Contents page Storyboard Storyboard Title Organisation Citizens … Wales Awards 200… · Contents...

Contents page Storyboard Storyboard Title Organisation Citizens at the Centre of Service Design and Delivery Integrated Mental Health Day Opportunities Service ABM University NHS Trust Sue Bevan/Vernon King Streamlining the Parent Education Programme ABM University NHS Trust Dianne Jones/Dawn Dilks The development of a vocationally-based Occupational Therapy service in adult mental Cardiff and Vale NHS Trust

health with service users to the fore of design and delivery, offering occupational and vocational assessment, advice and guidance leading to individualised vocational opportunities across a range of interagency settings Cherry Stewart

Developing a Flexible and Sustainable Workforce HI-ProfILE - Health Informatics Professional Development Informing Healthcare Jacqueline Barker/Susan Thomas Skills Development Programme Hywel Dda NHS Trust Susan Morgan Radiology & Endoscopy – Quick Hits have an Impact ABM University NHS Trust Ian McLelland/ Melanie Marchetti

Storyboard Storyboard Title Organisation Improving Patient Safety ASAP: Appropriate skills for appropriate places Powys LHB Marie Lewis Improving warfarin safety within an NHS Trust Conwy & Denbighshire NHS Trust Philippa Rogers/Don Hughes/Uttam Chouhan/Katie Firth/Dr David Gozzard Is 95% hand hygiene compliance an achievable target? Gwent Healthcare NHS Trust/ University Elizabeth Waters/ Moira Bevan of Glamorgan Leading on Service Improvement Cardiology Outpatient (Open Access) Project ABM University NHS Trust Dr Jonathan Goodfellow/Samantha Victor Challenging Chronic Disease - Collaborative Continuums of Care Camarthenshire LHB/Hywel Dda NHS Wendy Churchhouse/Claire Hurlin Trust Redesigning SLT services to effectively meet need Gwent Healthcare NHS Trust Dr Alison Stroud/Nicola Bailey Wood/Alison Llewellyn/Jayne Tibbs Promoting Better Health and Avoiding Disease Proactive Approach to Continence Care in a Rural Community Hywel Dda NHS Trust Linda Kriewald Crisis Resolution Home Treatment Service ABM University NHS Trust Malcolm Jones Improving the health of people with learning disabilities ABM University NHS Trust Prof Mike Kerr/Dr Glyn Jones

Storyboard Storyboard Title Organisation Promoting Better Health and Avoiding Disease Health Challenge Newport, Going for Gold: More People, More Active, More Often Newport LHB Claire Beynon Working Seamlessly Across Organisations Developing a Children's Integrated Disability Service (CIDS) North East Wales NHS Trust/

Judy Evans Flintshire LHB “Breaking service boundaries to fix failing hearts” Carmarthen LHB/Hywel Dda NHS Trust Wendy Churchouse/Helen Llewellyn-Griffiths/Rhoswen Davies Condition Management Programme ABM University NHS Trust Sara Forster

0031 - Working Seamlessly Across Organisations

NHS Wales Awards 2008

Storyboard submissions 1. Storyboard Title Developing a Children’s Integrated Disability Service (CIDS) 2. Brief Outline of Context This community service for disabled children and their families is based in an NHS Trust Children’s Centre and brings together specialist social workers, local authority occupational therapy staff, a specialist teacher, care coordinators, community learning disability nurses, special school nurses and Diana nurses in an integrated team. 3. Brief Outline of Problem The initial driver for change was the Inspection of Children’s Services Management and Practice (2000) in Flintshire County Council – which recommended that: “The Children’s Services Division should strengthen its arrangements for managing and developing its work with children with disabilities services” Working in partnership the three organisations (LHB, NHS Trust and Local Authority) initiated extensive consultation with families, professionals and organisations, and took into account evidence from research. The results identified many services across the partner organisations inequitable, fragmented and lacking in coordination with families of disabled children ill informed, confused and frustrated. 4. Assessment of Problem and Analysis of its Causes Of the 1,100 disabled children living in Flintshire, there is an increase in the numbers of children with both complex health care needs and autism. An initial consultation exercise with both parents and separately professionals highlighted the fact that organisations, departments and agencies differed in their models of service delivery. There were examples of good joint working hampered by existing organisation structures. Four highlighted areas for improvement were identified, and task and finish groups were held, which included parents, professionals and Voluntary Sector representation.


