Making Best Use of Inpatient Beds Project - National Priority Projects 07/08 Summary Document

NHSNHS Improvement

HEART

STROKE

CANCER

DIAGNOSTICS

Heart Improvement

Making Best Useof Inpatient BedsNational Priority Project

Making Best Use of Inpatient Beds is a national priority project of the Heart ImprovementProgramme focusing on a variety of approaches to reducing avoidable inpatient bed days.

The project ran over the period June 2007 to March 2008.

Key learning from the project is available in the following formats:

1. Project summaryThis document includes a description of the national project, supporting informationgained throughout the period and key learning from the project.

Project summaries include issues to address, actions taken and key outcomes from eachof the 12 projects participating in this work.

Contact details are included to provide additional information with regular updatesavailable on the website.

2. Presentations at National Conference 8 May 2008Copies of presentations from the speakers at the conference are available on the website:www.improvement.nhs.uk/heart

3. Web based resourcesProject team members found this a very useful opportunity to share learning across thedifferent project areas. These are now available to share on the improvement website at:www.heart.nhs.uk/priority_projects

These are categorised into four chapters:1. Admission avoidance and timely readmission2. Improving inpatient stay3. Hospital/community interface4. End of Life Care

Content includes:• Case studies and improvement stories• Protocols, procedures• Operational policies• Job descriptions• Business cases• Vox pops and video clips

Additional information will be included as it becomes available and existing materialsregularly updated.

Further information and updates email: [email protected]

3Making Best Use of Inpatient Beds

ContentsIntroduction

Key Findings

Project Summaries

Plymouth Clinical Assessment Service (PCAS)

Heart Failure - Rotherham

Central Manchester Left Ventricular Systolic DysfunctionProject in Primary Care

West Hertfordshire Brain Natriuretic Peptides (BNP) inSecondary Care Project

Reducing Length of Inpatient Stay for Myocardial Infarctionand Acute Coronary Syndrome Patients - Lancashire

Cardiac Surgery Inter-hospital Transfer Project - North West London

Continuing Development of Cardiac Services in North BristolNHS Trust – Southmead Hospital and Frenchay Hospital

Reducing Non-elective Arrhythmia Inter-hospital Transfer Waits Throughthe Implementation of an Internet-based Referral and TransferManagement System - North Central London

Heart Failure Early Discharge - North West London

Reducing Avoidable Hospital Admissions by Providing CommunitySupport for Patients Referred Through the Single Contact AccessNomination (SCAN) - Sheffield

Integrated Heart Failure Service Across All OrganisationalBoundaries - Surrey

Making Best Use of Inpatient Beds - Sussex

Project Teams and Participating Sites

4

6

11

12

13

15

17

18

20

21

22

24

26

27

28

29

4 Making Best Use of Inpatient Beds

Admission to hospital is essential forpatients requiring surgery, some invasiveinvestigations and stabilisation of medicalconditions.

Following on from the work oninterhospital transfers1 there are still somepatients waiting for unnecessarily longperiods as an inpatient for surgery andelectrophysiological procedures. This is bothclinically suboptimal for the patients andinefficient in terms of avoidable bed days.

Waiting unnecessarily long periods forinpatient procedures and regular admissionsto hospital can be demoralising and stressfulfor patients, their families and the staff whocare for them.

The recent NICE Commissioning Guidehighlights evidence to support effectivemultidisciplinary specialist services forpeople with chronic heart failure. These canhave a positive effect on patients’ lifeexpectancy and quality of life and help toreduce recurrent hospital stays by 30–50%2.

The Operating Framework requiresorganisations to reduce these avoidable beddays by putting systems in place to supportpeople with long term conditions in thecommunity.

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To improve health outcomes forpeople with long-term conditionsby March 2008 offering apersonalised care plan for themost at risk vulnerable people;and to reduce overall emergencybed days by 5% by 2008,through improved carein primary care and communitysettings for people withlong-term conditions.

PSA12a3: Emergency bed days

The NHS Heart Improvement Programmeestablished a national project to workwith a number of local project teams.

The aims of this work were:

• To reduce the number of avoidableemergency bed days

• To reduce overall length of stay• To develop alternative modelsof care.

Twelve projects across the country tookpart in this work and from the outset werecognised that many of the issues werecomplex and that there was no singlesolution.

1Making moves Heart Improvement Programme April 2006 www.improvement.nhs.uk2Commissioning a heart failure service for the management of chronic heart failure www.nice.org.uk3Operating Framework 2007/08

Introduction

www.improvement.nhs.uk/heart

The areas of work broadly divided into thefollowing:

• Prevention of admissions by improveddetection and management in thecommunity

• Redesign of the inpatient pathway• Reduction in the frequency andurgency of readmissions

• End of life care.



Key Findings



All 12 projects had very different approaches tomaking best use of inpatient beds and, as such,were able to look at a variety of ways to achievetheir results. The three areas addressed canbroadly be defined as cardiology services, heartfailure services and inter-hospital transfers. Thefindings include:-

Cardiology services• GPSI triage of cardiology referrals to effectivelymanage patients led to a 66% reduction inthe referrals requiring cardiologist input insecondary care

• Diagnostic testing performed and reported onin less than ten working days using ‘Choose &Book’

• Transferring services from two hospitals to oneled to an average reduction in length of stay(LoS) for myocardial infarction (MI) and acutecoronary syndrome (ACS) patients of fourdays.

Heart failure services• BNP testing used to 'rule out' heart failurereduced inappropriate medication andrequests for echo tests. Referral tocardiologists dropped by 30%

• BNP testing increased the percentage ofpeople discharged from hospital with adiagnosis of heart failure confirmed by echofrom 22% to 75%

• Electronic reporting of results reducedduplication of tests

• Re-configuration of services enabled areduction of heart failure admissions from 65to 21 per month and reduced length of stayfrom 8.59 days to 4.5 days

• An audit indicated that optimal prescribingand titration of beta blockers could reduceadmissions by 142 per year. This equates to a16% reduction. The guidelines have beencirculated to all GPs in one PCT

• A whole system integrated approach to heartfailure cut admissions by more than 50%for people with heart failure in primarydiagnosis position. The length of stay reducedby four days from 11 to seven, whichrepresents a nearly 40% decrease and a 20%reduction in the number of days waiting forecho.

Inter-hospital transfers• Treat and return policy implementation led toa reduction of an average by eight days stayfor ACS patients awaiting angiography

• Prioritisation and risk stratification agreementreached for targets that form part of thecommissioning framework with a resultantreduction in mean length of stay admission tosurgical transfer of 3.3 days per patient, andfrom work-up to surgical transfer of 7.25 perpatient

• Implementation of a web-based transfermanagement system for electrophysiologypatients showed a 55% reduction in total dayswaiting from the baseline.

