Delivering through ImprovementA report on the success of care pathway improvement work

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Delivering Through Improvement - Success of the care pathway improvement work is published by the NHS Institute forInnovation and Improvement, Coventry House, University of Warwick Campus, Coventry, CV4 7AL.

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Please view the attached DVD Delivering Through Improvement

To find out more about the Care Pathways Improvement work, please contact Annette Neath on 024 7647 5816or email annette.neath@institute.nhs.uk

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Contents

Page

1. Overall aims of the project 3

2. Aims of this report 4

3. Successes against improvement measures 5Fractured neck of femur 5

Acute stroke 7

4. Improvements for individual network trusts 9Mayday Healthcare NHS Trust 9

Bolton Hospitals NHS Trust 11

Cambridge University Hospitals NHS Foundation Trust 14

Milton Keynes Hospital NHS Foundation Trust 16

South Tees Hospitals NHS Trust 18

East Kent Hospitals NHS Trust 21

Luton and Dunstable Hospital NHS Foundation Trust 23

Medway NHS Foundation Trust 25

Barnsley Hospital NHS Foundation Trust 27

St George’s 28

Appendix 1 30Background to Delivering through Improvement 30

What was our vision? 30

What was the programme about? 30

Reflections from participating Chief Executives 31

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Delivering through ImprovementFractured neck of femur and stroke care pathway

improvement work

‘Success Headlines’

Substantial improvements against project metrics - Significant reductions in length of stay, mortalityrates, time to theatre for fractured neck of femur patients, increase in the number

of stroke patients receiving a CT scan.

Comments from staff and patients

“The whole project demonstrates that wheneveryone pulls together it comes together!”

“Discharge plans are now much ‘slicker’, with staffnot thinking someone else is doing a job and

waiting a week only to discover it has not beendone! Discharge planning starts on admission.”

“Using the Experience Based Design (EBD)methodology to engage patients in improving theservice has led to a truly collaborative approach in

the redesign of the service.”

“It has been inspirational to see the early resultsparticularly the reduction in mortality and Length of

Stay LOS.”

“Working with the Network to achieve excellencein the services we offer fractured neck of femur

patients has been an exciting and rewardingexperience.”

“It was very encouraging to see a group ofconsultants keen to play a part in the improvement

of the patient pathway.”

“The pathway work has been great for bringingpeople together, both acute and community

colleagues; communication has really improved and there is now a consistent approach to referrals

and discharges.”

“I have been here for four years and have beenasking for a meeting with the community, this is

the first time it has happened.”

“Such a simple approach to care planning andpathway work has now been shown to have

sustainable results.”

“I’ve never done anything like the emotionalmapping exercise before, I enjoyed it. I complainedwhen I was in and this was a chance to even things

up a bit and tell the team about all the goodexperiences as well.”

“All patients are thrombolysed in A&E whereverappropriate and 70% of patients are now seen by

the stroke team within 30 minutes.”

‘Everything we do in our Elderly Trauma Unit isdriven by the desire to make a difference for our

patients. We had commitment and input at a seniorlevel which gave the project status and impetus.”

“This unit has saved lives, that’s what it’s all about.”

“I can’t believe that when I came in I couldn’tspeak and couldn’t move my arm and leg and nowhere I am walking around and talking to you, I can

hardly believe it.” “It was great to see our first patient recovering infront of our eyes!”

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1. Overall aims of the project

The overall aim of the Delivering throughImprovement programme is to support chiefexecutives with their transformational changeprogramme. The programme began in October2006 with a group of sixteen chief executives fromacute trusts. The NHS Institute has supported themin: developing their leadership skills fortransformational change; creating their vision;developing a strategy and plans for transformation;and creating the culture to sustain the long termtransformation programme. More informationabout the programme, including the topics wecovered, can be found in appendix 1. There is alsoa DVD at the front of this report, which illustratesthe different aspects of the programme.

As part of the overall programme, it was essentialto demonstrate tangible and measurableimprovements and the network decided theywould like to work together on a ‘common cause’.The NHS Institute’s Delivering Quality and Value(DQV) team had recently completed series 1 of thehigh volume Healthcare Resource Groups (HRG)programme. The programme is based on theconcept that by focusing on a limited range of highvolume HRGs (or related care groups), the NHSInstitute can help the NHS to make the maximumimpact on improving the quality and value of carefor NHS patients. After reviewing their Dr FosterData for the eight HRGs that formed series 1 of theprogramme, the network collectively agreed towork on improving fractured neck of femur andacute stroke care pathways.

As well as demonstrating substantial improvementsacross these two care pathways, the aims were todevelop a methodology for improvement thatcould be applied to other care pathways and tobuild improvement capability within the networktrusts. Ten trusts participated in the pathwayimprovement work and each received support fromthe NHS Institute and McKinsey consultants, as wellas from individuals with clinical, analytical andimprovement expertise. Three national workshops

were held for each care pathway between May andOctober 2007. These provided an opportunity forthe improvement teams to hear from and debatewith leading clinical experts, to share theirimprovement experiences, and to learn from othertrusts in the network. The improvement teamshave also visited each others’ trusts to learn aboutbest practice.

A network academy was formed and each trustseconded one or two staff, leading on the pathwaywork, to the NHS Institute/McKinsey to developtheir improvement skills. Academy membersattended a series of training courses facilitated byMcKinsey, the NHS Institute and otherimprovement experts. The DVD attached to theback of this report provides an overview of theaims and achievements of the network academy.

The trusts have spoken to us about the benefits ofadopting a network approach to improvementwhere expertise, skills and resources can be shared.They said that this shared approach toimprovement has enabled them to achieve farmore than would be possible if the trusts workedin isolation.

The following network trusts participated in thepathway improvement project:

• Bolton Hospitals NHS Trust.

• South Tees Hospitals NHS Trust.

• Cambridge University Hospitals NHS Foundation Trust.

• St George’s Healthcare NHS Trust.

• Mayday Healthcare NHS Trust.

• Medway NHS Foundation Trust.

• East Kent Hospitals NHS Trust.

• Luton and Dunstable Hospital NHS Foundation Trust.

• Milton Keynes Hospital NHS Foundation Trust.

• Barnsley Hospital NHS Foundation Trust.

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2. Aims of this report

The purpose of this report is to demonstrate the achievements against measures agreed at the start of theproject and the improvements that have been made for patients and the staff delivering their care.

The participating trusts adopted different approaches and improvement methods and they focused theirwork on the parts of the pathways they identified as priorities for their trust. However, to be able todemonstrate the project’s success, the ten trusts and the NHS Institute identified six improvement metrics foreach pathway (see below).

The trusts were asked to collect data for each ofthese measures for April/May 2007, October 2007and February 2008. They were also asked to reporton the changes they introduced and anyimprovements that were made for patients and staff.

There are several data issues that we to drawattention to. The following information is based onself report data from each network trust. It wasagreed that all trusts would collect data usingexisting methods and systems. Some trusts did nothave systems in place to collect data for some ofthe agreed measures and others do not have dataavailable yet for February 2008. The reportindicates where data are not collected or are notyet available. If an improvement is not shownagainst one of the measures, it does not necessarilymean that improvements have not been made, itcould be that data are not available. It is importantthat comparisons are not made between the trusts,as there may be differences in terms of what thedata represent. For example, some trusts report

average length of stay for spell whilst others reporton superspell, particularly if rehabilitation takesplace within the trust. There are also differences inwhat mortality and readmission rates represent.

It is not ideal that the information in this reportshows data at only two points in time (May 2007and February 2008). It could be misleading in thesense that it might suggest that either thesignificant improvements reported here may not besustained, or that no improvements have beenmade when in fact there is a general trend ofimprovement. For example, reports of 0%readmission or 0% mortality may have beenachieved for the month data were submitted, butzero rates are unlikely to be sustained for thesegroups of patients. Similarly, it might appear thataverage length of stay has increased when theoverall trend is a reduction. The report is intendedto show general trends or indications of thesubstantial improvements that have been achieved.

Pathway improvement measures

Fractured neck of femur Acute stroke

Average length of stay (LOS)

Mortality rates

Time in A&E

Readmission rates

Discharge to home

CT scan within 24 hours

Average length of stay (LOS)

Mortality rates

Time in A&E

Readmission rates

Discharge to original place of residence

Patients operated on with 48 hours

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3. Successes againstimprovement measures

Of the ten trusts participating in the pathway improvement work, eight trusts worked on both carepathways and two worked on just one (i.e. nine trusts worked on each pathway).

The summary table below shows the number of trusts that made improvements against the number oftrusts submitting data for a particular measure. For example, 8 out 9 means that data were submitted by 9trusts and 8 demonstrated improvement.

Analysing each measure separately, enables use todemonstrate where the most substantialimprovements have been for both care pathways.

Fractured neck of femurAverage Length of stay (LOS)Eight of the nine trusts demonstrated a reductionin the average LOS:

• One trust reduced average LOS by eight days

o 27 days to 19 days.

• Three trusts reduced average LOS byapproximately six days

o 28.6 days to 22.7 dayso 17.6 days to 11.6 dayso 18 days to 12 days.

• Two trusts reduced average LOS by three days

o 24 days to 21 dayso 17.5 days to 14.5 days.

• One trust reduced average LOS byapproximately two days

o 23.9 days to 21.6 days.

One trust submitted data against two HealthcareResource Groups (HRGs) reducing the average LOS from:

• 17.5 days to 10 days (7.5 days)

• 25.5 days to 23.9 days (1.6 days).