The resulting report to all agencies highlighted the need for a single multi-agency team for disabled children, young people and their families, based on a single site, and providing a single simple pathway for families to access information, assessments and services, with one single manager, and included the development of care coordination. 5. Strategy for Change Stage 1 – audit, vision building, and getting “buy in” from all agencies.(Transfield and Smith 1991 model of change). One dedicated manager undertook the work, overseen by a multiagency management board. Within this period quick wins for families were achieved. Stage 2 – Implementation of the model. The cascade – sharing the vision throughout the organisation, and the sprint – the major phase of implementation (Transfield and Smith 1991) The CIDS Management Board led the application for additional funding for key posts - Service Manager, Team Manager and two care co-ordinators, and ensured implementation of the action plan. Staff from all agencies, were involved in planning the detail. A stakeholder group of significant professionals on the periphery of the core team was established to influence the delivery of the model. Successful funding applications ensured the accommodation was fit for purpose, with the necessary I.T. for all staff. Relocation of council staff onto the one site with their health colleagues took place– STEP CHANGE. Shared values and objectives and joint protocols were developed. These systems and processes all assisted in giving disabled children, young people and their families a single point of entry to the service, appropriate timely information, allocation of work without duplication and as each new system is put in place, stopped us asking families the same questions. The process of approval of these protocols was initially via the staff team, then the project group and finally the board, with annual consultation with families. The performance ratchet – maintaining commitment and momentum (Transfield and Smith 1991)


There is a move now to achieve a Section 33 Agreement – Integrated Provision. (Health Act – Wales 2006). Work continues towards shared files and a single assessment process. Key Actions Timetable Research and design of model agreed by all agencies

2002 - 2003

Appointment of key professionals

2003 - 2004

Development role of care co-ordinator

August 2004 – February 2005

Council staff re located February 2005 Development of systems structures and processes

June 2005 - ongoing

External evaluation November 2005 Move to formal Section 33 agreement

April 2008

6. Measurement of Improvement An external evaluation by NCH – November 2005.

(a) An evaluation of the preparedness of both staff within the team and the CIDS project board for full integration – July 2006

(b) Annual consultation with parents. (c) Three comparative case studies (before and after). (d) An evaluation of the Flintshire Cymorth Programme.

7. Effects of Changes Multi agency team co-located on a single site – the evaluation by NCH concluded that staff in one key location had been a success for disabled children, their families and staff alike, with the majority of families interviewed believing that multi agency services had improved their quality of life. Care co-ordination – the above evaluation noted the development of this new role had enhanced the quality of the service received by families. The three case studies undertaken illustrated how a greater degree of co-ordination has achieved better outcomes for families. Children and young people were better supported and work was focussed on assisting them to achieve their potential whilst trying to ensure that parents felt sufficiently supported to enable them to continue to provide care for their disabled offspring and to improve their parenting capacity.


The problems encountered within the change process included:- Staff did not understand the new role of care co-ordinator Staff who were already based at the Children’s Centre not realising that the development of the Team would affect them. Developing a “help line rota”, with all staff taking part in the process to ensure a single point of entry for families. It required a change in title (agreed by the team), direction from a manager and negotiations with the unions. 8. Lessons Learnt To develop long term change to meet the needs of disabled children and their families:-

• involve families in the design, planning and evaluation, • involve staff –from both the core team and in the wider

context, • develop a strong management board • Go for some quick wins • Take time to communicate – and be careful with the use of

language 9. Message for Others Keep outcomes for disabled children, young people and their families at the forefront of your planning. “Too many people ask too many questions – it is exhausting and wears you down” (quote from parent during consultation - Patti Colquhoun 2002) Working together reduces gaps, boundaries and duplication. It breaks down the communication barriers, reduces frustration and is a most rewarding way to achieve outcomes for families. Go for it.

