NHS
CANCER
NHS Improvement
Lung
DIAGNOSTICS
HEART
LUNG
STROKE
NHS Improvement - Lung
Improving the quality and
safety of home oxygen services:
The case for spread
Improving the quality and safety of home oxygen services: The case for spread
Contents
Improving the quality and safety of home
oxygen services: The case for spread
1: Introduction
4
1.1
1.2
1.3
1.4
Context
Summary of workstream learning
The case for spread
Use of data
4
4
8
9
2: Learning from the prototype projects
12
2.1
2.2
2.3
2.4
12
15
17
17
Components of a quality HOS-AR model
Practical service models
Issues and challenges
Overall project cost savings
3: Case studies
19
3.1
3.2
3.3
3.4
3.5
19
21
23
25
27
Oxford
Hampshire
Derby
Salford
Stockport
4: Additional information and resources
29
Appendix 1: North East procurement of HOS-AR provider –
a case study
29
Appendix 2: Project team process maps and other lung
improvement resources
32
5: Acknowledgements and references
34
3
Improving the quality and safety of home oxygen services: The case for spread
1: Introduction
1.1 Context
This prototype project final report
builds upon the learning from the
initial testing phase projects. The
lessons learned from the earlier work
are documented within two
improving home oxygen services
workstream publications entitled
Emerging Learning from the National
Improvement Projects1 and Testing
the Case for Change2.
The earlier publications highlighted
the work of 12 multidisciplinary
project teams based in various sites
across England. As part of the
national chronic obstructive
pulmonary disease (COPD) project
cohort these sites were supported in
the practical use of service
improvement methodology in order
to implement home oxygen service assessment and review (HOS-AR) as
specified within the national good
practice guide3.
Both the national COPD project work
and the development of the good
practice guide were constituents of a
wider respiratory programme of work
supporting the introduction of the
Outcomes Strategy for COPD and
Asthma4.
4
Home oxygen services have been a
particular priority within the
respiratory programme as earlier
work had revealed significant waste
in the use of resources with many
patients either not using, or receiving
no clinical benefit from, supplied
therapy. This problem was
compounded as an estimated 20% of
patients requiring therapy were not
receiving it5.
The testing phase work sought to
establish the case for change i.e. that
quality assured prescribing of home
oxygen therapy through structured
assessment and ongoing clinical
review not only improves safety and
quality but also increases cost
efficiency.
The results from the testing projects
successfully proved this concept and
so the goal of the prototype phase
was to establish the case for the
spread of good practice and so
establish HOS-AR across the country.
The work presented within this
publication was undertaken by the
six project teams comprising the
prototype phase of the national
COPD projects improving home
oxygen workstream.
The prototype work placed a great
emphasis on the safe and appropriate
use of home oxygen and as such was
well aligned with NHS Outcomes
Strategy Domain 5 - Treating and
caring for people in a safe
environment; and protecting them
from avoidable harm6.
The prototype project teams were
widely dispersed across England and
this report features case studies from
five sites: Hampshire, Oxford, Derby,
Salford and Stockport.
1.2 Summary of workstream
learning
A key objective of the prototype
project work was the refinement of
the testing phase approach in order
to identify the first steps clinical
networks should undertake when
trying to improve the home oxygen
pathway and also to define the key
success principles of practical service
implementation.
These ‘first steps’ and ‘success
principles’ have been published
separately but are included within
this document for completeness.
Improving the quality and safety of home oxygen services: The case for spread
First steps to improving chronic obstructive pulmonary disease (COPD) care
LIVIN
First steps to improving chronic obstructive pulmonary disease (COPD) care
G
WIT
H
What you can do
Why it matters
How to do it
7. Do not
prescribe
oxygen for
‘breathlessness’
and ensure
prescribing
remains
clinically
appropriate
and cost
effective
through
formal
assessment
and ongoing
review
Home oxygen is a treatment for
chronic hypoxaemia and NOT a
treatment for breathlessness. It
is a drug and should only be
prescribed where clinically
indicated otherwise it is of NO
benefit and potentially harmful
to some patients.
Promote the message to staff
and patients that ‘oxygen is not
a treatment for breathlessness’
and that there are often more
appropriate ways to manage
breathless patients.
In PCTs that have introduced a
review of their oxygen registers
coupled with the introduction of
a formal assessment service up
to £400,000 has been saved in
one year. If the scale of savings
were replicated across England,
it is estimated that they could
amount to between £10-20m.
Ensure only patients who have
been assessed by a specialist
service are prescribed oxygen and
that they receive ongoing review.
This involves measuring both
oxygen saturations and blood
gases and reviewing other clinical
data together with supplier data
on usage, flow rate, duration
and equipment.
Rationalise therapy in line with
clinical need and undertake
supported withdrawal of oxygen
providing no clinical benefit.
8. Oxygen
alert cards
should be
provided for
at risk
patients
Some patients with COPD or
other long term chest conditions
can become sensitive to medium
or high doses of oxygen. This
does not happen to everyone
with these conditions, only a
small number, therefore, if
oxygen is needed by these
patients, it should be given in a
controlled way and monitored
carefully.
Oxygen alert cards and 24%
masks (recommended in the
BTS 2008 guideline) can avoid
hypercapnic respiratory failure
by alerting healthcare
professionals that patients are
sensitive to oxygen. Oxygen
alert cards should be issued
to all at risk patients on
discharge as part of the
discharge planning process.
5
Improving the quality and safety of home oxygen services: The case for spread
Success principle 10: Home oxygen
NHS
10
Success principles
Making a real difference
NG
O UT
LIVIN
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WIT
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N THING
HE
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GO
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Lung
TEN:
FIND
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!
NHS Improvement
TO W
A
Home oxygen
Home oxygen therapy is provided to about 85,000 people in England, costing approximately £110
million a year. Home oxygen service assessment and review (HOS-AR) is variable as patients in many
Primary Care Trusts (PCTs) do not receive a quality assured clinical assessment and a review of their
ongoing need for long term home oxygen.
The variation in provision of HOS-AR increases the potential for poor quality care and waste and it has
been estimated that 24% to 43% of home oxygen prescribed in England is not used or provides no
clinical benefit.
Gross savings of up to 40% - equivalent nationally to £45 million a year or £300,000 per PCT can
potentially be achieved through the establishment of home oxygen services, oxygen register review and
formal clinical assessment.
S THE E
RD
Reducing variation in service provision can help tackle health inequalities and ensure consistency in the
safety and efficacy of services.
1. Implement Home Oxygen Service – Assessment and Review (HOS-AR) in line with nationally
identified good practice
ND
Why - In order to ensure quality of care, safe use of oxygen and the avoidance of waste.
How - Review the learning from the national COPD projects improving home oxygen service workstream
available at www.improvement.nhs.uk/lung
Liaise with your respiratory clinicians and make use of national good practice guide and the Department of
Health commissioning specification for HOS-AR in order to construct a business case and devise a service
specification.
Example: NHS Nottinghamshire County Community COPD Team, Sherwood Forest Hospitals NHS
Foundation Trust and County Health Partnership: ‘Patient review provides the ideal opportunity to recategorise the oxygen supply according to changing clinical and social needs.’
2. Use both clinical and oxygen supplier data systematically to support the assessment and
review process
Why - Data review enables the identification of patients who may potentially require therapy rationalisation
or the supported withdrawal of oxygen. It also helps identify sources of inappropriate prescribing and
maintain tight cost control.
6
Improving the quality and safety of home oxygen services: The case for spread
How - Provide HOS-AR teams with access to oxygen usage data from suppliers and ensure they work collaboratively
with managers and information specialists to routinely review the usage, flow rate, duration and equipment of home
oxygen patients.
Example: NHS Hull and the City Health Care Partnership: ‘Using cost and usage data from the oxygen supplier is
the smartest way to determine a starting point for assessing and reviewing patients.’
3. Integrate HOS-AR within the wider respiratory care pathway and coordinate activities with nonrespiratory specialties
Why - Oxygen therapy assessment and ongoing review provides the opportunity to optimise all other aspects of
patients COPD management (or their other long term conditions).
How - Undertake process mapping and also demand and capacity analysis to understand the whole pathway and
identify opportunities for new ways of working. Ensure that HOS-AR is explicitly detailed within the respiratory service
specification and that the HOS-AR team activities are aligned with other respiratory services such as pulmonary
rehabilitation. Ensure coordination exists with non-respiratory services such as cardiology, neurology and palliative
care.
