welsh clinical leadership training fellowships (wcltfs) · working closely with medical directors,...

Welsh Clinical

Leadership Training

Fellowships (WCLTFs) Project Outlines 2019/20

WCLTF 2019/20

Welsh Clinical Leadership Training Fellowships (WCLTFs)

Health Education and Improvement Wales in association with NHS Wales and the Welsh Government, is offering an exciting opportunity for up to 10 trainees to undertake a Clinical Leadership Training Fellowship in Wales, working closely with Medical Directors, or equivalent. These Fellowships are designed to develop high quality clinical leaders for the future NHS. Graduates from the Welsh Clinical Leadership Training (WCLT) scheme will be ideally placed to build and lead developments and improvements in the delivery of health care.

The Scheme will provide training and experience in clinical leadership and management and will equip trainees with the range of knowledge and skills they require to compete as medical and dental leaders in the modern NHS. The aim of the scheme is to recruit the most aspiring clinical leaders of the future.

The posts will represent a cohort of ‘WCLTF’ who will be able to preference leadership projects from a selection of proposals submitted by a variety of Health Care Organisations. Following discussions with the WCLTF Director successful applicants will be offered an appropriate project. Fellows will also be able to continue clinical duties up to a maximum of 20% of their time. Prior to applying for the Fellowship, applicants are required to obtain the support of their Programme Director in writing.

Applicants for the WCLT Fellowship programme should be medical or dental trainees considering involvement in clinical leadership and health service management as a part of their role on completion of training. Trainees who have completed foundation training and are currently undertaking core or higher training, and are able to take one year Out Of Programme, are encouraged to apply. Candidates wishing to train flexibly are welcomed and should indicate this on their application.

WCLTF 2019/20

Contents

Project Title Page

Ensuring Wales has a skilled and trained workforce to meet its current and future needs 4

Utilising clinical networks to facilitate spread and scale of successful QI projects 6

Engagement of trainee doctors in Cardiff and Vale UHB in quality improvement and leadership 8

Reducing risk and improving outcomes associated with Hospital Acquired Pneumonia 10

Reducing Medication-related harm through Supporting Doctors in Safe Prescribing 12

Developing an evidence based communication strategy to enable key staff groups to engage with the BCUQI Hub 13 Improving outcomes from Acute Kidney Injury (AKI) 14

Quality Improvement Escalator 15

Implementation of ERAS+ (Enhanced Recovery After Surgery +) 16

Developing a new Onco-Geriatric Service to improve management of older patients receiving anti-cancer treatment 18

Singleton Patient Flow Information System (SipFIT): Getting Rid of Papers Lists: Electronic Patient Flow, Task and Handover 20 Sustainable Theatres Project 21

Developing clinicians as leaders: engaging and equipping our talented people 22

Rapid Response to Acute Illness 24

Planning and implementing inpatient Tier 4 perinatal mental health services for Wales 26 Transforming Clinical Services – Pathway Re-design 27 Value Based Health Care – Measuring Outcomes in a Speciality Pathway 28 Controlling the Confusion (part three) : creating and sustaining composite teams in health care 30

Improving the well-being of junior doctors 31

Health in your Hand : Providing digital health & social care records to clinicians via a mobile hand held device to support the delivery of safe and effective patient care 32 Cancer Pathway Innovations to Detect Cancer Earlier: Supporting the introduction of a Single Cancer Pathway for Wales and exploring next steps for Rapid Diagnostic Clinics/Centres 33 Prehab to Rehab: Preoperative Assessment Expansion Project: Improving Perioperative Care 36

Creation of a Joint Medical Clerking document with Emergency Department to improve patient

assessment and flow in BCUHB at all sites 37

WCLTF 2019/20

Project Title: Ensuring Wales has a skilled and trained workforce to meet its current and future needs

Medical Director: Dr Pushpinder Mangat

Organisation: Health Education and Improvement Wales

Project Description: This project will cut across a number of the key functions of HEIW. HEIW has a leading role in the education, training, development and shaping of the healthcare workforce in Wales. HEIW’s key functions include: Workforce intelligence – HEIW will be the central, recognised source for information and intelligence about the Welsh health workforce; Workforce planning – HEIW will provide strategic leadership for workforce planning, working with Health Boards/Trusts and the Welsh Government to produce a forward strategy to transform the workforce to deliver new health and social care models of service delivery; Education commissioning – HEIW will utilise its funding to ensure value for money and the provision of a workforce which reflects future healthcare needs; Quality improvement – HEIW will quality manage education and training provision ensuring it meets required standards and improvements are made where necessary; Supporting regulation – HEIW will play a key role representing Wales in liaison with regulators, working within the policy framework established by the Welsh Government. HEIW will also undertake, independently of the Welsh Government, specific regulatory support roles; Leadership Development – HEIW will establish the strategic direction and delivery of leadership development for staff within NHS Wales at all levels; Careers and widening access – HEIW will provide the strategic direction for health careers and the widening access agenda, delivering an ongoing agenda to promote health careers; Workforce improvement – HEIW will provide a strategic leadership role for workforce transformation and improvement, and deliver within its functions an ongoing programme to meet that role’ Professional support for workforce and organisational development (OD) in NHS Wales – HEIW will support the professional workforce and OD profession within Wales. The workforce across NHS Wales is under significant pressure with increasing demand for services, rota gaps, trainee attrition and, in certain specialties, evidence of burnout, all contributing to an environment where achieving stability is increasingly difficult. Across NHS Wales Health Boards and Trusts are working extremely hard to achieve this much needed stability. There are pockets of good practice and innovative workforce solutions that can be used as future models across providers and specialties. Across Wales we need to ensure that:

we have a comprehensive system wide understanding of our workforce needs for the future;

best practice models are explored and shared;

the multiprofessional team are supported with the knowledge and skills for the roles they carry out;

we recruit and retain staff and provide them with opportunities and training to enhance their future skills to face future challenges;

practical solutions for the challenges ahead are developed. The WCLTF will be assigned to a number of multiprofessional projects and priority areas led or supported by HEIW to identify best practice and scope out future workforce models and requirements.

WCLTF 2019/20

Immediate supervisor(s) for the project:

Dr Helen Baker, Associate Director for Secondary Care [email protected]

mailto:[email protected]

WCLTF 2019/20

Project Title: Utilising clinical networks to facilitate spread and scale of successful QI projects

Medical Director: Dr Graham Shortland

Organisation: Cardiff and Vale University Health Board

Project Description: The WCLF will work as part of the improvement and transformation team to design and develop an approach to using clinical networks to support the spread and scale of successful improvements. The Health Board has a strong track record of delivering successful improvements to patient care. However, like many organisations, spread and scale of these improvements is rarely achieved. In order for the Health Board to achieve its vision, our system and process for scale and spread needs to be developed. The spread of innovation is the topic of a recent report by the Innovation Unit and The Health Foundation, “Against the Odds: Successfully Scaling Innovation in the NHS”. The authors looked in depth at 10 innovations that have successfully spread and have suggested eight key enablers. One of these enablers is the ability to build demand for an innovation through existing networks and narratives. Whilst Everett Rogers argues that interpersonal connections are critical for sharing information and creating demand for the diffusion of innovation, ‘Against the Odds’ suggests that demand needs to be built across wider audiences and geographies by tapping into existing networks that share common interests in order to reach more people. Utilising clinical networks is therefore a crucial aspect of enabling spread and scale. The WCLF will utilise learning from our current WCLF who is improving trainee engagement in the delivery of quality improvement programmes, and will work alongside the wider transformation team to design an approach to scale and spread that maximises the abundance of clinical networks within and around the Health Board. The output will be a documented approach and toolkit for using clinical networks to support scale and spread. The WCLF will also work alongside members of the continuous improvement team to update a network map that is currently in development. As scale and spread is a common challenge across the NHS, toolkits and learning from this project has the potential to influence systems beyond Cardiff and Vale. The transformation and improvement team works to and alongside the Deputy Chief Executive in her role as Director of Transformation, Improvement, Commissioning and Informatics. As a member of the team the WCLF will attend a range of leadership meetings regarding transformation and improvement alongside the Deputy Chief Executive. These include programme development meetings, clinical leads meetings and team meetings. The WCLF will be able to attend a number of other meetings with the Deputy Chief Executive and the Assistant Director for Organisational System Change. As a member of the transformation and improvement team there will be the opportunity to develop advanced quality improvement, leadership and project skills by getting involved in improvement projects alongside other members of the team. This will expose the WCLF to a wide range of areas within the Health Board and develop understanding of the wider strategic and operational challenges and opportunities. The team work closely with the AMD for Clinical Engagement and as such, the WCLF will have the opportunity to get involved in meetings such as the Clinical Senate where developments in the UHB are presented by the executive team, alongside clinical developments in quality improvement and the delivery of the strategy. A clinical learning alliance with Canterbury District Health Board is also in development that the WCLF will be able to be involved in. The aim of the clinical learning alliance is to maximise spread of learning between the different clinical systems in Canterbury, Sydney, Glasgow and Cardiff and Vale.

