Operational Productivity Sub Programme CIP
GuidancePathology………………………………………………………………………………………………………………..12
Imaging……………………………………………………………………………………………………….............15
Ambulance
Services………………………………………………………………………………………..........21
Estates &
Facilities………………………………………………………………………………………………....25
Introduction
This document has been prepared by the specialist teams in NHS
Improvement’s Operational Productivity Directorate to help identify
recurrent CIP opportunities for you to develop and deliver
effective, robust and comprehensive 2019/20 CIP plans. In each of
the 11 programmes included, you will find:
• Recent trends including pointers to where the most significant
efficiencies have been secured by trusts over the past 18 months.
You can use the case studies throughout the guidance which
demonstrate the approach to identification and delivery;
• Key success factors and barriers, with examples of how to harness
and overcome these respectively; and
• Links to existing guidance materials and tools in each
programme.
Please don’t hesitate to contact your Regional Productivity Teams
if you wish to discuss any information included in this guide.
Contact details are as follows:
North Region:
[email protected] Midlands and East
Region:
[email protected] London Region:
[email protected] South Region:
[email protected]
4 |4 |
Recent Trends
• The current year (grey line in chart) is already more costly than
the previous years (red
and blue) and the trend is that it will continue in this manner.
Year to date (YTD) position
is driven by an overspend of trainee grades pay of £99m and
consultants pay of £62m
through WLI’s (Waiting List Initiatives) and utilisation of
temporary staffing.
• YTD medical overspend is understated due to the phasing of the
medical pay award in
18/19.
• Medical workforce CIPs have been poorly recorded over the last
few years and Trusts
are beginning to recognise and own this. This is in part to trusts
not having a handle over
their demand and capacity and therefore unable to identify the
required establishment
needed to meet demand. Job planning is the direction that trusts
need to be moving and
are moving to in order to get to grips with this.
Medical Workforce
Establishment setting tools
• An establishment setting tool should be utilised by trusts, to
enable them to identify “what good looks like”.
• Tier systems that have been demonstrated in trusts should be
available in conjunction with the optimisation of e-rostering
functionality for different professional groups to be co-rostered
together.
• Trusts need to consider a workforce model which would describe
the capabilities of both doctors and newer roles such as PAs, ACP,
ENP, ANP etc.
• Trusts should be utilising a suite of metrics that enables
unwarranted variation in productivity and efficiency to be
identified
Optimisation of e-job planning and e-rostering
• Trusts should use e-rostering to deliver team e-job plans. Be
able to measure that against the Meaningful Use Standards and
Levels of Attainment framework.
• Team job planning should reflect the workforce
requirements.
• There needs to be a clear link between productivity metrics,
workforce planning and quality outcomes identified in facilitating
good quality care.
• Trusts should use the establishment tools to convert clinical
demand to workforce requirements.
5 |5 |
Medical Workforce
Data cleansing of ESR data
• Working with trusts and the Model Hospital team to firstly
understand how the data is entered onto ESR and to be able to
reduce
the amount of options available on ESR, this therefore steers the
trust to be more disciplined in the choices that they make.
This
work has already commenced and the charts below highlights how
important good quality data is. The data is submitted to NHSI
via the medical workforce template and this is then compared
against the data included on ESR.
• Trusts focusing on improving the quality of data on ESR not only
reduces the burden on trusts from the task of endlessly
completing spreadsheets, which is an exhausting task, but by using
ESR data will provide them with a true reflection of how the
trust is performing.
• A self-assessment framework (SAF) toolkit has been successful in
identifying /
confirming the areas of intervention that trusts need to focus
on.
• For a copy of the SAF please email
[email protected]
• Establishment Setting
Job Planning
• All consultant and permanent non-consultant grade (NCG) doctors
have a current signed-off job plan aligned with the Trust’s
strategic objectives and designed to ensure the delivery of a high
quality, 7-day clinical service which is consistent across all
trust sites:
• Planned activity is captured broken down to Direct Clinical Care
(DCC) & Supporting Professional Activity (SPA).
• Establish percentage of consultants with an active, signed-off
job plan.
- Maintain, or increase, to the 90% benchmark that NHS Improvement
has set.
- Annual job planning review in place. - Job Planning Consistency
Committee meet on a monthly
basis.
In year Consideration Medium / Longer Term
• Annualised team job planning review in place. • Job plan is
aligned to GIRFT (Getting It Right First Time).
E-rostering
• All medical rotas (Non-consultant grade and Consultants) are
managed using an e-rostering system to ensure visibility of
workforce deployment and rota gaps.
• Ensure effective rostering is in place and demonstrate that its
use can ensure the right team/personnel with the correct skill are
available to patients when and where they are needed i.e. a rota is
provided timely and job plan is in place for NCG doctors.
Productivity
• Review medical staffing efficiencies using Model Hospital metrics
such as WAU/DCC, DCC/FTE and Cost/WAU.
• Investigate negative variation to determine if it is warranted
which may present an potential opportunity for efficiency
gains.
Extra Duty Payments
• Review level of payment offered for extra-contractual sessions,
and align with other trusts in your STP.
• Ensure no EDP payments are made unless additional hours are
worked i.e. no EDP payments for undertaking clinical activity
during timetabled SPA sessions.
• Establish appropriate governance for approval of EDP payments
(likely to be >£100 p.h.).
• A robust plan in place to reduce Extra Duty Payments across the
Trust for both consultants and NCG.
Appraisal System
• Robust appraisal system is in place to ensure all the workforce
have achieved the goals for the year, and allow goal setting for
the next year, including expected levels of clinical activity (e.g.
OPAs, Theatre cases etc) for each DCC session.
Leave Management
System
• Job planning, e-rostering and Leave management systems should be
integrated to allow maximum transparency of where gaps are
appearing due to leave and sickness.
• Enforce 6 week minimum notice for annual leave to avoid
unnecessary cancellation of clinical activity.
• Ensure leave reporting is feeding into hospital capacity plans
regularly.
• Trust to utilises 4 week rotas, published at least 6 weeks in
advance, to ensure timely sign off to reduce the use of agency and
better accommodate staff requests for flexibility.
Establishment Setting
• Medical CIPs plan are identified and signed off by medical
director. Monthly validation of CIP delivery against plan and
ensure Medical CIPs are categorised correctly.
• Medical rotas are reviewed regularly and identify areas for focus
by the highest use of temporary staff.
• Job Planning Committee in place to facilitate delivery of metrics
e.g. clinical sessions per FTE, and consistency in allocation of
SPA. Introduce SPA “tariff” to ensure transparency.
• Align training needs (for doctors in training) with service
provision.
• Robust system in place to audit rota and job plans to help align
plans to patient and service need.
Agency & Bank
• Planned activities (DCC and SPA) are reported to ensure the
clinical services are met with no or minimum use of Locum and
agency staff.
• Review recruitment processes, establish and promote internal
banks. Improve fill rate of vacant shifts through in-house medical
bank.
• Review pay rates for bank shifts to ensure they adequately
incentivise bank over agency.
• Ensure board accountability for temporary staffs spend is clearly
defined and adequate management resources are allocated.
8 |8 |
Recent Trends
The national picture over the last 12 months shows continued
overspend on nursing pay, in the region of £280m above plan. There
is a
need to ensure the permanent workforce is deployed productively to
maximise availability and ensure additional spend on temporary
staff
is reduced. Over the last 12 months this has continued to rise with
a circa £104m increase from previous year. It is widely recognised
that
the overspend is caused by high vacancy rates, with over 40,000
nursing roles being vacant, as well as the impact of the 18/19
Agenda
for Change pay award. Therefore focus on retention of existing
staff and optimum use of e-rostering and e-job Planning is crucial.
The use
of evidenced based safe staffing establishment settings and the
metric of Care Hours Per Patient Day (CHPPD) should be used
to
regulate and manage deployment.
Optimal use of E- Rostering and E-Job Planning Tools
• Ensuring 4-week rotas are approved and published 6-8 weeks
in advance, with aim to extend to 12 weeks, KPIs and e-
rostering metrics should be reviewed monthly and reported at
Board Level.
• Net Hours - Ensure systems and processes are in place to
regularly track and monitor the contracted hours worked over
or
not worked, with transparent process and policy for
follows-on
actions e.g. recovery, restriction on bank shifts or overtime
payments where hours are owed.
• Monitoring the unavailability of staff in relation to
additional
spend on temporary staff to fill gaps and in addition
flexible
patterns to support work life balance. This should also be
reviewed at 6 monthly intervals.
