Respiratory
Optimal Service Design
Workshop
Defining “what to change” using the
NHS Right Care methodology
Part of the NEW Devon Way
Optimal Service Design Workshop
Structure - am
Activity
Introduction and Purpose of Today
The purpose of today’s workshop
Why NEW Devon CCG has adopted NHS Right Care
How NEW Devon CCG uses NHS Right Care in QIPP planning
Gap Analysis
Summary of deep dive findings
Review of deeper performance analysis
Best practice / optimal practice review
Q&A on deep dive findings
Adopt, Improve, Defend (AID)
Work in groups to define:
Which best/optimal practice should be adopted
Which current practice should be improved
Which current practice can be defended
Feedback AID recommendations
timing
25 mins
1hr 15 mins
1hr 15mins
Optimal Service Design Workshop
Structure - pm
Activity
Service Redesign
Taking AID outputs, design the specification for the service
Action / strategy planning
Produce action plan for new service specification and define
strategic statements for longer term improvement
Workshop Feedback
Feedback to make workshop a better learning experience
timing
2 hrs
Questions
Final opportunity for questions
5 mins
50 mins
10 mins
Optimal Service Design Workshop
Introduction &
Purpose
of Today
Optimal Service Design Workshop
Purpose
To understand how NHS Right Care is used by for NEW
Devon CCG
To understand the theory behind NHS Right Care
To understand the findings of the service deep dive and
further analyse the topics selected for improvement
To design optimal service solutions to:
Resolve issues identified during the analysis
Set performance parameters for the new service design
Identify any strategic requirements
Reduce unnecessary variance in outcomes, quality &
cost
To learn a standardised approach to evidence based
change in NHS NEW Devon CCG
Systematic QIPP Development
Adoption of NHS Right Care
NHS NEW Devon CCG must maintain a continuous list of improvement opportunities to ensure that
QIPP requirements can be met each year
To do this we must adopt a standardised approach to QIPP development that will bring clarity and
assurance to the QIPP proposals
NHS Right Care is designed for CCGs to tailor to their purposes using the overall methodology as a
blueprint
NHS NEW Devon CCG will develop its use of the Right Care system in outline and refine it as the
QIPP programmes develop, effectively testing it with delivery and improving as we go
5YFV “closing the gap” target for NEW Devon is to be upper quintile across the board, therefore all
opportunities will be valued at a top 20% indicator
The deep dive has selected areas showing variation in the service that we need to change to meet
peer performance and move towards national upper quintile
We are here to identify and agree changes to the service
to improve outcomes, cost and quality
Systematic QIPP Development
NHS Right Care Overall Methodology
1 key objective + 3 key phases + 5 key ingredients =
COMMISSIONING FOR VALUE
OBJECTIVE - Maximise Value (individual and population)
Five Key Ingredients:
1. Clinical Leadership
2. Indicative Data
3. Clinical Engagement
4. Evidential Data
5. Effective processes
We are here
“What to change”
Systematic QIPP Development
Phase 1 - Where to look
Where to look will happen once each year to produce a high level ranked list of opportunity to pursue
We do this using a series of nationally available indicative data comparing our performance against a selected
peer group of health economies
The output of this phase is a scoped and ranked list of opportunity
Expenditure on own population 2013/14
Programme Budgeting category
Total
23.Other
163,857,285
05.Mental health disorders
136,034,333
15.Problems of the musculoskeletal system
90,218,642
10.Problems of circulation
69,130,110
13.Problems of the gastro intestinal system
66,507,382
11.Problems of the respiratory system
61,204,284
16.Problems due to trauma and injuries
59,686,777
22.Social care needs
56,326,460
07.Neurological
52,353,207
44,138,000
02.Cancers and tumours
17.Problems of the genito urinary system
06.Problems of learning disability
04. Endocrine, nutritional & metabolic
problems
14.Problems of the skin
08.Problems of vision
21.Healthy individuals