WCLTF 2019/20

Immediate supervisor’s for the project:

Ruth Jordan, Head of Continuous Service Improvement [email protected] or 02920742262


WCLTF 2019/20

Project Title: Engagement of trainee doctors in Cardiff and Vale UHB in quality improvement and leadership



Project Description: The WCLF will work with and be supervised by the assistant medical director for clinical engagement and quality improvement. He/She will have access to the entire medical director’s office of assistant medical directors, in particular those for post graduate medical education and information technology and build on the work done by the current WCLF.

The purpose of the project is to assess and improve training grade doctors’ engagement in the organisation. The output will be an assessment of and improvement in a scale of clinical engagement by trainee doctors, delivery of a sustained quality improvement programme by trainees which aligns to the UHB’s Shaping our Future Wellbeing Strategy, an increase in the number of trainees in leadership positions and and a functional network of junior doctor leaders in the UHB.

Trainee doctors are vital to the delivery of our current and future services. They are a hugely underutilised resource when it comes to effecting change across the organisation. They have historically not been supported during their training to develop and utilise their leadership skills. Conversations with core medical trainees suggest that they feel overwhelmed by clinical/administrative work and do not feel they have the capacity to undertake quality improvement work. This needs to be examined more closely and processes put in place to ensure that trainees feel passionate about the quality of the services they deliver and have a sense of ownership in them.

Trainee doctors seldom recognise themselves as leaders yet, from the moment they start working as consultants they are expected to lead, in multiple different settings. As an organisation we need to better understand the reasons why this highly motivated group do not feel empowered to lead change and to develop a culture where leadership is taught and promoted at each grade, alongside the core clinical competencies. The WCLF will build on the work of the existing trainee to develop models of training where leadership is embedded. The WCLF will work closely with the medical education department and HEIW to develop these models, using improvement methodology.

Clearly, it will important that the UBHB works closely HEIW this project, to ensure that both organisations have the same strategy and that there is no duplication of work. The HB is encouraging trainees to attend and present at the Grand Round and at Clinical Senate. It is also offerering a QI coffee club, which is a monthly meeting of Junior doctors, with representatives from the HB and HEIW to learn about QI and to trouble shoot QI projects being undertaken. The WCLF is working to establish attendance at this meeting and what trainees would prefer from such a meeting. This work would be

continued by the successful applicant.

The WCLF will be a member of the medical director’s office. He/She will be able to attend the medical director’s meeting with the assistant medical directors and to shadow the medical director on occasional days. The AMD for clinical engagement is chair of the point of care testing committee and the WCLF will be able to attend quarterly meetings. The WCLF will also attend and be involved in the organisation of the quarterly Clinical Senate, which is a communication tool for the organisation where developments in the UHB are presented by the executive team, alongside clinical developments in quality improvement and the delivery of the strategy. The AMD also produces a regular bulletin for the medical director and the WCLF will assist in its’ production or may choose to develop a new method of communication, particularly to the trainee doctors, which may be more immediately accessible. The WCLF has the opportunity to develop/improve the Med Ed App, for junior doctors, so that it is more appropriate to the needs of trainees.

WCLTF 2019/20

The WCLF will have the opportunity to attend other meetings chaired by the other assistant medical directors and give some insight from the perspective of a trainee. These include the SCIMat group, chaired by the AMD for Information technology and governance (where junior doctor representation has been established but attendance is not robust) and the Cancer Leads meeting (where it has not). He/she will also be able to attend the innovation MDT, which is a collaboration between the university and UHB to enable innovation. There will be opportunities to attend Medical Education Operational Group meetings and also learn about professional standards in Wales. This will allow the trainee to observe different leadership styles, better understand the role of the medical director’s office as well as being able to contribute to the different meetings


Rachel Rayment, AMD for Clinical Engagement and Quality Improvement [email protected]


WCLTF 2019/20

Project Title: Reducing risk and improving outcomes associated with Hospital Acquired Pneumonia

Medical Director: Dr Evan Moore

Organisation: Betsi Cadwaladr University Health Board

Project Description:

Hospital acquired pneumonias (HAP) is a significant cause of morbidity and mortality amongst hospital inpatients, yet has not received the same attention as other hospital acquired infections (HCAI). We have learnt much from a coordinated approach to other HCAI, for example addressing infection prevention and antibiotic prescribing stewardship to reduce rates of clostridium difficle infection. We propose a similar systematic quality improvement response to HAP.

Background: A recent study conducted by the respiratory department in Ysbyty Gwynedd Bangor in collaboration with the School of Mathematics, Cardiff University, retrospectively reviewed 700 cases of HAP seen between June 2014 and June 2018 on a single respiratory ward. This allowed the estimation of a crude mortality rate of 28%. Furthermore, the study identified significant risks factors for increased mortality including; increased length of stay (over 12 days), age (over 80) and significant co-morbidities such as heart failure. Such that a patient in their eighties, with heart failure and a length of stay (LOS) over 12 days, had a mortality rate of approximately 40%.

A mortality prediction model was developed using these data. This demonstrated consistent features that predicted approximately 12 HAP episodes a month and 4 deaths per month with the study ward operating at current capacity. More recent hospital data suggest the model may provide robust prediction of HAP related mortality. The high observed and predicted mortality rates clearly demonstrate the importance of an effective response to HAP.

The respiratory team and infection prevention team in Ysbyty Gwynedd recognise that HAP is a major challenge to providing safe health care and an appropriate and worthwhile area for a Leadership Fellow to address and drive quality improvement. The leadership fellow would be expected to work across NHS, and potentially social care disciplines, to develop and then implement evidence based measures to reduce infections and mortality due to HAP’s. This will require collaboration across hospital disciplines and with other agencies within the community who have influence on modifiable risk factors, for example patient LOS.

The Fellow would be supported by an immediate supervisor who will be Dr Damian McKeon, Respiratory Physician, Ysbyty Gwynedd, who has a research interest in this area. The Fellow would also be supervised and supported by hospital leaders and quality improvement leaders including the site Medical Director, Dr Karen Mottart, the Medical Director for Quality and Improvement, Dr Brian Tehan, Public Health Wales Research Scientist, Dr Noel Craine and Microbiology Consultant, Dr Stuart D’Arcy. The Fellow would also have substantial support from our Postgraduate Department in Ysbyty Gwynedd.

There are two phases to the project; firstly, to better understand the epidemiology of HAP within the hospital setting, particularly by improving diagnostic clarity, and secondly to develop and implement an effective local response.

1. Develop an evidenced based investigation bundle. At present HAP diagnosis is based on a clinical suspicion. We need to prospectively identify patients with greater sensitivity and specificity, and request an ‘investigation bundle’ including radiographs and specifically sputum microscopy – such that narrow based antimicrobials can be used for treatment and pathogens identified. Improved diagnosis of HAP and identification of causal organisms is particularly important in order to help refine local antimicrobial treatment guidelines. In addition, if we can identify specific bacterial species commonly associated with HAP then it will be possible to look at potential environmental factors such as air quality, the microbiology culture in sinks, showers and toilets etc. that may be contributing to the acquisition of infection. At present, we have no description of the HAP patient biome or microbiological environment of our respiratory ward.

WCLTF 2019/20

2. Design an evidence based care bundle to reduce mortality of HAP Our previous project has identified risk factors for mortality; these are primarily older age, increased length of stay (over 12 days) and co-morbidities such as heart failure. Research has also identified other risk factors including NG feeding, recent intubation, recent abdominal surgery, urological conditions and malignancy. The Fellow would be tasked with developing a risk score such that patients could be stratified with respect to HAP acquisition and mortality risk to support potential changes in their management to ameliorate these risks.

Once patients are identified as ‘high risk’ our aim would be to develop a ‘care bundle’ to reduce their risk of infection and death. This bundle would address the modifiable risk factors identified within the literature and within our previous work. Looking at the literature there are potentially many interventions, from oral health to mobilization, and reducing LOS where possible. Part of the quality improvement project would involve working with other health and social care professionals involved in patient care to see how risk reduction can be delivered to individual patients.