• CNS e-job planning should demonstrate efficiencies across
services and pathways and complement other professional
groups e-rostering or e-job plans. Job planning related CIPs
are
more likely to be as a result of improved tariff remuneration
and
increased clinical capacity as opposed to any pay reducing
activity.
Levels of Attainment framework.
Use of Model Hospital and Productivity Metrics Cost per WAU
and CHPPD
Hospital compared to national averages as well at ward level
with selected comparable units. Unexplained negative
variation
will need investigation to determine if this is warranted. If
found
to be unwarranted, this may present a potential opportunity
for
efficiency gains.
• Consider Model Hospital CHPPD data at ward level and
capture
the CHPPD available on the roster against budgeted CHPPD
(per establishment) and also required CHPPD (using evidence-
based patient acuity / dependency models) on a daily and
basis
as a transparent basis for levelling and redeploying staff
across
wards in response to safety and quality of care.
Management of Enhanced Care Additional Staffing
• Ensure systems and processes such as enhanced care needs
assessments are in place to ensure evidence-based
assessment of clinical need and workforce deployment
required.
• Robust early approvals process for additional staffing and
to
optimise deployment opportunities.
staffing required to inform establishment reviews and local
workforce deployment arrangements.
• Evidence based establishment setting (safe staffing) is paramount
to ensure e-rostering templates ultimately reflect the patient
acuity
and dependency, ESR and the financial resource required to ensure
staffing is available to meet clinical demand, to ensure
CHPPD
can be used effectively as a metric to support workforce
deployment.
• E-rostering KPIs need to be understood and embedded from ward to
board to maximise the efficiency of the clinical workforce.
• Converting the use of temporary staffing from agency to bank
offers significant improvement to patient safety, staff wellbeing
and
workforce retention, whilst reducing excessive financial
spend.
• CHHPD needs to be understood and embedded particularly at ward
level to provide assurance at board level of variation
between
wards, clinical specialties and peer trusts.
• CHPPD should be used alongside clinical quality and safety
outcomes measures.
Nursing Productivity Opportunities for 2019/20
• Reduction in bank and agency spend through
effective workforce deployment created by optimal
use of e-rostering and e-job planning tools.
• Alignment of non-ward-based roles to better
understand how roles such as Advanced Nurse
Practitioner, ACPs, APs, CNSs fit into care
pathways, how they provide value and explore
how job planning can optimise these roles.
Long Term Plan
NHS Improvement’s Retention Collaborative has already delivered
substantial measurable improvements through targeted support
for
trusts with high turnover. We will extend this support to all NHS
employers, and NHS Improvement is committed to improving
staff
retention by at least 2% by 2025, the equivalent of 12,400
additional nurses.
Over the next two years we will focus on ten priority areas as part
of a strengthened efficiency and productivity programme by
improving
the availability and deployment of the clinical workforce to ensure
the right clinicians are available to patients at all times and
further
reducing bank and agency costs. By 2021, all clinical staff working
in the NHS will be deployed using an e-roster or e-job plan. By
2023,
all providers will be able to use evidence-based approaches to
determine how many staff they need on wards and in other care
settings.
This will provide staff with opportunities for flexible working
while helping reduce unwarranted variation and improve
safety.
10 |10 |
Nursing Workforce
Presentation title
• CHPPD
https://improvement.nhs.uk/resources/care-hours-patient-day-guides/
• E-rostering
https://improvement.nhs.uk/resources/rostering-good-practice/
• Trusts should consider their AHP CIPs in the context of
workforce redesign rather than cutting workforce (e.g. not
filling
vacancies). There are examples of successful ‘gainshare’ CIPs
where AHP services have been invested in to reduce overall
length of stay, or to substitute consultant / doctor time.
• Trusts should be looking at reviewing capacity and demand
for
diagnostic image reporting and using Radiographers and
Sonographers to supplement Radiologist reporting where they
have suitably trained staff. This may enable a cash-releasing
saving through reduction in requirements to outsource excess
demand or reducing medical agency or premium cost WLI
spend.
Practitioners to support the acquisition of diagnostic
images,
releasing registered Radiographers to work at the top of
their
licence.
• All AHPs services should implement job planning to their
AHP
services. Early examples of trusts that have done this shows
that efficiencies have been found which increased clinical
capacity (and therefore has potential to reduce (AHP) unmet
need and reduce LoS)
• Integrating acute Physio and OT services should be a
priority
for trusts that have not yet done this.
• Caution must be exercised when identifying opportunities
from
the Model Hospital AHP data – reasons for high AHP spend
could be:
clinics,
2) the trust hosts AHP services on behalf of another trust
(often this is the case for Speech & Language therapists
that incidentally are more expensive than other AHP
professions as they did well out of AfC review / banding).
3) trusts have already ‘invested’ in AHPs to create gain
share
CIPs across divisions. E.g. creating front of house AHP
teams to prevent unnecessary admissions.
12 |12 |
Recent Trends
The cost of delivering pathology in trusts that have not networked
services continues to be higher than what can be expected from a
fully
consolidated network service. Networks that have fully consolidated
services have seen the overall cost per test drop considerably as
the
benefits of consolidation are realised. There continues to be
pressure upon the workforce leading to activity being outsourced to
other
providers, normally at a higher rate. Nationally, agency spend is
high and Trust bank is under-utilised in this area, with an
estimated £20m
savings possible by removing agency spend and converting staff onto
an internal staff bank. Trusts are making progress:
• The first tranche of networks are in operation.
• Almost half of the proposed networks have delivered to NHS
Improvement Strategic Outline Cases and over a third are working
up
Outline Business Cases as they progress towards forming pathology
networks.
• Networks that are in the process of conducting joint procurement
activities are anticipating significant recurrent savings delivered
to
each partner, together with other efficiencies driven through use
of the same equipment across the network that will be
delivered
through common SOPs and training pathways for staff. In one example
we have seen circa £350,000 savings per annum with an
overall saving of £25m over the life of the contract
Pathology
Networking
Networking is a multiyear programme however there are a
number
of areas that trusts can concentrate on that do not detract
from
networking and proactively drive forward this strategic
direction
(see Productivity Opportunities for 2019/20 – Grip and
Control).
• Reviewing staff skill mix, including looking at advanced
and
extended roles.
vendors to buy at scale.
• Review services provided against long term strategy to
understand investment versus efficiency opportunities.
Key success factors and barriers
The main success criteria for ensuring pathology services
deliver
the long term strategic and the short term efficiency is
executive
engagement.
• The most important factor for trusts to remember is that
cost
improvements can be realised in year as services progress
toward consolidated networked services, however, these need
to be aligned to the networking agenda and not focus on
short-
term plans that will ultimately elongate the timeline for
delivering
a network. It is important that trusts work collaboratively
with
network partners.
• Approximately 40% of acute trusts in England do not report
pathology CIPs. Regional leads report that all the Acute
pathology services have CIPs based on visits to laboratories.
This is a classification issue that needs rectifying and trusts
to
report all their pathology CIPs for FY 2019/ 2020.
Pathology – Efficiency Actions (Jan ‘19)
Rapid actions
Governance & comms
Non- recurrent
• Consolidate referral activity to a single diagnostic provider. •
Review service contracts – Level of cover versus clinical
requirement. • Review logistics - operational delivery and
contracting
arrangements. • Business cases and Capex review. • Demand
management of testing – RCPath/IBMS/ACB guidance.
• Ensure all R&D activities are funded and appropriately
priced. • Sale of old equipment. • Asset review. Consolidation on
technology type across disciplines.
• Reduce reliance on agency / locums. • Review Out of hours
arrangements where the are outside of AfC. • Review sample delivery
time to reduce out of hour staffing
requirements. • Review Consultant Job plans. • Increase staff
availability – remote and flexible working. • Improve staff
retention –Training & Development.
• Governance and cash management – PO or approved testing request
route only.
• Capital and assets opportunities.
• Clear delivery plan on and around consolidation. • Engage staff
and key stakeholders, particularly Clinical users. • Clinical need
rather than clinical want.
In year consideration Networking / Collaborative
Opportunities
Inventory Management
• Adoption of just in time stock management. • Introduction of
automated stock management systems to meet
accreditation requirements and reduce staff time. • Removal of
ad-hoc deliveries via improved stock management.
Non-pay / all cost actions
• Ensure all R&D activities are funded and appropriately
priced. • Consolidate referral activity to a single diagnostic
provider. • Demand management of testing – RCPath guidance.
Procurement
• Review service contracts – Level of cover versus clinical
requirement.