The remaining trust saw a substantial increase inaverage LOS. However, this was attributed to anoutbreak of norovirus on the level where fracturedneck of femur patients are admitted. Wards wereclosed and this, together with staff shortages, alsodue to sickness, meant that patients could not bedischarged until they were well as they were notaccepted by community hospitals. The trust hasreported that LOS is now reducing.

Mortality rateMortality rate data were submitted by seven trusts(two reported that they do not collect data).

Six trusts saw the following reductions in themortality rate:

• 15% - 8% 7%

• 15% - 7.5% 7.5%

Fractured neck of femur Acute Stroke

Average LOS 7 out of 9Mortality rate 5 out of 7 Time in A&E 3 out of 5Readmission rate 3 out of 5 Discharged home 4 out of 8CT Scan within 24 hrs 4 out of 6 (2

remained high at 95%)

Average LOS 8 out of 9 Mortality rate 6 out of 7 Time in A&E 5 out of 6Readmission rate 4 out 7Discharge to place 6 out of 9 of residenceOperation within 48 hours 5 out of 7 (1

trust achieved 24 hours)

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• 19% - 0% 19% reduction (0% was achievedfor February and a sustained rate of 12% hasbeen reported)

• 9.4% - 9.1% 0.3%

• 10% - 5% 5%

• 10% - 6% 6%.

The mortality rate at one trust increased from10.3% to 11.1%.

Time waiting in Accident andEmergencyWhilst it was agreed to measure success againstthis metric, three trusts were unable to submit databecause: they did not collect data; sometimespatients fracture their hips through a fall whilst inhospital for another condition and are not seen inA&E; because a fast track process is in place. Datawere submitted by six trusts and five reduced thetime patients waited in A&E.

Two trusts reported an improvement in terms ofthe percentage of patients seen within two hours(the best practice target) from:

• 50% to 60%

• 28% to 40%.

Three reduced the average length of time patientswaited in A&E from:

• 3 hours 45 minutes to 3 hours 30 minutes

• 3 hours 30 minutes to 2 hours 30 minutes

• 3 hours 48 minutes to 3 hours 20 minutes.

In the remaining trust, the average waiting timeremained the same at 3 hours 38 minutes.

Readmission ratesSeven trusts submitted data for readmission rates,four of which reported a decrease from:

• 12% to 8%

• 13.8% to 11%

• 20.7% to 6.9% (April to October 2007 data only)

• 0.7% to 0.6%.

Three trusts reported an increase in readmissionrates from: 19% to 21% (April 2007 to Feb 2008),and from 6.8% to 9.7% and 4.1% to 8.40% (Aprilto Oct 2007).

With incomplete and potentially unreliable data, itis difficult to determine what the impact of theprogramme has been on readmission rates.However, it would seem that overall there has beenlimited success against this measure.

Discharge to original place ofresidenceNine trusts submitted data and six showed anincrease in the percentage of patients dischargedto their original place of residence:

• 62% to 83%

• 55.2% to 58.8%

• 53% to 81%

• 42% to 50%

• 65.9% to 71%

• 48% to 70%.

Three trusts showed small decreases from: 82% to80% (April 2007 to Feb 2008), and from 89% to82% and 68% to 64% (April to October 2007).

Operated on within 48 hoursThis was seen as an important goal to strive for inthe project. Clinical evidence shows the benefits ofpatients (who are fit) receiving surgery within 48hours of admission. All trusts agreed to worktowards making substantial improvements againstthis measure. Data were received from eight trusts:six reported substantial improvements from:

• 33% to 100% (67% increase)

• 40% to 90% (50% increase)

• 62% to 78% (16% increase)

• 62% to 90% (28% increase)

• 94% to 96.1% (2% increase).

One trust reported a decrease from 94% to 55%,although they report that the figures refer to allpatients, not just those fit for surgery. Anothertrust’s achievements were relatively consistentthroughout the course of the programme (60% to59%) and they reported a number of problemsincluding outbreaks of C Difficile, winter flu, and ashortage of surgeons. The remaining trust wasalready achieving 100% for patients fit for surgeryand their target was to operate within 24 hours. As a sign of commitment from the chief executive,staff were expected to report on each instance wherea patient did not receive surgery within 24 hours.

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Given that the time between admission andoperation has significant impacts on othermeasures (LOS, readmission, mortality), this is amajor achievement of the programme.

Acute strokeAverage length of stay (LOS)Seven of the nine participating trusts reduced theaverage LOS:

• Two trusts reduced average LOS by just overnine days

o 23.9 days to 14.7 dayso 29.1 days to 20 days

• One trust reduced average LOS byapproximately five days

o 17.48 days to 12.53 days

• One trust reduced average LOS by four days

o 14.5 days to 10.5 days

• One reduced LOS by almost two days

o 24.6 days to 22.9 days (April toSeptember 2007)

• One reduced LOS from 9 days to 8.8 days

• One trust reduced LOS by one day for patientson the ward and by nine days for patients onoutlying wards. (April to October 2007).

Two trusts did not reduce the average LOS. One reported a slight increase from 20.9 days to22.4 days. The other trust reported an increasefrom 15.1 days in April 2007 to 24.8 days inJanuary 2008. The reasons for this were outlinedabove (norovirus and staff sickness) and averageLOS has now reduced, although more recent dataare not yet available.

Mortality rateMortality rate data were received from seven trusts,and five trusts reduced the rate from:

• 22% to 19%

• 13% to 9%

• 23% to 6%

• 28% to 14% (April to November 2007)

• 13 deaths to 10 deaths (April to October 2007).

The mortality rate at two trusts remained the same:23% for one trust and 10% for the other.

Time in A&EOnly five trusts submitted data for this measure,which was partially explained by the trusts notcollecting data for time in A&E. However, it wasalso because patients are admitted directly to thestroke unit if a bed is available.

Three trusts reported a decrease in the averagetime spent in A&E from:

• 3 hours 30 minutes to 3 hours

• 2 hours 20 minutes to 1 hour 54 minutes

• 3 hours 48 minutes to 3 hours 14 minutes.

Average time in A&E increased from 2 hours 30minutes to 3 hours at one trust, and from 3 hours27 minutes to 3 hours 44 minutes at another.

Readmission ratesMissing data posed a similar problem in trying todemonstrate the impact of the project onreadmission rates. Of the six trusts submitting datathree reported a decrease in readmission rates from:

• 6% to 3%

• 5.7% (26 patients) to 0%

• 2 patients to 0 patients.

One trust reported a low and stable rate of onepatient, one a slight increase from 8.2% to 8.3%and the other an increase in from 6.8% to 9.7%,although data are not available for February 2008.

Discharge to homeOf the eight trusts submitting data for thismeasure, three demonstrated an increase in thepercentage of patients discharged to home:

• 23% to 39%

• 59% to 61%

• 65.9% to 71% (April to October).

Three trusts reported a decrease in the percentageof patients discharged to home for the period April2007 to February 2008: 51% to 43%; 53% to51%; and 56% to 47%. Two reported a decreasefrom: 60% to 45% and 60% to 50% for theperiod April 2007 to October 2007.

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Access to CT scan with 24 hoursSix trusts submitted data against this measure,although one began collecting data only inFebruary 2008. The latter reported that 95% ofstroke patients now receive a CT scan within 24hours, which is a significant increase.

Four trusts showed a substantial improvement from:

• 80% to 100%

• 10% to 47%

• 50% to 70% (February data not available)

• A reduction in the average time from 5 days to1 day.

One trust maintained a high level of success with95% of patients receiving a CT scan within 24 hours.

SummarySubstantial improvements have been made inreducing average LOS and mortality rates for bothfractured neck of femur and acute stroke patients.There has been a substantial increase in thenumber of fractured neck of femur patientsreceiving surgery within 48 hours and strokepatients receiving a CT scan within 24 hours.These two actions are proven to significantlyimprove clinical outcomes and reduce measuressuch as LOS and readmission rates.

There was a reduction in the time spent in A&E forfractured neck of femur patients at six trusts. This measure proved to be an inappropriate one forthe stroke care pathway as data were submitted byonly five trusts. There was limited data forreadmission rates but four out of six trustssubmitting data for fractured neck of femur andthree out of five trusts submitting data for acutestroke made improvements. The percentage offractured next of femur patients returning to theiroriginal place of residence increased in six trusts.There was limited success against this measure forstroke patients.

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4. Improvements for individualnetwork trusts

All of the network trusts made substantial improvements against some or all of the six improvementmeasures. We were aware that some trusts focused on improving all six areas (for each pathway) at theoutset of the project, whilst others chose to work on fewer areas and then broaden their work over time.We could therefore expect to see more improvements against more measures if data are collected at afuture date. As the following section shows, the network trusts also made substantial improvements inother areas, including those to patient and staff experience. We re-emphasise the points raised earlier interms of missing data and the differences in what the data represents in the network trusts.

In terms of other improvements for patients, thepathway improvement team has prioritisedfractured neck of femur patients on all trauma lists,rather than ‘batching’ them to dedicated operatinglists. There is now an additional trauma list with anextra session on Saturday morning with adedicated orthopaedic surgeon, consultantanaesthetist and operating theatre staff. There have also been improvements in pre-operative assessment and intervention.Coordination within the admitting orthopaedicteam has improved significantly to ensure that:

• Appropriate investigations are performed, andresults documented.

• Early orthogeriatric and anaesthetic review takeplace as necessary.