ChallengesThis work started in June 2007 and wasambitious from the outset. Below are some ofthe key challenges:

• The complexity of the issues presenting atlocal level required good information tounderstand fully the issues that face serviceproviders. Robust systems of data collectionand analysis were required and the initiationof such systems was slower than originallyanticipated.

• A variety of approaches to patient experienceacross the projects included surveys, patientdiaries and discovery interviews. The uptake ofvarious methods was encouraging; howeverachieving meaningful patient involvementcontinues to provide a challenge and will be akey element of future work.

• Demonstrating return on investment at a timeof early implementation of payment by resultsand development of the Improvement Systemgives added impetus to ensure that baselinedata and methods of data collection andanalysis are in place at the time of projectinception. The nine month timelineattributable to the projects has largely beenable to go some way to highlight and deliverreturn on investment and it is anticipatedthat this will gain momentum in futuremonths and years.

• Re-configuration at local level provedchallenging at times with competing agendas.

Key Findings



Baseline:

April

May

June

Average

Project

July

August

September

October

November

December

January

February

Total beddays saved

Mean LOS

8.59

8.81

5.36

7.59

4.3

5.44

3.15

6.61

4.17

7.08

6.92

4.52

Admissions

65

66

64

65

75

58

20

23

23

30

24

21

Reduction

3.29

2.15

4.44

0.98

3.42

0.51

0.67

3.07

Bed days saved

122

54

89

22

79

13

16

64

623

Bed day cost £

101

ROI £

62962

Return on Investment (ROI)The development of NHS tariffs is ongoing andwhere possible projects have been encouragedto show ROI as an outcome measure. However,the limited unbundling of diagnostics and therelative insensitivity of tariffs at this stage oftheir development to the effect of reducinglengths of stay has been a limiting factor inclearly identifying financial savings.

The following table sets out an example of ROIfrom one of the projects. The project aim was tofocus on emergency admissions and to identifyand reduce avoidable aspects of the patient stayand thereby to reduce the overall length ofhospital stay. A calculated cost per bed day of£101 was based on the average of each nonelective spell tariff for heart failure (E18 and E19)divided by their respective non elective stay trimpoint days to demonstrate an indicative returnon investment for each bed day saved againstthe project baseline.

The indicative savings shown may accrue to ahospital provider but are not reflected in areduction of cost to the commissioner throughthe tariff or contract mechanisms as theycurrently exist. Calculation of future tariffs willreflect changes in patient care.

These calculations are offered as an indicativeshort term saving and one which may be usedto stimulate local dialogue with the aim ofdeveloping appropriate arrangements to re-invest savings as appropriate to improve care ofpatients along the whole pathway. This ispremised on the understanding that thedevelopment of tariffs is not designed to preventimprovements in care from being realised.

The Heart Improvement Programme urges youto learn from this important work and discusslocally how you might apply some of thesolutions to your own environment for thebenefit of local cardiac patients.



Key learningWith a range of clinical presentations, includingheart failure, acute coronary syndrome andthose awaiting surgical and electrical procedures,by far the largest gain and the most challengingwas the heart failure group. Project teamcommitment has been impressive with feedbackhighlighting the positive effects of peer supportand national steerage.

Of crucial importance is having an integratedapproach across the pathway of care. For cardiacsurgery patients explicit communication isrequired, particularly between cardiology andcardiac surgery departments, and betweensecondary and tertiary care. Heart failure servicesrequire collaborative approaches particularlybetween community and secondary care,especially between nursing staff, and elderlymedicine and cardiology. This underpins theopportunity for a co-ordinated and team basedmanagement style promoting a smoothertransition across organisations, departments andservice providers for patients.

The development of a supportive infrastructurein primary care is essential when addressingadmission avoidance, early discharge andreduction in readmissions. Commissioningexpertise within the national team and locallyhas been beneficial to participating projects inthis regard.

Other aspects includes:• Good understanding of the complexity of allthe issues, through effective base-liningactivities and ongoing data analysis isessential

• Achieving earlier diagnosis ensures thatpatients are on the right pathway of care atan earlier stage to achieve improved clinicaloutcomes

• Increasing effective, appropriate and earlymedication, up-titrating and achievingmaintenance dose, promotes symptom controland prevents emergency admission,particularly for heart failure patients

• Supporting partnership between patients andhealth professionals, and where appropriatepatient self management is necessary, toachieve patient centred care

• Using a systematic approach for booking andtransfer of patients helps reduce avoidabledelays in the system

• To help patients shape future services andchoice, their involvement is necessary from theoutset

• Trust between organisations needs to bedeveloped to help avoid unnecessaryduplication of diagnostic tests, particularlywhen a patient needs to move betweenservice providers

• Education and training are crucial to theimplementation of change

• Greater flexibility of workforce and changingroles can increase capacity and effectiveness ofservice provision

• A greater focus on good working relationshipsacross the organisational interface will lead toa reduction in frequency of admissions andreadmissions and will promote seamless care.





Moving forward/next stepsThe online resource has been set up toencapsulate useful information. This is a dynamictool for accessing a huge variety of usefulresources that will be continually developingfollowing this initial launch and will provide anopportunity for fast tracking innovative working.

The next round of priority projects will includeheart failure and surgery and will start in thesummer of 2008 until 2010.

Heart failureSome of the projects above will continuethrough to the next stage of their work planwhilst other new projects will be recruitedthrough the process of application. In particular,we intend to work with networks andorganisations on the issues below:

• Prevalence and incidence• Diagnosis• Treatment• Maintenance• Supportive and palliative care.

Underpinning the applications, we areparticularly interested to look at issues affectingequity and access, information, audit andcoding, patient experience and workforce.

SurgerySurgical work will focus on the whole pathwayof care including elective and non electivemanagement. This will bring together learningfrom the 18 week pathway, making best use ofinpatient beds and the interhospital transferprojects.

Before discussing the specific projects it isimportant to acknowledge the hugereductions in inpatient bed days realised todate, for example through reducingunnecessary waits for urgent interhospitaltransfers for acute coronary syndrome andpathway redesign to meet elective targets.Generally speaking the remaining work ismore challenging due to the competingpressures on elective and non elective servicesand the increasing co-morbidity of patients.

The NHS Heart Improvement Programmeacknowledge that NHS staff want systems towork seamlessly to help them provide the bestpossible care for patients and that NHSorganisations need efficient and effectiveprocesses to make the best use of availablebeds.