Example: Wirral University Hospital NHS Foundation Trust and NHS Wirral: ‘Using a model that integrates
oxygen assessment and review with COPD and Pulmonary Rehabilitation services and is supported by secondary care
has contributed to the success of this community based service.’
4 Promote the message that ‘Home oxygen is a treatment for chronic hypoxaemia and NOT a
treatment for breathlessness’
Why - Oxygen is a drug and should only be prescribed where clinically indicated otherwise it is of NO benefit and
potentially harmful to some patients.
How - Establish ongoing and effective communication between the HOS-AR team, primary and secondary care and
also patients groups through education sessions and Forum meetings. A continuing dialogue should occur in respect
of best practice, treatment goals and HOS-AR referral criteria.
Example: NHS Birmingham East & North and Heart of England NHS Foundation Trust: ‘Engage GP consortia to
ensure the project has support and buy-in, engagement with the clinical lead may assist in terms of reinforcing the
message to patients and clarifying the indications for oxygen therapy’
5. Work collaboratively to formalise policies and procedures around the safe use of home oxygen
Why - Oxygen therapy is highly flammable and can result in serious injury or even death if not used safely.
How - Ensure patients and carers receive instruction in the safe use of home oxygen during the assessment and review
process and provide support to stop smoking. Work in partnership with oxygen suppliers and local Fire Rescue Services
to promote consistent messages around the safe use of oxygen and to establish risk identification, risk management
and clinical governance policies and procedures.
Example: NHS Hull and the City Health Care Partnership: ‘Working with the Fire Brigade has helped tackle the
challenges experienced by the team in educating patients and carers of the risks around health and safety and on
dangers of smoking to themselves and others, making such discussions more impactful’
7
Improving the quality and safety of home oxygen services: The case for spread
1.3 The case for spread
Sharing the learning: The home
oxygen workstream national
improvement lead sought widespread
collaboration with stakeholders. These
stakeholders included the Department
of Health home oxygen team, the
regional respiratory programme teams
and also the regional home oxygen
service (HOS) leads. This collaboration
was important in the promotion of
nationally endorsed good practice and
the spread of the emerging learning
from the national COPD projects.
As such, the national improvement
lead (NIL) participated in numerous
home oxygen best practice workshops
hosted by respiratory clinical networks
and regional respiratory programme
teams.
The workstream publications were also
widely disseminated in both print and
electronic form. The project teams
also played a major role forming an
informal virtual network for spread
and sharing their experiences with
colleagues across the country in local
education sessions and communities of
practice
Collectively this meant that even
before a formal spread programme
was established many localities and
regions were enabled to adopt much
of the learning and implement
improvements in their home oxygen
prescribing procedures, data
management and cost control.
8
Improving the landscape in respect
of assessment and review was
acknowledged as important in
supporting the efforts of the
Department of Health and the regions
as they sought to re-procure and
successfully transition the oxygen
supply contracts.
In many localities the strengthened
clinical input, better data management
and overall service coordination
provided by HOS-AR also assisted the
oxygen supply companies with the
transition process.
In addition, the important service
coordinating role undertaken by HOSAR teams together with their role in
educating both patients and
healthcare professionals and also their
role in supporting risk management
contributed in small part to the success
of many regional transition
programmes. It also strengthened the
case for HOS-AR to be available more
widely.
The goals of HOS-AR spread: Using
intelligence gained from initial surveys
of HOS-AR coverage, undertaken by
the Department of Health (DH), an
estimated 60% of Primary Care Trusts
(PCT) had established some form of
HOS-AR by the time a formal spread
programme was launched in
September 2012. These estimates are
being revised as a more robust survey
is currently underway.
It is difficult to establish exactly what
the coverage was prior to the start of
the testing phase project work but is
generally accepted that HOS-AR
covering the whole population served
by each local PCT was not widespread.
In devising a spread strategy it was
important to align the approach with
both the DH service specification for
HOS-AR5 (part of the COPD
commissioning toolkit7) and the
national COPD project learning.
This ensured a premium was placed
on quality by emphasising:
• structured assessment for accurate
diagnosis and appropriate
prescribing;
• information management; and
• patient and professional education
around the goals of treatment.
Safety was prioritised by
emphasising:
• ongoing review of clinical need;
• instruction in the safe and
appropriate use of oxygen; and
• risk assessment and clinical
governance.
Productivity was addressed by:
• rationalising therapy to reduce
waste; and
• matching prescribing to clinical
need.
In order to ensure the spread
strategy met these aims four
principle objectives for the
spread of HOS-AR were
established:
1. Adopt formal assessment
and review;
2. Reduce variation;
3. Commission services for
sustainability; and
4. Improve safety and
patient care.
Improving the quality and safety of home oxygen services: The case for spread
1.4 Use of data
Examples of home oxygen project service improvement measures
Home oxygen is an area of the NHS
that has a wealth of data available for
it to use, with invoice data, supplier
concordance reports, and local patient
caseload information. Oxygen usage
data from supplier companies is made
available on a regular basis to
commissioners in the form of large
spread sheets.
These large spread sheets can be
difficult for a non-expert to use and
interpret and often there is so much
data that it is difficult to identify an
area to focus. As a result, HOS-AR
services often lack key metrics that
might more usefully inform service
delivery and drive improvement work.
Metrics and measures
During the improvement projects,
teams were encouraged to focus on
driving the quality and appropriateness
of the supply of oxygen, and improve
the efficiency of services.
Project measures were chosen that
were appropriate to the goals, these
included:
• rules to check for patients potentially
on inappropriate supply and outside
of national clinical guidance;
• process measures to count the
number of patients reviewed;
• a measure on the referral source of
the new HOOF; and
• outcome measures including total
spend and change to size of
caseload.
1. What proportion of HOOFs were completed by the HOS-AR team?
2. How many patients have potentially clinically inappropriate supply,
for example:
• Over four hours of SBOT
• Under eight hours of LTOT
• Over or Underuse of prescribed oxygen
3. How much is spent on home oxygen supply per month?
4. How many patients receive home oxygen each month?
5. What is the service activity – e.g. How many therapy commencements
and removals?
The project metrics used were
dependant on the information
received from the suppliers, and some
required further local data collection.
The data requirements for
commissioning HOS-AR may differ
from those used in a service
improvement project. The service
specification in the Department of
Health Home Oxygen Assessment
and Review Commissioning Toolkit
suggests a number of commissioning
key performance indicators and a few
of these are listed below:
• The percentage of eligible people booked for their HOS
assessment who attend their appointment.
• The percentage of people prescribed oxygen therapy who have
a follow up home visit within four weeks.
• The percentage of people on long-term oxygen therapy who
have had a review in the last nine months.
• The number of inappropriate oxygen prescriptions identified
on assessment.
9
Improving the quality and safety of home oxygen services: The case for spread
The benefits of using data to
drive improvements in HOS-AR
As has been established during the
testing phase national project work,
the establishment of HOS-AR has a
potential to save money alongside
improving quality of care.
Effective use of data is a critical
success factor in realising these dual
benefits. Systematic use of supplier
and clinical data coupled with the
development of locally appropriate
service metrics are the foundations of
this approach. Below are listed a few
practical tips on data management
arising from the national project
work:
1. Use concordance data, but not in
isolation. Project teams found that
looking at the waste through using
the concordance data was an
excellent start, but combining this
alongside looking at quality of
prescribing enabled them to
identify many areas for
improvement
2. Who commences oxygen is a good
process measure. In some areas
with low spend and well managed
oxygen use, teams found that over
90% of commencements had
been initiated by a specialist from
their HOS-AR team.
3. Review how many patients are
supplied oxygen outside of
guidance, where it may not be
clinically appropriate. For example,
consider those on over four hours
of short burst oxygen a day, or
under eight hours of long term
oxygen therapy.
10
Sample Dashboard
4. Review how HOS-AR teams use
their time – often surprising results
were discovered in inefficient
administrative processes, and time
managing oxygen supplier
relations.
Making the data useable –
systems and approaches.
The data environment described
above meant that national COPD
project teams needed support from
the NHS Improvement - Lung team in
order to harness oxygen usage data
in a meaningful way to facilitate
appropriate prescribing, cost control
and clinical governance.
To this end the work stream was ably
supported by the NHS Improvement Lung senior analyst who worked
with the project teams in the
development of a monitoring
dashboard and helped them
understand and overcome the
data issues surrounding both the
improvement project work and the
transition in oxygen supply.
These dashboards together with
other locally devised data
management initiatives supported the
home oxygen teams in making
clearer patient care decisions and
motivated service change.