• Review provision of complex testing against savings of retiring
equipment and outsourcing.
• Consolidation of consumables providers within trust and across
aspirant network.
• Consolidate referral activity to a single diagnostic
provider.
Networking
• Consolidating pathology services allows for the most consistent,
clinically appropriate turnaround times, ensuring the right test is
available at the right time. It also makes better use of our highly
skilled workforce to deliver improved, earlier diagnostic services
supporting better patient outcomes.
• Taking a hub and spoke approach to this consolidation can ensure
an appropriate critical mass to support specialist diagnostics, so
that patients have equal access to key tests and services are
sustainable.
14 |14 |
Pathology
Supporting resources provided by NHSI / E The NHS Improvement
Pathology programme have produced a number of resources that can
support trusts and networks in
understanding where opportunities can be derived.
• Pathology programme Detailed Guidance
• National & Regional Teams
Regional and National pathology teams are on hand to support trusts
in reviewing plans to ensure they are appropriate which will
increase chance of successful delivery.
15 |15 |
Recent Trends
Delivering imaging services in trusts continues to rely on an
increasing spend on ‘outsourcing’ (Independent sector providers)
and
‘insourcing’ (use of extra sessional payments), to meet the
capacity shortfall. This increasing spend is not sustainable in the
longer-term
due to increasing costs, with vacancy rates remaining high (12.5%
Consultant Radiologists, 15% radiographers).
• Some imaging departments are beginning to organise themselves
into Imaging Networks, setting up programme structures and
rudimentary governance structures to begin working as a network and
gain benefits. Most networks have come together to gain
benefits from a joint procurement, to replace their existing PACS
systems and have started to recognise and look for wider benefits
of
working together across a number of areas (Workforce, Capital
Equipment, Training opportunities, ISAS accreditation). Some
networks have been successful in gaining funding for an IT platform
that will allow image sharing and offer them the opportunity
of
joint backlog reporting or shared reporting gains. Most of this
funding has been secured through either Cancer Transformation
Funds
or STP Transformation Funds, however, this funding is not universal
and large parts of England do not have funds to procure a
technical solution. Those with funding have encountered quite a
challenging procurement landscape and have not yet secured a
technical solution. Where technical solutions have been acquired,
there have been some benefits of joint backlog reporting
securing
savings over outsourcing solutions.
• NHS Digital are developing a Toolkit to support networks through
the technical procurement process to ensure an optimum image
sharing solution, based on the experience of networks to date. This
is due for completion in Spring 2019.
• There continues to be significant workforce challenges, with high
vacancy rates, however skill mix remains variable with the
percentage of plain x-rays being reported by advanced practice
radiographers varying from 80% to 0%. Backfill to replace
radiographers undertaking advanced roles remains a challenge and
Assistant Practitioner roles remain low. Challenges accessing
appropriate training for this staff group, and access to funding
for training remain an issue. The apprenticeship levy may offer
some
opportunity.
• Radiography academies / multidisciplinary radiology academies
have offered opportunities to increase skill mix by training
cohorts of
staff to develop reporting skills as Advanced Practitioners.
Innovation in new pathways for suspected lung cancer have had
success in
some trusts and are starting to be adopted in others.
• Some networks have started to work together on shared reporting
networks for on call, to increase the availability of
radiologists
available during the day and to increase training
opportunities.
Imaging
Networking is a long-term, multiyear programme however there
are
a number of areas that trusts can concentrate on that do not
detract from networking and proactively drive forward this
strategic
direction (see Productivity Opportunities for 2019/20)
• Reviewing staff skill mix, including looking at advanced
and
extended roles.
protocols (and reduce duplication / repeats).
• Rreviewing capital replacement requirements and understand
where ‘economies of scale’ can be leveraged (utilising
Category
Tower 7 – NHS Supply Chain).
• Negotiating ‘outsourcing’ contracts at scale, by agreeing
multisite deals and planning for known capacity shortfalls.
Key success factors and barriers
The main success criteria for ensuring imaging services deliver
the
long term strategic direction of imaging networks and the
short-
term efficiency gains is executive engagement. The Strategic
Plan
for Imaging is yet to be published, however, there is a
commitment
to Imaging Networks by 2023 in the NHS Long-Term Plan.
• Trusts will be able to deliver cost improvements in year as
services progress towards imaging networks, with ‘economies
of
scale’ being offered by collaborative working, procurement
and
training. Any local CIPs will need to be aligned to the
networking
agenda and not short-term plans that could cause challenges
for
delivering a network. It is important that trusts work
collaboratively with network partners, particularly when
considering PACS / RIS and image sharing solutions for the
next 10 years.
• Classification of CIPs for Imaging are not yet clear with
pathology and imaging opportunities only being identified
separately this year. Work needs to be done in identifying
where
imaging spend is accounted for in ‘outsourcing’ and
‘insourcing’
budgets, so that these can be transparent.
• Information submitted for national data collections such as
the
DID (Diagnostic Imaging Dataset) and the DM01 through
information departments should be ratified with imaging
departments to improve data accuracy.
Imaging - CIP opportunities (Jan ‘19)
Pay Cost
Coding & Classification
of CIP
Protocols & Pathway
Capital Equipment
• Understand where sourcing / outsourcing spend is accounted in
your budget and track alongside demand (overtime, locum,
WLI).
• Implement an annual leave policy (monitor compliance). • Review
“on call” or out of hours arrangements (could shift
systems offer improved cover). • Review staff availability and
flexible working arrangements
(e.g. 3 long days, reporting from home). • Use “retire and return”
to retain skilled staff at the end of
their career. • Review job plans for Consultant Radiologists and
advance
practice radiographers to ensure any shortfall in reporting
capacity is understood and planned for.
• Re-negotiate outsourcing contracts in a planned / effective way.
Utilise economies of scale across sites.
• Review use of advanced practice radiographers to ensure
appropriate utilisation of their skill set and attendance at
appropriate MDT, audit etc.
• Encourage multidisciplinary working to ensure advance practice
skills are developed and maintained while appropriate review and
supervision is undertaken.
• Agree referral protocols for defined care pathways and use
clinical decision support to improve the appropriateness of
referrals.
• Monitor inappropriate referrals and provide feedback. • Agree
standardised scanning protocols for the same type of scans
both within the organisation and for tertiary transfers e.g. Neuro,
cancer.
• Offer patients a choice of appointments (not next available slot)
by partial booking.
• Offer pre-assessment or telephone triage/ support for more
complex procedures (IR) or complex conditions.
• Consider having x-ray booking clerks in high volume clinics (to
agree appointments before the patient leaves clinic and minimise
DNA rates).
• Consider dedicated lists for patients with high DNA rates or
incomplete studies (anxiety to MRI).
• Ensure the age of capital assets (asset register) is understood
by the trust board and any risks of using older equipment are
documented.
• Have a capital replacement plan agreed and contingency plans for
sudden outage.
• Ensure that savings on consumables and contrast agents are
attributed to Imaging departments.
• Ensure staff groups such as “sonographers”, “mammographers” are
appropriately coded to imaging where they are not obviously
radiographic posts.
• Ensure staff are accurately coded within ESR to ensure financial
and workforce planning is informed by accurate workforce data
including support staff.
• Work with commissioners to review opportunities to deliver system
wide efficiencies.
Cash releasing / In year
consideration Longer Term Considerations
Networking / Collaborative Opportunities
• Consider tasks and opportunities for assistant practitioners to
release radiographers for advanced practice roles (some plain x-
ray or theatre). Scope of practice and supervision must be
clear.
• Access the apprenticeship levy to support the development of
assistant practitioners and new support roles.
• Work with information departments to agree and sign off DID and
DM01 returns. Be clear on how activity data is counted .
• Agree network wide protocols to enable easier shared reporting
and reduced repeats, reduce risk.
• Use intelligent reminder services (txt, appropriate calls,
artificial intelligence for those most likely to DNA).
• Use appropriately trained staff to protocol and vet requests
(justification must follow IR/(ME)R guidance.
• Review opportunities for cost effective replacement through NHS
Supply Chain to gain economies of scale or cheaper financing
options.
• Optimise capital replacement opportunities across multiple trusts
in an imaging network (incl PACS / RIS).