0063 - Leading on Service Improvement


Storyboard submissions 1. Storyboard Title Cardiology Outpatient (Open Access) Project 2. Brief Outline of Context Redesign of Cardiology Outpatient services have been taking place in Bro Morgannwg NHS Trust for the past two years. Non-invasive cardiac investigations were made directly available to local GPs – a new “open access” service. Development of this new service involved discussion and close collaboration with Cardiologists, GPs, LHBs in Bridgend and Neath Port Talbot, Medical directorate managers, outpatient services managers , nursing staff, cardiac physiologists and administration staff in the Princess of Wales Hospital and Neath Port Talbot Hospital. 3. Brief Outline of Problem Bro Morgannwg NHS Trust cardiology outpatient services had seen increasing waiting times and waiting lists for new patient appointments. Extra clinics to keep waiting times within targets (18 months in at the time) were only a temporary solution. The system needed redesign. Simple modelling of capacity and demand with variance was performed and indicated the need for redesign to achieve improvements. We performed:

1. A baseline review of a cohort of 200 patients who had been through the outpatient service and identified that over 60% had normal investigations and were only seen once by the Consultant (i.e. discharged at first visit)

2. Process mapping of the patients journey from primary care through secondary care investigation and diagnosis and found far too many steps (>40) and delays

Having identified problems with the existing service we proposed

the following:

1. Redesign to reduce number of steps in patients journey (to <20)

2. Allow GPs access to all non-invasive cardiological tests, eg Echo (transthoracic),Exercise Test, 24Hr ambulatory ECG, 24Hr BP monitor, 7 day event monitor


3. All tests ordered are reported on by Consultant cardiologists and results and advice sent by letter to the requesting GP. Patients with normal test results would stay within primary care. This in practice meant that 60% referrals now stayed in primary care with only 40% needing review in outpatient clinic.

4. Developed referral guidelines with primary care to guide referrals to the clinic or open-access investigations

The methodology we employed to deliver the changes was: 1. Action research using PDSA cycles of iterative change to

achieve the best outcomes 2. Employed a GP with special interest in cardiology (GPwSI)

into the service to act as liaison between primary and secondary care

3. The results of the changes were evaluated against preset outcome indicators

4. Assessment of Problem and Analysis of its Causes Identifying problems in the system was the first step to assessing the problem. The system of referral from primary care to secondary care had not altered significantly since the inception of the NHS in 1948. Most patients were pre-investigated before attending an outpatient clinic. This allowed for basic triage of all referred patients. Those with significantly abnormal test results were seen urgently, whereas those with normal tests waited up to 78 weeks to be seen. A retrospective analysis of a cohort of 200 patients referred to the service revealed that approximately 60-70% had normal test results regardless of whether the presenting complaint was one of chest pain, palpitations or breathlessness. 5. Strategy for Change Following consultation with LHB representatives, GPs and development of guidelines, the GPs were given “open access” to diagnostic testing for three main symptoms, which form over 80% of the total referrals, namely; chest pain, breathlessness and palpitations. Thus, local GPs have improved access to all non-invasive cardiology tests, enabling patients with normal test results to be excluded from cardiology clinics. Change was initiated following discussion with managers, the Local Health Boards and GPs in the Bridgend and Neath Port Talbot areas. Clinical guidelines were developed in collaboration with Primary Care for the three main symptoms – chest pains, palpitations and breathlessness, which form a major bulk of the referrals. An electronic referral from was drafted, which was user friendly and


had all the relevant details of the patient symptoms, risk factors and past medical history along with the results of the relevant investigations for that particular referral. The standard referrals to secondary care were also prioritised by Consultants and diverted to an outpatient clinic or open access investigations. 6. Measurement of Improvement GP satisfaction surveys were conducted at 1 month, 3 months and 6 months of starting the new system and provided positive feedback. In addition, simultaneous patient satisfaction surveys were also carried out with unanimously positive results.