Drawing on the findings from the scrutiny of the local epidemiology of HAP we would envisage the leadership Fellow working with the infection prevention team and microbiology department to use this knowledge to (a) improve the local infection prevention response and (b) to optimise local antimicrobial prescribing in light of the profile of causal organisms within this patient group.

The Fellow would need to be based in Ysbyty Gwynedd as at present the project would be based on the respiratory ward and working with the immediate supervisor based in the hospital. However, the other aspects of the program could be supported across BCUHB once developments have been piloted and evaluated. Future work could address, if appropriate, the roll out of these improvements across the health board and potentially across other Welsh health boards.

We believe this project offers an excellent opportunity to a potential leadership Fellow providing a broad education in terms of working with multiple teams to improve the sensitivity and specificity of HAP diagnosis and in developing effective protocols to reduce infection. They will have input from various teams and leaders in a busy acute site and experience the challenges and benefits from working in such an environment. This project will aim to produce significant direct improvements to patient care, and by learning the process of quality improvement the Fellow will be able to demonstrate that they have been involved in leading innovation in Wales. The fellow would be expected and encouraged to present the work at appropriate national conferences.

The teams and supervisors involved have a long track record both in terms of supporting quality improvement, and also in supporting and developing trainees and fellows to then spring board their learning for the next stage in their career.


Dr. Brian Tehan, Medical Director for Quality & Transformation [email protected]


WCLTF 2019/20

Project Title: Reducing Medication-related harm through Supporting Doctors in Safe Prescribing



Project Description: WCLTF will work with the Medical Directors for quality & transformation and Medical Director for Education. The purpose of the project is to support the WHO Global Patient Safety Challenge and the organisation with its strategic objective to reduce medication related harm. Prescribing errors are one of the major causes of healthcare associated harm and administration incidents frequently occur as a result of:

Illegible prescriptions

Omitted, incomplete prescriptions, or incorrectly transcribed medication at medicines reconciliation, inpatient medication administration chart re-writes, or take home prescriptions respectively. Workshops and evidence have identified that common reasons for prescribing errors are due to human factors; time; staffing, competing priorities; environment; processes; systems, particularly access to resources; competence, knowledge and experience.

A significant amount of time is wasted by all professionals looking for information to support safe prescribing, verifying and correcting prescriptions, which ultimately delays administration of medicines to patients and causes harm. Clinical pathways are difficult to find on the intranet, and so junior doctors resort to the internet using information from other health organisations. When prescribing errors do occur, it is often not possible to identify the prescriber from the prescription and so the incident report rarely gets back to the doctor or their consultant. Although prescribing errors form part of the learning covered during post-graduate development session, the process of individuals learning from their prescribing errors is not as effective as it should be. From The RCP published guide “Supporting Junior Doctors in Safe Prescribing” there are specific areas for a clinician to lead on improvements, which will result in reduced harm and increased safety. Working closely in particular with junior doctors but also with clinical teams, pharmacy and nursing, the remit for the WCLTF would be : 1. To produce a practical resource (handbook) for clinicians of all grades, accessible via an App, including local protocols and guidelines to support safe prescribing and signposting to accredited Apps. 2. Develop a safe learning feedback process for the review and handling of prescribing errors. Specifically to: a. Ensure that incident reports are not closed without reflection or lessons learned. This will require that the prescriber is identified and informed of the error as close as possible to the time of the error and that the supervising consultant is also notified of the error. b. Prescribing errors are discussed as part of the appraisal process




WCLTF 2019/20

Project Title: Developing an evidence based communication strategy to enable key staff

groups to engage with the BCUQI Hub



Project Description: The largest health board in Wales, with c 16,000 staff spread across a wide geographical area, communication is a persistent challenge. The digital revolution has made it much easier to disseminate messages more rapidly, but issuing the policy or memo is no assurance staff will respond or act as expected. Launching the BCU Quality Improvement Hub, the Health Board recognise effective communication as a challenge. Junior Medical Staff are a key group, and a likely first focus of the proposed project. Dependent on progress and learning, there is potential and need for this enquiry to extend to other staff groups. The purpose of the proposed fellowship is to a. Establish best evidence based standards for communication b. Identify modes of communication, and test these in the first instance (applied singly or as multiples) with Junior Doctors, and determine what will work best for communication in BCU c. Having success with that group of staff, to test and apply those standards and learning to other groups As members of the medical tribe, Fellows will have a knowledge and familiarity with this group and how they communicate; This project requires they explore bodies of learning with respect to communication, human factors, behavioral change, leadership… amongst others. It is envisaged this experience and knowledge will have broad benefits.




WCLTF 2019/20

Project Title: Improving outcomes from Acute Kidney Injury (AKI)

Medical Director: Dr Evan Mooore


Project Description: Acute Kidney Injury (AKI) is a common serious condition associated with a high mortality and morbidity. Reported incidence varies depending on the definition, clinical setting and population studied, but in hospital incidences are reported ranging from 4 to 18%. AKI is strongly associated with hospital mortality. Its estimated AKI increases risk of death 10 fold and a recent analysis of coding from HES found that 28.11% developing this condition die before discharge. In 2009 the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) (Stewart & National Confidential Enquiry into Patient Outcome and Death (Great Britain), 2009) estimated with improved care, 20% of AKI associated deaths might have been prevented. BCU data shows mortality static since 2015, suggesting consistent with NCEPOD, we too have room to improve. NICE Clinical Guideline [CG169] - Acute Kidney injury: prevention, detection and management, provides direction on how this may be achieved. Progress has been made already in BCU on AKI, but good / excellent in pockets, the challenge in proposing this project is to marshal and lead spread. Reliant at present on the Acute Intervention Team to flag AKI patients to their specialty team, we are unable at present to be confident this consistently applies to all at risk patients and the actions taken make a difference The purpose of this project is to build on current mechanisms of recognition and develop our systems of response across BCU such that expected improvements in outcome can be evidenced.




WCLTF 2019/20

Project Title: Quality Improvement Escalator

Medical Director: Dr Karen Mottart


Project Description: The Quality Improvement Escalator aims to facilitate the creation of a cohort of junior doctors that are able to deliver quality improvement in multi-disciplinary programmes at scale in the areas with the highest numbers of doctors in training: Emergency Departments, Acute Take, General wards. The project uses existing national and local infrastructure and links this through the Leadership Fellow to key performance indicators of BCUHB. Background: Unscheduled care remains a key challenge to NHS Wales in general and BCUHB specifically. Queuing at front doors represents a key challenge. Exist blocks are caused by poor flow and poor flow is in part due to poor planning of care episodes across the boundaries of hospital geography: ED, Acute Medical Unit, general wards, rehabilitation etc. Recruitment of Doctors in training has been challenging. Doctors have been described as ‘frustrated’, ‘disenfranchised’ and following disputes in NHS England rates of recruitment into acute specialties is a particular problem. Rational: Given that the bulk of the work load in these areas is delivered by doctors in training this would seem the natural focus of any improvement work. As ‘rotating’ members of the multi-professional team doctors in training after often not involved into discussion about service re-design but hold much of the informal expertise required to run inpatient care. Ownership is a pre-requisite for engagement. Projects need to be embedded into the long-term strategy of improvement but need to be owned by junior doctors. Many leadership program (see above) have suffered by keeping trainees on the outside of projects rather than at the inside (‘skin in the game’) thus limiting both their emotional involvement and impact. BCUHB is hoping to use this project to road test principles of future Quality Improvement Fellowships hosted jointly with Bangor Universities School of Health Sciences Improvement Science Hub. Project: The project has two elements: 1. Increasing recruitment into the training program in Quality Improvement at BCUHB 2. Application of training in co-produced cycles of change to the delivery of care in areas identified by doctors in training as part of their multi-disciplinary team. Examples might include improvement of sepsis performance metric, breaches in the Emergency Department, Red/Green days, SAFER bundle etc


Dr Christian P Subbe, Consultant in Acute Medicine, Senior Clinical Lecturer, Bangor University; Improvement Science with The Health Foundation. [email protected] Tel: 07771922890.


WCLTF 2019/20

Project Title: Implementation of ERAS+ (Enhanced Recovery After Surgery +)



Project Description:

ERAS+ is a multidisciplinary approach based on co-production with patients and their families to better prepare patients for major surgery and reduce the risk of post-operative complications.