18 |18 |
Supporting resources provided by NHSI / E
The NHS Improvement Imaging programme will be publishing the
proposed Strategy for Imaging (including Imaging Networks) in
Spring
2019. The resources to support its adoption will be:
• A Toolkit for procuring an Image Sharing Solution (In development
with NHS Digital)
• A resource plan for Imaging Networks (to support set-up and
infrastructure)
• A proposed programme of supportive workshops to share best
practice and identify ‘barriers to change’ – A National
Development
Programme
• A Leadership Development Programme (for identified network
leads)
• Regional and National imaging teams are on hand to support trusts
in reviewing plans to ensure they are appropriate and will
increase
their chance of successful delivery
• Case studies can be found below.
Case Study 1 – East Midlands Radiology (EMRAD) Shared Backlog
Reporting
Improving Efficiency through Collaboration, Technology and a
Shared Vision.
The Problem The EMRAD consortium supports eight NHS Trusts,
thirteen Hospitals and a 6.0 million population. There
simply aren’t enough Radiologists or reporting capacity to cover
the ever-increasing demand.
Fig1. Summary of the current landscape.
- Systems were installed in 2004 with multiple PACS and RIS in the
region.
- There was some very local workload sharing but no routine
regional image sharing.
- There was Case-by-case distribution using IEP with some regional
clinical pathways developed.
- The technology struggled to keep pace.
The Solution It was envisaged that radiologists reporting
images remotely would result in lower costs to
the Trust than the outsourced model and that
the model would also be financially and
logistically attractive to the radiologist. It was
predicted that cross-trust reporting would
deliver efficiencies that would assist in
reducing Trust backlog. Radiologists for a pilot
project were selected, specifically to review
and report neuroradiology images from the
Trust.
The challenges and lessons learned - The deployment of the
cross-Trust
reporting product was difficult at first as
the software didn’t quite work as expected
and there were issues with networks and
adoption of change.
hardest aspect, as there was an
established governance procedure and a
number of policies that, due to their
rigidity, were not set up to support this
model.
the current state of backlogs in Trusts,
current Trust outsourcing spend and the
method for bridging the gap should not be
underestimated.
Overview
To cope with increasing demand across the region, the EMRAD
consortium developed a pilot program of
cross-Trust reporting to assist in reducing Trusts’ backlogs and
reduce the spend on outsourcing. The pilot,
which was run by neuro-radiologists, was successful and has been
expanded beyond neuroradiology and now
includes radiographers too. Backlogs in the region have been
reduced as has outsourcing spend. The EMRAD
consortium is now looking at further innovations for cross-Trust
reporting.
Simon Harris. EMRAD Project Manager
[email protected]
Email:
• 5% increase in the total number of studies
reported during the 3 month pilot period.
• 240% increase in waiting list initiative
reporting activity.
generated the equivalent of 1.0 WTE
Radiologist.
was significantly higher than national
guidance.
reporters in the pilot and variation in the
amount of waiting list initiative
attributable to each Trust, there was an
overall significant increase in productivity.
The pilot study encouraged the expansion of
cross-Trust reporting beyond the three-
month trial, wider than neuroradiology and to
include radiographers. EMRAD colleagues are
leading the process of multiple Trusts
reporting on behalf of others in their
consortium, outside their NHS contracted
hours, which is assisting in meeting the
capacity gap.
expanded cross-Trust reporting has successfully
delivered:
- Insourced 38,826 Reports - Insourced 4,164 CT reports - Insourced
9,627 MRI Reports - Insourced 25,035 Plain Film Reports - 2017/18
financial year saving was £119,832.60 - Reduced the cost of
outsourcing by 30.84% for
the Trusts involved in the insourcing initiative
Fig 2. Job Planned, WLI and pilot reporting activity before
and
during pilot.
Future Opportunities For future successes:
- Reviewing of CT imaging is required prior to decision for
thrombolysis.
- Stroke prognosis dramatically improves with more rapid diagnosis
and timely treatment.
- Inability for remote image review/slow system start up can slow
time to treatment decision.
- Remote image review with portable tablet devices can speed up
decision making process.
“Cross-Trust reporting has afforded the opportunity to compile a
wealth of data allowing high level analysis of reporting volumes
and associated metrics and also the productivity of participating
radiologists in terms of both reporting throughput and report
quality.” - Simon Harris, EMRAD Project Manager.
0
500
1000
1500
2000
2500
3000
3500
WLI work only
Pilot work only
Developing a networked approach for sustaining your ‘on-call’
Overview The demand for overnight radiologist reporting was
stretching radiologist capacity across the south
west to an unsustainable level. Several models were evaluated which
lead to the creation of Peninsula
Radiology On Call [PROC]. PROC is a collaborative venture to
provide overnight radiology on call
services for four of the acute NHS Trusts in the south west
peninsula from a single location. It has
overcome many of the sustainability challenges faced by the region
and has delivered cost saving
benefits to the member Trusts as well.
The problem • There was an increasing demand for emergency CT
overnight across the region that was stretching the
radiologist reporting capacity
an adverse impact on training for the Specialist
Trainee Radiologists across the region as a result of
compensatory days off during routine working hours
in order to comply with the European Working Time
Directive (EWTD) and The New Deal.
• These factors lead to the overnight service reaching
an unsustainable level.
the entire region.
would employ the registrars.
• Administration.
overnight imaging has increased
interrupt reporting.
o Occasional PACS network failures which is
a challenge not unique to PROC.
o Images unavailable for viewing on the
consultant’s virtual private network
[VPN].
on call consultant
• To overcome the resistance to change a range
of tailored stakeholder engagement sessions
were held with the following groups;
o Service managers
o Consultant radiologists
o Radiology registrars
communication and stakeholder engagement
selected.
addressed the HR, governance and
administration challenges.
of Radiology is responsible for management
and governance of PROC.
emergency CT and MRI studies conducted
between 21:00-09:00, 365 days a year.
• All specialty registrars providing reporting services
for PROC are employed by Plymouth Hospitals NHS
Trust and have honorary contracts with their base
hospital. Trainees providing reporting services for
PROC will be covered by the terms of the honorary
contracts and the SLA. At the end of each shift the
on-call consultant reviews all scans acquired from
their locality
timely consultant review and regular audit. On call
radiologists are responsible for providing feedback
to reporting registrars on discrepancies.
• There has been a reduction in staffing costs.
Tom Sulkin
Email:
[email protected]
• An existing model for cross site working which
encourages collaboration and operational
• Registrar attendance during normal service hours
have been increased which creates a better learning
environment and more positive interaction with
imaging and hospital colleagues.
that is well supervised.
Case study 3 – Working Together ACS – A pilot Radiography
Academy
Working Together Programme
• Reporting radiographers training was accessed piecemeal across
Trusts; no consistent approach to either training or the scope of
professional competence and practice.
• A clearly identified need to provide effective clinical education
for trainee reporting radiographers from disparate hospital sites
was agreed and articulated across the South Yorkshire region.
• Recognising workforce pressures in radiology in terms of both
image acquisition and interpretation, the priority became to
increase reporting capacity to stabilise and provide sustainable
services and reduce financially crippling reliance on outsourcing
to the independent sector.
• Analysis of data across the patch showed activity rises of
approx. 7% and it is estimated that in 2-3 years’ time, the
reporting capacity gap would be approx. 750,000 images per
annum.
The challenges and lessons learned
The WTP principles are to pool collective expertise and
knowledge to support staff development. The challenges
are to expand the number of advanced practitioners and
recruit and retain radiologists:
• To provide effective clinical education for trainee reporting
radiographers across a number of hospital sites a number of
objectives needed to be agreed: o To establish governance processes
to
enable cross organisational working o To establish a standardised
educational
programme o To accelerate the learning period o To share resources
and efficiency gains
o To explore the challenges in delivering a collaborative
programme
o To robustly evaluate the initiative
o To identify opportunities for future
collaboration
equipment. Hosting arrangements was
number of barriers required overcoming:
o Student access to PACS
o Data transfer and sharing to allow
trainees access to the same images
o Information governance agreements
organisations
ensure the programme could be
shortened
WTP radiography clinical lead and a
part time clinical educator.
agreed to support the pilot with
funding for the university course
fees and backfill for training.
o Each Trust was asked to support the
academy with in-reach sessions and
a named mentor for the sign off of
the report competency portfolio.
The solution and future
established collaboration of 7 NHS Trusts with the aim of
collectively strengthening the ability to deliver safe,
sustainable local services.
Overview
With a national shortage of radiologists impacting on both the
ability to make timely reports for patient diagnosis, management
and
surveillance and afford time to train staff within each of the
separate Trusts, A solution was proposed and taken through pilot
study to see if a
Reporting Radiographer Academy jointly supported by hospital Trusts
in Sheffield, Rotherham, Barnsley, Doncaster, Bassetlaw and
Chesterfield would offer radiographic staff the opportunity to
up-skill and provide the eventual plug to the reporting capacity
gap.
