


7/25/2013

Theatres Work Stream

LOS

Outpatients

Theatres

Medicine Other

Surgery Other

Efficiency

Relationships & Interdependencies - Theatres

SLM OPU

SLM Urology


& Harm

Non Face-to-Face

Ophthalmology

PSA Tracker

Theatre Schedulin

g

ED Attendanc

e Avoidance

Ambulatory Care

FOCUS Unit


Acute Oncology

Paediadtric Pilot

Best Practice

Tariff


s

Green to Go

Increasing Day Case

Rates

Reducing Readmissi

ons

Back Office

Review

INNF

R&D Income

E-Rostering

Reduction in Agency

PACs System


s

Medical Workforce

- Med

Drugs Review

Medical Workforce

- Surg

SLM Gastro

Procurement

Terms & Conditions

Energy & Water

Patholgy


7/25/2013

Medicine Other Work Stream

LOS

Outpatients

Theatres

Medicine Other

Surgery Other

Efficiency

Relationships & Interdependencies - Medicine

2013/14’s Strategic Projects - Scoring1.1 Area B – New AAU1.2 Redn. Infection & Harm1.3 Redn. Re-Admissions 1.4 ED Attend. Avoids1.6 Acute Oncology1.8 Increasing Day Case Rates1.11 Bed Efficiency AAU1.12 Green To Go 1.13 Hip Fracture Pathway (N)

2.1a Reduction Diagnostics2.1d Radiology Efficiencies2.3a Medical Wkfce Job Plng Med.2.3b Medical Wkfce Job Plng Sur.2.4 SLM (x3)2.4i PSA Tracker2.5 Pathology2.6 Emergency Surgery (N)2.9 Drugs Review

3.1 Back Office Review3.2 Procurement3.3 R&D Research3.6 Energy & Water Cons.3.8 Estates Efficiencies3.10a Skill mix/Redn. Bank3.10b Skill Mix/Redn. Agency3.12 T&Cs

4.4a Non F2F Ophthalmology4.4b Non F2F Paeds4.6 OutP Efficiencies

5.1 Theatre Scheduling5.4 INNF EDS - Elec. Day Surgery Start TimesPV – Elec. Patient Validation

SAVINGS VALUE

£0

£1,000k

QUALITY

Low Medium High

ANALYSISSAVINGS & QUALITY

2.5

(Q) 3.12

2.1d (EPM)

1.4 3.3

5.4

2.3a

(Q) 1.2

1.6

(Q) 1.3

5.1 3.6

4.4c

4.4b

2.9 (EPM) 3.1 (Q) (EPM) 1.11

1.12 (Q) (EPM)

2.4

3.2 (EPM)3.10b (EPM)

(EPM

) 3.10a(EPM) 4.6 2.1a

£200k

£400k

£600k

£800k

1.13

2.3b

2.4i

2.6

3.8 4.4a

EDS

PV

1.8

2013/14’s Strategic Projects – Scoring Double Check1.1 Area B – New AAU1.2 Redn. Infection & Harm1.3 Redn. Re-Admissions 1.4 ED Attend. Avoids1.6 Acute Oncology1.8 Increasing Day Case Rates1.11 Bed Efficiency AAU1.12 Green To Go 1.13 Hip Fracture Pathway (N)

2.1a Reduction Diagnostics2.1d Radiology Efficiencies2.3a Medical Wkfce Job Plng Med.2.3b Medical Wkfce Job Plng Sur.2.4 SLM (x3)2.4i PSA Tracker2.5 Pathology2.6 Emergency Surgery (N)2.9 Drugs Review

3.1 Back Office Review3.2 Procurement3.3 R&D Research3.6 Energy & Water Cons.3.8 Estates Efficiencies3.10a Skill mix/Redn. Bank3.10b Skill Mix/Redn. Agency3.12 T&Cs

4.4a Non F2F Ophthalmology4.4b Non F2F Paeds4.6 OutP Efficiencies

5.1 Theatre Scheduling5.4 INNF EDS - Elec. Day Surgery Start TimesPV – Elec. Patient Validation

EFFORT

IMPACT

Low Medium High

ANALYSISEFFORT & IMPACT

2.5

(Q) 3

.12

2.1d

(EP

M)

1.4

3.3 5.42.