For more information and to get involvedplease contact [email protected]


Project Summaries



Issues to addressGeneral Practitioners’ with a Specialist Interest(GPSI) in Coronary Heart Disease (CHD) to triageall cardiology referrals in order to ‘stem the flow’of referrals into the acute sector by sharing anddiversifying pathways, and provide more servicesin the community e.g. NT Pro Brain NatriureticPeptides (NT Pro BNP) to:

• Increase choice of provider, with quicker accessto diagnostic tests and a quicker diagnosis ofthe disease

• Enter the patient on the right pathway fortheir care, see the most appropriate person fortheir care and be given medicinesmanagement therapies much sooner toimprove their prognosis

• Agree clearer pathways across organisationalboundaries

• Set processes up electronically to ensure apaperless trail to inform the referral totreatment time for the 18 week pathway

• Ensure speedy access to cardiologists forurgent cases from CHD GPSIs.

Actions taken• GPSIs were approached to ensure theiragreement and a small scale triage study wasinstigated to determine additional GPSIcapacity required for triaging referral letters(one hour of additional capacity per week wasrequired for the GPSIs to perform a turnaround time of less than five days).

• Clear outcomes and priorities of thesemeetings were established, delivered andevaluated by an inclusive PCAS project group.

• Cardiologists met monthly with the GPSIs fortutorials which also enabled speedier accessfor urgent referrals.

Key results/outcomesA pilot scheme was implemented (September2007) of the Plymouth clinical assessment service(PCAS) which showed:

• Only 34% of patients actually requiredreferral to a cardiologist

• All patient's are booked through Choose& Book and all diagnostic tests areperformed and reported on in less than10 working days

• Results and reports are sent electronically tothe GPSIs and are available to cardiologists

• Those requiring clinical assessment from theirtest result are booked into a communitycardiology service and offered either amedicine management plan, referral to theheart failure nurse or are referred back to theirGP for follow up.

BNP - NT pro BNP has been used to 'rule out'heart failure since April 07. A total of 400patients have been assessed using the test andfound that:

• 30% of patients were identified as 'nothaving heart failure' reducinginappropriate medication, request forECHO tests and referral to cardiologists

• early diagnosis has ensured patients aregiven appropriate medicines managementtherapies which may translate into betteroutcomes.

All Plymouth GPs now use Choose & Book for allcardiology referrals and thus capture thePlymouth population within the ClinicalAssessment Service. This will significantlyincrease current referral figures and capacityplanning is underway to meet the demand.

Contact informationChrissie BennettEmail: [email protected]

Plymouth Clinical Assessment Service (PCAS)Plymouth NHS Hospital Trust, Plymouth Teaching Primary Care Trust,Private provider: Express DiagnosticsPeninsula Cardiac Managed Clinical Network (PCMCN)



Issues to addressRotherham has a higher than national incidenceof heart failure (HF) coupled with a high rate ofemergency admissions and readmissions forpeople with a primary diagnosis of HF. The mainaim of this project was to achieve a 5%reduction in bed days for HF patients and todevelop a care package for people with threeor more admissions per annum.

• Avoidance of emergency admissions forpatients with heart failure – one of the highestcauses of admissions in Rotherham

• Getting patients onto the appropriate pathwayof care

• To ensure that admissions are timely andappropriate

• Education of staff in both secondary andprimary care

• Support and joint working between secondaryand primary care to improve the patientpathway

• Improved communication across the wholepatient pathway

• Reduction in bed days for heart failurepatients.

Actions takenA time limited multidisciplinary project groupwas established to oversee the project.

An admissions audit was performed from patientrecords to identify patients with three or moreadmissions. A readmission evaluation form wasdeveloped including admission source,medication on admission and noting changesmade, diagnostic tests performed and dischargedetails. This baseline audit, carried out on 2006data, identified 53 patients in this category.

Beta blocker prescribing rates were recognisedas a significant indicator of successful patientcare and a correlation was identified fromresearch evidence between the increased use ofbeta blockers in HF patients and a correspondingreduction in hospital admissions. An audit ofbeta blocker prescribing was carried out across39 practices using practice registers in April

2007 to identify the scope for training anddeveloping primary care teams, to optimise theirprescribing practice and reduce the need forhospital admissions. This highlighted significantvariation between primary care practices with anoverall low incidence of HF patients on betablockers licensed for HF and on the appropriatedose.

As a result of this work, titration guidelines havebeen developed and disseminated widely toprimary care teams. These are also available onthe PCT intranet.

A series of protected learning time events aimedat GPs, practice nurses and other primary carestaff were held. This forms part of a rollingprogramme of training and education.

The beta blocker prescribing audit waspresented at the cardiovascular localimplementation team (CVD LIT) meeting, andalso to primary care staff at the ProtectedLearning Time events in January 2008.

The main finding was that an indicated 142admissions per year could be avoided byoptimal prescribing and titration of betablockers. This equates to a 16% reductionin HF admissions.

A six month telemedicine pilot for heart failurepatients will be completed in August 2008 whena full evaluation will be carried out by SheffieldUniversity. The pilot will compare the effectsand outcomes of 30 patients, trained andequipped to download vital signs data daily viathe telephone line to a health care provider whowill alert the GP or nurse when changes aredetected, with those of a control group. The aimis to encourage patient self management andreduce readmission rates and the number ofvisits by specialist HF nurses.

Heart FailureRotherham PCT and Rotherham Hospital NHS Foundation TrustNorth Trent Network of Cardiac Care


Key results/outcomes• Two GP practices are due to commence a pilotlooking at ‘Enhancing the use of beta blockersin heart failure patients – preventing non-elective admissions and out patient referrals tosecondary care.’ It will be reviewed by the PCTin October 2008.

• The titration guidelines are currently beingprinted into booklet format and each GP willreceive a copy.

• Protected learning time events were organisedfor GPs, focused on CVD, and many of theworkshops were targeted at heart failure.

• GP practice and community staff are beingkept up to date with evidence basededucation and training

• This is part of a rolling programme of work forpatients with heart failure and will continue oncompletion of the project.

Contact informationAnn BainesEmail: [email protected]




Issues to addressThe aim of the project was to establish a localenhanced service (LES) in primary care for peoplewith left ventricular dysfunction (LVSD) to assessimpact on hospital admissions, length of stayand patient experience.