• Reduction in Waiting time ( p<0.01) • Reduction in Waiting list (p<0.01) • Increase in the number of cardiac tests performed (40%,

p<0.05) • Increase in GP referrals 11.6% per annum

However, the analysis of new patient clinics revealed that there was a trend towards improvement in the activity of clinics following the introduction of the open access tests. There was a significant improvement in DNA rate and a significant reduction in discharge rate. 7. Effects of Changes The open access service has led to:

1. Reduced waiting lists for cardiology outpatient appointment (1100 in 2004, 483 in December 2007 , p < 0.001)

2. Reduced waiting times (routine 17 months 2004 c.f. 4 months 2008, p < 0.001)

3. Reduced waiting times for urgent patients (230 days in 2004, c.f. within 7 days 2008)

4. Empowerment of local GP’s to manage simple cardiac conditions

5. Improved access to secondary care diagnosis and treatment for local patients

6. Appropriate use of Cardiology outpatient appointments for patients with significant cardiac problems

7. Continued improvement in service delivery 8. Lessons Learnt Involvement of primary care at start of project

1. Set up an inclusive project team with representation from all affected parties

2. A GP liaison 3. Regular reports to all parties involved


4. Importance of a baseline review and process mapping to inform about problems with current system

5. Excellent communication 6. Listen to criticism and act

9. Message for Others Service redesign can rapidly improve cardiology health care delivery by providing a range of new assessment options tailored to patient needs. This form of multidisciplinary action research coupled with detailed outcome measurement could have wide application in the NHS.

0084 - Promoting Better Health and Avoiding Disease


Storyboard submissions

1. Storyboard Title Proactive Approach to Continence Care in a Rural Community

2. Brief Outline of Context A bilingual, open access, District Nurse led continence clinic was established in a rural practice, designed to meet the specific needs of clients within the community. There has been a positive response to the initiative with audit demonstrating that both objective and subjective aims have been achieved. 3. Brief Outline of Problem An earlier local study of continence services had suggested that there were potential barriers in seeking help for those suffering from incontinence. This was particularly evident in remote areas. The aim therefore was to ensure that those living in the most rural areas had accessibility to continence services, thus ensuring equity across the county and reflecting the ethos of the Designed for Life (2005) agenda.

4. Assessment of Problem and Analysis of its Causes According to The Department of Health (DoH) (2000) 6 million people in the United Kingdom suffer with urinary incontinence. The earlier local study highlighted the reluctance to seek help for incontinence and with the increasing number of referrals to the District Nursing service for incontinence assessment the idea of setting up a clinic was conceived.

Discussions then followed between the District Nurse and Continence Advisor. The concept was presented to the head of District Nursing and to General Practitioners from two rural practices. The proposal was accepted and accommodation to run a clinic was secured at a GP Surgery. Plans were then drawn up to take the venture forward.

5. Strategy for Change The Practice News Letter and Health Promotion board displayed in the practice informed the practice population of problems associated with urinary incontinence and the ease of access to the clinic. (March 2005)


The GP’S and practice staff were made aware that the clinic would commence in July 2005, held on a monthly basis and would accept male and female clients of any age group.

Develop protocol and referral forms for the clinic by July 2005 Develop Audit Tool for use on an annual basis. Collate evidence to support effectiveness of the clinic. Disseminate experience and findings to colleagues at Carmarthenshire NHS Trust Professional Group Meetings. Attend and present annual report at the GP Professional Group meeting.

6. Measurement of Improvement Audit for 2005 - 2006 revealed resolution of incontinence in 50% of clients. Audit figures for 2006 - 2007 revealed clinic attendance at full capacity with a waiting list. Consequently following discussion with the GP and District Nurse manager it was agreed to hold a weekly clinic in order to accommodate the increasing demand.

7. Effects of Changes Objectively, an audit demonstrated resolution of incontinence in 50% of clients seen during the first year. Subjectively, a client satisfaction survey revealed that 68% would not have approached another professional if the service was not available and that 97% would recommend the service to others.

8. Lessons Learnt The sensitive nature of the condition required promotion of client awareness and educating colleagues to this taboo subject. This was done via the GP Newsletter and the local press. Securing funding for necessary equipment such as a bladder scanner was difficult. Consequently, through positive education of clients, staff and the general public, equipment was secured by numerous collaborative fund raising activities.

9. Message for Others A positive attitude towards Urinary Incontinence by the Health Care professional is paramount in their approach to providing holistic evidenced based care to clients who endure such distressing symptoms. As Woodward (1995) describes nurses often resort to providing incontinence pads to manage the problem but managing in this way is proved to be false economy. This can also be detrimental to the client as it can seriously affect physical and mental health.


Promotion of continence is therefore achievable providing there is a positive professional attitude.