3a

1.2 (Q)

1.6

(Q) 1.3 5.1

3.6

4.4c

4.4b

2.9

(EPM) 3.1 (Q) (EPM) 1.11

(Q) (

EPM

) 1.12

2.4 & 2.6

3.2 (EPM)

3.10b (EPM)

(EPM) 3.10a

2.1a

1.13

2.3b

2.4i

3.8

4.4a

EDS

PV

1.8 High

(EPM) 4.6

2013/14’s Strategic ProjectsTop Scoring Projects

PROJECTSavings/Quality

Impact/Effort

Major Projects

Projects which Scored 5 x 51.11 Bed Effi ciency AAU Y Y Y1.13 Hip Fracture Pathway Y Y2.6 Emergency Surgery Y YElective Day Surgery - Start Times Y Y5.1 Theatre Scheduling Y Y1.6 Acute Oncology Y2.4 SLM Y Y2.1a Reduction in Diagnostics Radiology Y Y1.12 Green To Go Y Y

Projects which Scored 5 x 4 and 4 x 53.1 Back Offi ce Review Y Y Y3.10b Skill Mix - Reduction in Agency Y Y Y2.9 Drugs Review Y Y1.3 Reduction in Readmissions Y1.8 Increasing Day Case Rates Y3.12 Terms and Conditions Y Y

2013/14 Major Projects4.6 Outpatient Effi ciencies Y3.10a Skill Mix Reduction in Bank Staff Y2.5 Pathology Y3.6 Energy & Water Consumption Y3.2 Procurement Y


RECOMMENDATIONS

Efficiency Projects

2.9 Drugs Review3.1 Back Office Review 3.2 Procurement3.3 R&D Income3.6 Energy & Water3.8 Estates Efficiencies3.12 Terms & Conditions

3.10a Reduction in Bank Spend3.10b Reduction in Agency Spend Run as a Programme3.14 E-Rostering


What should the order of priority be?

Recommended Drivers– Non Elective / Urgent Care- LOS & Patient Flow- SLM

2013/14’s Strategic ProjectsRECOMMENDATIONS

Front Door Projects

Back Door Projects 1.12 Green To Go 1.3 Reducing Readmissions1.13 Hip Fracture Pathway

3.10b Reduction in Agency3.10a Reduction in Bank3.14 ERostering

1.11 Area B / SAU2.1d Diagnostics Efficiencies1.6 Acute Oncology2.6 Non Elective Emergency Surgery

5.1a Theatre Scheduling Day Surgery Ringfence5.1b EPM Theatres Equipment and resources1.8 Increasing Daycase RatesElective Day Surgery Start Times (EPM)

4.6 Outpatient Efficiencies

Cross-Cutting Projects 2.4 SLM

2.1a Reduction in Diagnostics

2.3a Medical Workforce J.P. (M)2.3b Medical Workforce J.P. (S)

First Phase Second Phase(enablers for 2nd phase)

2013/14’s Strategic ProjectsPROJECT SCOPE

1.11 AREA B / SAUQIPP This project relates only to Acute Medicine; Surgery, ED and ED obs are excluded.

Improve the flow of patients from MAU to the hospital and back to the community by focussing resource on patients who can be quickly turned around and returned to the community. There are two key deliverables:1. Revised and enhanced model of care in the MAU, acting as an enabler for bed closures elsewhere in the Trust.2. Agree recording of activity through AAU, with a view to minimising the risk of hitting the non-elective activity threshold.