297,646,520
20.Adverse effects and poisoning
03.Disorders of blood
09.Problems of hearing
01.Infectious diseases
19.Conditions of neonates
12.Dental problems
Total Expenditure
Commissioning for Value
Ranked Programme Budgeting Themes
Rank
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
Category 2013/2014
15.Problems of the musculoskeletal system
05.Mental health disorders
10.Problems of circulation
16.Problems due to trauma and injuries
02.Cancers and tumours
13.Problems of the gastro intestinal system
23.Other
11.Problems of the respiratory system
01.Infectious diseases
03.Disorders of blood
04.Endocrine, nutritional and metabolic problems
06.Problems of learning disability
07.Neurological
08.Problems of vision
09.Problems of hearing
12.Dental problems
14.Problems of the skin
17.Problems of the genito urinary system
18.Maternity and reproductive health
19.Conditions of neonates
20.Adverse effects and poisoning
21.Healthy individuals
22.Social care needs
Total
Actual
Expenditure
180,000,000
140,000,000
20.2
26
8
15.8
7
4.7
1,097,103,000
£97m
2.8
10,163,600
12,647,955
-3,825,946
4,131,276
-5,720,156
-53,523
-8,769,283
-3,029,979
-662,269
2,863,011
-2,824,888
10,866,566
1,565,363
2,751,784
3,535,176
-102,034
5,749,467
-6,525,033
-1,673,443
-519,939
832,690
21,688,883
39,666,517
Expected effect on admissions
120,000,000
80,000,000
40,000,000
-
38
90
Average per day
15,088
97
45
105
245
Admissions expected with local demographic
profile (000s)
5,507
37
+4%
19
+16%
44
+15%
98
+9%
Average per day
15,088
101
52
121
268
Actual admissions with local demographic
profile (000s)
-
34
-8%
16
-15%
36
-18%
86
-12%
Average per day
-
93
44
99
236
Admission total numbers in thousands
Programme Budgeting
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28/4/15 Date
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PMO-0.3
09/5/15
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28/4/15
Noel Phillips
Version
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PMO-0.3
09/5/15
Noel Phillips
PMO-0.2
28/4/15
Noel Phillips
09/5/15
Devon
East
16
1,097,103,000
Project Mandate (Request for starting up a project)
Submission
version:
Project Mandate
(Request
for Draft
starting up a project)
Forward to [email protected] on completion
Submission
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Project Mandate
(Request
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Forward to [email protected] on completion
The Project Mandate process isProject
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PMO-0.3
Devon
North
35
Noel Phillips
NEW
Devon
20,000,000
•
With a scope
per theme
Devon
West
5,507
60,000,000
Atlas of Variance
Themes ranked
England
Admissions expected with English
demographic profile (000s)
100,000,000
Gold
Target Expenditure
variance
£m +/15% against peer
90,218,642
136,034,333
69,130,110
59,686,777
44,138,000
66,507,382
163,857,285
61,204,284
9,184,284
12,536,760
33,652,821
35,293,000
52,353,207
30,293,136
9,759,000
1,739,000
32,322,698
45,024,927
40,984,735
2,672,000
15,668,158
28,516,000
56,326,460
Emergency admission growth
160,000,000
Draft version
PMO-0.3
for PMO
Draft version
PMO-0.2
for review
PMO review
Draft version PMO-0.3 for PMO review
•
•
•
Local Interpretation
Benchmark, value, rank and prioritise themes
using agreed national and local data.
Identify opportunity of top ranked themes.
Produce a scope per theme.
Present scope to steering
group for go/no go decision.
Systematic QIPP Development
Phase 1 - Where to look (2013/14 data)
•
We have ranked all services
by value (a combination of
demand, outcomes, cost
and performance)
•
2013/14 performance shows
a total value against peer of
£116M and against the
national upper quintile
position of £268M
•
16 of the 22 categories have
been selected for deep dive
review in 4 waves in 15/16
•
These are not the QIPP
targets but an indication of
where our services are sub
optimal compared with other
health economies
Systematic QIPP Development
Phase 2 part 1 - What to change
What to change starts with a deep dive exercise focusing on the selected theme
The deep dive pack is analysed and QIPP plans are defined with sufficient evidence to produce a project
mandate.