Visual management is an important
tool in using data to drive
improvement. While project sites
often thought that they understood
their services well, improvements in
the analysis and representation of
these large amounts of data often
identified hidden issues.
These improvements also enabled the
sites to provide evidence of
improvement to themselves and their
commissioners.
Improving the quality and safety of home oxygen services: The case for spread
Here are a few points to
bear in mind when
developing a local data
dashboard
• Choose a few, focused
metrics to drive
improvement.
• Be pragmatic – it’s not
easy to get perfect data,
and often simple data is
more useful.
• Present the data in a
simple way that makes the
progress and goals clear.
We found a dashboard
was a helpful tool.
• Remember data is an
essential part of HOS-AR –
without it, we often do
not know who our
patients are or whether
our patients are receiving
benefit from this life
prolonging therapy.
Future work – tools to interrogate
oxygen supplier data under the
new contract
The new contracts for home oxygen
supply commenced at the end of the
home oxygen improvement projects,
which made it difficult for some
project sites to provide consistent
data during the transition.
The new data provided by oxygen
suppliers is very comprehensive and
includes information on the ordered
supply, the reported use of the supply
and a waste estimate. In addition, it
now itemises the number of ‘service
visits’ (Which include refills,
installation, risk assessment and
removal of equipment) and
equipment rental charges (itemised
by type of supply).
Knowing where to start, and working
with the comprehensive data now
supplied by the oxygen suppliers is a
daunting and intimidating task for
many.
Many teams start with the
spreadsheet, adding filters,
highlighting rows of interest, and also
adding columns to total costs. This
would often be a complex procedure,
and is usually reliant upon one
individual to process the data.
The data often resides in separate
tables for transactions, patient
invoices and concordance reporting,
and so linking data items together
requires the home oxygen service
lead to swap between different files,
writing down patient ID’s to
compare. It became evident that
support to process and analyse the
data was required.
By using a simple desktop database
such as Microsoft Access, the NHS
Improvement - Lung senior analyst
was able to increase the efficiency
and quality of the data provided to
the HOS-AR teams. The resulting
Access database tool enabled:
• Automation of simple data
processing tasks.
• Reduction of the repetition of data
processing in Excel.
• Introduction of ‘reports’ to highlight
patients to review, and combining
key data onto a single patient page.
• Production of more complex reports
– summarising transactions,
identifying outliers and risky data.
• A single page helpfully summarising
the oxygen usage data for a patient
which was well received by
clinicians.
Use of the Access database tool at
times required the support of data
experts to set up – but it was
anticipated that any future
maintenance would be minimal as
the data supplied from the oxygen
providers has an established format.
Key learning arising from using this database approach
1. There are sometimes discrepancies between the number of cylinders
charged for by providers and the number of cylinders ordered for
patients.
2. The types of cylinders provided may not those specified on the
order form.
3. Large numbers of cylinders are still being held in patient homes,
highlighting potential danger.
4. Patients are often receiving visits for refill of cylinders multiple times
per month, sometimes multiple refills per week.
5. There is frequent use of urgent supply services.
6. Clinically inappropriate supply is still occurring in some instances.
11
Improving the quality and safety of home oxygen services: The case for spread
2: Learning from the prototype projects
2.1 Components of a quality
HOS-AR model
The Department of Health good
practice guide3 published in 2011
identified a number of components
of a Home Oxygen Service
Assessment and Review and listed
them within appendix 6 of that same
document.
The national COPD project work
looked at these components from a
service improvement perspective and
re-articulated them as seven critical
success factors necessary for practical
implementation of an operational
service model. These are:
1. Commissioned Service (including service specification and
referral criteria)
All the project teams felt the need to reinforce the importance of
having the work undertaken by HOS-AR teams explicitly outlined within
the specification of a commissioned service.
This would ensure the sustainability of the service and ensure quality is
defined in terms of key performance indicators and articulated
standards.
Historically, much of the oxygen assessment work undertaken across
the country has not been detailed within existing respiratory service
specifications and in some respects it can be thought of as being
undertaken ‘at risk’ in terms of sustainability and quality assurance.
It is also very important to specify the local referral criteria and define
the patients whose care will be managed by the HOS-AR team and
those oxygen patients whose care is perhaps managed elsewhere e.g.
cardiology dept.
The Department of Health recently published a commissioning
specification5 for home oxygen assessment and review which is also
supported by a patient guide jointly developed by NHS Improvement
and the British Lung Foundation and available at
www.improvement.nhs.uk
In addition to the commissioning specification the Department have
also produced a costing tool which can be used to evaluate the
potential benefits of introducing a commissioned service. Both of these
resources are available at www.dh.gov.uk/health/2012/08/copd-toolkit
2. Initial formal assessment (in accordance with good practice)
It is critical that patients are formally assessed in respect of their clinical
need for oxygen before any oxygen supply is issued to patients. As well
as determining whether the patient is hypoxic or not, the patient will
be assessed to ensure they are receiving optimal care in respect of their
condition and potentially referred to other specialist services if
appropriate.
12
Improving the quality and safety of home oxygen services: The case for spread
3. On-going review (frequency laid down within guidance)
The condition of many Oxygen patients is often subject to change and so it’s important that the therapy they are
receiving is still appropriate to their clinical need. Oxygen is a life prolonging therapy and so it’s vitally important
that the prescription a patient is subject to is ‘fit for purpose’.
The vast majority of oxygen patients are affected by respiratory conditions and as such the DH good practice
guide published in 2011 sets out the gold standard in respect of review frequency.
However a significant number of patients are affected by other conditions such as Heart Failure or Cancer and as
such the healthcare professional (HCP) managing the patient’s condition should do so in line with their own
medical specialty guidelines.
4. Workforce competence in: (i) assessing and reviewing clinical need, (ii) modifying home oxygen
therapy and (iii) identify complications or signs of deterioration needing additional’ management or
onward referral to a specialist.
Complications in respect of an oxygen patient’s condition often arise and so the HCP should be able to spot
significant factors and either appropriately intervene or refer the patient to a colleague skilled in this aspect of
condition management.
Thus it is imperative that the HCP undertaking the assessment is competent to do so and that appropriate liaison
with a consultant is an integral part of the HOS-AR.
5. Integration with respiratory care and coordination with non respiratory specialties
Integration of HOS-AR within the wider respiratory care pathway provides opportunity for improved patient
experience as well as the opportunity to optimise clinical management.
Multi-disciplinary team meetings, shared information systems and well understood patient pathways, treatment
goals and care protocols all support service integration and also improve the responsiveness of services to
changes in a patient’s clinical condition.
There are also natural synergies in terms of the organisation of care and a good example of this is pulmonary
rehabilitation and ambulatory oxygen assessment and provision.
A significant proportion of home oxygen patients have non respiratory conditions such as heart failure or
specialist palliative care requirements. Whilst the HOS-AR may not necessarily manage the care of these patients
(although some teams do operate shared care arrangements) it’s important to have good lines of
communication with these specialties. This ensures care is coordinated enables the HOS-AR team (and
commissioners) to understand the basis upon which these non-respiratory colleagues initiate oxygen and also the
arrangements in place for patient follow-up by these specialties.
13
Improving the quality and safety of home oxygen services: The case for spread
6. Clinical and supplier data management
Collaboration between clinicians and managers around the effective use of data is vital to achieving safe,
appropriate and cost effective home oxygen prescribing. Clinicians can advise whether patients flagged as
outliers in terms of oxygen consumption are at risk or in receipt of inappropriate therapy. Managers and
clinicians together can use the data to performance manage their local oxygen supplier and familiarity with
equipment and charging mechanisms enables the identification of opportunities to appropriately rationalise
therapy.
7. Education of patients and HCPs (treatment goals/safety/risks)
The HOS-AR team’s role in supporting supplier performance management and their involvement in prescribing
cost control are obvious incentives for commissioning assessment and review teams. Perhaps another equally
value-adding function the HOS-AR team undertake is patient and healthcare professional (HCP) education.
The goals of home oxygen therapy are often equally misunderstood by non (oxygen) specialist healthcare
professionals and the general public alike, and much effort is expended on an ongoing basis to tackle through
education the inappropriate prescribing of oxygen for breathlessness.
In addition there are many risks associated with incorrect use of oxygen therapy especially as regards fire hazards
and tubing-related trips and falls.
The HOS-AR team are more likely to be aware of changes to home oxygen equipment and so they can support
other specialists who perhaps need to prescribe oxygen for their patients.