LEAN Urgent Care Programme – Key Aims: 1. Increase number of GP expected patients into assessment areas (SAU focused at present)2. Provide diagnostic tests and senior clinician review within 2 hrs of admission3. Improve access to GP information

QUALITY Safer Clinical Systems project - focussing on patients with Parkinson's DiseaseHealth Foundation SHINE project Emergency Laparotomy pathway Quality Improvement Care BundleDementia Challenge Fund projectImproving Nutrition will support reductions in LOS

CQUIN 7/7 working scheme [TBC]


QIPP To improve the emergency surgical pathway for category C/D (see NCEPOD classification) patients, thus reducing length of stay by;* Providing consultant led ring fenced emergency theatre lists* Providing consultant led daily urgent GP access clinics, with access to diagnostics, within the Surgical Assessment Unit (SAU)

The above is recommended in the RCS published guideline titled " Emergency Surgery - Standards for unscheduled surgical care (Feb 2011)

LEAN Non-Elective Patient Flow

QUALITY None as yet


PROJECT SCOPE2.6 Non-Elective Emergency Surgery


1.12 Green To GoQIPP To significantly reduce DTOC (all Health and Social Care) to 1%. Current performance for the RUH in 2012/13

has remained above 5%. This project led by the RUH will require service re-design across the health and social care community to ensure a sustained 1% DTOC level at the RUH. This will release in-patient capacity at the RUH based on the capacity currently used by patients that are delayed which will result in QIPP savings. The project will also review all patients Green (medically fit for discharge) as reducing DTOCs should also improve discharge across the Trust. The RUH will need to complete an analysis of the trigger points for escalation based on the number of patients on the Green Waiting list, this will need to be split by CCG.

LEAN Key Aims:1. Reduce LOS for Cat C/D emergency patients by providing additional emergency theatre capacity (pilot in place)2. Enhance IT to manage flow of patients within the hospital (new bed board) and with community teams3. Improve discharge planning (TTA process)4. Reduce patient moves (links with EOL pathway)

QUALITY Safer Clinical Systems project - focussing on patients with Parkinson's DiseaseHealth Foundation SHINE project Emergency Laparotomy pathway Quality Improvement Care BundleDementia Challenge Fund projectImproving Nutrition will support reductions in LOS



1.3 Reducing Re-AdmissionsQIPP 1. To reduce the numbers of 'avoidable' readmissions of patients back into the Hospital within 30 days of

discharge.2. To determine and agree the criteria and pathways of care (which presently flag as readmissions) and ensure they are coded correctly and are following the correct pathway. 3. To measure our numbers of readmissions (by HRG) against other similar Trusts using benchmark data (Dr Foster) to identify if we are outlying in terms of practice. 4. To determine any trends or cases whereby patients have been readmitted and the Clinical team needs to audit and review practice and if necessary change practice. 5. To work with our Commissioners on any shared pathways of care where it has been identified that an agreed pathway needs changing across the health community.

LEAN 1. Baseline data currently being captured for the Emergency Cat C/D patients to see if they fit into a re-admissions category

QUALITY Quality Accounts priorities - Improving the care of patients with COPD (reducing re-admissions) and Improving care for patients & carers at the End of Life (link to re-admissions audit)

CQUIN EOLC scheme- Ensuring appropriate conversations [details TBC]- Survivorship – focus on supporting metastatic disease [TBC]


2.1d Diagnostics EfficienciesQIPP The primary aims are to cease the reliance upon the use of mobile MRI which is currently supporting the

delivery associated with the increasing demand for MRI imaging. 1. To improve efficiency and productivity by utilising our own equipment assets and staff. 2. To reduce our current reliance on funded and unfunded outsourced mobile MRI paid for at a significant premium.3. To reduce the ad hoc reliance on the existing staff pool to pick up additional weekend sessions which longer term is unsustainable and places staff health and the 6 week target at risk.4. Utilisation of benchmarking data to achieve pay and non pay savings.5. Potential savings from remodelling the administrative functions.

LEAN Aims:1. Internal Requesting: To review demand and capacity to align diagnostics to where it is needed most to meet both patient needs and needs of the business.