The output of this phase is a project mandate
QIPP Project schedule of work
Apr
May
Key Milestones
Jun
Jul
Governing Body
Delivery system
development
Aug
Sep
Stretch QIPP
commence delivery
Annual plan resubmission
Plan the approach
Implement
Test and Sustain
NHS Futures & Turnaround Delivery as a single programme of work
Strategic
Framework
Plan the approach
Case for change :
Performance Analysis
PESTLE
Strategy Alignment
Scenario modelling
Develop Vision
Needs Analysis
Delivery &
Commissioner
Strategies
Communications
Start Developing
elements 1 to 7
Key System Stakeholders
On-going meaningful public discussion and consultation where necessary
Governance
Detail design
Governing body approval
Implement
34
NHS Right Care deep dive is
completed (6 weeks)
Detailed deep dive is analysed
and prioritised and planned
targets defined (3 days )
Note:
The mandate for today was circulated with the invitation
Implementation plans are
drafted, business cases defined
and project mandate produced
(2 days)
Mandate assessed
at steering group for
go/no go decision
Systematic QIPP Development
Phase 2 part 2 – What to change – today’s workshop
Once the mandate is approved we can undertake deeper analysis of the selected QIPP projects
This deeper analysis culminates in an optimal service design workshop including providers, patients and
CCG members
The output of this phase is a project initiation document including the new service design, strategy and
implementation plans
80th
%ile
Measure
Devon
Ratio of reported to expected prevalence of
chronic kidney disease (CKD)
LM
Improvenment
Opportunity
Percentage of patients on the Chronic Kidney
Disease (CKD) register whose most recent
blood-pressure measurement in the previous 15
months is 140/85 mmHg or less
LQ
Improvenment
Opportunity
Percentage of patients on the chronic kidney
disease (CKD) register with hypertension and
proteinuria treated with an angiotensin
converting enzyme (ACE) inhibitor or
angiotensin receptor blocker (ARB)
MQ
Options for Action
Service area/ type
Devon
There is considerable variation in the ratio of observed versus expected prevalence of diagnosed
CKD among PCTs (4.5-fold). A similar degree of variation is observed when practices within a
PCT are compared. It is likely that most of the variation is due to the variable detection of CKD.
The key to reducing unwarranted variation in the prevalence of chronic kidney disease
is to improve CKD screening. Screening should comprise: Estimated GFR measured on
a blood specimen obtained after 12 hours without eating meat; Repeat estimated GFR
after at least 90 days to confirm an abnormal result; Dipstick urinalysis and
measurement of urine albumin:creatinine ratio (UACR) to assess albuminuria. In NICE
guidance, it is recommended that patients with the following conditions or treatment
regimens should be screened for CKD: Diabetes; Hypertension; Cardiovascular
disease; Structural renal tract disease (renal calculi or prostatic hypertrophy);
Multisystem diseases with potential kidney involvement, e.g. systemic lupus
erythematosus (SLE); Family history of CKD stage 5 or hereditary kidney disease;
0.74 Chronic treatment with potentially nephrotoxic drugs.
CKD
NICE has suggested the following target pressures: For CKD patients without proteinuria,
120–130 mmHg systolic and 60–80 mmHg diastolic; For CKD patients with proteinuria, <130
mmHg systolic and <80 mmHg diastolic. The Quality and Outcomes Framework (QOF)
indicator for measuring and managing hypertension in CKD sets a target blood pressure of
140/85 mmHg or less, and an audit standard achievement rate of 40–70%. One patient with
CKD in every five does not appear to have a blood-pressure measurement within target. It is
important that blood pressure is adequately monitored and treated in people with
CKD. Barriers to treatment need to be identified and addressed including: Ensuring
that at-risk patients are screened for CKD, and documented on a register; Educating
people with CKD and healthcare professionals involved in their care about the
importance of blood-pressure control; Establishing that people with CKD are
prescribed appropriate antihypertensive medications and at appropriate doses;
Utilising available published data to identify localities where blood-pressure control in
CKD patients is less effective to guide the commissioning of resources and services;
Reviewing trial data on the effectiveness of bloodpressure control in CKD patients,
with particular attention given to different population subgroups, to guide national
75.6 policy and its implementation via QOF.
CKD
The most effective treatment to prevent decline of kidney function is to control blood pressure.
Angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs, also
known as A2 antagonists) – drugs that block the action of angiotensin – are effective at
reducing the damaging effects of blood pressure on kidney function. The prescription of these
drugs by general practitioners is incentivised under the Quality and Outcomes Framework
(QOF). Patients with proteinuria are most likely to benefit from ACE inhibitors and ARBs. For
the whole population of people with CKD to benefit from ACE inhibitors and ARBs, the
percentage of patients with CKD entered on the CKD registers of general practitioners
needs to increase. Patients with CKD can be identified relatively simply from data held
by pathology laboratories. To improve population health, it is a priority to make better
use of these data. Systematic identification and treatment of patients at high risk of
Improvenment
progressive kidney damage has been demonstrated to reduce significantly the
Opportunity
92 numbers of patients starting dialysis.
CKD
End-stage renal disease (ESRD) due to diabetes is rising. Measurement of the urine
albumin:creatinine ratio (UACR) can detect early disease and help to slow progression if the
renal disease is treated. NICE recommends that: If diabetic nephropathy is confirmed, an
ACE inhibitor should be offered with dose titration to maximum dose (unless an ACE
inhibitor is not tolerated); An A2 antagonist [otherwise known as an angiotensin
receptor blocker (ARB)] should be substituted if ACE inhibitors are poorly tolerated;
Blood pressure should be maintained at <130/80 mmHg if UACR is abnormal. To
increase the number of patients with diabetes and ESRD treated appropriately with
ACE inhibitors or A2 antagonists (ARBs), it is important to increase the knowledge and
Improvenment
understanding of primary care clinicians of: how to test for raised UACR; how to record
Opportunity
89.9 the diagnosis of raised UACR.