14
Improving the quality and safety of home oxygen services: The case for spread
2.2 Practical service models
The Oxfordshire project team during a process mapping event
The five project teams undertaking
the prototype project work cover very
different geographical locations and
employ varied staff groups.
Respiratory nurse specialists are by far
the most widely represented clinical
staff group but teams do also
comprise of respiratory
physiotherapists, physiologists/clinical
scientists and pharmacists/pharmacy
technicians.
In addition, the wider project teams
involved (and sometimes were
led by) non clinical managers
from commissioning, medicines
management, information
management and finance.
Some of the teams were based in
community based premises whilst
others operated out a hospital
setting. The majority of teams had
access to consultant physician advice
and worked as part of a wider
respiratory care pathway.
Some teams undertook other
respiratory management duties in to
addition home oxygen assessment
and review and it also varied as to
whether or not teams had clinical
responsibility for non–respiratory
home oxygen patients.
A table summarising the variation in
workforce model is shown on
page 16.
In terms of service models what
seems to be important in supporting
quality assured HOS-AR is that:
a) the workforce has the
competences to:
• assess, review and modify home
oxygen therapy
• optimise or recommend strategies
for optimising a patients overall
management
• recognises when complex or
unusual presentations require
specialist intervention.
b) the service is accessible and
operates on a basis that reflects the
local populations need and
preferences.
c) the service is viewed as responsive,
integrated, cost effective and
sustainable by local commissioners.
The Department of Health have
developed a COPD commissioning
toolkit which includes a best practice
service specification and costing tool
to support the commissioning of a
high quality home oxygen assessment
and review service. These resources
can be accessed by visiting
www.dh.gov.uk/health/2012/08/
copd-toolkit
The costing tool uses actual historical
oxygen consumption in conjunction
with old and new supply contract
prices and applies assumptions in
relation to workforce (reflecting the
Oxfordshire model) clinic and home
visit frequency and duration in order
to generate a model of the potential
cost impact of introducing HOS-AR.
The tool does not try to quantify the
benefits arising from improved
patient care and whilst it does allow
you to tailor assumptions to more
accurately reflect local priorities it
should be remembered that it is a
model all be it a very useful one and
can not for example convey the
importance of home oxygen as a
constituent part of an admission
avoidance strategy.
15
16
520
HOS patients
Hampshire
No
0.6 WTE band
6 nurse (at
recruitment
phase)
0.6 band
2 admin
No
No
No
No
Band 7 1 WTE
Physio 37.5 hours
Band 6 0.5 WTE
Nurse 18.75 hours
Band 3 0.27 WTE
Admin assistant
10 hours
No
No
No
No
1.0 wte 37.5
Band 6
0.2 wte 7.5
Admin
No
No
No
No
2 X Band ?
Respiratory
Nurses
(? WTE)
No
Yes
No
No
1.6 WTE band 7
nurses and 1 band
6 nurse plus Respiratory
Physiotherapist
led Amb. O2
assessments
No
Yes
Yes
No
2 WTE Band 7
Respiratory Specialist
Nurses and 1 x WTE
Respiratory Specialist
Physiotherapist
Yes 19 hours
per week
No
No
No
2 x Community
Matrons
No
Consultant
Physicians
Yes
Consultant
Physicians
Yes
Monday clinic
Home visits Tuesday
to Friday incl.
Consultant
Physicians
Yes
Wednesday and
Friday clinics, Home
visits Monday to
Friday incl.
Consultant
Physicians
Yes
Monday to
Friday incl.
Consultant
Physicians
Yes
Monday to Fri clinics
in varying locations
3 X Consultant
Physicians
Yes
Monday - Friday clinics
08.00-16.00
Consultant
Physicians
No
Yes
Yes
Yes
No
Band 7 COPD Nurse
(1.28WTE), plus Band
8a COPD Nurse (0.13
WTE), GPwSI 0.05WTE),
Band 3 Admin (0.5WTE)
Yes
Yes
Respiratory Nurse
Consultant GP with a
specialist interest in
respiratory medicine
Yes
Yes
Yes
Yes
No
Band 7 respiratory
nurse specialist
(1 WTE), Band 6
Specialist Pharmacy
Technician
Yes – post improvement
project – now have a
band 3 (1WTE)
Yes – non O2 patients
under ongoing review,
eg. ILD patients to
determine O2 need if not
already on therapy
Respiratory Nurse
Consultant
Consultant
Physicians
Yes
Home Visits Monday to
Friday. Clinics once a
month at 3 venues
across the city
Hospital
Yes
Yes
Yes
Yes
Not clinically but
manage equipment
& data
Band 7 full Time
Nurse Practitioner
(1 WTE), Band 6
Nurse Assessor (28hrs
week 0.75 WTE)
Fulltime project
support officer
No
Consultant
Physicians
Yes
Home visits,
Community Clinics,
Acute Ward visits
Hospital and
Community
Yes
Yes
Yes
Do not Rx O2
for paediatrics
but support
once on O2 and
monitor usage
2.6 WTE band
6 nurses
1 WTE
administrative
hours
Yes
1 hour per week
of respiratory
consultant input.
Yes
Clinic- Mon, Wed
and Thursday
(9 to 5)Home visits –
Mon-Friday (9 to 5)
Hospital and
Community
Yes
Cluster headache
Palliative care
Paediatrics
Workforce
Dedicated
administrative
support
Do the HOS-AR
clinicians manage
other (non-oxygen)
respiratory patients?
Clinical support
Integrated working
withwider respiratory
pathway?
Operations
Clinic location
Home visits
Hospital and
Community
Yes
Hospital
Yes
Hospital
Yes
Community
Yes
Hospital and
Community
Yes
Lymington New
Forest Hospital
only at present
Yes
Community
Yes
Community
locations *3
Yes
Daily clinics spread over
3 locations Home visits
Monday to Wednesday
incl. Thursday clinic
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
300 patient
case load
Isle of Wight
Yes
Portsmouth
No
Southampton
Yes
Fareham
400 patient
case load
Basingstoke,
N.E Hampshire
and Farnham
259 patient
case load
640
Lymington
381 patient
case load
Andover
Yes
280 patient
case load
340
Stockport
Yes
480
Salford
Heart failure
600
Derbyshire PCT
(south) & Derby
City PCT
Derby
Respiratory
Patient management
Oxfordshire
Service as at January 2012
A table summarising the variation in workforce models across the home oxygen project teams
Improving the quality and safety of home oxygen services: The case for spread
Improving the quality and safety of home oxygen services: The case for spread
2.3 Issues and challenges
Analysis of oxygen usage data,
process mapping exercises
undertaken individually with project
teams and knowledge exchange at
collective project cohort peer support
events uncovered both differences
and similarities as regards the issues
and challenges faced by the teams in
implementing high quality HOS-AR.
Historically, the clinic DNA rates in
both Salford and Stockport had been
identified as problematic and so to
this end both teams had searched for
ways increase their capacity to
undertake home visits.
Salford, prior to starting the project
had already reduced the number of
clinics they performed in order to
increase their capacity to undertake
home visits.
However, by analysing the processes
associated with an individual
assessment clinic they spotted
opportunities to change practice and
reduce the duration of the initial
oxygen assessment. This enabled
them to create additional capacity for
a dedicated clinic for palliative oxygen
assessment.
Stockport also reorganised their
clinics and increased home visits
capacity. They overcame the
challenge of requiring two staff per
home visit (in order to transport
laboratory style blood gas analyser
equipment and concentrators) by the
adoption of portable blood gas
equipment
The Derby team had historically had a
challenge with inappropriate
prescribing arising from General
Practice. With support from the
national programme senior data
analyst and the use of data
dashboards they were able to
establish that GP prescribing of home
oxygen was now significantly reduced
and that the current sources of
inappropriate prescribing were based
in the hospital setting.
In Oxford the process mapping
exercises highlighted that slight
variations in practice had arisen
among the team in response to
specific clinical scenarios. The team
had a long-standing practice of
holding regular clinical update and
knowledge sessions and so they
provided a forum to ensure
consistency across the team was reestablished.
In Hampshire, both the data analysis
and the series of process mapping
events with teams across the county
supported a gap analysis in respect of
adherence to national standards,
resource constraints and potential
variations in prescribing behaviour.
This information further informed the
development of a Pan-Hampshire
service specification and provided the
basis for a service investment
business case.
The administrative and data
management requirements of HOSAR are a challenge that all teams held
in common. Incomplete information
upon referral often meant that highly
skilled clinical resource spent a lot of
time trying to establish a more
complete clinical picture of patients in
advance of their appointment.