• Patients are appropriately consented and marked.

• Patients are starved and allocated to appropriate lists.

Mayday Healthcare Trust has made a concertedeffort to ensure that potential pitfalls are picked upearly and dealt with by the appropriate clinicians toreduce potential morbidity, mortality and prolongedstay.

Mayday has also incorporated an Experience BasedDesign (EBD) approach into their work, which isanother of the NHS Institute’s projects, led by Dr Lynne Maher.

Mayday reported that professional boundaries andhierarchies within the group have been brokendown and there is now a more ‘open and honest’culture. The lead for the project said:

“The work has really brought the whole teamtogether and consequently, communicationbetween all parties is very much improved.”

The trust made improvements between April 2007 and February 2008 against:

Average LOS 28.4 days to 23.6 daysMortality rates 19% to 0% (0% was achieved for February and

a rate of 12% has been sustained)Discharged to original place of residence 62% to 83% (rate of 68% has been sustained)Operations within 48 hours 33% to 100% (rate of 90% has been sustained)Readmission rates 19% to 14%.

Data are not available for time in A&E

Mayday Healthcare NHS TrustFractured Neck of Femur

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Acute StrokeThe average LOS for stroke patients at MaydayHealthcare Trust increased slightly from 20.9 days to22.4 days. Time spent in A&E also increased slightlyfrom 217 minutes to 224 minutes. The mortality rateremained the same at 23% and the percentage ofpatients discharged to home fell from 51% to 43%.

Readmission rates fell from 6% to 3%. A multidisciplinary team, which includedconsultants from A&E, radiology and stroke/elderlycare, worked closely together to improve the strokecare pathway. They met each week to assessprogress and problem solve all issues that arose.The entire team worked on the pathway, whichensured immediate action from ‘first contact’ withthe patient. Their work involved training theambulance and A&E teams to carry out the FASTexamination and take prompt action. Their achievements include:

• Pathway protocol for thrombolysis, developedand agreed by the whole team.

• Protocol to ensure that suspected strokecandidates can access CT scanner promptly fordiagnostic purposes.

• Training and education for all staff including thehospital stroke team, London AmbulanceService, A&E staff and medical teams.

• Appointment of an elderly care consultant whohas joined the thrombolysis team.

The trust introduced an 'in-hours' thrombolysisservice in August 2007 and a 24 hour service isavailable through the implementation of a SouthWest London stroke network (this is the first inLondon, if not the country). Both patients and staffcommented positively on the impact of thethrombolysis service.

The impact on staff experience

“The national workshops were very useful andinteresting - it was particularly useful to see howother organisations had engaged staff andmanaged change. Much of the success can beattributed to the clarification of roles andresponsibilities for all the staff involved but this isparticularly true for the junior doctors who nowhave very clear guidelines and dedicated supportfrom their seniors. The whole project has reallyraised the profile of fractured neck of femurpatients and in doing so we have had great successin terms of quality and reductions in length of stay.It is not surprising the staff are really proud of theirachievements!” Interim Director of Operations

“The whole project demonstrates that wheneveryone pulls together it comes together!”Clinical Director/Consultant Surgeon - Planned Care

“The whole experience has cemented inter-specialtyworking relationships in the trust and attending thenational workshops gave us a great opportunity toshare information and knowledge. We got greatsatisfaction sharing the work we thought we didwell! We haven’t formally measured patientsatisfaction yet but we definitely seem to have lesscomplaints and the patients genuinely seem happywith their journey through the system. It was quitetough in the beginning but we are all really proudof our achievements!”

Orthopaedic Research Fellow

The following comments illustrate the positive effects of the project on staff experience:

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The trust has worked closely with Croydon PCT tocreate a community stroke team. This was as adirect result of their community wide mappingevent, which resulted in a significant injection offunding by the PCT to improve stroke services forCroydon patients.

Mayday has said that their successes in improvingthe stroke care pathway are as a result of:

• Involving staff who know the processes ‘inside out’.

• The active, enthusiastic willingness of clinicaland managerial staff to implement new ways of working.

• Building local capability for problem solving theelimination of 'waste'.

• Rapid improvement events that are action-oriented with changes made during andimmediately after the events.

• A strong partnership between Mayday's serviceimprovement team and the network academyto build rapport with teams, get immediateresults that are aligned with the trust's strategy,and ensure sustainability of changes.

• Management who understand and support lean thinking.

Bolton Hospitals NHS TrustBolton Hospitals NHS Trust already had wellestablished teams working on improving the twocare pathways and they had a rigorousimprovement methodology, Bolton Improving Care

System (BICS), based on lean methodology that isapplied consistently to all improvement projects.Significant improvements had already been madeto these two care pathways before the Deliveringthrough Improvement project began.

An improvement lead joined the network academyand participated in the training and learningevents. Although their successes are not directlyattributable to the Delivering through Improvementwork, they reported improvements against some ofthe measures and for patients and staff.

Fractured neck of femurThe trust made improvements between April 2007and February 2008 against average LOS, reducingit from 23.9 days to 21.6 days. The percentage ofpatients discharged to their original place ofresidence decreased slightly (68% to 64%) anddata were not submitted for mortality rates,operations within 48 hours, time in A&E, andreadmission rates.

Bolton began their work on improving the traumapathway three years ago using the BICSmethodology. Orthopaedics was at the forefront ofimproving pathways and the work was initiatedbecause of a poor mortality rate and long length ofstay. The Orthopaedic team is committed toimprovement and believe that understanding whatpatients value and find important is key. They have made significant improvements inreducing mortality and improving processes.

Positive impact of thrombolysis for patients and staff

“More people need to know about this treatment,I am sure if they did you, could help more peoplelike me.” Patient

“It was really rewarding for me on a personal level,as I’m often the first person to assess patients whomight be suitable for thrombolysis.” Stroke NursePractitioner

“It was great to see our first patient recovering infront of our eyes.” Stroke Nurse Practitioner

“I can’t believe that when I came in I couldn’t speakand couldn’t move my arm and leg and now here Iam walking around and talking to you, I can hardlybelieve it.” Patient

“We have just thrombolysed our third patient and Iwent to the ward for a chat today, it is just amazingto see the result and even though I don't practice'hands on nursing' now, I can't tell you what a joy itis to talk to these patients knowing full well whatthe alternative could be without this fantastictreatment!” Trust Improvement Lead

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In November 2007 a new vision and future statefor orthopaedics was designed to identify furtheropportunities to eliminate waste from the traumaprocess. The team reflected on the Deliveringthrough Improvement network’s learning to identifyfurther opportunities to improve efficiency andquality by eliminating waste. They found thewebsite and networking opportunities helpful.

Bolton has made improvements in the following areas:

• Overall time to theatre reduced by 30% -around 50% currently get to theatre within 36hours. The team is currently working with A&Eand theatres to improve this and support a ‘fasttrack’ programme.

• Length of stay reduced by 32% - currentlyaround 22 days. LOS reduced by proactivelymanaging patient pathways, but delayeddischarges remained an issue and work hascommenced to reduce LOS to 14 days.

• There are approximately 140 fewer deaths fromfractured neck of femur compared with thenumber there would have been had the Q42007 death rate remained unchanged.

• Improved access to emergency equipment intheatres and time spent looking for things onthe ward is reduced by promoting a place for everything.

Staff commented on the BICS improvementmethodology and the commitment of clinicians toimprovement work.

“Traditional management tools take a small groupinto a room and ‘solutionise’ without proper

evidence, people on the ground becomedisengaged. Now, all stakeholders are engagedand actively involved in improving services.”Orthopaedic Surgeon

“Clinicians are desperate to improve care forpatients... nothing has been done before whichhighlights waste in this way, if you can’t see it youcan’t do anything about it!” Orthogeriatrician

“This unit has saved lives, that’s what it’s all about.”Orthopaedic staff member

The trust has a project underway to involvepatients further in improving services fororthopaedics, based on the Experience BasedDesign approach. Patient feedback has influencedthe processes for fractured neck of femur patients.For example, staff and patients commented on theexperience of moves to a different ward.

“Moving older patients around upsets themparticulary when they have to move wards, theythink they have done something wrong.”

“I was worried about who would move mybelongings and how my relatives would knowwhere they have moved me.”

These comments led to further investigations intowhat was taking place in the process and morediscussions with patients about their experience. It was found that moving patients was of limitedbenefit and it was also impacting on staff morale.The event team changed the pathway for patients:the ward functions and layouts were altered in aweek and no longer require a move as the wardfocuses on proactive management of patients.

Improvements for stroke patients were made against the following measures:

Average LOS 24.6 days to 22.9 (April to October)Mortality rate 13 deaths April – 10 deaths OctoberReadmission rate 5.7% to 0%CT scan within 24 hours 80% to 100%

Acute Stroke

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In April 2007, 31 out of 52 patients weredischarged to home and in February 2008 thenumber was 23 out of 37 patients. Data were notsubmitted for time spent in A&E. Bolton hasreported substantial improvements in patient andstaff experience and they have incorporatedExperience Based Design into their work.

The trust identified stroke as one of its four mainvalue streams for improvement in October 2006and the Stroke Service Lean Improvement Journeystarted in January 2007, using BICS. The journeybegan by looking at the ‘end to end’ patientpathway and it involved hospital staff; consultants;‘fresh eyes’ from paediatrics; colleagues from thePCT providing neuro-rehabilitation - includingcommissioner of services; and JIGSAW, which is thesupport group for stroke survivors and their carers.