0091 - Improving Patient Safety


Storyboard submissions 1. Storyboard Title ASAP: Appropriate skills for appropriate places: 2. Brief Outline of Context The two-day residential training is held in a remote Welsh farmhouse. This enables the scenarios to be acted out in home surroundings realistic to a community midwives work. Midwives are required to bring with them their own equipment, which they would normally carry in the community and use this throughout. The obstetric emergencies included among others: Undiagnosed breech delivery on the stairs, cord prolapsed in the lounge, shoulder dystocia in the bathroom and a PPH in the bedroom. Attendees have to work through their actions and practice their skills. Feedback is given to attendees via the use of OSCE score sheets.

The courses have so far been piloted using internal midwives and will this year be run for external midwives allowing us to share our work across the UK. 3. Brief Outline of Problem Midwives have been providing expert maternity care to women and there families for many years. The challenges faced by midwives in providing an up to date evidence based service can be many and wide-ranging. One difficulty encountered by midwives who are now expected to be skilled in many areas of practice and remain up to date in a rapidly changing field of evidence is that of competence in specific skills. This is difficult for most midwives but can be even more challenging for midwives who work in small midwife led units in the community, using some skills very infrequently. An essential element in supporting midwives to maintain their competence and provide a quality service is pro-active midwifery education and development. 4. Assessment of Problem and Analysis of its Causes Midwives need to be prepared for the unthinkable and be equipped to deal with it. There are several training courses aimed at preparing midwives for dealing with obstetric emergencies but most focus on caring for women within a DGH working as part of the medical team. They are usually held in classroom type settings. Training needs to be available for midwives working in the community.


We have developed a training programme which offer midwives the opportunity to practice obstetric emergencies and other key areas of midwifery care within a home setting. Whilst still promoting the midwives role in normality and facilitating normal birth. 5. Strategy for Change To deliver a training programme, which would meet the needs of community midwives and encourage partnership working with local paramedics. • To enable midwives to practice key emergency skills • To encourage team work and communication • To promote care in the community as a safe option for women. The set up: The two-day residential training is held in a remote Welsh farmhouse. This enables the scenarios to be acted out in home surroundings realistic to a community midwives work. Midwives are required to bring with them their own equipment, which they would normally carry in the community and use this throughout. The obstetric emergencies included among others: Undiagnosed breech delivery on the stairs, cord prolapsed in the lounge, shoulder dystocia in the bathroom and a PPH in the bedroom. Attendees have to work through their actions and practice their skills. Feedback is given to attendees via the use of OSCE score sheets. 6. Measurement of Improvement All attendees are asked to complete an evaluation form and to score each session on a scale of one to five. There is also a space for comments and recommendations for change. All internal attendees have expressed that they had thoroughly enjoyed both days and valued the opportunity to practice these skills in realistic settings using their own equipment. The obstetric emergency drills were scored five [excellent]. 7. Effects of Changes Since completing the workshops midwives in Powys have experienced several Obstetric emergencies in the Home. They have all been dealt with appropriately and midwives have been commended by the DGH for the excellent care provided. Midwives who have reported such incidences have stated that they felt more confident as a direct result of attending the workshop. An improvement in midwives confidence and competence can result in a safer provision of care within the home. The problem with such workshops is one of resources and prioritisation. They are not the


cheapest way and it can be difficult to release staff for two days. However it is believed that this needs to be a priority in service provision as adverse outcomes in this area can be catastrophic for clients, midwifes and the organisation 8. Lessons Learnt Midwives will only take the training seriously if the scenarios are real to them and appropriate to their place of work. It is essential when planning such programmes to reflect real cases and real environments. The biggest success of this course is that it is held in a home setting and not in a class room. Midwives do get board and will assume what is going to happen next. It is therefore essential to continually change the scenarios and the set up to maintain the element of surprise. Some midwives find the days very stressful and can become over whelmed by the realness of working through difficult situations. More time is needed in the programme for debrief and general calm discussion to allow reflection on feels and anxiety 9. Message for Others This training is an excellent example of doing training that is tailored to the individual staff needs and reflective of their real work environments. You need to think about what your particular group of staff need and look at providing training appropriate to meet that need

0140 - Working seamlessly across organisations

NLIAH submission 2008 1. Story board title “Breaking service boundaries to fix failing hearts”

2. Brief outline of context

The Nurse led heart failure service was a joint initiative between Carmarthen Local Health Board and Carmarthenshire NHS Trust, West Wales; serving a population of 175,000. The region is predominately rural with large areas of urbanisation resulting in pockets of social deprivation.