In some instances this was addressed
somewhat by more complete and
robust referral processes and
documentation and by reinforcing/relaunching referral criteria.
However, the need to monitor
oxygen usage data and keep track of
guideline mandated review dates
does require administrative support.
2.4 Overall project cost savings
The HOS-AR teams included within
the prototype project cohort had
already demonstrated to the
satisfaction of their local
commissioners their ability to
prescribe and rationalise home
oxygen therapy in an appropriate and
cost effective manner prior to
embarking upon this phase of work.
Prior to the project work many of the
teams had already comprehensively
reviewed supplier concordance and
invoice data, cleansing the data of
anomalies (such as charges for
deceased patients, multiple data
entries for a single patient etc) and
had married this data with clinical
information to create home oxygen
patient registers or actual databases.
17
Improving the quality and safety of home oxygen services: The case for spread
These teams were already routinely
updating these registers establishing
cycles of patient therapy assessment
and review and identifying candidate
patients for therapy alteration/
removal post clinical review.
The prototype works main thrust was
to identify key elements in the
implementation of quality assured,
safe and appropriate home oxygen
therapy.
However, NHS Improvement - Lung
was also interested in these teams
ability to continue the tight control of
any increases in expenditure
associated with optimised therapy or
uncovering unmet need.
It was therefore of considerable
interest that many teams were still
able to demonstrate cost savings
(prior to oxygen supply contract
transition and its inherent contractual
cost efficiencies) through appropriate
home oxygen prescribing and therapy
rationalisation.
Difficulties in ascertaining consistent
data in the immediate aftermath of
the supply transition (which for most
teams took place during the midpoint of the project) made it difficult
to differentiate between savings from
HOS-AR related functions and those
benefits deriving from a more
efficient contract.
18
Best estimates seem to indicate that
the prototype teams were on target
to achieve an average of £100,000
per site in HOS-AR related annual
prescribing cost efficiencies (based
upon comparison with the annual
spend in 2010/11), resulting in a
collective workstream annual forecast
saving of approximately £570, 000.
Despite the intrinsic cost efficiencies
deriving from the new national
oxygen supply contract, there is still
the potential for costs to rise if
patients are not initially assessed for
their need for home oxygen therapy
by healthcare practitioners who are
both thoroughly familiar with the
various equipment modalities and
also acquainted with current charging
structures.
HOS-AR team clinicians across the
country attend on an ongoing basis
the oxygen device training sessions
held by the oxygen suppliers and so
have a complete understanding of
the range of equipment available and
also each device’s suitability for the
different presenting symptoms and
changing patient clinical needs.
HOS-AR teams are also best placed to
prescribe a treatment modality which
is both clinically appropriate but also
cost effective – a generalist or a
specialist clinician who has not
undergone this training is unlikely to
be able to do this on a consistent
basis.
Although the prototype project sites
had completed thorough data
validation exercises, there were still
opportunities for further savings from
reviewing data on a regular basis.
This finding only serves to reinforce
earlier workstream learning about the
need for HOS-AR teams to have a
regular plan to review data and not
see it as a one off exercise.
The absence of regular data review
will inevitably lead to a slow increase
in costs. Although the new supply
contract does include large penalties
for supplier data errors, the new
contractual arrangements are not
sufficient to deliver the data quality
improvements alone.
This is particularly the case for those
suppliers who are dealing with a
legacy of equipment and inaccurate
historic data.
3
3: Case studies
Improving the quality and safety of home oxygen services: The case for spread
3.1 Oxford Health NHS Foundation Trust
Improving and fine tuning Oxfordshire’s
Home Oxygen Service
What was the problem?
Oxfordshire’s home oxygen service
has been operational for
approximately three years and is
recognised nationally for having
successfully improved patients
experience as a result of appropriate
and cost effective oxygen therapy
prescribing undertaken by trained
professionals.
Staffing changes had created an
identified skills gap and the service
was subject to an ongoing
commissioning requirement to remain
both high quality and cost effective.
The team also identified areas for
improvement such as smoking related
incidents, out-of-hours coverage and
100% underuse of prescribed oxygen
therapy in a large number of patients.
In addition, the team wanted to
make a smooth transition to the new
oxygen supply contract.
What was the aim?
The project team sought to improve
the quality and standards of the
service in three areas:
1. To reduce the number of patients
with significant (100%) underuse
of prescribed oxygen therapy by
25%
2. To reduce smoking related
incidents
3. To reduce the cost of prescribed
oxygen by 10% over one year.
They planned to achieve this by
meeting the following objectives:
• Review and update patient
pathways
• Develop a new competency
framework
• Train staff and ensure competency
in key areas
• Develop a risk assessment tool in
order to formally risk assess patients
who smoke
• Manage the transition to the new
oxygen supplier.
What did they do?
The team allotted project
responsibilities and met regularly with
support from NHS Improvement-Lung
in order to refine their aims and
objectives, plan project activities,
identify stakeholders, review the
patient journey and undertake
process mapping (with the
commissioner in attendance).
Through contact with clinical teams
across the country at NHS
Improvement-Lung peer support
events the team were able to reflect
upon their clinical practice and
capture ideas for potential new
ways of working.
What has been achieved?
Process mapping enabled the team to
examine differences in the service
across the county and confirm the
skills required at different parts of the
pathway. It was also instructive in
ensuring that all members of the
team were applying a consistent
clinical approach.
The team also undertook a demand
and capacity exercise in order to
better understand the impact of
travelling and administration on
face-to-face time with patients.
19
Improving the quality and safety of home oxygen services: The case for spread
In terms of the stated objectives
the team:
• Reduced under users from 115 to
54 (53% reduction)
• Began development of a smoking
risk assessment too
• Increased teams awareness of
smoker safety and general oxygen
safety
• Developed greater awareness of
service demands
• Reduced oxygen costs by 12%
from September 2011 to April
2012
• Gained insight into team member
knowledge levels and began
implementing a competency
framework
• Started weekly training sessions to
improve the knowledge and skill
mix (e.g. maintain competences in
arterial blood gas measurements)
• Successfully managed supply
contract transition which was
initially characterised by significant
increase in calls from patients
• Implemented an out of hours
oxygen ordering pathway
• Exploring the use of portable
(capillary) blood gas analysers on
home visits and acquiring
equipment through cost savings.
20
What are the key learning points?
• The importance of risk
identification (in general) and
shared awareness among the team
in respect of patients who pose a
higher risk due to smoking
• Service improvement methodology
provides effective tools for
identifying ‘risk’ areas and areas for
quality improvement
• Knowledge exchange with other
teams (and opening pathways of
local and national communication)
promotes the development of new
ways of working
• The importance of regularly
evaluating clinical knowledge
among the team in respect of more
complex patients (CO2 retention,
hypercapnoea, use of oxygen in
exacerbations etc) and the value in
implementing ongoing training.
Contact
Jo Riley
Respiratory Service County Lead
Tel: 01865 225472
Email:
[email protected]
Sophie Beveridge
Respiratory and Home Oxygen
Service Nurse
Tel: 01865 787185
Email:
[email protected]
Improving the quality and safety of home oxygen services: The case for spread
3.2 NHS Southampton, Hampshire IoW Portsmouth; SHIP PCT Cluster
The Hampshire Model for the Home Oxygen
Service - Assessment and Review
What was the problem?
Considerable differences in the type
of service experienced by home
oxygen patients across Hampshire
were known to exist as a result of the
way the teams undertaking home
oxygen service – assessment and
review (HOS-AR) had evolved in the
different geographical localities.
In many instances these different
service models reflected differences in
local need but they were also a
reflection of differences in local
funding arrangements and
differences in the interpretation of
(and compliance with) national
guidance.
In addition, the impending change in
oxygen supply provider and
contractual changes necessitated
further strengthening in the
arrangements for monitoring oxygen
usage in preparation for the
transition by building upon recent
analyses of patient concordance.
What was the aim?
The aims of the project were to
1. Develop robust Pan-Hampshire
service plans, specifications and a
business (investment) case which
reflected national guidance
2. Further improve data management
to achieve ongoing active
monitoring of oxygen usage and
ensure the successful transition of
supply in March 2012.
Specific project objectives included:
• Gap analysis - to understand
levels of compliance with national
standards in respect of HOS-AR
• Staffing review - to understand
the workforce variations across the
county
• Care pathway review - to
understand differences in the
patient journey experienced across
the county.
What did they do?
Pathway analysis: A series of
process mapping events were
initiated across the county involving
the home oxygen teams situated in
Lymington, Fareham and Basingstoke
respectively.