It has been introduced as part of a health foundation project in Greater Manchester and already has numerous online resources connected with it including an app. So far more than 2000 patients have benefited in the Greater Manchester area alone. The instigators of the project have presented and published widely and are very supportive to other institutions who wish to introduce ERAS+. Their outcomes show a reduction of time need on critical care and a reduced post-operative length of stay for patients as well as a marked reduction in postoperative pulmonary complications.

https://www.erasplus.co.uk/

The key goals are to

Reduce the incidence of postoperative pulmonary complications (PPC)

Promote shared decision making in preparing for and recovering from surgery

Improve patients' physical and psychological well-being before and after surgery

Educate both professional groups and patients in preparation for surgery

The ERAS+ programme includes group educational sessions for patients preparing for major surgery across several disciplines. In Ysbyty Glan Clwyd patients undergo major surgery in vascular, urological, orthopaedic, general surgical, gynaecological and head and neck procedures. At present patients take part in a traditional pre-operative assessment process augmented in orthopaedics by an educational programme known as ‘Joint school’ and by meetings with specialist nurses to discuss post-operative stoma care for general surgery.

https://www.erasplus.co.uk/pdf/Surgery%20School%20Feb%202017.pptx

The presentation above covers the six aspects of ERAS+ 1. Get active 2. Chest training (see iCough below) 3. Muscle strengthening 4. Surgery school 5. Live well 6. Eat well iCough UK is a specific educational process comprising i: incentive spirometry C: coughing O: oral healthcare U: understanding G: getting out of bed H: head of the bed elevation

https://www.erasplus.co.uk/

https://www.erasplus.co.uk/pdf/Surgery%20School%20Feb%202017.pptx

WCLTF 2019/20

With support from an anesthetic consultant the WCLTF will be the coordinator of the ERAS+ project at its introduction. They will work with colleagues from anesthetics, surgery, critical care, nursing, allied health professions and operational management teams to bring the project to life.

The WCLTF will liaise closely with our corporate communications teams to explain and promote the scheme in the wider community using print, broadcast and social media. They will present the results of the ERAS+ project to hospital and board level meetings.


Dr Shrisha Shenoy, Consultant Anaesthetist [email protected]


WCLTF 2019/20

Project Title: Developing a new Onco-Geriatric Service to improve management of older patients receiving anti-cancer treatment

Medical Director: Mr Dougie Russell

Organisation: Abertawe Bro Morgannwg University Health Board

Project Description: Over recent years there have been significant improvements in both early diagnosis and treatment of cancer, however it still remains the case that a large number of patients cannot be cured. Of patients treated with systemic anti-cancer therapy approximately 80% are receiving this treatment with palliative intent. The aim of treatment for these patients is to prolong life and improve quality of life. Older and frail patients often experience severe toxicity associated with cytotoxic chemotherapy and other new systemic anti-cancer treatments and it is therefore important to consider and balance risks when embarking on a treatment plan. Frailty is more common in the elderly population. The National Confidential Enquiry into Patient Outcome and Death looked into the benefits and potential harms caused by palliative chemotherapy in their 2008 report “for better, for worse”. It reported that in 27% of patients palliative chemotherapy either caused or hastened their death. The report also highlighted that 43% of patients who died within 30 days of chemotherapy suffered severe treatment-related toxicity. However evidence also shows that some older patients are at a disadvantage because they may be less likely receive palliative chemotherapy due to their chronological age. The aim of the project is to develop an Onco-Geriatric service and promote closer working between the two departments to deliver integrated and comprehensive care for patients. Many patients will be under the care of both Oncology and Care of the Elderly Services anyway but at present there is no joint working or standard referral pathways. If we could better assess frailty this would guide decision making regarding treatment decisions and if we could select out those with mild or moderate frailty and address deficits prior to embarking on treatment then this should reduce toxicity, hospital admissions and length of stay and improve quality of life. Currently there is no standard way of assessing patients’ risk of treatment related toxicity. The comprehensive geriatric assessment is a well evaluated tool, however it is time and labour intensive and requires the active involvement of a geriatrician and multidisciplinary team. This resource is often limited. The electronic frailty index has been developed for use within the general population using data which is already routinely collected in Electronic Health Records in Primary Care. It uses 36 common deficits which can be automatically populated from primary care records. Patients are then classified into four groups,

no frailty

mild frailty

moderate frailty

severe frailty It has been used to assess risk of morbidity, mortality and risks of hospital or nursing home admission within one year. Given the relative simplicity of the electronic frailty index it is an attractive prognostic tool. If we could risk stratify patients this way we could then identify those who would most benefit from the resource intense comprehensive geriatric assessment and from pretreatment optimisation. This is most likely to be those in the moderate frailty group. It would also guide clinicians and patients in having up front discussions about the risks and benefits of palliative treatment options. Alongside driving forward the Onco-Geriatric service the fellow will seek to validate its use in Oncology patients (through collaborative working with SAIL) as this could potentially be included in the referral criteria.

WCLTF 2019/20

A fellow who is unfamiliar with oncology may initially find the complexity of the pathways and problems a constraint. If the fellow is unfamiliar with the service delivered there will be a programme of observation in clinics, radiotherapy, pharmacy and physics to allow the fellow to gain an understanding of the roles each member of the team has. Clinical work will include a Chemotherapy clinic and occasional (maximum 0.2) participation in the Oncology on-call rota during the day with opportunity to attend Care of the Elderly clinic and frailty service for learning.


Dr Rachel Jones, Consultant Medical Oncologist [email protected]


WCLTF 2019/20

Project Title: Singleton Patient Flow Information System (SipFIT) Getting Rid of Papers Lists: Electronic Patient Flow, Task and Handover

Medical Director: Dr Richard Evans

Organisation: Abertawe Bro Morgannwg University Health Board

Project Description: In the summer of 2018 the department of medicine at Singleton Hospital, working with informatics colleagues, developed a patient flow, task and handover system to support patient care in the Singleton Medical Assessment Unit (SAU). Prior to the introduction of this system 15 lists were being compiled manually on pieces of paper, whiteboards and computer files by multiple groups: nursing, medical, reception staff, pharmacists, bed management. There was no live Admission, Discharge and Transfer information available. Using the Microsoft Sharepoint platform the Singleton Patient Flow Information Tool (SiPFIT) was developed. Overnight this replaced the whiteboards and introduced to all staff the routine use of an electronic system to manage clinical activity. It was highly successful in improving the efficiency and accuracy of patient lists. It rapidly became clear that there were many uses other than simple lists for such a system, including supporting the assessment of patients with suspected sepsis, managing the deteriorating patient and delivering useful information to support bed and general management. In the first instance SiPFIT only covered SAU; when a patient moves to a ward the information is lost and the old way of paper, whiteboard and Word document recommenced. The Fellow will lead this project is the next phases of implementation:

The further rollout of SiPFIT to all inpatient wards

The use of it to support hospital wide teams such as the palliative care and acute oncology services

Development of the deteriorating patient element

The introduction of mobile devices to support clinical care and to feed data into SiPFIT

Increasing the IT skills of the workforce in preparation for the introduction of more technology in patient care.

To identify further uses for the system, develop and implement them

In addition the Fellow will be closely integrated with the health board Informatics Team to work on the development and implementation of key informatics projects e.g.:

Welsh Clinical Portal

E-Prescribing

The Fellow will be a key link between the IT department and trainee medical staff with the goal of increasing their participation in Quality Improvement work, especially in the field of informatics.


Dr Chris Hudson, Consultant Physician and Clinical Director of Medicine [email protected] Tel: 01792 205666


WCLTF 2019/20

Project Title: Sustainable Theatres Project



Project Description: The carbon footprint of the NHS is significant. Within the NHS, a major contributor to this is the operating theatre environment. The Sustainable Development Unit estimates that the NHS produces 3% of all UK carbon dioxide emissions, of which 20-30% is estimated to originate from the operating theatre environment. We believe that building on work already undertaken by the school of architecture at Cardiff University in the design and build of a SMART home that is able to give energy back to the grid, that we can apply similar principles to the operating theatre. (https://www.cardiff.ac.uk/news/view/122063-smart-carbon-positive-energy-house) We aim to develop, conceptualise, design and build an innovative theatre that is “sustainable”, that aligns to the Well Being and Future Generations Framework and will provide a long term solution for the Clinical Theatres in Wales and act as a benchmark for theatre construction around the world. The sustainable theatre project aims to combat the huge amounts of waste occurring at every stage in the theatre environment, with every aspect requiring a ‘cradle to grave’ analysis and PDSA cycle. This project will encompass all aspects of theatre design and use, from energy sources, building materials, design and flow, lean thinking, environmental procurement, collaboration with industry partners to create sustainable equipment, waste management team involvement, staff education and culture change.