A member of JIGSAW commented on theopportunity to be involved in the work.

“Excited that we are being involved in theimprovement work, it is about time more peoplewere made aware of stroke.”

The trust reported on the improvements that havebeen made over the last fifteen months:

• Opening of an acute stroke unit in August2007.

• CT scans improvements have moved from 80%in April 2007 to consistently 100% fromDecember 2007.

• The number of patients admitted to the acutestroke unit has increased from 77% to 95 % in(April 2008) of which 65% were admittedwithin the first 24 hours.

• Swallow assessment has improved with 73%being assessed within 24 hours.

• 100% of patients are now weighed within firstweek, and 50% within the first 24 hours.

• The real time monitoring of key indicators hasbeen the result of the team setting up aninformation centre that is on display in theacute stroke unit. This allows information to bedisplayed for staff and for patients and visitors.It also promotes ownership of theimprovements and supports problem solving inthe clinical area.

A core team has led the improvement work andcomments from the team and other staff showedthe positive impact it had had on staff.

“I believe in the methodology, and we are making great strides forward, but still have a long a way to go.”Consultant

“I can’t believe the improvements in staff morale and the willingness of staff to change things. I have seena significant change in the expertise and skills of the staff. Since starting this I have had my ‘lean goggles’on all the time.” Matron

“It’s a really exciting time for stroke care, and leading a team is very motivating and seeing the changeshappen using BICS.” Ward Manager

“We feel part of the team and our opinions matter.” Health Care Assistant

“Using tools like the ‘waste walk’ allows us to focus where improvements will have the biggest impact onstaff and patients.” Physiotherapist

As much of the work was already underway usingBICS methodology, the core team felt the benefitsfrom being involved in the network were mainlythe opportunities it provided to network withother trusts and share experiences and learning.The team report having made good contacts and

they will continue to keep in touch and updateeach other on progress. The team was impressedwith the Experience Based Design approach and isplanning to use this more widely in the nearfuture.

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Cambridge University HospitalsNHS Foundation TrustThe trust had established project teams working onboth fractured neck of femur and acute stroke carepathways and they had already achievedconsiderable success when the Delivering throughImprovement project began. The improvementteams joined this project to build on their successesand to learn from the other trusts in the network,with an improvement lead also joining the networkacademy. Although not directly attributable to thisprogramme, the trust made significantimprovements against some of the measures andthere were improvements for patients and staff.

Fractured neck of femurAn elderly trauma unit was established inNovember 2006. This centralised unit bringstogether a multidisciplinary and more holisticapproach to caring for patients with fractured neck

of femur. The unit has a lead elderly care physicianwhose role is complemented by the senior clinicalnurse responsible for the nursing teams on the unit.

Data are not available for time in A&E and noimprovements were made in discharging patientsto their original place of residence (55.2% to 58.8%).

All patients fit for surgery were operated on within48 hours before the project began and the trust seta target of 24 hours. The chief executive made acommitment to the work and requested a report ifa patient did not receive surgery within 24 hours.The increase in the percentage of patients receivingsurgery with 24 hours from January to October2007 is shown below.

The trust made improvements against:

Mortality rates 9.4% to 9.1% Readmission rates 20.7% to 6.9% (April to October).

% Operated on within 1 day of being fit for surgery

100%90%80%70%60%50%40%30%20%10%0%

Jan

-07

Feb

-07

Mar

-07

Ap

r-07

May

-07

Jun

-07

Jul-

07

Au

g-0

7

Sep

-07

Oct

-07

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The trust’s monitoring shows that only two patientsdid not receive surgery within one day of being fitfrom August to October 2007. This was achieved byallocating the first slot on each trauma list to afractured neck of femur patient when possible, andby introducing scheduled weekend trauma operating lists.

Average LOS increased; however, this was attributedto a norovirus on the level where fractured neck offemur patients are admitted. Wards were closed andthis, together with staff shortages, also due tosickness, meant that patients could not be dischargeduntil they were well as they were not accepted bycommunity hospitals. The trust has reported thataverage LOS is now reducing.

To support their work in reducing LOS, theimprovement team set up a detailed variance trackingsystem, to monitor the progress of all patients on thefractured neck of femur pathway, capture information

on all variances, and the reasons for variance up today 10. They developed a template for collating datawith some ‘rules’: it had to be visual, easy to use, andmust be used to support the entire pathway. It alsohad to force the length of stay and the team agreed atarget of ten days.

The table below shows that whilst Dr Foster dataindicate an average LOS of 16 days, the trust’s ‘readyfor discharge’ information, collected through theirdata mapping exercise, shows that their target of 10days could have been met. They report that thepurpose of the comparison was to: provideinformation to explain the differences between thenationally reported figures and their own data forpatients discharged in July and August; highlight theactions taken to continue to drive down the length ofstay; and explain the factors beyond their control.

The trust’s data showed that during this period (Julyand August 2007) 25 patients were fit for dischargeprior to their actual discharge date. This represents275 bed days saved (equivalent to approximately 4.5beds) if these patients had been discharged whenacute provider care was no longer required.

The main factor affecting length of stay, beyondtheir control, is discharge to nursing or residentialhomes when patients no longer require acute care.Information was escalated to the chief executiveand director of operations, who took discussionsforward with the trust’s healthcare partners. The trust improvement team is workingcollaboratively with PCT leads with a focus ondischarge. Representatives from CambridgeUniversity Hospitals and the PCT discharge planningteam now attend the fortnightly project groupmeetings and this has helped develop a mutualunderstanding of the issues related to thedischarge of patients. The trust team is taking thefirst steps towards reducing motion, transportationand waste on the ward and they have introduced a‘visual management board’ which clearly showspatient flow.

Staff spoke positively about the improvement work:

“Mapping data to the pathway has geared themultidisciplinary team into believing that a 10 daylength of stay and less is achievable. The exercise isalso beneficial to patients on and off our unit as itensures I see the patients at day 5 and day 10. Ithas also helped the team focus on how the patientis getting home instead of when.”Geriatric-Orthopaedic Consultant

“Regular meetings as a multidisciplinary team havemeant we continually chip away to makeprogress.” Project team feedback

“Everything we do in our elderly trauma unit isdriven by the desire to make a difference for ourpatients. We also had commitment and input at asenior level which gives the project status andimpetus. This not only expedited decision makingbut ensured that these decisions werecommunicated to and taken on board by everyoneinvolved.” Pathway Lead

Reported Dr Foster data Trust ‘ready for discharge’ data

Mean LOS 16 10.6 (against target of 10 days)

Mode 14 7.5

% staying 10 or less days 33% 68%

Source: #NoF Business Manager & Data Mapping from ETU

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Average LOS increased because of the same reasonsoutlined above. Readmission rates remained low overthe duration of the project at approximately 8%. The percentage of patients receiving a CT scan within24 hours (rather than the 48 hour target for thenetwork) remained high at 95%.

The trust reported two other major achievements:patients are thrombolised in A&E whereverappropriate, and 70% of patients are now seen bythe stroke team within 30 minutes.

In terms of other improvements, the acute stroketeam has been coached in setting up ‘high impactdaily facilitated meetings’ so that they can highlightissues and problem solve. They have piloted anintegrated care pathway document and to improvethe patient experience, refurbishment and expansionof the stroke unit is on-going.

Cambridge University Hospitals said there have been significant improvements in patient and staff experience.

The stroke team incorporated the ExperienceBased Design to ‘give patients a genuine voice intheir pathway improvement work’. Their successes include:

• Much greater awareness among staff of whatthe pathway feels like for patients and carers.

• Bays painted in different colours to helppatients find their way back to their bed, givingthem greater independence.

• Training a cross section of 20 staff to usepatient experience in service redesign.

“This piece of work has been very valid to what weneed on the ward. It has been very worthwhile andmade staff think more about the patients and theirexperience.” Assistant Based Practitioner.

Mortality rate 22% to 19%Discharge to home 23.8% to 39%

Acute Stroke

Improvements to Stroke pathway

• Currently in the top 10% of the country’s LOS.

• Using ‘high impact daily facilitated meetings’ so the team can highlight issues and problem solve.

• Setting clear measurements for the pathway, eg 100% of patients who present in the emergencydepartment must be seen within 30 minutes by the stroke team. This target achieved in 70% ofcases and work is ongoing.

• Piloting an integrated care pathway document.

• Refurbishment and expansion of unit is ongoing.

• Bid to become the regional acute stroke unit (hub and spoke).

• A visual management board has supported expediting of patient flow.

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The pathway improvement team worked together toreview the current state and potential future state.They reviewed multidisciplinary team (MDT) workingand arrangements were made for skills transfer,teaching and competency assessments for MDT staff.

As a result of the work, Milton Keynes has seenimprovements in the following areas:

• Fast track developed for A&E.

• Nurse prescribing for certain medications (withinagreed criteria) written and approved by pharmacyfor use in A&E.

• Falls assessment taught to ward staff. Ongoingacute trust falls work on risk assessing thosepatients at risk and developing strategies toprevent falls, which includes a wristband tool toassess and highlight those most at risk from falling.

• Introduction of a patient information booklet.

• Reduction in reworking, duplication, and delay.

• More effective and structured communication.

• Executive board proposal for the introduction of anorthogeriatric position.