A staged approach was agreed to:

• Identify patients on practice systems with anaccurate diagnosis of LVSD

• Design and implement an educationprogramme for primary care clinicians toensure a high level of knowledge and skillamongst participating practices

• Fully implement a LES to support specialistservices for people with LVSD and to raise thelevel of care delivered to them in primary care.

Actions taken• As part of the LES, all 41 practices withinCentral Manchester were asked to audit theirpractice registers for patients with LVSD

• Data was collected from all practices withinCentral Manchester as well as practicesparticipating in the LES using the TacticalInformation System (TIS). This included lengthof stay (LoS) and admission/readmission rates

• Development of a training programme for theenhanced service for LVSD to provideparticipants with the knowledge & skills basesufficient to provide an enhanced service tothese patients

• A key component of the educationprogramme focused on patient and publicinvolvement. A pack was provided to staffwith useful references to follow up and teamsproceeded with their chosen methodologyover the course of the project, targetingpeople appropriately from their heart failureregisters and utilising the cardiac network forsupport.

Key results/outcomes1. Audit of practice registersOut of the 41 GP practices in the central hub ofManchester PCT, 29 practices responded.

Below highlights some of the key results:

Confirm the diagnosis of those patients withread code G58• 66% of patients have their diagnosisconfirmed by echocardiography

•12% of patients are awaiting anechocardiogram to confirm their diagnosis

Establish how many of these currently beingfollowed up in secondary care could bemanaged in the practice•There are potentially another 100 patients fromthe practices that responded that could havetheir follow up in primary care

Identify the number of new patients diagnosedin the last year and consequently require up-titration of their medication• Last year there were 95 new patientsidentified with a further 12 awaitingcardiology assessment

• Out of these, only nine were followed up andup-titrated in primary care, potentially leavinga possible 98 patients that could have beentreated in primary care.

2. Data collection from Tactical InformationSystem (TIS) - Data at the end of tenmonthsDue to the two month time lag between activityand data collection, the March ‘08 data was notavailable at time of publication.

This data will be incorporated onto the GreaterManchester and Cheshire website atwww.gmccardiacnetwork.nhs.uk in May 2008.

Central Manchester Left Ventricular Systolic Dysfunction Project in Primary CareManchester Primary Care TrustGreater Manchester and Cheshire Cardiac Network



3. Educational programme for the enhancedservice for left ventricular systolicdysfunctionThe content for this programme was developedby GPSI working closely with the Professor ofCardiology from the local tertiary centre and histeam.

4. Patient involvementTwo practices are using ‘Discovery Interviews’ togain insight into the patient experience. This isbeing utilised to shape future developments asper local and national guidelines. Other practiceswill be required to involve patients and this isbeing followed up.

Contact informationCaroline HewittEmail: [email protected]



Organisations involved• Hemel Hempstead General Hospital (HHGH)• Watford General Hospital (WGH)

Issues to addressAssessing the effect of introducing urgent BrainNatriuretic Peptides (BNP) testing at one site(Hemel Hempstead General Hospital) andcomparing this to a neighbouring site whichdoes not perform BNP (Watford GeneralHospital):

• Identifying patients with suspected heartfailure

• Confirming diagnosis earlier• Getting on to heart failure pathway (or other)earlier

• Reducing in-patient echocardiograms• Increasing percentage of patients with primaryheart failure discharge diagnosis confirmed byecho

• Reducing length of stay (LoS).

Actions takenAt Hemel Hempstead General Hospital (HHGH):• Negotiated with the pathology lab to dourgent BNPs (result within 2 hours) forbreathless patients being admitted with aquery cardiac or definite cardiac cause for theirbreathlessness

• Informed consultants and trained juniordoctors in the use of BNP

• BNP available from November 2007• Organised for Pathology to send copies of BNPresults to heart failure specialist nurse for herto visit all patients with a positive result toensure echo and cardiology follow up

• Monitored BNP usage.

At both Hemel Hempstead General Hospital(HHGH) and Watford General Hospital (WGH)• Organised for data collections through IT• Baseline audits in Sept/Oct• Follow up audit in February 2008 andcollected/analysed data in March 2008.

Key results/outcomes

West Hertfordshire Brain Natriuretic Peptides (BNP) in Secondary Care ProjectWest Herts Hospital TrustBedfordshire and Hertfordshire Heart and Stroke Network

Before introductionof BNP

Mean LoS for heartfailure primarydiagnosis in thethree months priorto BNP:

• HHGH 6.8 days• WGH 5.4 days

Median LoS forheart failure primarydiagnosis in thethree months priorto BNP:

• HHGH 2 days• WGH 4.3 days

Number of IP echoesin HHGH: 48

Percentage of patientswith HF diagnosis ondischarge withdiagnosis confirmed byecho: 22%

After introductionof BNP in HHGH

Mean Los for heartfailure primarydiagnosis first 3months with BNP atHHGH:

• HHGH: 4.6 days(down 2.2 days)

• WGH: 5.6 days(up 0.2 days)

Median LoS forheart failureprimary diagnosis inthe three monthswith BNP in HHGH:

HHGH: 1.6 days(down 0.4 days)with BNPWGH: 5.1 days(up 0.8 days)

Number of IP echoesin HHGH Feb 08: 68

Percentage of patientswith HF diagnosis ondischarge withdiagnosis confirmedby echo: 75%

This interim report demonstrates a reduction inboth mean and median length of stay at HemelHempstead General Hospital (HHGH), and aslight increase at the neighbouring hospital site,although the statistical significance has not yetbeen assessed. The results so far indicate thatthis has not reduced the number of inpatientechos at this site, however the number ofpatients discharged with a diagnosis of heartfailure on discharge confirmed by echo hasincreased from 22% to 75%.

Contact informationCandy Jeffries:Email: [email protected]



Issues to addressEast Lancashire Hospitals Trust consisted of twomain District General Hospital sites 15 milesapart, serving a population of 500 000 people.The trust had a disparate cardiology service,consisting of 45 dedicated cardiac ward bedsand 12 coronary care beds split across the twosites, with two cardiologists at Burnley, and twoat Blackburn, one of whom was a locum whoworked solely in the cardiac catheter lab. Therewas no cardiology on call service, and thecoronary care unit did not come under themanagement auspices of the cardiologists.

Patients who attended with MI were admittedonto a ward under the general physician of theday, rather than a cardiologist; and somepatients with ACS would complete theirinpatient stay without seeing a cardiologist atall. The catheter lab, based at the Blackburn site,only performed procedures on ‘cold’ electivepatients. Acute ACS patients were referred tothe tertiary centre, remaining as in patients untilthe angiography had been done. The averagewait for transfer to the tertiary centre was 15days, but on occasion the wait could be as longas 21 days.