Mr James Horwood, Consultant Colorectal Surgeon [email protected] Dr Fiona Brennan, Anaesthetic Consultant [email protected]

https://www.cardiff.ac.uk/news/view/122063-smart-carbon-positive-energy-house



WCLTF 2019/20

Project Title: Developing clinicians as leaders: engaging and equipping our talented people

Medical Director: Dr Paul Buss

Organisation: Aneurin Bevan University Health Board

Background ABUHB offers a number of in-house development programmes for its staff. The ELMP is a 1 year programme based on 12 monthly development days and 3 assignments delivered using a Juran Trilogy framework, along with the philosophies of W Edwards Deming. Attendees are taught quality management and improvement skills equivalent to Improving Quality Together (IQT) silver but there is wider context for leaders in senior roles within complex systems. Increasingly, teaching material uses experiential methods of delivery. The programme is continuously evaluated using a 4 level Kirkpatrick evaluation framework. ELMP is designed for people with current leadership responsibilities: clinical directors, aspiring clinical directors, senior clinicians from other disciplines and senior managers from the full range of disciplines. Participants are mentored by senior members of the ABCi staff. The most recently recruited cohort, cohort 7, has 24 members. Half of these are doctors. ELMP is a considerable investment by ABUHB in the development of its staff. Rationale With four years’ experience and well over 140 alumni, there is now an opportunity to review ELMP to determine:

1. How can recruitment be better targeted to meet the needs of the health board? 2. How can the delivery of the programme be changed in order to better meet the needs of

participants? 3. What changes can be made to the curriculum to better reflect the current and emerging

needs of the health board and its patients? 4. What changes can be made to the curriculum to better reflect the development needs of

course participants? 5. What improvements can be made to the mentorship of ELMP? 6. What links should be made to organisations and people in and outside the health board in

order to better contextualise the delivery of ELMP? The report “Quality Improvement - Training for better outcomes” published by the Academy of Royal Colleges in 2016 emphasises that in the absence of “one size fits all models” training and development should be evaluated in its local context. Furthermore, the increasing interest in adult learning methodologies provides the opportunity to develop more innovative and engaging ways of providing training. Project description Over the course of the fellowship, the fellow will be expected to provide evidence based recommendations which offer improvement and evaluation against the above six criteria based on:

Evaluation data continuously collected by ABCi

Direct interview of participants

Direct interview of sponsors and colleagues of participants

Review of clinical, strategic and operational factors which are likely to determine the leadership requirements within the health board

Review of career development pathways

WCLTF 2019/20

Review of leadership development offerings by other organisations The fellow will be working within the ABCi team and with the ELMP Programme Director. Many of the information sources (such as recruitment and evaluation data) already exist and so will not have to be generated de novo. The fellow will be supported to use and learn new techniques in quality management and data analysis. They will also have links with a team from Swansea University who are evaluating another ABCi programme through a Health Foundation funded programme. However, they will be expected to propose, plan and lead a work and reporting schedule for their year in ABCi. It is expected that the project will be an ideal opportunity for a doctor who is interested in building a career in leadership to learn about leadership roles and requisite skills, gain an understanding of current and aspiring leaders, build a knowledge base of contemporary and emerging leadership models, and to apply quality management, evaluation and improvement techniques within a practical setting. It is also expected that the fellow will publish on the basis of this work.


Dr Alan Willson, ABCi associate and lead for Enhanced Leadership [email protected]


WCLTF 2019/20

Project Title: Rapid Response to Acute Illness

Medical Director: Dr Quentin Sandifer

Organisation: Public Health Wales

Project Description: Unrecognized and untreated acute deterioration has long been known to be the cause of a significant amount of avoidable harm and death in all healthcare settings in Wales

Two syndromes, Sepsis and Acute Kidney Injury (AKI), are the cause of most cases of acute deterioration in hospital.

Sepsis has a hospital prevalence of 4% and associated mortality 30-39% which equates to approximately 2000 deaths per year in Wales.

In-hospital incidence of AKI varies between 4 and 18% with a 90 day mortality of 26%.

There is no ‘magic bullet’ with which to address the problem of acute deterioration but, instead, there is the necessity to improve the systems for the identification, escalation and treatment of these syndromes.

It is essential to incorporate these systems at all levels from ‘ward to board’.

The purpose of this project is to contribute to the development of a standardised approach to Acute Deterioration in Wales.

The RRAILS programme first established itself in Acute Hospitals but is now pushing out into several new areas including primary and community care and paediatrics.

The RRAILS/1000Lives approach is to use small scale, Quality Improvement cycles with an emphasis on local engagement and measurement of process.

The Clinical Fellow would be integral in establishing and overseeing their own project in this area.

1. Work with and report to the All Wales RRAILS steering group

2. Work with clinical teams to undertake their project

3. Promote and communicate innovative practices in service improvement in clinical and managerial arenas.

4. To contribute to the strategic development of acute deterioration services in Wales.

5. To work in collaboration with each organization to develop a unified approach.

6. To contribute to national workshops and events.

7. To build relationships with Local Clinical leads and management

8. To meet with Health Board executive leads around planning strategy.

9. To work with 1000 Lives Improvement and Public Health Wales colleagues to ensure unity of purpose.

10. To report back to Welsh Government and 1000 Lives Improvement on progress and outcomes.

11. To be involved with with the Cross-Parliamentary group on Sepsis.

12. To represent 1000Lives at national and international forums.

WCLTF 2019/20

Given the large scope of the Acute deterioration programme the actual project undertaken by the Fellow will depend, in part, upon their own clinical background. Possibilities include:

Improvements in sepsis treatment at the hospital ‘front door’ by implementing ‘DRIPS’ methodology

Reducing the harm caused by AKI by implementing clinical response to electronic AKI alerts.

Reducing antibiotic resistance by improving clinical behaviours to ‘start smart then focus’

Utilise the all Wales sepsis registry to improve outcomes for sepsis survivors following hospital discharge.

Help to improve outcomes for children by assisting in the development of a paediatric acute deterioration system

Improve the recognition of sepsis and AKI in community and care home settings

Ensure that in-hospital acute deterioration systems are integrated into the National Electronic Patient Flow Programme (NePFP)

Work with academic institutions to develop the role of simulation in acute deterioration training programmes.


Mr Chris Hancock, Programme Lead – Acute Deterioration [email protected]


WCLTF 2019/20

Project Title: Planning and implementing inpatient Tier 4 perinatal mental health services for Wales

Medical Director: Dr Jennifer Thomas

Organisation: Welsh Health Specialist Services Committee (WHSSC)

Project Description: In October 2017 the Children and Young Peoples Education Committee recommended that an inpatient perinatal mental health (Mother & Baby) unit should be established in South Wales and funded on a national basis to provide services for the whole of Wales. They also stated that travelling to south Wales is unlikely to be suitable for populations elsewhere, particularly the north. They noted that north Wales alone does not have the necessary birth rates to sustain a specialist MBU, and called on the Welsh Government to engage proactively with providers in England to investigate options. In response the Cabinet Secretary for Health and Social Care asked WHSSC (Welsh Health Specialised Services Committee) to look at the options for inpatient services. They considered the following:

Perinatal Mental Health Tier 4 Services provided using the IPFR process through a secured contract

A single regional Mother and Baby Unit established for Wales

A regional Mother and Baby Unit established in South Wales and services contracted in England for North Wales.

Following a series of workshops with the perinatal mental health community Welsh Government has requested that a further option is pursued and that work is undertaken to look at an interim and long term commissioning arrangement. This work will be taken forward within the mental health commissioning team in WHHS. The team consists of an Associate Medical Director (AMD) for Mental Health (Dr Robert Colgate), a senior NHS planner, a finance manager and a quality lead. The Leadership Fellow will be the clinical lead for this project of work but will be supported by the wider team. A particular challenge in developing the options has been as assessment of the population need for the service. Wales has lower rates of access than England but we also know that demand in England is falling as community services are strengthened. In addition community services within Wales vary considerably. An important first step in the project will therefore be a population needs analysis. Alongside this the leadership fellow will need to develop a service specification. This means looking at current guidelines and professional standards as well as working with clinical experts to develop a document which describes the key characteristics of a high quality service. Following on from this there will need to be development of policies which describes access criteria for patients. When this is complete provider proposals will need to be assessed including a financial assessment before a commissioning decision is made both for a new service in south Wales and a formal commissioning arrangement for north Wales.