A team of 3 heart failure specialist nurses was formed in 2006. It was part of a chronic disease service, consisting of 1 co-ordinator, 3 diabetic specialist nurses, 2 chronic obstructive pulmonary disease specialist nurses [COPD], 1 COPD physiotherapist and 2 administrators.

The heart failure service was designed to cater for the needs of patients and their relatives/carers from diagnosis through to palliative care and death. Service provision includes, one-stop diagnostic clinics supported by the Cardiologists, inpatient reviews, follow-up and drug titration clinics, delivered in both hospital and community locations. House bound and hard to reach individuals are visited at home, including residential and nursing homes.

3. Brief outline Prior to 2006, the care of heart failure patients in Carmarthenshire was inadequate and inequitable. In addition, the knowledge of health professionals in regards to best practice was meager. A surge of new clinical research highlighted the poor outcomes associated with heart failure and the immense NHS costs attributed to avoidable, frequent medical admissions. Therefore, it was proposed that Carmarthenshire patients and their family/carers would benefit from seamless and integrated management; transcending primary, secondary & tertiary care, social care and voluntary agencies. Care would subsequently be provided at “the right time, right place and by the right person”. Furthermore, it was vital the new service became fully integrated into existing medical, nursing, social and voluntary services, in addition to the acute response / rehabilitation services, recently introduced as part of the modernisation and chronic disease strategy.


Additionally, in order to sustain and improve evidence based care; an ongoing, nationally validated education programme in the management of heart failure would be delivered locally.

4. Assessment of problem In response to three key documents (Tackling Inequalities in CHD in Wales [NSF] [2001], Wanless Report [2003] and Design for Life [2005], a service needs review was conducted between 2004/5. Inadequacy and inequality in the deliverance of structured, evidence based heart failure care throughout Carmarthenshire was identified. In addition, as part of their modernisation strategy, the NHS Trust and LHB were developing collaborative, innovative strategies to improve chronic disease management. A working steering group was formed to investigate the scale of the problem, and identify solutions based on the findings of other health communities within the UK and globally. Eventually, a pioneering solution, based on the Kaiser Permanente model was agreed. This included the joint appointment by Carmarthen LHB and the NHS Trust of 3 heart failure specialist nurses, as part of a chronic disease team.

5. Strategy for change Formation of steering group consisting of Cardiologists, GPs, nurse advisors, modernisation manager, Nurse directors from Trust and LHB and patient representatives [2005/6].

• Appointment of chronic disease co-ordinator and 3 heart failure specialist nurses [January 2006]

• Co-ordination of “top up”, clinical assessment skills training for specialist nurses [March 2006]

• Personalised visits to Carmarthenshire GP surgeries, secondary care medical and elderly care teams, A&E, medical admission units, CCU/intensive care teams, district nursing teams and newly appointed admission avoidance teams/services; informing them of the heart failure service [June 2006]

• Identify 1 heart failure link nurse in each GP surgery [October 2006].

• Baseline review of medical emergency admission rates and QoF data [2005/2006]

• Update needs analysis regarding current heart failure service and training needs in primary and secondary care [October 06- Mar 07]

• Introduction of “Heart Save” heart failure training course [2006/7]


• Produce evidence based diagnostic and treatment algorithms [June 2006]

• Update Heart failure section in the Carmarthenshire CHD “tool kit”, designed to facilitate standardised management for CHD patients throughout Carmarthenshire [November 2007].