This enabled differences in clinical
practice to be identified and the
specific local challenges and resource
constraints documented and
understood.
In addition, the teams in Isle of
Wight, Southampton and Portsmouth
provided information about local
resources and the patient journey by
completion of a mapping table
questionnaire.
Data management: Work on the
analysis of patient concordance was
intensified to gain an accurate picture
of usage activity in each location and
an understanding of the variations in
prescribing costs across the county.
This was supported by use of the
data dashboard devised by the NHS
Improvement-Lung senior analyst and
liaison with both the outgoing and
incoming oxygen supply providers.
Service planning: The team also
reviewed NHS Improvement national
publications, the Department of
Health (DH) Good Practice Guide,
early versions of the DH
Commissioning toolkit for COPD &
Asthma and the DH Specification for
HOS-AR in order to develop a PanHampshire service specification and
business case framework which can
support the development of local
investment cases by constituent
clinical commissioning groups (CCGs)
across the county
21
Improving the quality and safety of home oxygen services: The case for spread
What has been achieved?
A better understanding of the
differences in service models and
delivery across the county has
enhanced the ongoing discussions
taking place between the service
provider organisations and the
commissioners of the services.
The Pan-Hampshire service
specification has been accepted by all
constituent CCGs across the county
and its recommendations in respect
of service levels will be reflected in
local service performance indicators.
The various options outlined in the
Pan-Hampshire business case have
prompted a number of CCGs to
consider investment in their local
HOS-AR to ensure compliance with
good practice and to also examine
the extent of wider respiratory service
integration.
Good lines of communication were
established with the incoming oxygen
supply provider and home oxygen
patients who were concordance
outliers were identified and flagged
up with clinical staff for review and
22
What are the key learning points?
1. Differences in service models
across the county did not
necessary imply differences in
service quality. However,
differences in adherence to
national guidance could be a
source of service inequality
especially in respect of ongoing
clinical review.
2. Differences existed across the
county in terms of the prescribing
cost per patient and this might
also be attributable to differences
in each teams capacity to review
patients changing clinical need
(and modify therapy) or differences
in the use of oxygen device
modalities especially in relation to
palliative care.
3. Significant clinical time is taken up
by routine administration as a
result of lack of admin. support.
4. Clinical teams lacked consistent
and concise information and
central management support
concerning home oxygen patients.
Contact
Chris Slade
Clinical Networks Manager
Tel. 02380 627672 / 07833293074
Email: [email protected]
or [email protected]
Improving the quality and safety of home oxygen services: The case for spread
3.3 Derby Hospitals NHS Foundation Trust,
Derbyshire County PCT, Derby City PCT
Service improvement review to ensure
sustainability and consistency of the Derbyshire
Home Oxygen Service
What was the problem?
The introduction of home oxygen
service-assessment and review (HOSAR), with blood gas monitoring
available both within clinic and home
settings, and the establishment of
clinical and oxygen supply usage data
review and management had enabled
great strides to taken in addressing
historic problems of inappropriate
oxygen prescribing and sub-optimal
management together with
inequalities of care associated with
patients varying ability to travel to
hospital for assessment or review.
This had enabled the newly
established service to meet all its
initial quality and financial measures
during its first two years of existence.
However, problems still remained
with many local healthcare
professionals still not familiar with the
principal goals of oxygen therapy
(addressing hypoxia) resulting in
inappropriate therapy initiation.
Many patients understanding about
both their condition and their therapy
was still variable and the
administrative and governance
processes for the local HOS-AR
needed to both keep pace with the
changing primary care landscape and
enable greater analysis and reporting.
What was the aim?
The project aimed to address these
problems by developing and
implementing plans to:
1. Improve data coordination, analysis
and reporting by reducing
administrative duplication,
inconsistent recording and getting
greater clarity around lines of
reporting.
2. Achieve greater consistency of
message among healthcare
professionals in terms of the
message to patients and in terms
of the goals of therapy.
3. Identify clearly who, where and
why home oxygen was prescribed
through improved.
4. Improve ambulatory oxygen
assessment and monitoring
procedures.
5. Improve the removal pathway for
patients without a clinical
requirement for home oxygen.
What did they do?
• The team undertook a process
mapping event and involved
patients, community and hospitalbased respiratory staff together
with colleagues from palliative care,
IT and the Trust transformation
department.
• Patient referral forms and data
entry processes were reviewed to
capture redundancy and identify
areas for improvement.
• Ongoing dialogue and training was
undertaken with the (new) incoming oxygen supplier in order to
manage the transition to a new
supply contract.
• The team worked with the NHS
Improvement - Lung senior analyst
to develop data dashboards which
would more easily enable the
tracking and monitoring of oxygen
usage and prescribing.
• An initial demand and capacity
exercise was undertaken to identify
ways of increasing service capacity.
• Patient information literature was
revised in order to strengthen
messages about the goals of
oxygen therapy and also the safe
and effective use of equipment.
23
Improving the quality and safety of home oxygen services: The case for spread
What has been achieved?
• Inappropriate prescribing has been
reduced by establishing a local
consensus among healthcare
professionals about the use of the
new part a/b Home Oxygen Order
Form (HOOF).
• Prescribing guidance for all
modalities of oxygen is now more
closely aligned to national
standards and best practice and as
such is both tighter and clearer. It
has also been made widely
available and is being incorporated
into the Trust website.
• Data harmonisation work has made
progress and all (clinical and supply
usage) data will be entered onto
System1 to enable it to be accessed
across the multi-disciplinary team.
• The new patient information leaflet
has been well received and the
quality of prescribing has improved
with a shift from 60% of patients
having an optimal oxygen
prescription to 90%.
• A thorough review of the
governance arrangements in
respect of oxygen therapy and
persistent smokers has been
undertaken inclusive of liaison with
expert legal counsel.
24
What are the key learning points?
• Changes in respect of the new
HOOF were initially a source of
frustration for GPs and Consultants
but these changes have now been
agreed.
• Access to data, and critical review,
has been particularly valuable in
identifying the priorities and
objectives for the service.
Previously, the team believed that
they had issues with GP
commenced HOOFs, however the
data suggested that this was no
longer the case. This indicates that
both the original work has been a
success, but also that resources
could now be focused elsewhere in
order to achieve improvements in
areas of a greater need – the team
are considering supporting inhospital prescribing.
• Service Improvement has become a
key part of the team’s thinking,
and ensuring that they have
evidence has been helpful for the
team, but also in supporting
discussions with commissioners.
• The team could have continued
being ‘good enough’ – the service
improvement work has encouraged
them to think critically and aim for
better.
Contact
Sue Smith
Specialist Practitioner for
Home Oxygen
Tel. 01332 787825
Email. [email protected]
Improving the quality and safety of home oxygen services: The case for spread
3.4 Salford Royal NHS Foundation Trust
Maintaining a safe, cost effective and accessible
Home Oxygen Therapy Service (HOTS)
What was the problem?
Home oxygen service – assessment
and review (HOS-AR) had been
successfully introduced in Salford in
2008 with the establishment of the
Home Oxygen Therapy Service
(HOTS). Robust referral processes
had been implemented and the HOTS
team were part of an integrated
respiratory service. They also had
very strong links with other nonrespiratory disciplines.
The team had access to supplier
invoices and reports which they used
to monitor oxygen usage, the sources
of prescribing and also the range of
clinical conditions existing among
patients in receipt of home oxygen
therapy.
The use of an electronic referral
proforma (incorporated within local
GP computer systems) together with
systematic changes to clinic venue
locations and the establishment of
home visit clinics improved access to
HOTS significantly.
However, each month there remained
a small number of new Home Oxygen
Order Forms (HOOFs) originating
from outside of the HOTS team and
initiating home oxygen in un-assessed
patients. This was of great concern
as the HOTS team were uncovering
(un-assessed) home oxygen therapy
patients with chronic type 2
respiratory failure for which oxygen
therapy could be potentially harmful.
What was the aim?
A safe, cost effective and accessible
home oxygen service was a local
priority and so the primary aim was
that 95% of all HOOFs originate from
the HOTS team (5% allowance for
paediatric and end-of-life patients).
Continuous service improvement
would be achieved by:
• Reviewing HOTS referral processes
and documentation
• Continued integration of HOTS
with wider respiratory team to
support delivery of a high quality
COPD care bundle
• Greater links with end-of–life carers
and staff to ensure appropriate,
beneficial and cost-effective home
oxygen prescribing, therapy
alteration and follow-up
• Continued monitoring of home
oxygen usage data to support
transition to a new oxygen supply
provider, maintain clinical
governance and ensure costeffectiveness
What did they do?