Professor Beverly Snaith, Clinical Professor of Radiography
[email protected]
Be
This has been achieved by:
• Clinical Academy for Radiographer Reporting (CARR) - in 4 months
CARR was ready to run the initial pilot and accept the first cohort
of radiographers.
• A successful pilot has seen the training of 8
reporting radiographers within this first cohort.
• This first pilot has run for nine months.
Delivered over 3 phases the structure of the
programme meets the needs and expectations
of professional bodies:
Phase 1: Sep-Dec
scenarios, peer review and practical reporting
experience.
and transition into the clinical environment at their own
base hospital.
practice, working alongside radiographers and
radiologists. They attend the academy 1 day per month
for ongoing peer support.
(minimum) case reports with an accuracy of at least
95%.
organisational boundaries – a first in addressing
reporting radiographer workforce issues across
an entire region.
delivered a cohort of radiographers who are
ready to work as advanced practitioners and
support clinical services with a single standard
across organisations.
facilitated peer support “One of the key
benefits for me is that we are all learning lots
from each other, not just the tutor.”
• Duplication of effort has been reduced by
sharing the training in a single setting. This has
not only facilitated the sharing of resources
(including educators) but has allowed
intensive, timely clinical support to take place.
One educator has been able to provide the
support to 8 trainees which is far more efficient
than the input of a single trainer in each
organisation.
specialist input from external trainers – an
opportunity which would not have been easy to
access over multiple sites.
Advanced Practitioners are delivering
• The intensive nature of the programme has
allowed the trainees to complete their course 4
months earlier than normal but with no
reduction in quality or skill set.
• The reporting capacity generated by these
individuals will be key to delivering clinical and
cost-effective efficiencies across organisations.
boundary working as governance, evidenced
based outcomes and standards are agreed.
• Importantly, the cohort will be able to
challenge each other’s practice, provide peer
support and expert opinion to the benefit of
patients and their care and management
teams.
Interest from around the UK has been high with regions
across Scotland, East Midlands, East Anglia and
Manchester already developing plans to replicate the
model.
reporting radiographer numbers.
A second cohort has been planned with the prospect of
extending the anatomical scope of practice. There is no
doubt: this model, its structure and delivery programme
provides unparalleled opportunities for advancing
radiographic reporting practice
is now part of the South Yorkshire & Bassetlaw Shadow
Integrated Health and Care System (sICS).
approach to ISAS Accreditation
Background
The Acute Care Collaboration Vanguard in Dorset has a mission to
create One NHS in Dorset and one
of their work streams is radiology. The collaboration consists of
The Royal Bournemouth and
Christchurch Hospitals NHS Foundation Trust, Poole Hospital NHS
Foundation Trust, Dorset County
Hospital NHS Foundation Trust and Dorset Healthcare University NHS
Foundation Trust.
The Aims of The Radiology Work stream
One of the key aims of the radiology work stream is to achieve ISAS
accreditation. The group has
identified this accreditation as a tool to support the integration
of radiology staff from the four
trusts involved. Achieving ISAS accreditation for all the radiology
services in Dorset demonstrates to
patients, staff and commissioners that services are safe, of high
quality and well managed.
The Experience & Outcomes
As the group works towards ISAS accreditation, with the assistance
of an appointed project
manager, clinical leads have worked with their colleagues across
all four Trusts to share ideas and
agree pan-Dorset policies and protocols, based on best practice and
guidelines. The positivity of the
experience is highlighted by Poole Hospital Radiology Manager,
Mandy Tanner:
Overview
The Radiology Work stream of the One Dorset Acute Care
Collaboration Vanguard is working towards obtaining
ISAS accreditation across the region. This process has brought the
Trusts closer together and fostered positive
close working collaborations. A shining example of this is the
Pan-Dorset Lumbar Spine X-Ray Referral Guidelines
which have reduced unnecessary X-Rays by up to 37%. Not only is
this great for patients as there is less
unnecessary exposure to radiation, but it highlights the positive
results that working together, standardising
services and reducing variation can have.
Mandy Tanner: Radiology Manager, Poole Hospital NHS FT
Email:
[email protected]
“Previously, any joint working within Trusts has largely been at a
higher management level. With
ISAS, teams are really starting to work openly together with
colleagues in other Trusts for the first
time. Staff are enjoying collaborating and are proud of the
improved experience for patients taking
place across the sites as a result of their work. The work for ISAS
offers us a unique opportunity to
define common standards across the sites and to explore the
potential for sharing staff expertise.
This will help us as we strive to improve the quality of service we
provide to our patients throughout
Dorset.”
The Lumbar Spine Example
A prime example of how the ISAS accreditation process is having a
positive effect on the service is
the standardisation and implementation of the Pan-Dorset Lumbar
Spine X-Ray Referral Guidelines.
The guidance was adapted from existing guidance by the lead
clinicians from all 3 acute Trusts and
reflects current best practice.
Dr Robert Ward, Clinical Lead for the radiology vanguard work
stream explains:
“The typical effective dose for a lumbar spine plain film x-ray is
particularly high at 1.0 mSv,
equivalent to the radiation dose from 50 chest x-rays or five
months of background radiation -
therefore it is particularly important that these investigations
should only be undertaken when
needed to inform patient care. Unfortunately in many common
scenarios these x-rays provide only
very limited value and so these guidelines will hopefully help to
ensure that only patients who will
gain some benefit undergo this examination.”
The guidance has had an immediate effect on demand management and
curbed unnecessary
referrals by up to 37%.
“Working collaboratively as part of the vanguard has enabled us to
provide uniform advice for GPs,
share best practice and make positive changes for patients in
Dorset.” - Mandy Tanner
The problem
• Despite a long-standing record of 100%
recruitment to clinical radiology training
posts, approx. 1 in 10 consultant posts
remains vacant
to meet demand for imaging services
• Potential to increase clinical radiology
training numbers is limited by resources
including capacity to teach and
supervise and by difficulty accessing
training time and equipment in busy
departments
professional learning environment
• Collaborative academy-style learning
direct consultant supervision in
comparison to traditional training
clinical departments improve training
experience because they:
activities
technology-enhanced learning
(e.g. simulation)
formal assessment of knowledge
peer and academic support
Observations
accelerates the development of
• Networked off-site training environments
be supported at any one time
• Academies provide safe and supported
teaching, supervising and assessing
trainees and for advanced and consultant
practitioner radiographers and
support clinical radiology training
Overview
In 2005 the Department of Health and the Royal College of
Radiologists collaborated to set up
three Radiology Academies - Leeds & West Yorkshire, Norwich and
Peninsula (Plymouth) – with
each academy co-ordinating training across a network of individual
NHS Trusts.
Since their set up the academies have boosted Clinical Radiology
trainee numbers in their local
geographies and offered a high standard of speciality training
alongside the more widespread
traditional hospital-based training schemes.
Following a national review in 2018, access to the academies and
development of further
academy-style learning environments is being extended to the wider
multiprofessional
healthcare team involved in delivering imaging services.
Case study 5 – The ‘academy’ approach to training in Clinical
Imaging
Multiprofessional Clinical Imaging Training Academies
Paul.Deeley-Brewer
19 |19 |
Recent Trends
The significant volume of CIP delivery is routinely from medicines
management, with the data tracked in the Model Hospital via the Top
10
Medicines metrics. However, several additional CIP initiatives are
delivered by provider trusts (see CIP Opportunities slide below)
these
can be split into cash releasing, longer term and workforce related
initiatives.
Hospital Pharmacy & Medicines Optimisation
• Trusts achieve best success through detailed and tracked
‘CIP
Pipeline’ work.
scrutiny and accountability. Assessment of use of both e-
rostering and e-job Planning should be measured against the
Meaningful Use Standards and Levels of Attainment framework.
Productivity Opportunities for 2019/20
• The slide below sets out the CIP initiatives we believe are
prudent for 2019/20 these are categorised into the following
areas:
• Cash Management
Supporting Resources
• A template has been developed for trusts to adapt and track
each suggested CIP initiative. We have seen this work well in
a
number of trusts, providing a RAG status for each initiative
and
highlighting opportunities for CIP pipeline work, the
template
can be found below.
Assessment Framework (below) has been developed to help
NHS trusts review their approach to medicines optimisation.
• A number of webinars / workshops are being planned during
the CIP planning process, hosted by the NHSE-I Regional
Pharmacists, further details to follow.