Dr Robert Colgate, Associate Medical Director (Mental Health) WHSSC Tel: 01443 443443 X8100 [email protected]


WCLTF 2019/20

Project Title: Transforming Clinical Services – Pathway Re-design

Medical Director: Dr Philip Kloer

Organisation: Hywel Dda University Health Board

Project Description: Hywel Dda University Health Board has embarked on an ambitious, clinically led, whole system transformation programme and is finalising its Health and Care Strategy (incorporating Clinical Strategy) based on a number of key clinical recommendations recently agreed by the Board and following an extensive public engagement and consultation process. The new model of care puts the focus firmly on a social model for health with prevention and early intervention at its heart and will be delivered from predominantly community-based services. Community networks are supported by re-purposed community-based hospitals at Withybush and Glangwili, a new build acute general hospital in the zone identified between Narberth and St Clears, Prince Philip Hospital and Bronglais General Hospitals. The Health Board has committed to a process of continuous engagement and co-production with staff, patients and the public to design and develop the new care model. The clinical Fellow will have the opportunity to be part of this exciting transformation programme, working as a key member of the programme team, leading on the co-design of a number of identified clinical a pathways as part of this programme. Supported by the associate Medical Director for Transformation, the Transformation Director and the programme team, the Clinical Fellow will be able to choose areas of service change set out in the strategy and agreed clinical model that matches their clinical interest. This could be within primary care services, community services or hospital-based services. The Clinical Fellow can choose clinical pathways for re-design as part of the programme working as a core member of the programme team, and a wide range of staff and stakeholders. They will need to work with clinical teams within these pathways to scope and co-design a transformed pathway that fits within the programme. Pathway redesign could be for any specialty and may include:

development of new pathways spanning primary, community and secondary care, with in-reach, outreach and use of technology to deliver care closer to home

integrated working with health, social care and third sector

new roles, new ways of working

innovative approaches to support self-care and management re-designed pathways to improve patient experience and outcomes


Dr Meinir Jones, Associate Medical Director Transformation (01267) 239569

WCLTF 2019/20

Project Title: Value Based Health Care – Measuring Outcomes in a Speciality Pathway

Medical Director: Dr Philip Kloer

Organisation: Hywel Dda University Health Board

Project Description: The challenges the NHS and other international health systems face both now and in the future will require its services to provide the best value possible to the public. Hywel Dda University Health Board has embarked on an ambitious transformation programme to change the way services are delivered into the future but we also need to engage our clinicians and patients to deliver the best possible care with the minimum resource and to ensure that we achieve improved outcomes that matter to patients. To deliver this aim in a systematic manner and to ensure this engagement we are establishing a value based health care programme. The delivery of a value based system is a key priority for both the Health Board and Welsh Government. Delivering value requires a focus, not only the more traditional concepts of productivity and efficiency, but also on outcomes (whether the healthcare intervention has met the expectations of the patient) and impact (how the healthcare intervention has changed the life experience of the patient and those around them) and resource utilisation. Value based healthcare (VBHc) at it simplest is defined the equation outcomes divided by resource use. There are three types of value in this context which include “Allocative value” (whether the right amount of resource is allocated for to each service, “Technical value” (whether resource is used in the best way within a service area), and “Personalised value” (whether the outcomes of the service were individualised for the service user and their family / carers). VBHC therefore brings in the concepts of quality, safety, outcomes and resource utilisation within its remit. Outcomes are the results people care about most when seeking treatment, including functional improvement and the ability to live normal, productive lives. Internationally there has been slow progress on developing suites of comparable outcome measures for clinical pathways. Hywel Dda UHB has already made progress in the lung cancer pathway, taking advantage of the WG relationship with ICHOM (the International Collaboration for Health Outcomes Measurement). Following this WG committed to invest in the South West Region for Hywel Dda UHB and ABMU, to set up a VBHc programme, supported Swansea University. It is intended that the VBHC programme build on previous experience and develop suites of outcome measures across a range of clinical pathways and costing of pathways, generating a culture of VBHc within the organisation. Initially the plan is to strengthen the work on lung cancer and work on other areas where clinical engagement already exists. Whilst Four specialty areas have been identified for initial specific focus, other areas would be considered depending on the area of interest of the leadership fellow and potential engagement within the Health Board. Orthopaedics, Ophthalmology, ENT and Urology are the areas already identified. Specific pathways will be identified within these specialities. Both clinical and patient reported outcomes will be a vital part of the value programme within the Health Board. Measuring outcomes against validated standards will enable the Health Board, our clinicians and our patients to compare ourselves with our peers. It will also support decision making at a pathway level to make changes to care that represent the best value based on what patients need and what is the most cost effective. Vitally though measurement of outcomes enables clinicians to properly understand the impact of disease and treatment on the patient and to have this discussion with the patient within the consultation. The Vision for the programme is to initially develop a suite of outcome measures for a range of clinical pathways and aligned costing data for those pathways. The future aims are to be a VBHc

WCLTF 2019/20

organisation, demonstrating that it achieves outcomes that matter to patients, whilst being good stewards of the finite resources available. The VBHc programme will identify a number of pathways in the 4 specialty areas above, and other pathways. Standard minimum data sets for will be used to collect clinical and patient reported outcome measures to look at each step within the pathway. The Clinical Fellow will be able to choose one or two pathways to work on and will apply value based methodology to achieve the vision above. Each workstream will capture patient and clinically reported outcomes, in parallel with costing across the whole cycle of care to establish how this helps to re-assess, re-model the pathway. Based on the outcome measurements together with the cost of each step of the pathway will determine the value and the pathway will then be re-modelled to maximise the value and deliver the outcomes that matter to patients. Working with IT and informatics, the patient reported outcomes will be displayed within the patient record and utilised within the consultation to inform future treatment options.


Dr Phil Kloer, Medical Director and Director of Clinical Strategy (01267) 239698

WCLTF 2019/20

Project Title: Controlling the Confusion (part three) : creating and sustaining composite teams

in health care

Medical Director: Mr Kamal Asaad

Organisation: Cwm Taf University Health Board

Project Description: Creating and sustaining composite teams in health care settings is an important activity. Educationalist and consummate communicator Ken Robinson describes creativity as: ‘the process of having original ideas that have value - more often than not comes about through the interaction of different disciplinary ways of seeing things (TED Talk 2006)’. Composite can be defined as: made up of distinct parts or elements (Collins Dictionary). Within the Bridgend mental health service for older adults is a care home in reach team which is composed of Foundation Programme medical staff, social work and occupational therapy as well as the more traditional psychology, nursing and psychiatric staff. In addition several of these staff are part of another composite team on the shared care ward 18 on the Princess of Wales hospital site in Bridgend – RGN and RMN qualified nursing staff working together within a defined area alongside general medical and psychiatric medical staff. The essence of this project is to explore these two closely related existing teams within the mental health service in Bridgend and to tease out the elements that are both innovative and valuable; which in turn will directly influence service change in mental health across the Health Board. Health care teams exist in a dynamic workplace where change is the norm. The typical hospital in patient profile in the United Kingdom is now an older adult with multiple complex physical and mental health morbidity – sometimes described as the new normal. The local service models have been published in Advances in Psychiatric Treatment (Colgate and Jones 2007 and Colgate et al 2012) establishing a firm foundation for this project.