The trust has reported other improvements, includingthe introduction of a ‘Productive Board’ as a way ofreducing LOS. This gives an immediate visual updateon the patient’s journey, their stage on the pathwayand discharge plans. All staff on the ward (both acuteand PCT), can see at a glance what has been doneand what needs to be done to achieve the setdischarge date. The trust discharge team can see at aglance any potential delays and reasons why patientsare still in hospital. This has minimised staffinterruptions from their clinical duties and ensuredmore effective working and communication. Each discipline now has responsibility and ownershipfor their areas and updating the board. Needless

writing in medical notes, patients’ records andhandover sheets has been reduced anddocumentation is more streamlined.

The trust says that:

“Discharge plans are now much ‘slicker’, with staffnot thinking someone else is doing a job and waitinga week only to discover it has not been done!Discharge planning starts on admission, with a clearaim and plan from the start.”

Staff feedback has been extremely favourable andthey may roll out a similar system across the trust ifsuccess continues to be proven.

There have been a number of improvements forpatients. Structured events have been organised onthe trauma ward to help with rehabilitation and toprovide a structure to the day. These include bingoand chair gym classes. The trauma ward has pressurerelieving mattresses so that all fractured neck of femurpatients can be admitted onto an appropriate surface.There was a successful bid to the trust League ofFriends for slippers to be purchased for the traumaward to ensure that all fractured neck of femurpatients have safe and appropriate footwear.

A key milestone for the trust was the opportunity topresent to the Management Executive Committee,particularly on the use of trauma sessions in theatresto improve patient access. The lead for this improvement work commented onthe successful outcome.

“Following on from an audit of our trauma theatrelists at the end of last year and linking in with thenational best practice guidelines in time to theatre (i.e.within 48hrs) we presented to the trust board andhave successfully commenced three afternoonfractured neck of femur only operating lists. This will

Milton Keynes Hospital NHS Foundation Trust

Average LOS 17.6 days to 11.6 daysPatients seen in A&E within 2 hours 28% to 40%Discharge to original place of residence 53% to 81%Operation within 48 hours 40% to 90%.

Data for readmission and mortality rates are not available.

Fractured neck of femurThe trust made improvements between April 2007 and February 2008 against:

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There have been further improvements sinceFebruary: 70% of patients were discharged to theiroriginal place of residence during March and April.

The trust involved staff across the entire healthcommunity in their work, including staff fromnursing homes, community hospitals, PCTs and theambulance service. This multidisciplinary approachhelped staff understand the roles of the differentorganisations and work together to avoidmisunderstandings, delays for the patient, and

duplication of work. One example of this is ahospital ward where staff believed that nursinghome staff wanted to assess patients beforereturning home, and nursing home staff thoughtthat this was an essential part of hospitaldischarge. South Tees, working in partnership withthe health community, has made significantimprovements to this care pathway, resulting inbenefits for patients and staff. The following table highlights some of the changesthe trust has introduced.

The trust made improvements against all six measures:

Average LOS 18 days to 12 daysMortality rate 10% to 5%Patients seen in A&E within 2 hours 50% to 60%Discharged to original place of residence 42% to 50%Operations within 48 hours 62% to 78%Readmission rates 13% to 5%.

South Tees Hospitals NHS TrustFractured Neck of Femur

help to ensure a timely theatre slot, within theagreed window and also allows the anaestheticsteam time in the morning to assess and ensure theseoften frail patients are optimally fit for theatre. Thelists will be overseen by the consultants but will berun by a staff grade, who has also acceptedresponsibility of auditing the past against revisedpathway and ensuring data is submitted to theNHFD, which we have registered with.

It is obviously early days with regards to this newway of working, but gaining approval from all of

the consultants, anaesthetists, theatre teams andtrust board was a huge achievement for us andfeedback so far appears to be favourable.”

Commenting on this approach to pathwayimprovement, the trust’s improvement lead said:

“Such a simple approach to care planning andpathway work has now been shown to havesustainable results.”

Milton Keynes did not participate in theimprovement work for acute stroke care.

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The improvement team has been working closelywith patients, interviewing and videoing them intheir own homes. Patients said that givingfeedback in their home was:

“Brilliant and totally non threatening.”

“I’ve never done anything like the emotionalmapping exercise before, I enjoyed it. I complainedwhen I was in and this was a chance to even things

up a bit and tell the team about all the goodexperiences as well.”

Patients watched the videos together and discussedtheir experiences to identify priorities forimprovement. A patient information pack has beendeveloped containing information from time ofadmission to discharge.

Improvements to fractured neck of femur care pathway

• Implementation of warfarin reversal policyreduced delays to theatre. The overall averagetime delay for anti-coagulated patientsbetween November 2006 and October 2007was 3.9 days. This is now 2 days.

• Development of a trust wide clopidogral policyis in progress.

• Patients have protected meal times and thereare improvements in the meal delivery system.

• Colour coded mobilisation symbols aredisplayed at patient’s bedside. Staff can seemobility status at a glance (see below). The percentage of fit patients mobilised within24 hours rose from 70% May to 100%September 2007.

• Real time communication and additionaltraining has benefited patients at minimal cost.

• Morphine is now the gold standard analgesiain all ambulances across the region for thisgroup of patients.

• Patients admitted from nursing homes return at48 hours post-operatively if stable. Informationaccompanies the patient.

• One discharge/transfer document (previouslyseven) has been developed.

• Private ambulances used when necessary toreduce the delay (up to three days in an acute bed) in transferring patients tocommunity hospitals.

• A one stop pharmacy service prevents delays in discharge, reducing length of stay and staff frustration.

• Geriatrician referral criteria have been agreedand patients are referred to their service earlierin the pathway.

• Nursing home and ambulance staff agreed thatto ensure immediate transfer to hospital andprompt pain relief, a 999 call is needed for anypatient who displays signs and symptoms of afractured neck of femur.

• Fractured neck of femur assessment tool hasbeen developed.

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The readmission rate was low at the start of theproject at one patient per month, and this hasremained at the same low level. The percentage ofpatients receiving a CT scan within 24 hours remainedhigh at 95%. The percentage of patients dischargedhome decreased slightly from 56% to 47%. The trustreported that the ‘discharge home data’ reflects thefact that the acute stroke unit is the first step of thepatient’s rehabilitation process and they are oftentransferred to ‘stroke specific’ community hospitalbeds before discharge to normal places of residence.The unit has an Integrated Care Plan that is used toensure that the patient is moved to the suitablerehabilitation setting and acute beds are usedappropriately to admit patients in the hyper acutephase of stroke management.

The increase in the time spent waiting in A&E, 2.3hours to 3 hours, was as a result of an overall increasein A&E activity during the winter period.

The trust has said that the pathway improvementwork has raised the profile of the stroke unit. It has resulted in a multidisciplinary team trained inusing improvement tools, which has enabled them touse data appropriately and identify issues that need tobe addressed. The trust has seen improvements in thefollowing areas:

• Oxygen and suction provision within the wardenvironment.

• CT scanning process.

• Patient swallowing assessment on admission.

The multidisciplinary team has shared theimprovement tools and techniques with staff in theirown disciplines. Reviewing the entire pathway, notjust what takes place on the stroke unit, has led tothe creation of a local network with closercommunication with peripheral services. This approach has resulted in:

• Robust database now in operation that crossesover with primary care data.

• Criteria developed with the ambulance service toensure that all patients who meet the 3 hourthrombolysis timeframe will be “fast tracked” intoJames Cook University Hospital (JCUH).

• Protected beds for stroke admission.

Prior to the improvement work, the team had weeklycase conferences to discuss patients and staff felt thatsometimes assessments and treatments were plannedaround the timings of the ward rounds rather thanclinical priorities. This potentially increased length ofstay: for example, a patient may have beendischarged by all individual therapies on a Mondaybut a case conference to agree discharge might notbe until Thursday. A daily ‘board round’ was started.The therapists now meet daily and categorise allpatients as red (patients who are not at dischargeplanning stage, eg poorly, new patient that day),yellow (could leave ward if specific actionscompleted), green (therapists happy for patient toleave ward to go home or to a rehab unit). The medics can review the board and haveknowledge of the situation on a daily basis.

The improvement lead for the stroke pathway workspoke about the positive impact of incorporating theExperience Based Design (EBD) approach into theirimprovement work:

“Using the Experience Based Design (EBD)methodology to engage patients in improving theservice has led to a truly collaborative approach in theredesign of the service. By engaging the patients andgathering their experiences we were able to identifywhat the key moments or events were for thosereceiving this service.”

These three examples illustrate how listening topatients and acting on their suggestions led to improvements:

• One patient commented “when I reached for thetoilet roll, which was on the same side as myweakness, I felt unsafe”. The trust planningdepartment has designed a new toilet roll holder

South Tees reported improvements against:

Average LOS 14.5 days to 10.5 daysMortality rates 13% to 9%.

Acute Stroke

21

Operations within 48 hours remained the same atapproximately 60%. The number of patientsdischarged to their original place of residence didnot increase, but remained high (89% October2007 – 82% February 2008).

As a result of the reduced length of stay, themajority of East Kent’s fractured neck of femurpatients are now admitted to a dedicatedorthogeriatric ward, where more specialist care canbe provided. This has further improved outcomesfor this group of patients. Not only has the trustreduced mortality rates by 7%, they also report lessvariability in the monthly results. Over the course ofa year, this is equivalent to 24 lives saved.

Additional theatre slots have been added forfractured neck of femur patients, which togetherwith a new common pre-operative criteria, areexpected to eliminate all delays for surgery.