Hospital Pharmacy and Medicines
Gap Analysis
Assurance Patient Access Scheme price arrangements in place -
reimbursement sought for any overpayment
Yes/No/Partial
2
Yes/No/Partial
3
Yes/No/Partial
4
Yes/No/Partial
2
Engage pharmacy & organisation staff and key stakeholders (e.g.
STP leadership)
Yes/No/Partial
3
Yes/No/Partial
Yes/No/Partial
3
Yes/No/Partial
4
Yes/No/Partial
5
Yes/No/Partial
6
Full engagement with Local Workforce Advisory Board on funding for
apprenticeships
Yes/No/Partial
1
Ensure all R&D including clinical trials are appropriately
priced and fully funded (including non-commercial trials)
Yes/No/Partial
2
Purchasing agreements in place for best value consumables including
dispensing & aseptics
Yes/No/Partial
1
Review service contracts in all areas to provide assurance of VFM
including supply & educational input
Yes/No/Partial
2
Ensure charging structure in all SLAs covers full costs of service
not just salaries
Yes/No/Partial
3
Local purchasing agreements for all medicines not on
regional/national contracts
Yes/No/Partial
4
Yes/No/Partial
5
Acceleration of progress to full electronic ordering and invoicing
for medicines
Yes/No/Partial
Medicines
1
Process in place to plan for patent expiries and immediate uptake
of new contract waves
Yes/No/Partial
2
Yes/No/Partial
3
Check pharmacy stock levels are appropriate and cannot be
reduced
Yes/No/Partial
4
Yes/No/Partial
5
Yes/No/Partial
1
Clear formulary and process for shared care in place including
funding arrangements
Yes/No/Partial
2
Yes/No/Partial
3
Yes/No/Partial
4
Yes/No/Partial
Governance and cash management - PO or approved use route
only
Yes/No/Partial
2
Yes/No/Partial
3
Yes/No/Partial
4
Capital and assets opportunities including review of asset
registers & capital charging
Yes/No/Partial
Key information/enablers:
1) Finance and pharmacy work together to create clear, open view of
medicines spend with Joint governance processes e.g. joint monthly
medicines budget control meeting
2) Proactive use of Rx-Info Define benchmarking to generate Cost
Improvement Plan pipeline
3) Link to efficiency and productivity of clinically facing
pharmacy work e.g. ward rounds etc.
4) CIP opportunities that require clinical engagement present an
additional challenge
5) Barriers to change within trust from some clinical areas
&P/&N
Trust:
Acute services
Other
Adapted and prepared by Richard Seal, Chief Pharmacist, NHS Trust
Development Authority, June 2013. Updated March 2014
Introduction
INTRODUCTION TO THE FRAMEWORK
1.
SUMMARY
The purpose of this hospital pharmacy and medicines optimisation
assessment framework is primarily to help NHS trusts to review
their approach to medicines optimisation (MO) and pharmaceutical
services. In addition, the outcome will be used by NHS Improvement
to provide an assessment of the extent and quality of services
provided by NHS trusts as a focus for developmental support.
The framework is based on an approach developed by the NHS Trust
Development Authority.
This framework can help you understand where you are now and where
you might need to be to develop. It should used as a guide rather
than a blueprint for service delivery.
The core domains and criteria used in the framework draw on a wide
variety of sources for inspiration. These include standards and
guidance published by the Department of Health, National Patient
Safety Agency (now part of NHS Improvement), Care Quality
Commission, NHS Litigation Authority, Audit Commission and the
Royal Pharmaceutical Society.
The framework content has been devised in consultation with NHS
trust Chief Pharmacists, as well as peers and other clinical
colleagues. It is intended to meet the specific needs of NHS
Improvement. However, it may be of interest to other healthcare
providers.
2.
ABOUT THE FRAMEWORK
The purpose of the framework is threefold. Namely to enable trusts
to:
l
l
Identify areas of existing good practice but also areas for
development
l
Provide assurance on medicines optimisation and pharmaceutical
services
The framework should ideally be completed by the senior management
team with responsibility for hospital pharmacy services and
medicines optimisation (usually the Chief Pharmacist, Director of
Nursing and Medical Director). It provides an opportunity for both
clinical leaders and managers to reflect on the trust's overall
approach to medicines optimisation and to consider how systems and
processes contribute to delivering the organisation’s wider
clinical strategy and assurance on the provision of safe, effective
and patient-centred services within the trust.
Following completion of the framework, the outcome should be
considered as part of strategic planning and organisational
development to ensure that high quality, sustainable services are
provided.
The outcome of the assessment should also help organisations
identify areas for future development and improvement.
3.
APPROACH
The framework builds on earlier work published by a number of
national bodies and professional organisations. It takes into
account the requirement to adhere to the principles described in
the NHS Constitution and to deliver the NHS outcomes
framework.
4.
The framework is divided into the following 7 core domains:
l
Use of resources
Each of the 7 core domains is made up of the following:
l
l
Each criterion is further divided into four levels against which
trusts assess their level of attainment
In addition, there are two additional worksheets where you can
identify areas for development and examples of good practice for
sharing.
5.
HOW TO EVALUATE THE OUTCOME OF THE ASSESSMENT
Most trusts should expect to identify areas of both good practice
and areas for further development. It would be unusual for any
trust to achieve the maximum score across all of the core domains
in the framework. However, you may anticipate that:
l
Most trusts will perform well within the core domains of safe use
of medicines and effective choice of medicines and mixed scores
within the other domains.
l
There is no right or wrong outcome. This will be influenced by a
number of factors including the type of services provided, the
patient demographic and previous investment in medicines use and
pharmacy services within the trust.
l
Some of the benefit from completing the framework will arise from
comparing the outcome for your organisation with those of
organisations similar to your own. There will be some areas for
development which are common to a number of organisations and these
will be used as the focus for development support from NHS
Improvement.
Guidance
GUIDANCE ON COMPLETING THE ASSESSMENT
Getting started
Providing information about the organisation
The assessment framework is based on a number of Excel
spreadsheets. Individual domains can be accessed by clicking on the
appropriate domain title tabs at the bottom of the workbook
page.
Access the first page by clicking on 'TITLE_PAGE' tab.
The title page provides space for the following details:
l
l
l
The date of the completion of the assessment
Save your own copy of the workbook as "(Name of your trust) self
assessment framework"
Saving your assessment
You can stop work on the assessment at any point although you must
make sure you press the 'Save' icon to save the work that you have
done.
2.
Information about the self assessment framework and
instructions.
You can access further information about the framework by clicking
on the "Introduction" tab at the bottom of the page. This section
provides an overview of the self-assessment framework and advice
about interpretation of the results.
3.
The individual domains.
The framework has 7 domains. These are: Strategy, Risk and
Governance; Safe use of medicines; Effective choice of medicines;
The Patient Experience, Environment for medicines optimisation,
Workforce for medicines optimisation and Use of Resources. For each
domain there are 6 criteria. Work through the core criteria for
each domain one at a time. Each criterion provides four statements.
You should make your assessment by clicking on the button in the
box that is most closely matches you trust's position. The
statement may not fully reflect your local circumstances in which
case, choose the statement that is closest. Remember to press the
save button as you progress through the domains.
Note: You should complete all of the criteria in each of the 6
domains in the assessment. The default level for each criterion is
level 1.
4.
The charts and dashboard.
As you make an assessment of your trust's level for each criterion,
the relevant chart for that domain will automatically be updated to
reflect your choice. In addition the overall summary chart will
also change to reflect your choices.
Upon completion of the entire assessment, the data will be visually
available as:
l
l
l
A summary dashboard. The darker the colour, the higher your level
of assessment.
5.
Saving and printing.
You can keep a hard copy of the assessment by clicking on 'File'
then 'Print'. Make sure you select 'Entire workbook' from the
'Print' options.
&G
DOMAIN 1 - STRATEGY, RISK & GOVERNANCE
Medicines optimisation is integrated into the trust's strategy,
systems, working practices and culture at all levels. The roles of
managerial and clinical leaders are aligned and unambiguous. There
are clear lines of accountablity for medicines optimisation from
the board to operational delivery units. Risks are identified and
mitigated.