QUALITY None as yet.


1.6 Acute OncologyQIPP Implementation of an Acute Oncology Service this is an invest to save initiative which includes reducing in-

patient beds, reducing LoS, preventing admission, providing day care/outpatient treatments wherever possible and increased outpatient activity. From the benefits realization work this indicates that there is a potential gain (in line with Dr Foster Upper Quartile and additional work to reduce DNAs in Clinical Oncology) by three clinics per week. The aim is to reduce the number of follow ups through continuous review of clinical protocols to be in line with Upper Quartile and to grow the new and follow up activity in line with the Acute Oncology Business Case and Cancer Business Plan 2012/13. The project has already achieved the Implementation of a Consultant Oncologist 24/7 on-call and weekend ward rounds to enable effective discharge. 1) Reduce the number of both non-elective and elective admissions by transferring treatment delivery to Day Care/Chemotherapy, review in outpatients and avoiding admissions. 2) To close four beds across the Trust by March 2013. 3) To be upper quartile LOS by December 2012. 4. Integrate acute oncology service to Front door.

CQUIN Acute Oncology Scheme- Patients admitted via A&E due to complications of chemotherapy to be reviewed by a member of the acute oncology team within 24hrs of admission- 1hr to antibiotic pathway for patients with neutropenic sepsis

LEAN None as yet

QUALITY None as yet


3.10a Skill Mix – Reduction in Bank

QIPP To review staffing levels for key staff groups against benchmarked data To make recommendations to divisional management teams regarding potential for skill mix change in relation to key staff groupsTo bring RUH staffing levels for key staff groups in line with nationally benchmarked equivalent organisationsTo release monies in support of the QIPP programme

Link with 3.10b Agency Red’n and 3.14 eRostering

LEAN - None as yet

QUALITY - None as yet

CQUIN - None as yet


3.10b Skill Mix – Reduction in Agency

QIPP Reduce Agency expenditure within agreed LTFM figures for all nursing agency and Operating Department Practitioner spend.

Link with 3.10a Bank Red’n and 3.14 eRostering

LEAN Recruitment Project:1. Recruitment teams aim is to reduce the number of vacant positions by processing external applications in five weeks, from advert to conditional offer.


CQUIN - None as yet


3.14 ERostering

QIPP 1) Rollout E-Rostering achieved for all employees across the Trust2) Record planned and actual time worked - leading to phasing out use of paper timesheets and bank forms3) Pay all employees using E-Rosters5) Reduce bank and agency spend and interim payments due to delayed reporting of actual time worked, including enhancements6) Increase flexibility of workforce7) Enable detailed analysis of department rosters to identify improvements in employee deployment to increase productivity and ensure time worked, A/L and S/L match contracts of employment and continuous service entitlements.

Link with 3.10a Bank red’n and 3.10b Agency Red’n

LEAN - None as yet


CQUIN - None as yet


1.13 Hip Fracture Pathway

QIPP Project in development - None as yet

LEAN Enhanced recovery was identified as a theme for ‘what does good look like?’ and is currently being scoped, could enhanced recovery work for hip fractures?

QUALITY Project in development - None as yet

CQUIN Project in development - None as yet


Next Steps

1. Create Trust-wide Strategic Transformation Plan aligning QIPP, LEAN, Quality & CQUIN projects2. Ensure alignment with the Trust’s “Continuous Improvement Strategy”

3. Plan in and show dependencies with 75 I.T. & 14 Commercial Development Projects etc.

4. Resulting in a Trust-wide Programme Plan showing all projects & dependencies for the year

2013/14 – 4 Months in – 92% delivery

2013/14 – 12 Months YTD – 94.6% delivery

strategic alignment of projects v5 - looking back

Documents

theatre closures y y

radiology y n y n

bank staff y n y y

pathology y n y p

drugs review y n y n

procurement y n p n

office review y

bed efficiency aau y