East Kent has reported additional improvement forpatients and the staff delivering their care:

• The multidisciplinary team has been

strengthened through the addition of a ward-based orthogeriatrician.

• Introduction of defined post-operative careprotocol (or ‘bundle’).

• Increased focus on rehabilitation.

• Fast track protocol developed to reduce timespent in A&E.

• A patient experience ‘day by day’ illustratedguide has been produced.

• A rehabilitation care protocol (or “care bundle”)has been developed, which includes:

o therapy assessment within 24 hourso discharge plan within 48 hourso mobilising within 24 hourso dressing in own clotheso no commode by the bedside o patients taking meals in the

rehabilitation space.

The trust made improvements against:

Average LOS 24 days to 21 daysMortality rate 15% to 8%Time spent in A&E 3 hrs 45 to 3 hrs 30 Readmission rates 12% to 8%

East Kent Hospitals NHS TrustFractured Neck of Femur

system that can be attached to grab rails on bothsides of the toilet.

• Patients and relatives said that the wardenvironment was not conducive to opportunitiesfor social interaction. At no additional cost, theward has been reconfigured to provide rooms thatcan be used as a patient/relative sitting area.

• Patients commented on the lack of information, itstiming and to whom it was given: often it wasgiven only to the patient. Information is nowprovided when a relative is present and at differentpoints of the journey from General Practitionersurgery to the community rehabilitation ward.

A ‘patient passport’ has been designed to provideinformation about inpatient stay and contactdetails of the different health and social careprofessionals involved in their care.

The improvement lead said that by using theExperience Based Design approach and improvementmethodologies, staff felt that they had an opportunity,regardless of status, to contribute to improving theservice in a non threatening environment. This approach has given the team ownership of theproject and ensured that they are fully engaged.

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A member of the pathway improvement teamcommented on the impact of the work:

“We knew there were issues in delays in traumaand because of the project there has been a focuson a team approach across all directorates, not justorthopaedics. Orthopaedics is now takingownership of the pathway.” Orthopaedic ClinicalService Manager

The acting chief executive for East Kent supportedand gave encouragement to the work and hecommented on the positive impact of thisapproach to improving care pathways, includingthe benefits of working with other trusts in theDelivering through Improvement Network.

“Working with the network to achieve excellencein the services we offer fractured neck of femurpatients, has been an exciting and rewardingexperience. The approach taken to deliveringimprovement has had many key features,including: strong data analysis and clearpresentation of statistics, taking a pathwayapproach to service analysis, and ensuring broadengagement of stakeholders in analysis andproblem solving.

Clear data analysis provides the means to engageclinical staff in improving services and allowsmonitoring of progress throughout the project andinto the future. Taking a pathway approach allowsstaff to clearly see how they can engage in theproject and make a real difference.

During my period as chief executive I have alwaysfelt that if we could make a success of a pathwayas complex as fractured neck of femur then weshould have the ability to make a success of themajority of pathways.

The incorporation of the patient perspective isanother key feature and one we have undervaluedtoo often within the NHS.

I am confident that the changes made through thefractured neck of femur project will be sustained.”Acting Chief Executive

Acute StrokeThe trust experienced problems in collecting dataagainst the improvement measures. The averageLOS decreased by almost five days; from 17.48days to 12.53 days, which has enabled them toreduce the number of beds.

The Delivering through Improvement programmeprovided an opportunity for East Kent to build ontheir existing improvement work across the strokecare pathway. They introduced a trust widethrombolysis service in May 2007, using protocolsthat had been agreed with the PCT and KentAmbulance Service. By the end of February 2008,eleven patients had been successfullythrombolysed. A protocol was agreed jointly byradiology and medical physicians, which ensurespatients presenting with stroke symptoms are fasttracked from A&E and ECC to CT scan. The trustreported that clinical engagement of the multidisciplinary team has been excellent, particularlyamongst the medical staff. The personal supportfrom the chief executive was “definitely a factor inmaintaining the project’s profile and sustainability”.In addition, joint working with the PCT wasdescribed as “excellent and a significant factor inagreeing a seamless patient pathway between theacute and community setting”.

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Average LOS for HRG 87 specifically, fell from 17.5days in 2006 to 10 days by February 2008.

The mortality rate, which was 10.3% in April 2007rose to 15.2% in October and decreased to 11.1%by February 2008. The percentage of patientsdischarged to their original place of residencedecreased slightly from 82.7% to 80%.

Luton and Dunstable’s improvement lead said:

“Champions and role models were identified inorthopaedic and other directorates to work as part ofthe team. Having good clinical team engagementand dedicated project management from the traumanurse specialist helped the project move forward.Team members have gained improvement skills andcontinue to work on the pathway.”

Patients and their carers were interviewed in theirhome to help identify the improvements that wererequired and ideas for how they should beimplemented. With input from all staff, the teamdeveloped and implemented a training packagerelating to A&E care and ward care during the first48 hours: this included nutritional assessment.Chief executive support was strong and the teamreported breaches of any patients who were notoperated on within 24 hours, the reasons why andsuggestions for improvement.

Luton and Dunstable has seen improvements in thefollowing areas:

• A clear pathway for each type of fractured neckof femur patient that all staff follow.

• Priority on trauma lists for this group ofpatients. Improvements in the use of existingtheatre capacity.

• Fascia Iliaca compartment blocks, developed aspart of a nurse led service, continue to be usedfor pain relief.

• A reduction in re-working with 70% of patientsgoing to theatre within 24 hours.

• A model of care agreed between A&E,orthopaedics and Department of Medicine forthe Elderly, resulting in a change of wardplacement arrangements and re-organisation ofphysiotherapy services: care of the elderlyphysiotherapists can support colleagues on theorthopaedic ward.

• Falls assessment and use of the falls care bundletaught to ward staff.

• A falls nurse specialist identifies patients whowould benefit from preventative bone treatmentsand follow on care from the orthogeriatrician.

• Implementation of a standardised way ofundertaking pre-operative anaesthetic assessment.

• Implementation of an agreed, standardisedpolicy for the management of patients with aderanged INR pre-operatively, eg. patients onanti-coagulant medications.

• Intermediate care capacity identified withpriority given to patients requiring this settingfor rehabilitation. This includes a jointassessment with the physiotherapist and socialworker at day five with transfer, if suitable, atday seven.

Staff have developed a streamlined way ofcollecting data and report on the improvementmeasures in directorate and audit meetings.Responsibility for these patients is now shared byall orthopaedic consultants. The team is finalisingnew patient/carer information and presenting acase for more staff to support existingorthogeriatric consultant sessions.

The trust made improvements against four of the six measures:

Average LOS 25 days to 23.9 daysTime spent in A&E 3.5 hours to 2.5 hoursReadmission rates 13.8% to 11.1%Operations within 48 hours 62% to 90% Operations within 24 hours 30% to 70%

Luton and Dunstable Hospital NHS Foundation TrustFractured Neck of Femur

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Acute strokeStaff across the local health economy, patients andcarers were already working together to improvethe stroke care pathway when the Deliveringthrough Improvement project was launched, andthey had made some improvements.Multidisciplinary team working across secondaryand primary care was reported as particularly goodby the Delivering Quality and Value team, which isanother of the NHS Institute’s programmes.

Data for readmission to any consultant within 28 daysof a previous discharge show: zero readmissions forApril 2007, 4 out of 40 patients for October 2007,and 4 out 27 patients for February 2008.

Staff worked with patients and carers through jointworkshops to understand their experience and todecide together the next steps to improve thepathway. Admission to the stroke unit was the mainissue to emerge. Families and staff realised thatpatients admitted directly to the stroke unit receivedbetter care and had a better experience, a shorterlength of stay, and fewer ward moves. The teamagreed this was a priority. A member of the team said:

“It is evident what makes a good pathway and agood experience and this includes fast track throughA&E, early CT scan and arriving on the stroke unit asthe first and only ward placement.”

The trust now operates a ‘one in one out’ policy forthe stroke unit, using criteria to identify whichpatients can be moved off the unit if a new strokepatient needs to be admitted. Many more patientsnow reach the unit as their first placement despitehigh bed occupancy levels across the hospital.

The team devised a stroke pathway document withpatients. It includes a specific management plan forthe first eight days of care, which they believe mayhave contributed to the reduction in length of stay.The team has also developed approved local strokeguidelines and these have been adopted by partnerorganisations.

Stickers itemising the elements normally included inthe sentinal audit, eg. swallowing screen in less than24 hours, have been introduced for each patient atmultidisciplinary weekly meetings. The team hasproduced an ongoing defect chart treating everyomission of an item for a patient as a defect. This provides further information about pathwayperformance and areas for improvement. All resultsare displayed on ‘mission control’ type boards in thestroke unit.

The first six patients received thrombolysis betweenAugust 2007 and February 2008 and the team isplanning to extend the service beyond daytimeweekday hours.

Improvements were made against five measures:

Average LOS 23.9 days to 14.7 daysMortality rates 28% to 14% (April and November 2007)Time spent in A&E 3.5 hours to 3 hoursDischarged home 59% to 60.9%CT scan within 24 hour 50% to 70% (April to October 2007)

25

The trust believes that average LOS could have beenreduced further if patients did not have long waits forrehabilitation beds outside of the acute hospital. Bedpressures in the trust prevented them from reducingthe waiting time in A&E further. During March 2008the wards were reorganised to ease the burden onbed pressures and the trust expects further reductionsin A&E waiting times.

There have been other successes and benefits for patients:

• Patients are allocated priority on the traumaboard. This was approved by all multidisciplinaryteam members and the Trauma Meeting Group members.