Actions taken• Mapping of MI and ACS care pathways• Baseline information for the previous 12months of MI and ACS data was obtainedfrom healthcare resource groups (HRG).Prospectively, data was analysedmonthly in relation to length of stay,readmission rate and bed days

• A flow tool that measured throughputthrough beds was obtained from critical care.The flow tool was implemented on coronarycare at both sites one month prior to themove, and then was used to monitor activityuntil 31 December

• All cardiology inpatient services centralised onto one site

• Treat and return policy instigated with tertiarycare centre for acute ACS patients. Thismeant that patients needing urgentangiography were identified to the tertiarycentre, taken for the procedure in a dedicatedcardiac vehicle once the slot was available, andreturned to point of origin afterwards, withoutbecoming a tertiary centre inpatient. A webbased ‘whiteboard’ referral system wascreated to facilitate this process

• Three interventional cardiologists recruited(making a total of six cardiologists in total)

• Instigated 24/7 cardiology on call service• Daily consultant ward rounds on cardiologywards, coronary care and medical admissionsunit (MAU). MAU referral guidelines werecreated by the cardiologists to identify andaccelerate referral of appropriate patients

• Instigated a pacemaker implantation service• Catheter lab activity expanded to include lowrisk inpatients. Balloon pump policy created,training instigated, and ‘dummy run’transfers trialled.

Reducing Length of Inpatient Stay for Myocardial Infarction (MI)and Acute Coronary Syndrome (ACS) PatientsEast Lancashire Hospitals NHS TrustLancashire and South Cumbria Cardiac Network



Average LOS MI/ACSinpatients (days)

10

6

Average length of stayreduced by 4 days

LOS ACS patients awaitingangiography (days)

15

7

Average length of stayreduced by 8 days

Number of BedsCCU Ward

12 45

10 26

19 cardiologybeds removed

Baseline position

Position afterimplementation

Notes

Key results/outcomes

Contact informationJennifer WattsEmail: [email protected]



Issues to addressIn July 2007 it became apparent that significantdelays were occurring for inpatients requiringurgent transfer from a District General Hospital(DGH) into a tertiary centre for a surgicalprocedure. The reasons behind these delayswere complex and varied, and related to bedpressures, access to diagnostics and also towork-up procedures. In July 2007, the web-based Inter-Hospital Transfer (IHT) systemshowed that the average wait from admission totransfer for an urgent inpatient surgical referralin North West London was 18 days. The projectwas designed to address these issues andfocussed on Ealing NHS Trust and the tertiarycentres it refers patients into (see above).

Actions takenThe project team looked at the entire patientpathway for urgent surgical inpatients andidentified bottlenecks and agreed actions totake to address these issues. These bottlenecksfell into three main areas:

1. Pre-operative work-up2. Patient referral/tertiary care delays3. Clinical prioritisation and risk scoring

Three project meetings were held at which aims,approaches and actions were agreed. Actionswere undertaken outside the meeting in variousareas:

• Development of a protocol for cardiothoracicsurgical work-up for patients to improveinterhospital transfer to a tertiary care centre -Ealing NHS Trust

• Definition and agreement of standardisedsurgical work-up criteria

• Clinical prioritisation and risk scoring• Audit of tertiary care bottlenecks and delays• IHT system amended to facilitate cardiacsurgery work-up criteria.

The network board was regularly updated onthe project’s progress and key issues wereagreed there as appropriate.

Key results/outcomesTransfer targetsMeetings have taken place and agreementreached that the targets listed below will formpart of the commissioning framework for NorthWest London. This is a significant step towardsensuring that the aims of the project are met,and that urgent surgical patients waiting fortransfer can go to the centre with the shortestwaiting time.

The targets agreed state that:1. 100% of high risk patients needing

cardiac surgery should have beentransferred, and received their surgery,within five days of the request for a fully‘worked-up’ patient to be transferred

2. For intermediate risk patients, 90%should be transferred and have theirsurgery within five days

3. The risk scoring system devised andapproved by the North West LondonCardiac Network should be utilised

4. The North West London CardiacNetwork’s web-based transfer systemshould be fully utilised by all trusts inNorth West London to monitor thistarget

5. The web-based transfer system will beused to flag the patient for transfer toanother trust within North West Londonif a patient cannot be transferred andoperated on within five days.

Cardiac Surgery Inter-hospital Transfer ProjectEaling Hospital NHS TrustImperial Healthcare NHS Trust (incorporating Hammersmith and St Mary’s sites)The Royal Brompton and Harefield NHS TrustNorth West London Cardiac Network

Transfer times from Ealing:A comparison of eight week audit data collectedat the beginning and end of the project showsthat the following savings are being made:

Mean wait fromadmission tosurgical transfer

Mean wait fromwork-up completeto surgical transfer

3.3 days savedper patient

7.25 days savedper patient

Contact informationJason Antrobus.Email: [email protected]



Issues to addressSouthmead and Frenchay Hospitals serve thepopulation of Bristol and the surrounding area,supported by the Royal Bristol Hospital TertiaryCentre which is only a few miles away. There arecurrently two inpatient wards that receivecardiac patients, supported by a coronary careunit. It became apparent that patients admittedwith a primary cardiac diagnosis were subject toa prolonged length of stay; that once admittedpatients transfer to a cardiac ward was delayed;and that less than 60% were transferred to thecare of a cardiologist. In addition, targets for thetransfer of appropriate patients to the tertiarycentre were not being achieved, and it wasbelieved that opportunities to prevent patientreadmission after discharge were not being met.

At the same time, there was a need to developappropriate pathways and guidelines for theimminent opening of a new catheter lab at theFrenchay site.

Actions taken• Developed and piloted a cardiac support nurserole which actively pulled cardiac patients onto the cardiac wards

• Developed a patient journal for cardiacinpatients to records their thoughts regardingtheir stay

• Operational policy and guidelines for the newcatheter lab were formulated

• Staff were very kindly supported and trainedby national specialist units

• Patient tracking system implemented• Catheter lab opened on 18 February 2008,providing angiography for low risk ACSinpatients, a pacemaker insertion service andPCI

• A second catheter lab is due to be openedimminently

• A further cardiology consultant is due to jointhe team in May

• Preparing for BCIS accreditation.

Key results/outcomesUnfortunately, an outbreak of Noravirusinfection resulted in ward closures during thecourse of the project, which had an impact onthe performance of the cardiology service.However, despite this, the figures show that theimprovements that had been made in thesystem managed to prevent the performance ofthe service from deteriorating significantly frombaseline levels.