Indicator
Level
Str 1.2
1
Criterion 2 - There is an executive level medicines policy group
for overseeing medication safety and policy development
Str 1.3
1
Criterion 3 - The management of medicines is underpinned by an
overarching medicines policy
Str 1.4
1
Criterion 4 - There is oversight and control of clinical risks and
costs associated with medicines
Str 1.5
1
Criterion 5 - A Chief Pharmacist plays a leading role in medicines
optimisation
Str 1.6
1
Criterion 6 - The Trust Board and senior management are actively
involved in medicines optimisation
Total
6
The trust does not have a hospital pharmacy transformation
plan
Level 1
The trust does not have a strategic oversight group for developing
medicines policy, procedures and guidance and providing oversight
of medication safety.
Level 2
There is a draft hospital pharmacy transformation plan but it has
not been approved by the board or it has not been fully
funded
Level 2
The trust has a strategic oversight group for developing medicines
policy and procedures and overseeing medication safety.
Level 3
A fully-funded hospital pharmacy transformation plan has been
approved by the Board. An implementation plan, with timescales, is
in place.
Level 3
The trust has an oversight group for developing medicines policy
& procedures and it is responsible for making decisions about
medicines that are implemented across the trust
Level 4
As level 3 plus key performance indicators developed and mechanism
in place to regularly review and report progress to the board
Level 4
The trust can provide evidence that implementation of policy,
procedures and decisions about medicines applies across the whole
trust. The oversight group produces regular board reports.
Level 1
No evidence that there is an overarching medicines policy that
supports an integrated approach to medicines optimisation across
the whole organisation.
Level 1
The trust does not have robust business and financial planning,
management, monitoring and reporting systems to manage clinical
risks costs associated with medicines.
Level 2
There is a comprehensive, overarching medicines policy that
supports an integrated approach to medicines optimisation across
the whole organisation.
Level 2
The trust has rudimentary business and financial planning,
management, monitoring and reporting systems to manage clinical
risks & costs associated with medicines.
Level 3
There is an overarching medicines policy in place and all clinical
staff receive a copy or can access a copy as part of their
induction.
Level 3
The trust has robust business and financial planning, management,
monitoring and reporting systems to manage clinical risks &
costs associated with medicines.
Level 4
The is a comprehensive, overarching medicines policy in place and a
regular audit programme exists to assure compliance.
Level 4
The trust has robust business & financial planning, management,
monitoring & reporting systems to manage clinical risks &
costs associated with medicines. These are routinely shared and
discussed with commissioners.
Level 1
The trust does not have a chief pharmacist (or equivalent).
Level 1
There is no named lead board level Director for medicines
optimisation and medication error incident reporting and
learning.
Level 2
The trust has a chief pharmacist (or equivalent) responsible for
operational pharmacy management and service delivery.
Level 2
There is a named lead board level Director for medicines
optimisation and medication error incident reporting and
learning.
Level 3
The trust has a chief pharmacist who has trustwide responsibility
and is held accountable for medicines optimisation and
pharmaceutical services.
Level 3
There is a named lead board level Director for medicines
optimisation and medication error incident reporting and learning
and Board members are generally informed about medicines related
issues
Level 4
As per level 3 and reports directly to a named Executive Board
member eg. Medical Director, Director of Nursing.
Level 4
There is documentary evidence via Board minutes of active
participation by the named lead Director and Board discussion of
medicines optimisation & safety issues that impact on the
trust's business and its service users.
© NHS Improvement 2017. All rights reserved.
3butts: These details must be entered on the 'Title_Page'
worksheet.
&"Arial,Bold"&16Medicines Optimisation and Pharmaceutical
Services Framework &G
Page &P of &N
1.1
Safety Criterion 1 - Hospital pharmacy transformation planning
Criterion 2 - There is an executive level medicines policy group
for overseeing medication safety and policy development Criterion 3
- The management of medicines is underpinned by an overarching
medicines policy Criterion 4 - There is oversight and control of
clinical risks and costs associated with medicines Criterion 5 - A
Chief Pharmacist plays a leadin g role in medicines optimisation
Criterion 6 - The Trust Board and senior management are actively
involved in medicines optimisation 1 1 1 1 1 1
1.4
1.3
1.6
1.5
1.2
DOMAIN 2 - SAFE USE OF MEDICINES
Systems, processes and work practices are designed to prevent or
reduce the risk of harm to patients from medicines.
Indicator
Level
Saf 1.2
Saf 1.3
1
Criterion 3 - Medication errors and harm from medicines are
measured & lessons learned are routinely embedded in policies
and practice
Saf 1.4
1
Criterion 4 - The quality impact of cost reducing schemes involving
medicines or pharmacy services is routinely assessed and
monitored
Saf 1.5
1
Criterion 5 - Policies and procedures for the safe use of medicines
are in place
Saf 1.6
Total
6
Level 1
No evidence of a system to routinely monitor and review the safe
and secure handling of medicines to meet the clinical needs of
patients and legal and Regulatory requirements.
Level 1
No evidence that there is a formal system for medicines
reconciliation of medicines as recommended by national
guidance.
Level 2
Evidence the trust has an effective system to routinely monitor and
review the safe and secure use and handling of medicines to meet
the clinical needs of patients and legal and Regulatory
requirments.
Level 2
Evidence that there is a medicines reconciliation policy in place
and medicines reconciliation takes place for some patients.
Level 3
The trust has an effective system to monitor & review safe
& secure handling of medicines and a named pharmacist is
responsible for safe & secure handling of medicines. Regular
compliance audits undertaken.
Level 3
Evidence that there is a medicines reconciliation policy in place
and medicines reconciliation takes place for the majority of
patients within a specified time after admission.
Level 4
The Board receives regular audit reports on the the safe and secure
handling of medicines and takes steps to address shortcomings. The
Board is assured that it meets legal and Regulatory
requirements.
Level 4
Medicines reconciliation takes place for more than 80% of patients
within 24 hours of admission and actions are routinely followed up,
documented and communicated.
Level 1
Medication incidents are not routinely monitored & reported
across the trust. There is not a documented mechanism to enable
learning from medication incidents to be shared. Medication safety
officer not identified or not in post.
Level 1
No evidence that the impact on service quality of CIP, QIPP, CRES
or other cost saving measures related to medicines use and pharmacy
services are formally assessed.
Level 2
There is an effective system for identifying, monitoring, analysing
and reporting medication incidents across the trust. Evidence that
learning from medication incidents is routinely shared across the
trust. Medication safety officer identified.
Level 2
Cost reduction schemes (as level 1) involving changes to medicines
use or pharmacy services are devised and signed off by the Chief
Pharmacist (or equivalent).
Level 3
There is a robust system, which includes performance measures, for
routinely monitoring, reporting and embedding learning from
medication errors across the trust. Medication safety officer
identified and in post. Harm related to medicines is identified and
reported to the Board.
Level 3
Cost reduction schemes (as level 1) involving changes to medicines
use or pharmacy services are quality assessed and signed off by the
Chief Pharmacist and another senior Trust manager.
Level 4
Action plans to reduce medication errors are devised, implemented
and audited. Evidence that the Board is able to assure itself that
the trust complies with national "best practice" guidance for
medication safety through regular reports on learning arising from
incidents. Medication safety officer identified and in post.
Level 4
Cost reduction schemes (as level 1) involving changes to medicines
use or pharmacy services are quality assessed and signed off by the
Trust Medical Director or Director of Nursing. Quality impact is
monitored regularly and reported through governance
arrangements
Level 1
No evidence that the trust has a set of comprehensive policies and
standardised procedures to minimise the risk to patients from
medicines.
Level 1
No evidence of a policy for the safe use of unlicensed, ''off
label' or investgational medicinal products
Level 2
Evidence that the trust has comprehensive policies and standardised
procedures to minimise the risk to patients from medicines. This
includes policies for patient group directions and non-medical
prescribing.
Level 2
Policy for the safe use of unlicensed, ''off label' or
investgational medicinal products in development
Level 3
As level 2 and a clear description of the responibilities of all
staff involved in medicines procurement, supply, prescribing and
administration is available and included in staff appraisals.
Process for regularly reviewing all patient group directions is in
place.
Level 3
Policy for the safe use of unlicensed, ''off label' or
investgational medicinal products implemented for all patients and
regularly audited.
Level 4
As level 3 and evidence that compliance with medicines policies and
procedures is monitored routinely and reported through the trusts
integrated goverance system. All patient group directions are
up-to-date.
Level 4
Policy for the use of unlicensed, ''off label' or investgational
medicinal products. Evidence that all patients consent to the use
of such products and this is routinely recorded in their clinical
notes.