• Awareness of these patients’ needs has been raisedand access to theatres has improved: patients nowreceive surgery much sooner.

• The reduced length of wait for surgery (themajority within 48 hours) has allowed the rehabprocess to begin earlier in the patient pathway,providing better outcomes.

• Administrative tasks, previously completed bynurses, are carried out by appropriate staff in themultidisciplinary team, allowing ward nurses tospend more time with patients.

• The rehabilitation service has increased from fivedays to seven days, giving patients access to thisservice at weekends.

The team has said that the successes and benefits forstaff have been greater than initially anticipated at thebeginning of the project. The following comments arefrom staff involved in the improvement work.

The trust showed improvements against all six measures:

Average LOS 17.5 days to 14.5 daysMortality rate 10% to 6%Time spent in A&E 3 hours 48 minutes to 3 hours 20 minutes Readmission rate 0.7% to 0.6%Discharge to original place of residence 48% to 70%Operations within 48 hours 94% to 96.1%.

Medway NHS Foundation TrustFractured Neck of Femur

The impact of the pathway work on staff

“A key success for the project was engaging thetrauma and orthopaedic consultants during the earlystages of the project. It was very encouraging to seea group of consultants keen to play a part in theimprovement of the patient pathway. The fracturedneck of femur project core group is very proactiveand took every opportunity to inform staff groupsabout the project and provide them with keysuccesses and progression updates.” Project Manager / Service Manager

“I have welcomed the opportunity to walk throughand process map a pathway and makerecommendations and implement changes to thepathway to benefit the patients, families and staffmembers.” Physiotherapy Manager

“The introduction of the fast tracking system to x-rayhas reduced the length of time that the fracturedneck of femur patients spend within A&E making itmuch better for staff.” Senior Staff Nurse, A&E

“The fractured neck of femur core group includesrepresentatives from appropriate departmentswithin the trust as well as individuals from externalagencies, ie, South East Coastal AmbulanceService, Social Services etc. The core groupenabled team working across the health economy.

Improved communication links have been achievedthrough the newly devised electronic traumaboard. The live trauma board information enablestreatment plans to commence immediately andappropriate discussions regarding the patients’care are undertaken sooner.

Introduction of the warfrin policy has improved theawareness of the medical staff and obtaining ananaesthetic lead for fractured neck of femurpatients has enabled a uniform approach to pre-operative processes and procedures undertakenwithin the theatre environment.” OrthopaedicNurse Practitioner

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Time spent in A&E increased and there was a slightdecrease in the percentage of patients dischargedto home from 53% to 51%.

A thrombolysis service has been introduced alongwith other changes to the care of stroke patients:

• The nurse led TIA/minor stroke clinic providesdaily access Monday to Friday for urgentspecialist assessment and investigation.

• Local referral protocols have been agreedbetween primary and secondary care. Allpatients with minor stroke and all high-riskpatients with TIA (for example ABCD2 score >5)should be assessed and treated within 24 hours.

• Service level agreement enables carotid imaging(Doppler ultrasound, MRA or CT) to beperformed at initial assessment or not be delayedfor more than 24 hours after first clinicalassessment in TIA patients.

• A referral process with the vascular surgeonsenables carotid endarterectomy for recentlysymptomatic severe carotid stenosis to be regardedas an emergency procedure in patients who areneurologically stable. It is recognised that theseshould ideally be performed within 48 hours.

• All patients with TIA or minor stroke arefollowed up six weeks after the event.

Average LOS 9 days to 8.9 daysMortality rate 23% to 6%Readmission rate 2 patients to 0Scan with 24 hours 10% to 47%.

Acute Stroke

The stroke team has also made substantial improvements to staff and patient experience:

Improvements to patient experience Improvements to staff experience

• Some staff have been on stroke courses, tounderstand how to care for stroke patients.

• The more spacious environment has increasedstaff morale dramatically. Sickness levels have reduced.

• Staff have had training sessions onthrombolysis and in-house training about theimportance of accurate observations, eg MAP(Mean Arterial Pressure),MEWS (Medway EarlyWarning System).

• Ongoing training is given in respect of movingand handling, infection control, intermediatelife saving, basic life saving, health and safety etc.

• Ex-patients are encouraged to see staff, whenthey come to outpatients. Staff are delightedto hear about their progress.

• Students are keen to have their placements onASU, which raises morale.

• Staff know of the plan to improve the patient’spathway and are encouraged by its high profile.

• There is greater interaction with the MDT andstaff feel they are working for the same goals.

• Move to a larger ward with more space betweenthe beds to help maintain privacy.

• New bedside chairs have improved theenvironment.

• Protected meal times between certain hours: onlypeople actively involved in helping to feed patientsallowed on the wards.

• Nutrition specialist nurse advises staff on how toimprove nutrition.

• CDToxin and MRSA Bacteraemia levels havesignificantly reduced.

• Cannulation packs are provided to reduce infectioncaused by poor insertion techniques.

• Blood taking equipment has been changed toprevent decontamination and reduce the need forbloods to be repeated.

• Special pressure relieving mattresses have reduced pressure ulcers and it is rare that an ulceris acquired.

• A special pad which ‘talks’ to the patient whenthey stand up, has reduced the number of falls.

• Patient representatives are kept informed aboutthe stroke pathway initiatives and attendoperational meetings.

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The trust reported that mortality and readmissionrates are not measured. The percentage of patientsdischarged to home fell from 60% to 50%between April and October 2007.

Patients now have direct access to the stroke unitfrom A&E between 9am and 4.30pm Monday toFriday and the number of stroke unit beds hasincreased from twelve to fifteen. The trust has thefacility to CT scan stroke patients on arrival to A&Ebetween 9am and 5pm and they are looking toextend this to 24 hours a day, seven days a week.

A locum neuro OT was appointed which led tosignificant improvements in patient care andassessment. All patients are seen by a specialist OTand they are returning home sooner withappropriate equipment, which has reduced clinicalrisk and readmissions. The trust reports asignificant reduction in the length of stay forpatients who are seen by the OT on day one andthey said that ‘the Integrated Care Pathway fails ifan OT is not included in the team’.

Barnsley’s evaluation of their work on the strokepathway found the following improvements forpatients, relatives and staff:

• Reduced anxiety for relatives and patientsleading to better patient experience.

• Patients nursed in specialist area with specialist,dedicated staff.

• Commencement of the integrated care pathway.

• Better access to multidisciplinary experiencedstaff and prompter ward based referrals.

• Fewer ward transfers leading to continuity of care.

• Raised profile of stroke services.

• Improved team work and communication withother departments in the hospital.

• Direct access to the acute stroke unit with aspecialised skilled multidisciplinary workforce.

• Networking with other hospitals.

• Timely discharge planning.

• A relatives/carers clinic.

Barnsley participated in the stroke pathway work only, reporting improvements against the followingmeasures:

Average LOS 12 days to 11 days(data for two different areas/wards) 16 days to 7 daysTime spent in A&E 2 hrs 20 to 1 hr 54 (April to October 2007)Average time waiting for CT scan 5 days to 1 day.

Barnsley Hospital NHS Foundation Trust

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Time spent in A&E remained the same at 3 hours 38minutes although the trust examined the raw datawhich show that the majority of patients left A&Ewithin 2 to 21/2 hrs. Three patients are recorded ashaving had excessively long stays in A&E, which maybe due to incorrect recording on the A&E system: allthese patients were admitted during the late eveningor early hours of the morning.

Readmission rates rose slightly from 6.8% (April2007) to 9.7% (October 2007); data are not availablefor February 2008. These figures were taken from DrFoster data which records any admission within 28days in any other hospital and may not necessarily berelated to the original diagnosis.

The data show that there has been a significantreduction in the percentage of patients havingsurgery within 48 hours: from 94% (baseline data)in April 2007 to 55% in February 2008. However, the trust reports that the data are basedon all patients and not patients assessed as ‘fit forsurgery’. New arrangements for the managementof trauma came into force at the end of December2007 and therefore the data do not yet show theimpact of the change.

St George’s introduced a number of other changesto the fractured neck of femur pathway and theyhave reported on the following achievements:

• New trauma arrangements came into place inDecember 2007, which will reduce the delays ingetting this group of patients to theatre.

• Implementation of a new protocol based on‘best practice’ for anaesthetic assessment,written by two ‘champion’ consultantanaesthetists to eliminate variable practice.

• The trust joined the Fractured Neck of FemurNational Network led by the best practice unit atPeterborough Hospital.

• The consultant therapist and the ward chargenurse developed ward goals for patients withfractured neck of femur. These include nutrition,hydration and mobilisation and more robustdischarge planning.

• A new fractured neck of femur trust policy isbeing published.

A member of the improvement team commented:

“It has been inspirational to see the early resultsparticularly the reduction in mortality and LOS.”

Trust data for time spent in A&E show the averagetime for all stroke patients and includes patientssuitable for thrombolysis, which is received in the A&Edepartment before being admitted to the AcuteStroke Unit, usually within one hour or less for theprocedure. This represented approximately 3% ofstroke patients, but has now increased as the trusthas introduced 24 hour thrombolysis and covers ‘outof hours’ provision for South West London. They report cases of patients returning home fullyrecovered after only a few days. The number ofpatients receiving thrombolysis has increased fromone to two per month, to one to two per week and isexpected to rise further.