The team undertook a number of
project activities in support of the
above objectives:
Multidisciplinary engagement: A
process mapping event involving
numerous staff types, assorted
medical specialties and stakeholders.
This highlighted areas for
improvement both in respect of
clinical and administrative processes.
It also illustrated the evolving role of
the HOTS team and raised awareness
of issues across the wider respiratory
care pathway.
Change in clinical practice: Further
low-level mapping of the actual
oxygen assessment process prompted
the team to continue taking blood
gas measurements on air in both the
first and subsequent (three week)
clinic visit but to undertake titration
on oxygen (to target oxygen
saturations) in the three week clinic
assessment visit only.
25
Improving the quality and safety of home oxygen services: The case for spread
Many patients present with markedly
improved blood gas levels at the
three week assessment and so the
original titration exercise was
unnecessary. In addition, patients
(with no known heart failure
diagnosis) who have a PaO2 > 8.3kPa
at the first initial assessment are
referred back to their GP with advice
for subsequent re-referral to HOTS if
the patient deteriorates. Previously
patients were kept under review if
their PaO2 < 9kPa
Administrative and data
management changes: The referral
form was altered to include
additional information to establish
that patients are medically stable
prior to assessment. The involvement
of the commissioner in the mapping
events supported the team’s efforts
in acquiring administrative support to
help improve data management in
advance of oxygen supply transition
and oversee the introduction of
additional data recording and audit
tools.
The team have also established a
generic email address which allows
for prompt processing of referrals and
a shortened appointment booking
process.
26
What has been achieved?
Home oxygen prescribing – The aim
of ensuring safe quality assured
prescribing of home oxygen though
the 95% HOOF target has been met.
This was accompanied by continued
month-on-month reductions in
prescribing costs in the months
preceding the transition of oxygen
supply (which is likely to introduce
further cost efficiencies).
Increased assessment clinic capacity –
Initial assessment clinic duration times
have been reduced through the
change in practice, reducing waiting
times for new referrals and enabling
an additional clinic slot for urgent
assessment for palliative oxygen.
Further safeguards against acute
oxygen toxicity - the multi-disciplinary
whole pathway discussions prompted
the routine issuing of oxygen alert
cards to all patients in need of non
invasive ventilation (NIV).
What are the key learning points?
• Process mapping supports the
identification of opportunities to
quickly change both clinical
practice and also the organisation
of care processes.
• Multidisciplinary involvement in
service re-design enables
consideration of the whole
pathway of care and identification
of areas for improvement outside
the immediate project scope.
• Quality assured prescribing and cost
efficiency will only be maintained
by continual monitoring of oxygen
usage by the HOTS team and tight
control of HOOF prescribing.
Contact
Melissa Collinge
Respiratory Nurse Specialist
Tel. 0161 206 0865
Email. [email protected]
Improving the quality and safety of home oxygen services: The case for spread
3.5 Stockport NHS Foundation Trust
Fit for purpose – clinical quality, cost
effectiveness and patient satisfaction
What was the problem?
The Oxygen Assessment Service in
Stockport (Oasis) and local
commissioners jointly identified the
need to expand the communitybased service to enable GPs to refer
patients for specialist home oxygen
service - assessment and review
(HOS-AR) and also to appropriately
repatriate home oxygen patients
(whose condition did not require
acute hospital / tertiary centre care)
back to the community.
The service also needed to prepare
for the transition to a new oxygen
supply contract, which was
happening in parallel with the team
transferring from the Primary Care
Trust (PCT) to the local Foundation
Trust, by identifying and
implementing improvements in
service efficiency, data management
and prescribing
What was the aim?
The project was established to
achieve the following objectives:
• Review the current service in order
to identify both good practice and
areas for improvement
• Identify gaps in consistency of care
to patients prescribed home oxygen
• develop clinical and prescribing
data management systems in order
to meet the requirements and
timescale for implementation of a
new national Home Oxygen supply
contract (2 July 2012)
• Expand the service to ensure that
all patients who would benefit from
oxygen therapy are offered timely
high quality assessment and care
appropriate to their needs
• Maximise the cost effectiveness of
the HOS-AR service whilst
minimising the cost of prescribed
oxygen
• Ensure that oxygen is prescribed
safely, (without causing increased
carbon dioxide retention), and only
when clinically beneficial (hypoxic)
• Build close working relationships
with other local clinical teams
managing patients prescribed
oxygen and ensure care is
consistent across the health
economy.
What did they do?
The project team undertook a
number of specific project activities
namely:
• Care pathway mapping: The
team process mapped the journey
for patients currently cared for by
Oasis in order to identify
inefficiencies, highlight patients
who fell outside of the pathways of
care and reveal inequalities in
service provision. This was used to
generate improvement ideas
• Patient reconciliation: Patients
prescribed oxygen but not known
to the service were identified by
reconciling to the oxygen provider
(Air Products) concordance report
to their patient care records
• Audit of GP oxygen prescribing:
This enabled the team to estimate
the numbers of expected GP
referrals upon commencement of
GP direct access to Oasis
• Patient categorisation: Patients
were stratified according to disease
complexity, age and prescribing
modality short burst/long-term
oxygen therapy in order to support
discussions between clinicians
about which patients should be
provided full HOS-AR by Oasis
those patients who should be
known to the service but managed
by other specialist services
27
Improving the quality and safety of home oxygen services: The case for spread
• Workforce modeling: The team
worked with their commissioner in
the development of a tool to
estimate staff numbers required for
the new expanded service and to
develop the business plan. The tool
used information from:
• GP prescribing audit and the
patient categorisation exercise
• the revised care pathway from
the mapping exercise
• projected volume of patients
receiving full HOS-AR care from
the patient reconciliation exercise
• Department of Health good
practice guide requirements in
respect of clinical competence
• demand and capacity information
in respect of assessments,
reviews, administration and data
management.
This model also took account of
appointments being a mix of home
visits and clinic based appointments
with an increased emphasis on home
visits in order to address the relatively
high historic DNA rates for clinic
appointments.
• Review of Home assessment
equipment: As part of the national
COPD project cohort the Stockport
team were able to discuss
alternative blood gas analyser
equipment with other HOS-AR
services and select clinically
effective portable equipment that
could be managed by one person
as two staff are currently required
to deploy the current analyser and
other equipment.
28
• Development of a referral
pathway for GPs for acute
assessment: Working with the
primary care respiratory lead / GP
with a specialist interest and the
local commissioners the team
developed a referral pathway which
incorporated use of the Choose
and Book service.
What has been achieved?
The project met all the stated
objectives and delivered a number of
notable achievements namely:
• Development a GP referral pathway
and proforma ensuring that GP’s
no longer issue Home Oxygen
Order Forms.
• Increased clinic / visit capacity
enabling the creation 1x urgent slot
available daily Mon-Friday
• Development of an Out of hours
pathways with the Mastercall
service
• Reduced the costs associated with
home visits through use of a
portable blood gas analyser by a
single nurse
• Improved patient data
management enabling historic
oxygen usage and patient clinic
contact records to be viewed
together
What are the key learning points?
• Collaboration between the clinical
team and the local commissioner in
the use of patient clinical data and
the oxygen supplier data enabled a
model of service workforce
requirements to be developed
which met the needs of the local
population
• Working with the PCT quality team
enabled the development of an
improved reporting tool which
could merge monthly supplier
invoice data with the active patient
clinical list.
• Networking with other national
COPD project teams assisted the
process of clinical practice review
and generated ideas for
improvements to service delivery
such as:
• use of portable equipment to
facilitate blood gas analysis of
housebound patients
• shift to a locality based work plan
to reduce travel time and mileage
and
• development of new template for
patient contacts to reduce time
spent dictating letters
• The new service arrangements have
uncovered challenges associated
with the initiation of oxygen
therapy for palliative /End-of-life
patients
• The ability to safely and
appropriately initiate oxygen
therapy immediately following a
senior specialist nurse home visit
should increase patient satisfaction
and service effectiveness – this
assertion will be tested through
patient satisfaction surveys and
continued monitoring of clinical
and usage data.
Contact
Karen Fern
COPD Team Leader
Tel. 0161 426 9613
Email: [email protected]
Improving the quality and safety of home oxygen services: The case for spread
4: Additional information and resources
Appendix 1: North East procurement of HOS-AR provider – a case study
The North East (NE) Respiratory
Programme team undertook a
baseline assessment of Home Oxygen
Service-Assessment and Review (HOSAR) within existing clinical provider
organisations and uncovered wide
variation in the provision of HOS-AR.