CKD
When CKD progresses to endstage renal disease (ESRD), renal replacement therapy (RRT)
considerably improves both longevity and quality of life. However, the cost of RRT is substantial.
The data for this indicator describe the effect of geographical location at PCT level on RRT
incidence rates [expressed as the standardised acceptance ratio (SAR), i.e. the observed
acceptance rate divided by the expected acceptance rate]. The top 42 and bottom 46 health
economies have higher or lower than expected rates. Commissioners and providers need to
identify differences in healthcare provision with the help of resources such as the
‘Health Inequalities and Chronic Kidney Disease in Adults’ report by NHS Kidney Care
(http://www.kidneycare.nhs.uk/document.php?o=465), and the interactive maps
provided by the UK Renal Registry (http://www.renalreg.com/Maps/maps.html). As
improved data lead to better decision-making, commissioners and providers need to
improve: the identification, recording and coding of CKD and comorbidities (e.g. NHS
Kidney Care Kidney Disease QOF toolkit 2011) – early identification will lead to
improved patient care through more timely management; data accuracy and reporting
to the NHS and the UK Renal Registry, which will improve the quality of the analyses
that can be conducted, such as the Chronic Kidney Disease PCT profiles, and the UK
Renal Registry annual report. Shared Decision Making can help improve the rate of
Improvenment
RRT (see http://www.kidneycare.nhs.uk/resources/my_kidney_care_plan/).
Opportunity
N/A
RRT
Assess gaps to best in class
Percentage of patients with diabetes with a
diagnosis of proteinuria or micro-albuminuria
treated with angiotensin converting enzyme
(ACE) inhibitors (or A2 antagonists)
Standardised acceptance ratio (SAR) for
incidence of renal replacement therapy (RRT)
by PCT
LM
MQ
Standardised prevalence rate of RRT
LM
Standardised pre-emptive transplantation ratio
MQ
Complete
Strategy to action
plans, full
business case, &
full PID
The UK is in the lowest quintile for levels of renal replacement therapy in the developed world.
That is, all have improvement potential with regard to RRT. To determine whether the degree of
variation observed is real, it is necessary to adjust for the socio-demographic factors. Patients
from ethnic minority groups, with higher levels of deprivation or increasing age, are more likely
to have renal disease. It is important to consider incidence rates of RRT, in particular:
Are these lower than expected? Are prevalence rates low as a reflection of low uptake
rates?; Survival rates for patients receiving RRT and for the PCT population: Do these
compare favourably with rates in other PCTs? Does your renal centre have
significantly higher death rates thereby reducing prevalent RRT numbers?; Renal
centre facilities: Is there capacity to accommodate appropriate numbers of patients to
the end-stage programme? It is essential that non-nephrology physicians in primary
and secondary care are made aware of CKD guidelines and resources to ensure that:
Improvenment
patients are referred in a timely and appropriate manner to renal services; there is
Opportunity
N/A
equity of access to RRT for all in need.
RRT
A pre-emptive transplant (i.e. a transplant before starting dialysis) is considered the ‘gold
standard’ treatment option because not only does it maximise health outcomes for the patient
but also it is the most cost-effective treatment option. Commissioners need to adopt an
“invest to save” strategy to eliminate resource-dependent variability because preemptive transplantation is considerably more cost-effective than the other treatment
options for ESRD.To improve local care and eliminate variability due to patient- and
resource-independent factors, providers need: to review their patient pathways; to
compare their performance on pre-emptive kidney transplantation with that of other
renal centres, and identify the reasons why certain renal centres might have a better
Improvenment
performance than their own.
Opportunity
1.46
RRT
Clinically led pathway redesign
Test against
gold target and
initial objective
Strategy for theme
Full PID assessed
at steering group for
go/no go decision
Systematic QIPP Development
Phase 3 - How to Change
Once the PID is approved we can start to implement the planned changes
Implementation will follow the NHS NEW Devon CCG turnaround methodology and will seek to deliver
benefits as fast as possible
Projects will be
delivered and sustained
under the Turnaround
governance structure
Governance & Delivery
Turnaround - Team
Quality
Turnaround
Steering
Group
Clinical
Effectiveness
Planning
Finance
Turnaround Working
Group
Project Manager
Project Manager
PMO
Project Manager
Control Centres
Clinical Lead
Clinical Lead
Clinical Lead
BI, HR & Finance
BI, HR & Finance
BI, HR & Finance
Optimal Service Design Workshop
Systematic QIPP Development
Questions?