Although St George’s were unable to start the improvement work until July/August 2007, they madesignificant improvements against the following measures:

Average LOS 27 days to 19 daysMortality 15% to 7.5%Discharge to original place of residence 65.9% to 71%.

St George’s Fractured Neck of Femur

LOS 29 days to 20 days Time in A&E 3.48 hours to 3.14 hours

Acute Stroke

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The mortality rate remained the same at 12%, whichis well below the national average. Readmission ratesrose from 4% to 8% between April and October2007, however the trust commented that the datarefer to the number of patients admitted to anyhospital after 28 days and could be unrelated to theoriginal diagnosis.

Discharges to home decreased slightly from 45% to44% although more recent data for February are notavailable and there may have been someimprovements. As the trust pointed out, ‘dischargehome data’ is based on ‘spell’ and not ‘super spell’and does not account for admission into therehabilitation unit. This is classed as another ‘spell’and a separate admission. They suggest that the dataare distorted as many of their stroke patients gostraight to rehabilitation rather than home following astay in the acute stroke unit.

The trust does not collect data for access to CT scanwithin 24 hours; however, all patients (100%)routinely receive a CT scan from A&E, within twohours if possible, but always within 24 hours.

A ‘rapid improvement day’ was held to examine thestroke pathway. It included process mapping toidentify ‘hot spots’ and agree an action plan.

The lead consultant having been ‘a bit wary’ aboutsuch events said:

“I have been here for four years and have been askingfor a meeting with the community, this is the firsttime it has happened.”

As a result of the event, the trust’s communitycolleagues are now full members of the pathwaygroup and have been proactive in seeking to makechanges. Other staff spoke positively about the eventand the changes that were made as a result of it.

St George’s has reported a number of improvementsin the overall patient experience, beyond themeasures outlined above. There have also beenimprovements in staff experience, not only within theacute trust, but across the entire stroke pathway (seetable below).

A matron who was involved in the work said:

‘The pathway work has been great for bringingpeople together, both acute and communitycolleagues; communication has really improved andthere is now a consistent approach to referrals and discharges.”

The pathway improvement group has made significant progress and continues to meet on a regular basis, with allmembers committed to making the project successful. They are exploring the use of a quality of life questionnaireto look at qualitative outcomes.

Improvements for patients Improvements to staff experience

• A cohesive project group that is committed tomaking changes for the benefit of patients.

• Good relationships have been establishedbetween the acute stroke and communityteams in two PCTs.

• The processes for referral to community teamsand discharge information have improvedsignificantly.

• A new ‘virtual’ clinic, based in the communityto discuss very complex cases with all theprofessionals involved, has been established.

• Improved IT technology has been introduced tospeed up discharge summaries and links tocommunity IT systems.

• Agreement within the information andtechnology department to work withcommunity colleagues to open up electronicpathways, to allow for the confidential transferof information and electronic referrals.

• Much improved transfer of care to thecommunity teams and a more standardapproach to community referrals.

• Improved information for patients and carersabout the rehabilitation process.

• The involvement of the existing stroke patientgroup developed by a consultant involved in thestroke pathway improvement work.

• Additional stroke rehabilitation beds (due to theexpansion of the thrombolysis service).

• A reduction in waiting time in two PCTs forcommunity assessment; now all patients aretelephone screened within 24 hours and seenwithin one week. This is an improvement of theprevious six weeks wait in one of the PCTs.

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Appendix 1

Background to Deliveringthrough Improvement

What was our vision?The NHS Institute’s vision for ‘Delivering throughImprovement’ was to work in partnership with NHSleaders to identify and test new approaches,models and frameworks for transformationalchange. We believed that transformational changeacross an entire NHS organisation was possible.

We visited NHS chief executives across the countryto learn about their experiences of leadingtransformational change. We heard about thefantastic improvement work taking place, but theseleaders also told us about the difficultiesencountered in spreading these improvementsacross their entire organisation. They told us abouttheir desire to create ‘a movement forimprovement’ and they asked for support indeveloping a programme for transformation.

We began working with the first group of chiefexecutives in October 2006. The programme, entitled‘Delivering through Improvement’, was aimed at chiefexecutives of NHS provider organisations who wereambitious in their aims for their organisation, patientsand staff. It was not about partial or incrementalchange. It was about building and strengtheningtransformational leadership skills and developing avision, strategy and implementation plan that leads toexceptional results.

What was the programme about?We adopted a truly co-productive approachthroughout the programme. We had ideas aboutthe topics we might cover, but we wanted toensure that the programme was driven by theneeds of the chief executives. It evolved throughworking in close partnership with the chiefexecutives, leading management consultants,individuals with expertise in leadershipdevelopment and transformational change andacademic experts.

The NHS Institute supported the network through aseries of workshops and 1:1 coaching around thetopics of personal leadership development andtransformational change. The chief executives havevisited world class organisations and heard fromleading experts from other healthcare systems andother industries. We have also provided expertisedirectly at their trusts to engage their executiveteams and leaders of service improvement. The topics we have covered over the last eighteenmonths include:

• linking transformational aspirations with radicalredesign of front line services to deliverexceptional results

• support in setting out and communicating vision,strategy and plans in a way that engages staffthrough writing and sharing a uniquely engagingtype of ‘transformation story.

• support to engage staff to develop a plan ofaction that sits behind the change story andmakes it real

• coaching and workshops from leading experts to develop and expand transformational leadership skills.

• opportunities to share with and draw on theexperiences of other chief executives.

• 1:1 coaching to enable the chief executives tofocus on their transformational objectives andopportunities to develop their own coachingskills to motivate staff to perform at their best

• opportunities to learn from other healthcaresystems and organisations outside of healthcare.

During the course of the first programme, we wereable to identify the characteristics of the leadersand organisations that have gained the most from‘Delivering through Improvement’. These include:

• a leader who is prepared to invest his/her timeand effort into making change happen and iswilling to support staff, allowing them time todedicate to individual improvement projects

• a chief executive who is a strong leader andcommitted to transformation and enhancingtheir transformational leadership skills

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• a chief executive who is receptive to new ideasand approaches to transformation and is willingto change him/herself

• an executive team that is supportive of andcommitted to improvement

• evidence of improvement projects and someimprovement capability throughout theorganisation

• a trust where an improvement methodology orapproach is not advanced to the extent that newideas are dismissed, but an organisation wantingto adopt a more rigorous approach totransformation.

The chief executives collectively agreed to work ona project to improve the delivery of patient careand the experience of staff delivering their care.The project they chose was to develop animprovement methodology for fractured neck offemur and acute stroke care pathways.

The first ‘Delivering through Improvement’ is stillgoing strong and we have demonstrated that theimpact of working together as network and sharingresources is far greater than it is for organisationsworking in isolation. The first group of chiefexecutives that took part have delivered outstandinglocal results and they have told us that the experiencehas fundamentally changed their perspective onchange and enhanced their confidence to deliver it.But it has also led to significant improvements in thedelivery of patient care.

Reflections from participatingChief ExecutivesHere are just some of the comments the ChiefExecutives made about their experience ofparticipating in the programme:

“The programme has been different from any otherthat I have attended. It has been one of the mosteffective programmes in which I have had thepleasure to be involved. ‘Delivering throughImprovement’ has allowed Chief Executives to co-create a programme which supports them asindividuals and also allows their organisations totake the first steps along the road to a new andbetter kind of healthcare.”

David Fillingham, Chief Executive, BoltonHospitals NHS Trust

“I can see better how to engage and encouragepeople to get on board. I am explaining ourobjectives with a new clarity that works out realpriorities. People understand our priorities and wehave a better chance of achieving them.”Jane Collins, Chief Executive, Great OrmondStreet NHS Trust

“The whole programme has been invaluable. It hashelped me gain clarity on my personal style andvision and set the framework for how to approachthings. Being part of the programme has helpedme separate the big issues. Without [the network]we would have written a strategy that would havesat on a shelf, instead we are doing the stuff thatreally matters.” Helen Walley, Chief Executive, Mayday NHS Trust

“The Delivering though Improvement programmehas had a tangible impact and raised myaspirations. The whole thing has been tremendous,it has really helped us make improvements, mademe see that the L&D should be pushing more.Participating in the programme has seriouslychanged the way I do things. It’s all part of being amore strategic leader. A real metamorphosis. It’sall been valuable but most distinctive has been thestory. The story is allowing me to redefine the roleof the chief executive.”Stephen Ramsden, Chief Executive, Luton andDunstable NHS Foundation Trust

“I have participated in many study tours, visitingeighteen countries and this has been the best andmost successful and informative study that I havebeen on. What we saw in practice is the reality ofthe more advanced systems for achieving qualitypatient outcomes and quality care. I intend takingsome of my staff back to learn from theseexemplary healthcare organisations.”

Dr Gareth Goodier, Chief Executive, CambridgeUniversity Hospitals NHS Foundation Trust

Please view the attached DVD Change In The Air

To find out more about the NHS Institute, email:enquiries@institute.nhs.uk

You can also visit our website at www.institute.nhs.uk

If you require further copies quote NHSIimprvpathwayContact: Prolog Phase 3Bureau ServicesSherwood Business ParkAnnesleyNottingham NG15 0YUTel: 0870 066 2071Email: institute@prolog.uk.com

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ISBN: 978-1-906535-69-8

© NHS Institute for Innovation and Improvement 2008.All rights reserved.

To find out more about the Care Pathways Improvementwork, please contact Annette Neath on 024 7647 5816 oremail annette.neath@institute.nhs.uk