SERVICE INNOVATION
Supporting innovation, in service design and delivery, and the use of new technologies or improvement tools and techniques will be an increasing feature of IST in the coming years.
Some initial work has been undertaken to test a model for identifying when innovations should be supported, with a clear focus on strategic priorities and innovations which will have the greatest impact and applicability across NHSScotland.
This section outlines the lessons from three programmes of work:
- CitiStat Programme
- ENT Tele-Endoscopy
- Rapid Improvement Events
09: CitiStat Programme
BACKGROUND
Originating in Baltimore, USA, CitiStat is a performance management system which uses recent operational data on key performance indicators as the basis for discussions on the delivery of key organisational targets.
The CitiStat model provides a useful mechanism for enabling NHS Boards and Chief Executives to track performance against their plans, and to hold executive teams to account using operational data that is as recent as possible.
The model is based on 4 key principles:
- Having the right data for managing performance and identifying improvement; enhanced data quality and analysis are key to the process and set it apart from existing performance management models
- Undertaking thorough analysis of the data in the context of strategic objectives and providing data which supports decisions to act
- Regular sessions, led from the top, to rigorously review the data and associated performance; the high level involvement of Chief Executives and senior non Executives focusses the agenda on improvement, scrutiny and accountability, and gives a clear sense of organisational and partnership priorities
- Immediate follow-up of forward actions by creating a link between actions agreed at one meeting being rigorously reviewed at the next; this ensures the link between data, performance and agreed actions at a corporate level
The CitiStat model was piloted in Scotland during 2005/6 in two NHS Boards ( NHS Ayrshire and Arran and NHS Tayside) and two local authority areas, with the aim of ensuring that senior executive teams and Board members have a clear and timely view of their organisation's performance against plans in respect of key priorities for the NHS.
The pilot was externally evaluated with positive results.
OBJECTIVES
- To support the roll out of CitiStat and an enhanced approach to existing performance management arrangements within NHS Boards
- To provide a focus on driving forward improvements in internal performance management and measurement
The team promoted the CitiStat roll-out by inviting NHS Boards to become early adopters, by offering financial support, technical expertise and project support. As a result, five NHS Boards worked with the programme as early adopters: NHS Forth Valley, NHS Grampian, NHS Highland, NHS Lothian and the Scottish Ambulance Service.
IMPROVEMENT STRATEGIES
Following a launch event in December 2006, the CitiStat national team supported Boards in implementing their plans through:
- identifying a project leader to bring appropriate colleagues together locally to agree the governance arrangements which would be put in place, and the data systems and analysis required to support them. The delivery of HEAT (Health Efficiency Access Treatment) targets was the main starting point to establishing the new system
- adopting an appropriate approach to suit local circumstances, but delivery of the key principles outlined above was the baseline for all
- supporting local developments, whilst also bringing together Chairs and project leads to offer opportunities to share learning at national events
- integrating the key principles and developing systems of meetings and review throughout the year; the end-of-project reports have highlighted the learning from the implementation phase
OUTCOMES
- As a result of the advice and support offered to the early adopters 4 NHS Boards now use the Citistat model as part of their mainstream performance management framework
The Health Delivery Directorate will continue to apply the principles of CitiStat ensuring full alignment to HEAT, national outcome indicators and strategic objectives.
10: ENT Tele-endoscopy
BACKGROUND
The Scottish Centre for Telehealth ( SCT) is currently supporting NHS Boards across NHSScotland to pilot the use of Telehealth to help redesign and improve patient access to health care no matter where they live.
Telemedicine has been used successfully in a number of clinical areas such as dermatology, neurology and cardiology. Telecommunication technology is used to transfer images via videoconferencing to specialists. It can help to reduce the need for patients to travel to major cities and hospitals to receive their care and treatment.
In ENT, endoscopy is now a key diagnostic tool and ENT Consultants are reporting increasing patient referrals for assessment. The incidence of head and neck cancer is increasing and the importance of rapid diagnosis and treatment is reflected in the requirement to deliver the 62 day target from urgent referral to first treatment.
In May 2006, IST supported the project team at SCT by funding a pilot to test the 'proof of concept' in the use of tele-endoscopy. This used remote diagnostic technology to facilitate the examination of an airway for patients with symptoms of head and neck cancer.
The pilot was divided into 3 phases:
Phase 1 - to deliver a remote diagnostic service from Aberdeen to Shetland. This service went live in July 2007 and the clinics are now part of routine service delivery. Patients are reporting high levels of satisfaction with the service. Plans are also underway to train two local nurse endoscopists in Shetland.