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&"Arial,Bold"&16Medicines Optimisation and Pharmaceutical
Services Framework &G
Page &P of &N
2.1
Safety Criterion 1 - Medicines are handled safely and securely
Criterion 2 - Medicines are reconciled routinely Criterion 3 -
Medication errors and harm from medicines are measured &
lessons learned are routinely embedded in policies and practice
Criterion 4 - The quality impact of cost reducing schemes involving
medicines or pharmacy services is routinely assessed and monitored
Criterion 5 - Policies and procedures for the safe use of medicines
are in place Criterion 6 - Unlicensed and 'off-label' use of
medicines 1 1 1 1 1 1
Safety - Developmental
2.2
2.4
2.3
2.6
2.5
DOMAIN 3 - EFFECTIVE CHOICE OF MEDICINES AND PATIENT OUTCOMES
Systems and processes help to deliver good clinical outcomes
through effective medicines optimisation supported by robust local
decision-making.
Indicator
Level
Eff2.1
1
Criterion 1 - There is an effective local decision-making process
for medicines use
Eff2.2
1
Criterion 2 - There are metrics for monitoring the cost and
quantity of medicines used
Eff2.3
1
Eff2.4
1
Eff2.5
1
Eff2.6
1
Criterion 6 - The trust has a published formulary for
medicines
Total
6
Level 1
No evidence that there is a clearly defined process for overseeing
and deciding on the medicines that are used within the trust.
Level 1
No evidence that there is regular review of the types of medicines,
quantity and cost of medicines used across the trust.
Level 2
Evidence that there is a drugs and therapeutics committee (DTC) or
equivalent local decision-making body for overseeing effective use
of medicines within the trust including new medicines.
Level 2
Evidence that the types of medicines, quantities and cost used by
individual directorates, wards or teams are reviewed
regularly.
Level 3
As level 2 plus the DTC has a formal business plan approved through
the integrated goverance process. The introduction and use of new
medicines is audited.
Level 3
Evidence that information on the types of medicines, quantities and
cost used by individual directorates, wards and teams are reviewed
regularly and sent to team managers.
Level 4
DTC monitors and regularly reviews implementation of its decisions
and takes action to address non-compliance. Evidence of active
engagement with commissioners
Level 4
Evidence that senior managers receive and act on information about
the types of medicines, quantity and cost used by their wards and
teams.
Level 1
There is no use of the Pharmacy and Medicines compartment of the
Model Hospital
Level 1
No evidence of a policy to support the judicious use of
antimicrobials and promote antimicrobial stewardship.
Level 2
Pharmacy and Medicines compartment of the Model Hospital accessed
infrequently (<1 access per month)
Level 2
Evidence of a specific policy to support the judicious use of
antimicrobials. Antimicrobial stewardship audit undertaken.
Level 3
Pharmacy and Medicines compartment of the Model Hospital accessed
regularly (at least 1 access per month)
Level 3
Trust antimicrobial policy contains specific recommendations on the
implementation of national "best practice" guidance (eg Start Smart
then Focus) and a lead pharmacist for antimicrobials is in post.
Evidence of active engagement across local health economy.
Level 4
Pharmacy and Medicines compartment of the Model Hospital accessed
routinely (at least 5 accesses per month) and used to drive service
improvements and choice of medicines
Level 4
As level 3 plus lead pharmacist has specific responsibility for
monitoring and auditing antimicrobial usage and is a formal member
of infection prevention and control committee (or equivalent).
Evidence that audit results influence use of antimicrobials.
Level 1
No evidence of a formal process for implementing relevant NICE
technology appraisal guidance.
Level 1
Level 2
Evidence of a process for implementing relevant NICE technology
appraisal guidance within 90 days of publication.
Level 2
Level 3
Evidence of an effective mechanism for monitoring and reporting on
the implementation of NICE technology appraisal guidance and taking
action where poor compliance is identified
Level 3
Comprehensive formulary developed and published in a publically
accessible format. Evidence that commisioners have been actively
engaged in development of the formulary.
Level 4
Level 4
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&"Arial,Bold"&16 Medicines Optimisation and Pharmaceutical
Services Framework &G
Page &P of &N
3.1
Safety Criterion 1 - There is an effective local decision-making
process for medicines use Criterion 2 - There are metrics for
monitoring the cost and quantity of medicines used Criterion 3 -
Use of Model Hospital Criterion 4 - The prinicples of antimicrobial
stewardship are implemented Criterion 5 - NICE guidance is
implemented effectively Criterion 6 - The trust has a published
formular y for medicines 1 1 1 1 1 1
3.2
3.4
3.3
3.6
3.5
DOMAIN 4 - THE PATIENT EXPERIENCE
Patients (and carers) are involved in decisions made about their
medicines and supported to take their medicines as intended
Indicator
Level
PE6.1
1
Criterion 1 - There is a policy and suitable facilities for the use
of patient's own medicines
PE6.2
1
Criterion 2 - Patients who are competent to do so can self
administer their medicines
PE6.3
1
Criterion 3 - Patients are supported to take their medicines as
intended
PE6.4
1
Criterion 4 - A duty of candour is applied to harm from
medicines
PE6.5
1
PE6.6
1
Criterion 6 - Transfers of care occur according to national 'best
practice' guidance & pharmaceutical care plans
Total
6
Level 1
The trust does not have a policy for use of a patient's own
medicines and there are no/limited facilities in patient areas for
the safe storage and ready access to patient's own medicines
Level 1
The trust does not has a policy to enable patients to be assessed
as competent to administer their own medicines.
Level 2
A policy for use of patient's own medicines is in development and
there are facilities for the safe storage of patient's own
medicines in some clinical areas.
Level 2
Level 3
A policy for use of patient's own medicines is in place and there
are facilities for the safe storage of patient's own medicines in
most clinical areas.
Level 3
Self administration policy and assessment scheme in place and some
patients assessed as comptetent to do so are able to administer
their own medicines
Level 4
A policy for use of patient's own medicines is in place and audited
regularly and there are facilities for the safe storage of
patient's own medicines in all clinical areas.
Level 4
Self administration policy and assessment scheme in place and all
patients assessed as competent to do so are able to administer
their own medicines
Level 1
No evidence that patients have access to and are helped to
understand information about their medicines
Level 1
The trust does not have a mechanism for monitoring, reporting and
informing patients (or their carers) when they have suffered harm
as a result of a medicines-related issue eg. adverse reaction,
medication error etc.
Level 2
Level 2
A policy to include a duty of candour with respect to
medicines-related incidents is in development.
Level 3
Patients are provided with written and verbal information about
their medicines.
Level 3
Duty of candour policy in place and staff are trained to ensure
effective implementation. Duty of candour requirement included in
staff job descriptions.
Level 4
Evidence that there is a mechanism to ensure that patients have
understood the information that has been provided and know how to
get help with their medicines should they need.
Level 4
Evidence that patients are routinely informed when they have
suffered harm as a result of a medicines-related issue. Chief
Pharmacist routinely involved in investigation of all incidents
leading to harm.
Level 1
The trust does not routinely monitor omitted and delayed
doses.
Level 1
The trust does not have a process that complies with NICE guidance
[NG5] for ensuring that medicines information is communicated
accurately and efficiently following a hospital episode
Level 2
Level 2
The trust has a manual process that complies with NICE guidance
[NG5] for ensuring that medicines information is communicated
accurately and efficiently following a hospital episode
Level 3
Mechanism for monitoring omitted and delayed doses implemented and
audited. Results are reported to service managers.
Level 3
The trust has an electronic process that complies with NICE
guidance [NG5] for ensuring that medicines information is
communicated accurately and efficiently following a hospital
episode
Level 4
Mechanism for monitoring omitted and delayed doses implemented and
audited. Trust can provide evidence that it is actively taking
steps to make improvements.
Level 4
As level 3 and implemented in all wards or departments and that
this is regularly audited, including feedback from relevant
stakeholders (eg GPs, care homes) plus ability to include the
community pharmacy of the patient's choice when this is
appropriate
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&"Arial,Bold"&16Medicines Optimisation and Pharmaceutical
Services Framework &G
Page &P of &N
4.1
Safety Criterion 1 - There is a policy and suitable facilities for
the use of patient's own medicines Criterion 2 - Patients who are
competent to do so can self administer their medicines Criterion 3
- Patients are supported to take their medicines as intended
Criterion 4 - A duty of candour is applied to harm from medicines
Criterion 5 - Patients receive the medicines that they need
Criterion 6 - Transfers of care occur according to national 'best
practice' guidance & pharmaceutical care plans 1 1 1 1 1
1
4.2
4.4
4.3
4.6
4.5
Environment