Optimal Service Design Workshop
Gap Analysis
Deep Dive
Summary
Optimal Service Design Workshop
Gap Analysis
Performance
Analysis Review
Optimal Service Design Workshop
Gap Analysis
Best / Optimal
Practice Review
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Gap Analysis
Questions?
Let’s take a break!
Optimal Service Design Workshop
Adopt, Improve or Defend
Optimal Service Design Workshop
Adopt, Improve, Defend
What:
• Identify the key elements of the service that
are sub-optimal
• Determine if there is better practice for the
element
• Elect to adopt better practice, improve
current practice or defend current practice
How:
• Map the backbone of the service in patient flow
order
• Under each mapped step record the performance
of the step
• Identify better practice for the suboptimal steps and
put it under each step
• Elect to Adopt, Improve or Defend for that element
Pathway Backbone
Patient
managed in
primary care
Patient
managed in
primary care
then referred on
Patient seen at
outpatients but
discharged at
first appointment
Patient receives
follow up
appointment
Patient
admitted
Pathway Performance
38% more than
average in
primary care
72% patients
referred on from
primary service
29% more than
average
discharged at
first appointment
23% more than
average follow
up
appointments
4.8% more
patients
admitted than
average
Better practice
NICE guidance
on primary care
management
Gloucester
model for
primary care
management
Oxford model for
O/P triage
NICE guidance
on patient
initiated follow
up
Royal College
recommendation
on decision to
admit
AID
Defend
Adopt
Improve
Adopt
Adopt
Optimal Service Design Workshop
Service Redesign
What:
• Having elected an AID category for each step
of the service define what the step will look
like and how it will perform
• Specify reasons with evidence for any
defend decisions
How:
• Map the backbone of the new service
• Under each mapped step record the expected
performance
• Record key changes to current step to achieve the
new one - “must” statements
• If necessary add a strategic statement for the step
New Backbone
Patient still
managed in
primary care
Patients
requiring acute
service
identified early
Patient triage
completed by
DRSS for GPwSI
service
Patient
initiated follow
up iaw NICE
guidance
Conservative
treatment
offered iaw
guidance
Expected
Performance
38% more than
average
managed in
primary care
50% reduction
of patients
managed in
two settings
40% reduction in
discharge at first
appointment
25% reduction
in follow up
appointments
4% reduction in
admissions
Currently best
use of interface
service in UK
- Change spec for
primary service
- GP funding for
back referrals
Key Changes /
Defend evidence
Strategic statements
To increase
primary care
management
Setup GPwSI
service
Adopt Oxford
triage protocol
- Standard letter
to patient
- Reappointment
“hot line”
Conservative
treatment made
available
To use patient
decision aids
To reduce
surgical
intervention
Optimal Service Design Workshop
Action Planning
What:
• Determine actions to make the key changes
happen
• Align the actions with the project timescale:
• Implementation = making the change
• Delivery = measuring the benefit
Action: stop all physio
referrals to outpatients
Outcome: 2,300 unnecessary
outpatient referrals stopped,
500 back referrals to GPs
started
Date (from –to): ASAP
Owner: F Bloggs,
commissioning lead
How:
• Complete a post it for each action as shown
• Put the post it on the timeline where the task starts
• Add new planning categories as they emerge
• For quick wins: date is ASAP; position on the
timeline is not relevant
Implementation
Planning Category
Strategy
Commissioning policy
Pathway changes
Quick wins
Sep
Oct
Nov
Dec
Delivery
Jan
Feb
Mar
Optimal Service Design Workshop
Workshop feedback
Optimal Service Design Workshop
Feedback
While completing your feedback forms please consider what went well, what didn’t go well, what helped
it go well and what hindered it. Put comments on post its on the flip chart at the front
What went well
What went not so well
Group
working
was good
I didn’t
understand
the data
More biscuits!
Not enough
pre reading
CPD meant I
could come
today
What helped
I don’t think
we’ve picked
the right
subjects
Not being
involved in
analysis
hindered
What hindered
Optimal Service Design Workshop
Next Steps
In the next two weeks, the CCG project team will:
•
•
•
•
Complete a project plan and business case for the proposed changes (PID)
Complete any further analysis required to support the business case
Identify and inform stakeholders of the planned changes
Submit to the CCG turnaround steering group for formal acceptance as a QIPP
scheme
Optimal Service Design Workshop
Thank You