In its first month, the catheter lab has seen andtreated 100 patients. Further developments andthe continuation of this work are expected toproduce significant positive impacts on thecurrent situation.

Contact informationNicola HughesEmail: [email protected]

Continuing Development of Cardiac Services in North Bristol NHS Trust –Southmead Hospital and Frenchay HospitalAvon, Gloucestershire, Wiltshire and Somerset Cardiac and Stroke Network



Issues to addressPatients who required treatment for a non-elective arrhythmia were referred by five NorthCentral London (NCL) hospitals to the tertiarycentre at University College London Hospital(UCLH). The referral was faxed from the acutehospital to the catheter lab co-ordinator, and aninter hospital transfer (IHT) arranged. Every stageof this process required lengthy medicalsupervision. Anecdotally, long waits werereported but no robust audit system existed.

• Successful introduction of the web-basedtransfer system (WBTS)

• Reduced length of stay for arrhythmia inter-hospital transfer (IHT) patients within NorthCentral London

• Improved communication between referringand receiving centres as well as between staffand patients

• Transparency of IHT wait, through on-linewaiting lists

• Easily accessible length of stay data for all keystakeholders.

Actions taken• A retrospective audit of time from admissionto referral, and from referral to IHT wasestablished (25 patients)

• Implementation of on-line IHT referral andtransfer management system (Web BasedTransfer System) at the end of August 2007 inthe referring and receiving hospitals across theNorth Central London sector. This incorporateda WBTS also a tracking and audit tool

• Initial training of the main users at all centresduring the month preceding going-live date

• Dedicated user support during office hours fora further month

• Further user training delivered betweenOctober and December 2007 for user change-over (mainly junior doctors)

• In-house WBTS training and administrationfunctions given back to each hospital.Implementation of in-house WBTS champion

• Feedback lines of communication throughWBTS champions

• Cross-organisational team building andproblem solving through regular ‘Learn andShare Events’

• Daily dedicated permanent pacemaker slots atUCLH

• After implementation of WBTS a prospectiveaudit of waiting times was performed,matching types and number of procedures ofbaseline audit (25 patients)

• WTBS user satisfaction questionnaires used todetermine staff response to changes.

Key results/outcomesThe key results are shown in the table below:

Reducing Non-elective Arrhythmia Inter-hospital Transfer Waits Through theImplementation of an Internet-based Referral and Transfer Management SystemThe Heart Hospital (University College London Hospital), Barnet Hospital,Chase Farm Hospital, North Middlesex Hospital, Royal Free HampsteadHospital, Whittington Hospital and North Central London Cardiac Network

Baseline

WBTS cohort

Reduction frombaseline in %

Admission toreferral (total days)

193

87

55%

Referral to transfer(total days)

155

140

10%

Admission totransfer (total days)

348

227

35%



The user satisfaction questionnaires weredistributed to WBTS users including ward sisters,receivers (personnel organising transfers atreceiving centres) and referring consultants.

These showed• Referrers and ward sisters at the referringcentres reported greater transparency of theIHT wait and improved communicationbetween the centres

• The information on the WBTS was believed tohave contributed to improved bed usage andbetter team working across hospitalboundaries

• Referring consultants believed that the benefitsof the WBTS outweighed the increased workload.

In addition, the 'live' waiting list has alsoenabled all stakeholders to highlightexceptionally long patient waiting times and attimes enabled intervention to limit these.Greater participation of more stakeholders in theIHT process also ensures better sustainability ofthe transfer process within the NCL sector.

Contact informationSwetlana WolfEmail: [email protected]



Issues to addressPatients with heart failure currently tend to stayin hospital longer than necessary because theclinical staff must ensure that patients arecompletely stable before discharge. Because ofdifficulty with continuity of care by juniordoctors, the period between the patient comingoff intravenous diuretics and being stabilised onoral medication is often prolonged. Also,patients are kept in hospital longer thannecessary because the medical staff realise thatthey may not see them after discharge for sometime because access to clinics is inflexible.

This project reviewed the existing pathway ofcare and assessed length of stay and emergencyreadmissions, the objective being to re-engineerthe pathway of care to reduce length of stay.Other areas reviewed were the existingcardiology services relationship with otherspecialities such as general medicine, care of theelderly, respiratory, gastro, endocrine and thecollaborative care team (CCT).

Fifty data fields were included in the audit and afurther 30 for use from day one to ten of theircare, which includes inpatient and communitycare episodes. The following points outline themost significant areas:

• Twenty-four patients were identified for entryonto the baseline audit – our original target of30 patients couldn’t be reached due to thepatient criteria, which limited the patients thatcould be included. This was recognised as arisk to the pilot and it was agreed toinvestigate whether it would be possible toextend the project to include Brent patientsadmitted to Northwick Park Hospital

• Sixteen men and eight women who fitted theset criteria (patients treated with IV diureticswith LV systolic dysfunction and not admittedwith ACS) were identified to include in thebaseline. Six were <65 years and 18 were >65years, this age split is typical of heart failurewhere the majority of patients tend to beelderly.

• Average length of stay was nine days• Patient’s follow up was conducted at thecardiology or heart failure hospital clinic.All patients had one or more co-morbiditieswith hypertension and diabetes being themost prevalent.

Actions takenA project steering group was set up with keymembers (involving hospital and communitystaff) to guide and inform the project. A processmapping exercise was conducted to review theexisting care pathway and a baseline audit wasconducted for the first eight weeks. Thefollowing points outline the areas reviewed anddeveloped within the project:

• Early discharge protocol and proformadeveloped by the heart failure (hospital andcommunity) and CCT

• Promoting information for early dischargethroughout the hospital and with otherspecialties

• Working closely with CCT to support the heartfailure nurse with early discharge. Patientswere identified within A&E, CCU and wards todiscuss possible early discharge

• A questionnaire was sent out to patients whowere on the baseline audit asking to commenton their recent admission and the serviceprovided – this information was used to makechanges to the pilot

• The project was piloted for four months• Following the change in management process,a further 24 patients were audited and as withthe baseline audit, there were similar problemswith recruitment. Prior to discharge of eachpatient an individual management plan wasput together to provide appropriate continuingcare and adjustments to medication(continuing the stabilisation of the patientwhich otherwise would have happened inhospital). A combination of CCT, hospital heartfailure nurses and community heart failurenurses was used depending on the patient’srequirements – home visiting or attendances athospital

Heart Failure Early DischargeCentral Middlesex Hospital (part of North West London Hospitals NHS Trust)Brent PCT (Wembley Centre for Health and Care and other Community Clinics)North West London Cardiac Network



• A patient personal notebook (previouslydeveloped by North West London CardiacNetwork) was offered to patients on the pilotto promote self-management of care

• CCT staff attended a heart failure nurses clinicon a rotating basis as part of a trainingschedule.