Dr Robert Colgate, Consultant Psychiatrist and Associate Medical Director (WHSSC) [email protected] Tel: (01656) 752752 ext 2252


WCLTF 2019/20

Project Title: Improving the well-being of junior doctors

Medical Director: Dr Pushpinder Mangat

Organisation: Health Education and Improvement Wales (HEIW)

Project Description: The 2018 GMC NTS results highlighted concern regarding fatigue in junior doctors. Long and intense working hours, heavy workloads and the challenges of frontline medical practice are affecting doctors’ training experience and their personal wellbeing. Nearly a quarter of doctors in training and just over a fifth of trainers told us they’re burnt out because of their work. Almost a third of trainees said that they are often or always exhausted at the thought of another shift. And well over a half of trainees, and just under a half of trainers, reported that they often or always feel worn out at the end of their working day . A fifth of doctors in training and trainers told us they feel short of sleep when at work. A number of associations are pushing for the concerns around fatigue to be addressed. AAGBI (Association of Anaesthetists of Great Britain & Ireland) have launched “The Fight Fatigue Campaign”. The AAGBI believes it is time for healthcare professions and NHS managers to acknowledge that working at night is not the same as working in the day. For the sake of patient safety, steps must be taken by all parties to manage night working safely. It has set out a three-point plan of DETECTION, EDUCATION and PREVENTION to address the culture surrounding doctor fatigue in hospitals and tackle the problem of excessive fatigue. https://www.aagbi.org/professionals/wellbeing/fatigue EMTA (Emergency Medicine Trainees Association) launched the #RESTEM campaign. We are unable to perform at our best throughout our entire shift, every shift. Working at night and demanding disrupted sleep cycles from shift work bring with it further dangers to our physical and mental health. We cannot change the fact that we need to deliver an acute service 24h a day but there are simple practical steps we can take to minimise the risks of variable shift work and improve our core sleep, with better outcomes for us and our patients. We want to kick start the conversation from individual to Trust and National Level that we must consider the impacts of our work schedules on our health and our ability to care for our patients. http://www.emtraineesassociation.co.uk/rest.html The BMA has launched a fatigue and facilities charter to recommend best practice and, while not mandatory, to support an awareness campaign on good sleep practices. It outlines simple steps that can be taken to improve facilities and reduce fatigue, so you can safely, effectively and efficiently care for your patients. https://www.bma.org.uk/advice/employment/working-hours/fatigue-and-facilities-charter The project could be done initially on one site to benchmark current practice, review areas of good practice locally and nationally and implement changes to improve the current situation. (The project initiation plan could be informed in large part by the relevant points in the BMA Fatigue and Facilities Charter)


Dr Amanda Farrow, Head of School for Emergency Medicine & ACCS [email protected]

https://www.aagbi.org/professionals/wellbeing/fatigue

http://www.emtraineesassociation.co.uk/rest.html

https://www.bma.org.uk/advice/employment/working-hours/fatigue-and-facilities-charter


WCLTF 2019/20

Project Title: Health in your Hand : Providing digital health & social care records to clinicians via a mobile hand held device to support the delivery of safe and effective patient care

Medical Director: Mr Rhidian Hurle Organisation: NHS Wales Informatics Service (NWIS)

Background & Rationale The Welsh Clinical Portal is an ‘All Wales’ NHS digital solution that supports the delivery of healthcare to 3.3 million patients across the NHS in Wales. It is the core application of the National Architecture and is on a journey to becoming the Digital Health Record for Wales. Currently, WCP is primarily used as a desktop application in secondary care and it provides:

An ‘All Wales’ view of test results, images and documents

Links directly with the GP summary view

Key patient information to Welsh Ambulance Service Trust and Out of Hours service

Electronic prioritisation of referrals

Electronic discharge summaries

Over recent years, the demand for hand held mobile technology had increased significantly and many staff and patients are using this type of technology in many aspects of their lives. There is a growing expectation that these tools should also be available within healthcare to provide health and social care professionals the key information at point of care but also with the ability to update the record in real-time. The national programme recognises the importance of this and as such has just commenced a project to develop WCP Mobile. Project Description The aim of this project is to support the design and delivery of an All-Wales mobile platform that provides health and social professionals with the right information at the right time, to reduce duplication, improve efficiency and increase patient satisfaction. This will be achieved by:

Working with colleagues to understand the clinical priorities for a mobile platform

Utilising clinical expertise to understand the end user requirements

Understanding clinical workflows to ensure that the solution is fit for purpose

Ensuring that any solution is safe and easy to use

Promoting the benefits of digital transformation

The clinical fellow will play a key role in acceleration of the WCP mobile platform and will be an integral part of the WCP mobile project team. They will be based in the Clinical Directorate within the NHS Wales Informatics service and work alongside other clinicians and informatics professionals to support and guide them in their role. They will be expected to report progress to the project team and the Head of Clinical Informatics & Business Analysis to support collaborative working.


Suzanne Rodgers, Head of Clinical Informatics & Business Analysis Programmes [email protected]


WCLTF 2019/20

Project Title: Cancer Pathway Innovations to Detect Cancer Earlier: Supporting the introduction of a Single Cancer Pathway for Wales and exploring next steps for Rapid Diagnostic Clinics/Centres

Medical Director: Dr Tom Crosby Organisation: Wales Cancer Network (part of the NHS Wales Health Collaborative)

Project Description Broadly, the Clinical Leadership Fellow will join the Detecting Cancer Earlier (DCE) programme team and support with the implementation of a Single Cancer Pathway for Wales. It is anticipated that the Clinical Fellow will drive two specific areas of work:

1. Supporting the national roll out of a Single Cancer Pathway (SCP) – the Clinical Fellow will provide clinical input to the capacity & demand modelling being undertaken as part of the national SCP programme, with the aim of understanding the impact of the SCP on system capacity, in particular diagnostic capacity. There will also be a significant amount of pathway improvement work to support Health Boards to transform their pathways to deliver against the new SCP standard. This is a significant piece of work that needs substantial clinical engagement and clinical leadership.

2. The central evaluation of the Rapid Diagnostic Clinics / Centres (RDC) pilots – the Clinical Fellow will also be integral to the Wales Cancer Network’s evaluation of the two-year RDC pilot currently underway within two Health Boards. This will include reviewing the evaluation data to inform what the optimal clinical model for an RDC could look like and proposing recommendations for further national roll out as appropriate.

Both strands of work are key elements of the Wales Cancer Network’s work programme and have a high profile at local and national level (including with Welsh Government and the Cabinet Secretary for Health & Social Services). Background to DCE The Cancer Delivery Plan contained the aspiration of a “relentless drive for earlier diagnosis of cancer” as one of best opportunities to improve patient outcomes. The DCE programme is a formal sub-group of the Cancer Implementation Group (CIG) chaired by Dr Tracey Cooper (CEO, Public Health Wales). It incorporates initiatives across the patient pathway from screening to awareness and from referral through diagnosis to treatment start. Project 1: Single Cancer Pathway Although a number of improvements have been made in cancer services over the last few years, we face considerable challenges in relation to the burden that cancer poses on our population, the demand placed on health services, equitable and timely access to high quality cancer care, the Welsh health system’s current performance and our current cancer outcomes in Wales. However, learning from other countries and scaling up best practice in Wales, there are significant opportunities for us to transform the outcomes and experience for our patients and their families. The implementation of the Single Cancer Pathway (SCP) provides us with a driver and enabler to achieve many aspects of this change. The Single Cancer Pathway (SCP) will measure Cancer Waiting Time (CWT) target from the Point of Suspicion ( pathway start point) of cancer until treatment for all patients. It aims to ensure the vast majority of all patients presenting with a suspicion of cancer are treated within 62 days. It is anticipated that the Cabinet Secretary for Health & Social Services will announce a revision to the Cancer Waiting Time (CWT) targets in Wales from Summer 2019, which will, for the first time

WCLTF 2019/20

anywhere in the UK, begin to record and publish cancer pathway times from the point of suspicion (rather than referral) for all patients regardless of their route of referral into the system. The current cancer waiting times (CWTs) which have been a Welsh Government (WG) performance target for approximately 10 years are:

Urgent Suspected Cancer (USC): Patients referred from primary care as suspected cancer, fulfilling specific criteria (usually NICE guidance), and accepted as suspected cancer by site specific specialists in secondary care, should start treatment within 62 days of the receipt of the original referral. It has a compliance target of 95%

Not Urgent Suspected Cancer (nUSC): For all patients diagnosed with cancer by other referral routes e.g. via A+E, or a surprise finding on an investigation for something else. It is currently measured from the time the patient accepts their treatment plan (Date of Decision to Treat or ‘DDT’), to receipt of treatment with a target of within 31 days. It has a compliance target of 98%.