Phase 2 - to deliver a remote diagnostic service from Raigmore to Stornoway. A local Speech and Language Therapist has been trained to perform the endoscopy and facilitate the clinics. Clinics are due to go live in February/March 2008.
Phase 3 - to deliver a Head and Neck review appointment service to a local Community Hospital in Aberdeenshire, which is currently under discussion.
It was agreed with IST at the outset, that if the pilots were successful, then the new service model of care should also be tested in other luminal study areas. An economic evaluation of the project is currently being undertaken by the Health Economic Research Unit ( HERU) at the University of Aberdeen.
IMPROVEMENT STRATEGIES
The redesign project is comprised of several strands which will assist in meeting the increasing demand for specialist ENT outpatient services. The project will also gauge the potential impact that telehealth solutions may have in improving other patient pathways in support of delivery of the 18 weeks standard.
- Developing and piloting synchronous ENT tele-endoscopy services that will assist in the rapid diagnosis of the airway and reduce the need for patient, carer or Consultant travel
- Training non-specialist staff to perform ENT tele-endoscopy to improve patient access to a specialist ENT opinion
- Developing the use of remote luminal studies projects to test 'proof of concept'
- Working with staff from HERU to conduct an economic evaluation of the project
- Disseminating the lessons learned and potential impact of the projects to the wider NHS
OUTCOMES
- Safe, effective and acceptable upper airway tele-endoscopy services for patients and carers are now being delivered
- Additional endoscopy clinics are now provided in between visiting specialist ENT services from Aberdeen. The additional clinics will also be provided from Inverness in March 2008. This demonstrates better use of equipment and improved clinical outcomes for patients
- The number of patients who have to travel to Aberdeen or Inverness for an urgent referral/appointment has been reduced
- Patient and carer travel time and costs to Aberdeen and Inverness have been reduced
- Consultant travel time and costs to Shetland and Stornoway will be reduced
- Access to specialist ENT education for local healthcare staff has been improved
11: Rapid Improvement Events
BACKGROUND
IST uses a range of tools and techniques to support improvement in healthcare. Increasingly, healthcare leaders in other countries are using Lean approaches to deliver significant improvements. In 2006 the Performance and Innovation Unit published a report which concluded that Lean was applicable within the public sector in Scotland.
There are a number of Lean tools and techniques that can be used to make improvements and, amongst others, IST has chosen to use Rapid Improvement Events ( RIEs). These require a trained team of facilitators to deliver improvements, so IST selected three members of staff to be trained in this methodology.
Rapid Improvement Events are week-long events involving two facilitators and a team of 12 to 16 people. The RIE looks at a particular service, or part of the service, and the team is made up of representatives from all stakeholders within that service. The teams generally consist of hospital consultants, nurses, porters, estates, administration and management staff. Prior to the RIE there are many weeks of preparation to define the scope of the project, awareness raising, and data collection.
The RIE gives the staff an opportunity to properly review the service, discuss and, in most cases, discover what the other groups of staff do on a day to day basis. Over the week they discover how patients actually travel through the service, the duplication and delays in the system. They write an action plan which identifies improvements they will make within a week, a month and three months.
OBJECTIVES
The IST work on RIE had four main objectives:
- to deliver real improvements for patients and staff in Scotland
- to provide "proof of concept" for Rapid Improvement Events for NHSScotland through successful case studies in clinical settings
- to build capacity and capability within IST
- to encourage NHS Boards to build their own capability for Lean approaches to improvement
Case Study 1
NHS Tayside
The first event was undertaken in the urology service at Perth Royal Infirmary in February 2007. The event aimed to reduce the waiting times for patients with Frank Haematuria (blood in your urine) by removing the waste and inefficiency in a patients progress along the pathway. It also set out to make the working environment better for the staff and raise morale throughout the service. Before the RIE, an average patient waited for 48 days from referral through to diagnosis. After the RIE this has reduced to 10 days. The maximum wait reduced from around 80 to 100 days, to 20. The graph below demonstrates this improvement:
OUTCOMES
The IST team gathered feedback from the urology team.
"It's going to be far better for staff. I think they feel they've been listened to this week."
Urology Clinical Team Manager.
"It's been an intense week. We were able to change things quickly that might have taken months, years, if we hadn't taken the time out."
Consultant Urologist
This event was the winner of the innovation award at the 2007 Daily Record Health Awards.
Rapid Improvement Events have been undertaken by very few organisations in the public sector. To date, the team have delivered 11 events. This represents one of the first such sustained programmes of work within NHSScotland, and complements the work of NHS Lothian with GE Healthcare. Lean approaches such as RIEs will offer NHSScotland opportunities to deliver the 18 week target in Better Health, Better Care.