Key results/outcomesThe length of stay of patients in the secondaudit was eight days. Although the numbers ofpatients in the study was not enough to allowstatistical analysis, the reduction in length of staywas in the area predicted at the start of theproject (10%), and if born out in a larger studywould represent a significant saving.

Furthermore, this approach to patient care isapplicable to other specialties. The project didprovide some unexpected findings and morequalitative than quantitative results.

The following points provide a brief outline ofthe conclusions:

• Heart failure patients are often complex,admitted with co-morbidities and socialissues which impact on being able toprovide early discharge

• Developed better links with otherspecialties

• Developed a training schedule for CCTand HF to educate A&E staff inrecognising HF symptoms and dischargingpatients without admitting to hospital

• Patient follow-up was expanded toincorporate different resources accordingto need

• Further work to review emergencyreadmissions for patients on pilot in nextsix months to establish continuity of care

• Further work to estimate the resource costof providing the service to put against thereduction in length of stay.

Contact informationTemo DonovanEmail: [email protected]



Issues to addressSCAN is a referral system into and out ofsecondary care, initiated to provide support inthe community.

With the restructuring of the primary care trust(PCT) back into one PCT and the admissionavoidance work, the heart failure nurse servicewas reviewed and a new model introduced.

Some of the aims were to:

• Focus activity to reduce admissions andmaintain reduction in admissions

• Increase use of single contact accessnomination (SCAN) by primary and secondarycare and develop further to enablepatients/carers to self refer to SCAN forinformation/visit

• Review heart failure pathway in line with the18 week wait

• Signpost patients to the appropriate service• Reduce discharge delays whilst patients waitfor social services to provide care packages

• Reduce variation in discharge information fromheart failure service in secondary care toprimary care.

Actions taken• Single point of access (SCAN) for nominationsand management of the system in place fromprimary, secondary care professionals, carehomes, social care, patients and carers.Signposting by skilled senior nurses

• Development of System One as anadministrative/management function as aregister for 'Very High Intensity Users’ (VHIUs)

• An additional three nurses from communitynursing appointed

• A change of role for secondary care nurses soall inpatient and secondary care patients areassessed and if appropriate, referred to thecommunity heart failure team. Educationprovided for staff working on the medicaladmissions unit. ‘link nurses’ developed andcriteria for case finding agreed

• Support and speed of response led bypatient need

• Utilises a mixture of urgent and non urgentresponse community services

• Local intelligence and directory of servicesused to signpost appropriately

• Guidelines and protocols in place to underpinprocess and delivery

• Identified gaps in service and skills• Feedback loop in plan• New model enables two specialist nurses tocase find in secondary care, assess and referpatients to community heart failure team.

Key results/outcomes• 300 cumulative heart failure referralsinto SCAN

• Rate of GP referral increasing rapidly – 73heart failure referrals in last quarter

• Evidence of patient satisfaction• Increased capacity through service redesign eg.community staff nurses with special interest inheart failure take less complex patients withsupport from the specialist nurses

• Reduced admissions and improved triagesystem

• Dedicated heart failure ward discussions• Heart failure rehabilitation pilot• Early discussion in Telly Health• Investment and support.

Contact informationColette LongfordEmail: [email protected]

Reducing Avoidable Hospital Admissions by Providing Community Support forPatients Referred Through the Single Contact Access Nomination (SCAN)Sheffield Primary Care Trust;Sheffield Teaching Hospitals NHS Foundation TrustNorth Trent Network of Cardiac Care



The aim of the project was to provide fullyintegrated heart failure services across allorganisational boundaries to improve the clinicalmanagement of all heart failure patients. Thisincluded increasing referrals to the heart failurenurses and integrating the service with the GPwith special interest ‘heart function’ clinics.

Issues to address• Reduce heart failure admissions• Reduce length of stay (LoS)• There were two heart failure nurses in oldNorth Surrey locality

• Successful BHF bid for heart failure nurses.Came into post July/September 06 (didn’t takepatients on until late 2006)

• Two to three weeks waits for inpatient echowith up to 16 week wait for outpatient echoin secondary care

• Links with palliative care team established butnot consolidated

• End of life stage – improved access topalliative care and hospice.

Actions taken• New consultant cardiologist with specialinterest in heart failure and imaging appointedin April 06

• Data collection to review heart failureadmissions for the first quarter in years 2006,2007 and 2008 for comparison

• Data collection to establish LoS from April toMarch 2007/08

• Review documentation; new West Surrey wideclinical guidelines and patient information

• Establishment of a heart failure nurse serviceacross the whole of West Surrey to reviewprotocols

• Establish a process for direct access toconsultant cardiologist for his opinion withcomplex patients for both heart failure and GPwith special interests (GPSI)

• Established links with palliative care• Access to network shared drive in order toaccess information by all parties involved inproject

• Purchase of portable ECG machines for allheart failure nurses across West Surrey

• Purchase of weighing scales to help inpatientself-management

• Audit of patient satisfaction via questionnaire.

Key results/outcomes• Establishment of local HF nurse activity

database. For Nov 07 – Jan 08demonstrates 72 avoided GP contacts,three avoided hospital admissions andone avoided A&E admissions

• Community Heart Failure Consultantreview – this was a four month audit ofthe direct access by HF nurses toconsultant opinion. Review indicates apotential saving of 24 inpatient days and15 outpatient attendances

• Reduction of heart failure admissions from65 to 21 per month

• Reduction in LOS from average of 8.59days to 4.5 days

• A strong heart failure steering groupcommitted to improving services

• Improved access to consultant cardiologyopinion

• Improved patient management within thehome and across organisational boundaries

• Home ECG audit – expedited referral tosecondary care where appropriate forintervention/treatment. Improved medicinesmanagement within the home. Reducedunnecessary care/GP appointments. Increasedreassurance for patients and carers

• Improved links with palliative care and othercommunity services

• Consistent documentation across localities• Through audit and patient and publicinvolvement, established sound evidence toinform business proposal for continuation ofheart failure nurse led service

• Engagement from network commissioninggroup for continuation of service and spreadto other localities across Surrey

• New one stop echo/heart failure clinic run byconsultant cardiologist within secondary care.