Over the past 7 years, a number of audits have been undertaken demonstrating that patients are waiting a long time from the point of suspicion (PoS) of cancer until they start treatment, especially when on the nUSC pathway. It was clear therefore that the system was:

Not accurately reporting the actual patient experience

Not accurately reporting the pressures in the diagnostic system

Not driving improved performance through identifying the causes of delays Why is the Single Cancer Pathway change important? Survival outcomes in Wales are poor compared to other similarly developed countries. It is accepted that stage of disease at diagnosis plays a major contribution to these relatively poor patient outcomes. However, it is known that patients with a given set of signs/symptoms are less likely to be investigated for suspected cancer and that after presentation patients in Wales, spend longer in the healthcare system before starting treatment than all other countries and jurisdictions. This supports the case for change, the SCP will demonstrate the actual time in the system for all patients and provide a platform for improving this. The WCN is in the process of agreeing arrangements (subject to grant funding) to work with Cardiff University’s Operational Research Unit, School of Mathematics, to analyse and model the diagnostic phase of the single cancer pathway with the support of highly respected academics in this field. The Clinical Fellow will provide clinical leadership and input into this work and provide insight on the realities of clinical pathways at an operational level to the modellers, as well as supporting the learning outputs from this work. Project 2: Evaluation of the Rapid Diagnostic Clinics / Centres (RDC) pilots Developing systems which expedite cancer diagnoses and treatment provide the foundation for strategies aimed to improve cancer outcomes. The Rapid Diagnostic Clinic/Centre (RDC) provides rapid access to a range of diagnostic tests in a one-stop clinical setting for patients with vague non-specific but concerning symptoms that could be indicative of cancer. The RDC is an innovative concept supported by a multi-professional team, integrated across primary and secondary care, and underpinned by learning from international practice modelled on the Danish ‘three-legged’ strategy introduced to support early cancer diagnosis. Both ABM and Cwm Taf UHBs successfully secured £200k funding via the Wales Cancer Network (WCN) Cancer Innovation Pathway Funding Programme in 2016 to develop and deliver a 2-year pilot based on the RDC concept for their health population. The WCN Innovation Funding was match funded by each Health Board.

WCLTF 2019/20

During the Summer of 2019, the WCN will be leading a co-ordinated evaluation of both RDC pilot sites to determine whether the model has been a success, and what (if any) the implications might be for the optimal RDC clinical model and National roll-out. Context Only 35 – 45 % of all cancers in Wales are diagnosed via the accelerated USC route. The majority of cancer patients present via other non-accelerated routes with a significant proportion having vague symptoms that do not fit the NICE Suspected Cancer Referral Guidance (NG12) recommended ‘red flag’ symptoms, with other patient groups presenting late as an emergency or are found to have cancer whilst being investigated for other signs/symptoms. In reality, early stage cancer presents very differently in primary care and there is no clear referral pathway for patients with vague, non-specific but concerning symptoms that do not meet the criteria for referral via a site specific urgent suspected cancer pathway route. The introduction of RDCs provides a low risk, not no risk pathway where primary care has a gut instinct something serious is wrong, possibly cancer but no USC red flags for primary care to refer this cohort of patients. The RDCs benefit from same-day clinic access to radiological tests with live reporting (mainly CT) to facilitate a MDT discussion and enable same-day diagnosis or management plan. Interim RDC Outcomes (12 months)

Both clinics have been operational since June/July 2017 and reviewed their outcome data at 12 months. The key finding to date are:

A total number of 50 cancers were diagnosed and staged resulting in a combined conversion rate of 10.5%.

Within this patient group the stage of presentation remains late with the majority having stage III / IV cancer at diagnosis.

The common symptoms upon referral for both pilots were weight loss, new onset of fatigue, abdominal pain and loss of appetite.

The time taken from point of suspicion to radiological diagnosis ranges between 4.4 – 9 days.

In addition to the cancer diagnoses, a significant amount of chronic disease was diagnosed within the clinics resulting in either an onward secondary care referral or discharge back to GP for primary care management (approx. 30%), with a range of diagnoses. No clinical abnormality was found in the remaining cohort.

In addition to the potential benefits for detecting cancers earlier, wider discussions (including those with similar pilots in England) have suggested the utility of the RDCs as a ‘problem solving clinic’ for primary care offering a timely, one-stop environment for managing complex patients.

Both the patient and GP experience of the RDC is extremely positive with patient satisfaction reported as >96% (93% extremely satisfied) and GP satisfaction at 96% (ABMU RDC).

Based on the 12 month outcome data, the initial results from the RDC pilots are very encouraging. The leadership and insight of a Clinical Fellow to lead the joint evaluation and engage clinically to develop national recommendations to take this model forward would be invaluable.


Carys Jones, DCE Programme Manager [email protected]


WCLTF 2019/20

Project Title: Prehab to Rehab: Preoperative Assessment Expansion Project: Improving Perioperative Care

Medical Director: Dr Graham Shortland Organisation: Cardiff and Vale University Health Board

Project Description In order to achieve a gold standard POAC service at CVUHB there are many overlapping workstreams. Currently we have a multi-disciplinary working party including anaesthetists, surgeons, nursing staff, non-medical and administrative staff. We are well supported by our managers. The overall aim is to improve the standard of perioperative care to all elective surgical patients, reduce the rates of day-of-surgery cancellations, and improve post-operative outcomes. The project will involve developing the various processes required for the elective surgical patient “journey”. From referral pathways and points of data collection, to expanding the functions of the existing POAC, to streamlining bookings and correctly managing our patients postoperatively, in terms of location and resources. We need to standardise our existing processes whilst remaining sensitive to the needs of individual surgical specialties. The capacity of the clinic is set to gradually increase this year as we invite those surgical specialties to refer their patients where they do not currently. The number of consultant anaesthetist sessions will increase to close to 20 sessions per week, as will the numbers of nurses and healthcare assistants and administrative staff. We aim to develop a Frailty Service with Elderly Care Physicians, to develop smoother access to physicians including cardiologists, and employed a dedicated pharmacist. We need to expand our existing intravenous iron service which has the potential to deliver huge benefits to patients undergoing major surgery, many of whom arrive anaemic. We aim to deliver the same standard of care across both hospital sites, to include the orthopaedic preassessment service in Llandough Hospital. The trainee will work in partnership with the project team, including dedicated project manager. Continual project evaluation and ongoing data collection building on the work we have already started will be key to identifying interventions, and keeping the various workstreams together. We need to better identify our own data systems and tools used in the UHB to inform changes in the POAC. Communication with the team, and other stakeholders will enable the trainee to develop a strategy of interventions. There will be the opportunity to collaborate with other teams, for example with smoking cessation, anaemia pathways, weight loss and other important public health interventions.


Dr Tessa Bailey, Consultant Anaesthetist [email protected] Dr Anna Jolly, Consulant Anaesthetist [email protected]



WCLTF 2019/20

Project Title: Creation of a Joint Medical Clerking document with Emergency Department to

improve patient assessment and flow in BCUHB at all sites

Medical Director: Dr Gareth Bowdler Organisation: Betsi Cadwaladr University Health Board

Project Description To liaise with colleagues in various departments across the 3 sites in BCUHB to improve patient assessments and stream line flow of inpatients to create a Joint single clerking proforma with ED for inpatient referrals to both medical and surgical specialties. Currently there is a great pressure on emergency departments and medical admission units across the 3 sites with patients waiting for initial assessments. For a number of patients in ED refereed to other specialties there is a considerable time lag in being assessed by specialty consultants. this is often due to dual assessments due to the patient history and presentations not being documented in an approved format and followed up. This often results in time lost in reassessment and clerking in patients again by junior doctors in the specialties which create another layer of patient delay due to time lost hence adding to the existing delay. Methodology:

Scoping average time needed for patient assessments at present and ED waiting times. Meeting with leads in various specialties across the 3 sites to discuss the issue and agree a joint proforma ( already started work on this aspect)

Creation of an agreed ‘joint proforma’ with ED and key medical/surgical specialities.

Creation of a generic clerking sheet for junior doctors to use for daily assessments on medical wards to promote safe patient care as well as discharge planning.

Piloting the joint proforma once agreed on one site and then on other sites

Re auditing outcome measures and spreading the message if successful

Roll out of the joint proforma across all 3 sites by end of the year. There would need to be agreement with specialty leads regarding an optimal assessment proforma. Site management commitment to pilot the Joint Performa’s will include cost of printing and monitoring. Engagement needs to be had with specialties to agree on this single assessment proforma. I have already started several discussion meetings to identify barriers to patient discharges from hospital when they are medically fit. These include a potential risk averse attitude on part of health professionals requesting for unnecessary assessments. Sometimes there is no ownership of who should do referrals to therapies or engage with social worker. Junior doctor work force at all 3 sites and community hospitals will need additional training and education on how to use the new proforma and daily assessments. Anticipated Key Outcomes (max 150 words) *

1. Creation of a ‘Joint clerking proforma’ with Emergency Department and medical/surgical specialties in BCUHB.

2. Creation and use of a structured daily assessment sheet for use of medical junior doctors to improve assessments and patient flow on the principles of SAFER.

3. Improve referrals for therapy assessment in efficient and timely manner and thus improve patient care and flow.

These measures would seek to improve patient care and reduce assessment times. It is hoped that this would lead to improve ED waiting time for patients and improve length of stay on wards.


Dr Gareth Bowdler, Area Medical Director East

welsh clinical leadership training fellowships (wcltfs) · working closely with medical directors,...

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