The need to address the identified
gap in HOS-AR provision and
establish a quality service in line with
a recently published national good
practice guide prompted an alliance
of stakeholders in the former NHS
North East to develop a tender and
procure a local HOS-AR capability.
A sense of urgency was created by a
number of driving factors, most
notably:
1. The NE was scheduled as the
second region to transition to the
new nationally developed oxygen
supply contract
2. It had been agreed as a strategic
priority following a Respiratory
programme stock-take meeting
between the NE Regional
Respiratory Leads, Managers and
Directors of the former North East
Strategic Health Authority and the
National Clinical Directors for
Respiratory Medicine
3. Some individual Primary Care
Trusts (PCTs) in the NE had
attempted to commission HOS-AR
in the past but did not followthrough due to other competing
local priorities.
Thus followed an approximately 12
month procurement process
(beginning late March/early April
2011) which involved PCT
commissioning managers,
procurement managers and staff
from a centralised contracting
(shared) services team and the NE
Respiratory Programme team.
A total of seven PCTs (Gateshead,
South Tyneside, Sunderland, County
Durham, Darlington, Middlesbrough
and Redcar & Cleveland) agreed to
work collaboratively with the NE
Respiratory Programme team with
one PCT acting as the lead on behalf
of the collective.
This approach built on a strong
legacy of local cluster working. The
seven PCTs agreed that the tender
would be for one regional service
specified in accordance with national
good practice to provide assessment
and review adult Respiratory,
Cardiology and Palliative care patients
requiring home oxygen therapy.
The procurement process was guided
by local NHS procurement managers
who were able to keep a tight track
of the process using an electronic (eTendering) procurement software
system. The (clinical healthcare)
nature and value of the tender meant
it fell outside of the requirement to
advertise on a Europe-wide basis and
also permitted more flexibility in
relation to the specified timelines.
A ‘Request for information’ (RFI) pretender process was established. This
enabled the proposed service
specification to be circulated in
advance to interested parties to solicit
comments and feedback in advance
of the final tender process and
elicited additional expressions of
interest.
29
Improving the quality and safety of home oxygen services: The case for spread
No objections were raised to the
service specification which aligned to
a payment regimen involving a ‘block
contract’ in year 1 with a mixture of
cost & volume and payment by
results schedules in subsequent years.
The contract also utilises the
Commissioning for Quality and
Innovation (CQUIN) payment
framework to drive service quality
performance.
All seven PCTs are signatories to the
HOS-AR contract thus its contractual
terms and conditions should
transition smoothly to the successor
Clinical Commissioning Groups
(CCGs).
The procurement team were struck
by the differences in approach
between potential NHS and
commercial bidders, the latter being
adept at asking very pertinent and
astute questions in order to support
the process of gathering information
which might support their potential
future bids.
Devising a robust questioning,
evaluation and scoring methodology
and sourcing an external evaluator is
time consuming, as is the process of
developing a tender and service
specification. Engagement of local
stakeholders such as CCG leads
should be initiated early in order to
be sure of getting the right decisionmakers involved.
A total of four bids were received
these included two oxygen supply
companies as well a bid from a
consortium of local NHS Foundation
Trusts who decided at a relatively late
stage to mount a joint bid.
The HOS-AR provision tender was
eventually awarded to Air Liquide
(formerly the regional oxygen supplier
but now succeeded by BOC as a
result of the national oxygen supply
re-procurement and regional
transition process).
Staff recruitment has commenced in
line with the service beginning in
October 2012.
30
Key learning points
1. Ensure the process is allotted
sufficient time.
In addition, there is a lead time for
the service to be established which
must take account of staff
recruitment, liaison with
neighbouring services, securing
service premises etc.
2. Establish a team comprised of
the right skills and disciplines.
The NE team were able to build upon
strong existing shared commissioning
and cluster working arrangements
supported by proactive expert clinical
input from the Regional Respiratory
Programme and an experienced local
procurement team.
3. Gain a clear understanding of
potential service demand,
service costs and identify
appropriate funding streams.
The NE team had to reference service
costs from a neighbouring PCT and
use information from the incumbent
oxygen supplier to develop a costing
model and establish potential cost
efficiencies resulting from the new
service.
This process was conducted in
advance of the recently published
COPD Commissioning Toolkit
(containing a Commissioning
specification for HOS-AR) which
addresses this need.
4. Ensure a strong contract
management framework and a
robust service specification
The NE team built service quality and
(caseload responsibility) safeguards
into the eventual service specification
to ensure the new service is
integrated within the wider
respiratory care pathway and the
existing contract management
processes mitigated any risks posed
from a potential situation in which (as
a the result of the tender process) the
clinical service provider and the
oxygen supplier were the same
organisation.
Improving the quality and safety of home oxygen services: The case for spread
5. Appointment of a
non-NHS provider involves a
considerable time commitment
in respect of change
management in order to:
a) ensure whole service integration
through collaboration between the
new commercial HOS-AR provider
and existing NHS respiratory
service providers
b) meet local NHS concerns about
the commissioned arrangements
to sustain high quality care and
workforce competence
c) establish trust and open
communication between all
stakeholders.
Contact:
Vikki Bailey
Respiratory Programme Manager North East (NHS North of England)
Mobile: 07824342721
Email: [email protected]
31
Improving the quality and safety of home oxygen services: The case for spread
Appendix 2: Lung improvement resources and sample project
team process maps
Process mapping was used by all of
the prototype project sites to help
diagnose problems and identify areas
of their respective services in need of
improvement.
You can also download a copy of the publication entitled ‘First steps
towards quality improvement: A simple guide to improving services’
by visiting the publications section of the lung website.
All of these process maps (which
reflect the service before the
improvement project) make
interesting reading but due to
publication printing constraints it is
only possible to reproduce one of
these maps here.
For more information about process
mapping and other service
improvement tools and techniques
please visitthe lung website
www.improvement.nhs.uk/lung
The following resources are also available from the lung website:
32
Improving the quality and safety of home oxygen services: The case for spread
33
Improving the quality and safety of home oxygen services: The case for spread
5: Acknowledgements and references
Acknowledgements
References
Further information
NHS Improvement - Lung would like
to thank all the national improvement
project sites for their hard work and
dedication to improve the quality and
care for people with COPD, and also
for their support and contributions to
this document.
1. Home Oxygen Service –
Assessment and Review – Good
Practice Guide, NHS Primary Care
Commissioning (2011)
2. NHS Improvement - Lung
Improving Home Oxygen Services:
Emerging Learning from the
National Improvement Projects,
NHS Improvement 2011
Publication Ref:IMP/comms011 –
April 2011.
3. NHS Improvement - Lung: National
Improvement Projects Improving
Home Oxygen: Testing the Case
for Change, NHS Improvement
2012 Publication Ref: NHSImp
Lung 0001 - May 2012
4. An Outcomes Strategy for Chronic
Obstructive Pulmonary Disease
(COPD) and Asthma in England,
Department of Health, July 2011
5. COPD Commissioning Toolkit:
Home Oxygen Assessment and
Review Service Specification, NHS
Medical Directorate, August 2012
6.The NHS Outcomes Framework
2013-14, Department of Health,
November 2012
7. COPD Commissioning Toolkit, NHS
Medical Directorate, August 2012
For further information about this
publication please contact:
In addition, the following people also
contributed to the overall prototype
project cohort learning and their help
is gratefully acknowledged:
• Lorraine Curtin
Bedford Hospital
• Fiona Maryan-Instone
Bedford Hospital
Final thanks go to the national clinical
directors for respiratory medicine, the
regional home oxygen service leads,
the regional clinical leads for
respiratory medicine and also the
Department of Health home oxygen
team for their ongoing support and
expertise.
34
Ore Okosi
National Improvement Lead
Email:
[email protected]
Tel. 0776 644 1093
NHS
NHS Improvement
CANCER
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NHS Improvement
NHS Improvement’s strength and expertise lies in practical service improvement. It has over a
decade of experience in clinical patient pathway redesign in cancer, diagnostics, heart, lung
and stroke and demonstrates some of the most leading edge improvement work in England
which supports improved patient experience and outcomes.
Working closely with the Department of Health, trusts, clinical networks, other health sector
partners, professional bodies and charities, over the past year it has tested, implemented,
sustained and spread quantifiable improvements with over 250 sites across the country as
well as providing an improvement tool to over 2,400 GP practices.
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