Contact informationAlex BennettEmail: [email protected]

Integrated Heart Failure Service Across All Organisational BoundariesAshford and St Peters NHS Trust, North West Locality of Surrey PCT(to be extended to South West Locality and Frimley Park)Surrey Heart and Stroke Network



Issues to addressThe Conquest Hospital inpatient heart failureservice offered an excellent package of care forthose patients who were referred to them, butthe service became fragmented for the patientswho were admitted to other consultant teamselsewhere in the hospital. Problems included:

• Delays in getting echos done• Heart failure team not being informed of thepatient admission

• Undue delays in medical admissions unit(MAU)

• Patient not on the correct pathway foroptimisation of care

• Longer length of stay (LoS)• Unnecessary readmissions• Lack of specialist support for patientsfollowing their discharge.

Actions taken• Established a project steering group andprocess mapped acute and community careheart failure pathways

• Baseline information data was obtained andsubsequent data was collected and analysed

• Early identification of heart failure admissionsthrough existing and enhanced methods.These included a telephone hotline for heartfailure admissions with an accompanyingposter initiative, and an ‘alert’ feature on thehospital information system to highlight allknown patients and guidance aroundcontacting the heart failure team

• MAU consultants and their teams worked tofast track patients to the heart failure acuteteam, all cardiology inpatient admissions werecentralised to dedicated wards and earlyaccess to echocardiogram on the ward wasfacilitated

• Management plans were in place for all heartfailure patients following an acute heart failurepathway, and optimised discharge and followup care were established

• Cross boundary communications were furtherenhanced through multi-disciplinary teamdischarge planning meetings, ward rounds forheart failure acute teams, enhancedcommunity heart failure nurse links to wardsand the establishment of ward-link nurses

• Both Tai Chi rehabilitation programmes andhand-held records were available for heartfailure patients

• Teaching/education sessions for practicenurses/community nurses/acute nurses tookplace

• Links with the hospice team and expansion ofthe palliative and supportive care services weredeveloped and progressed.

Key results/outcomesJan 1998 – Dec 2007• 51.04% reduction in average no. of

admissions/quarter with heart failure inprimary diagnosis position

• 36.6% reduction in median LOS/quarterhas decreased from 11 to seven days

• 23% reduction of deaths in hospital innon-elective admissions with heart failure.

Aug 2007 – Mar 2008• 20% reduction in number of days waiting

for echo from date of referral to dateof test.

Please note that these results are calculatedon incomplete HRG performance data.

Contact informationToni De FreitasEmail: [email protected]

Making Best Use of Inpatient BedsConquest HospitalSussex Heart Network


Project Team Membersand Participating Sites





Thelma DalyAvon, Gloucestershire, Wiltshire and SomersetCardiac and Stroke NetworkBristol, Southmead Hospital, North Bristol NHS Trust

Nicola HughesAvon, Gloucestershire, Wiltshire and SomersetCardiac and Stroke NetworkBristol, Southmead Hospital, North Bristol NHS Trust

Candy JeffriesBedfordshie & Hertfordshie Heart and Stroke NetworkHemel Hempstead Hospital, West Herts NHS Trust

Caroline HewittGreater Manchester and Cheshire Cardiac NetworkCentral Manchester, Central Manchester PCT, CentralManchester and Manchester Childrens UniversityHospitals NHS Trust and PBC Hub

Luke ColemanGreater Manchester and Cheshire Cardiac NetworkCentral Manchester, Central Manchester PCT, CentralManchester and Manchester Childrens UniversityHospitals NHS Trust and PBC Hub

Jennifer WattsLancashire and South Cumbria Cardiac NetworkBlackburn, East Lancashire NHS Trust, BlackburnRoyal Infirmary

Rita BriggsLancashire and South Cumbria Cardiac NetworkBlackburn, East Lancashire NHS Trust, BlackburnRoyal Infirmary

Ann BainesNorth Trent Network of Cardiac Care - RotherhamRotherham, Rotherham PCT and Rotherham NHSFoundation Trust

Colette LongfordNorth Trent Network of Cardiac Care - SheffieldSheffield, Sheffield PCT and Sheffield TeachingHospitals NHS Trust

Swetlana WolfNorth Central London Cardiac NetworkHampstead, Royal Free Hospital NHS Trust and HeartHospital

Jason AntrobusNorth West London Cardiac NetworkEaling, Ealing Hospital NHS Trust, St Mary's Hospitaland Hammersmith Hospital

Temo DonovanNorth West London Cardiac NetworkBrent, Central Middlesex Hospital and Brent tPCT

Chrissie BennettPeninsula Cardiac Managed Clinical NetworkPlymouth, Plymouth tPCT and PlymouthHospitals NHS Trust

Toni De FreitasSussex Heart NetworkHastings, Conquest Hospital and Hastngsand Rother PCT

Alex BennettSurrey Heart and Stroke NetworkWoking, Surrey PCT and Ashford andSt Peter's NHS Trust

Mimi ParkerSurrey Heart and Stroke NetworkWoking, Surrey PCT and Ashford andSt Peter's NHS Trust

National Team Members

Sheelagh MachinDirector, NHS Improvement

Carolyn HeyesNational Improvement Lead, NHS Improvement

RichardLongbottomCommissioning Advisor, NHS Improvement

Jennifer WattsService Improvement Manager, NHS Improvement

Anne ColemanPersonal Assistant, NHS Improvement

Jonathan ShribmanNational Clinical Lead, General Practitioner

David WalkerNational Clinical Lead, Consultant Cardiologist

Steve LiveseyNational Clinical Lead, ConsultantCardiothoracic Surgeon

Project Team Members and Participating Sites

NHS Improvement

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Telephone: 0116 222 5101 | Fax: 0116 222 5184

www.improvement.nhs.uk

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NHS Improvement

NHS Improvement is a newly formednational improvement programmeworking with clinical networks and NHSorganisations to transform, deliver andsustain improvements across the entirepathway of care in cancer, cardiac,diagnostics and stroke services.

Formed in April 2008, NHS Improvementbrings together the Cancer ServicesCollaborative ‘Improvement Partnership’,Diagnostics Service Improvement, NHSHeart Improvement Programme andStroke Improvement into oneimprovement programme. With over eightyears practical service improvementexperience in cancer, diagnostics andheart, NHS Improvement aims to achievesustainable effective pathways andsystems, share improvement resources andlearning, increase impact and ensure valuefor money to improve the efficiency andquality of NHS services.

©NHS Improvement 2008 | All Rights ReservedPublication Ref: IMP/heart0004

Health & Medicine

Making Best Use of Inpatient Beds Project - National Priority Projects 07/08 Summary Document