• Develop standardised clerking and communication documentation for the service [January 2008]

• Establish patient focus groups to evaluate and inform service development [November 2007]

6. Measurement of improvement Collated a directory of each heart failure GP link nurse, outlining their method of systematic GP follow up • Medical emergency admission rates from the Trust and QoF

data from each GP surgery was provided monthly to the LHB, and compared quarterly against the previous years data

• Staff questionnaires issued to primary and secondary care, ascertained their heart failure local management and training needs

• Evaluation questionnaire regarding the “Heart Save” heart failure course

• Patient focus groups and user satisfaction questionnaires • Comparatives of quality of life scores [Minnesota QoL

questionnaire] • Comparatives in application of evidence based prescribing • Referral waiting times for diagnostic echocardiograms

7. Effects of changes Reduced heart failure emergency medical admissions by a staggering 23.3%, [more than double the expected admission avoidance rate]. • 37% improvement in patients Quality of Life scores • 99% improvement in prescription rates of evidence based

medication • Reduced waiting times for diagnostic echocardiograms • High levels of user satisfaction • Excellent course evaluation and high pass rates • Improved liaison and shared care between primary &

secondary care, community rehabilitation, acute response services, palliative care and voluntary agencies.


8. Lessons learnt Ensure:-

• Adequate administrative support, office and storage space for clinical staff

• Effective systems of prompt communication between all agencies involved in the patients care

• Service models need to be flexible to suit users needs • Patient involvement in service design is essential

9. Message for others By breaking the traditional models/boundaries and working across the interface of primary, secondary, social care and voluntary agencies; patients now have greater continuity and co-ordination of their care. By utilising a flexible continuum of care within a multi professional and multi agency chronic disease model, medical admissions can be significantly reduced; allowing patients to have improved access to care/services either in their homes or local communities.

Therefore, shared goals and collaborative working is the key to sustainable management of change; allowing the NHS to shine and deliver a world class service in the global health care challenge of the 21st century.

References:

Wanless, D [2003] Review of health and social care in Wales. HMSO/WAG. Cardiff Designed for Life: creating world class health and social care for Wales in the 21st century [2005]. Wales: Welsh Assembly Government. DOH [2001] Tackling coronary heart disease in Wales : implementing through evidence. HMSO. Cardiff.

0146 - Leading on service improvement

NLIAH submission 2008 1. Story board title

“Chronic Disease - Continuums of Care” 2. Brief outline of context The Specialist nurse chronic disease service was a joint initiative between Carmarthen Local Health Board and Carmarthenshire NHS Trust, West Wales; serving a population of 175,000. The region is predominately rural with large areas of urbanisation resulting in pockets of social deprivation.

The chronic disease team was formed in 2006, consisting of 1 co-ordinator, 3 heart failure specialist nurses, 3 diabetic specialist nurses, 2 chronic obstructive pulmonary disease specialist nurses [COPD], 1 COPD physiotherapist and 2 administrators.

The service was designed to cater for the needs of patients and their relatives/carers from diagnosis through to palliative care and death. Service provision includes, one-stop diagnostic clinics supported by the Consultants, inpatient reviews, follow-up and drug titration clinics, delivered in both hospital and community locations. House bound and hard to reach individuals are visited at home, including residential and nursing homes. In addition education packages are delivered to patients and health care professionals.

3. Brief outline Prior to 2006, the care of heart failure, COPD and diabetic patients in Carmarthenshire was inequitable. In addition, the knowledge of health professionals and patients in regards to best practice was variable.

A surge of new clinical research highlighted the poor outcomes associated with the above chronic diseases, and the immense NHS costs attributed to avoidable, frequent medical admissions. Therefore, it was proposed that Carmarthenshire patients and their family/carers would benefit from seamless and integrated management; transcending primary, secondary & tertiary care, social care and voluntary agencies. Care would subsequently be provided at “the right time, right place and by the right person”. Furthermore, it was vital the new service became fully integrated into existing medical, nursing, social and voluntary services, in addition to the acute response / rehabilitation services, recently introduced as part of the modernisation and chronic disease strategy.


Additionally, in order to sustain and improve evidence based care; an ongoing, nationally validated education programmes in chronic disease management would be delivered locally.

4. Assessment of problem In response to 4 key documents (Tackling Inequalities in CHD in Wales [NSF] [2001], Diabetic NSF [2002], Wanless Report [2003], and Design for Life [2005], a service needs review was conducted between 2004/5. Inadequacy and inequality in the deliverance of structured, evidence based chronic disease management throughout Carmarthenshire was identified. And, as part of their modernisation strategy, the NHS Trust and LHB were developing collaborative, innovative strategies to improve chronic disease care.

A working steering group was formed to investigate the scale of the problem, and identify solutions based on the findings of other health communities within the UK and globally. Eventually, a pioneering solution, based on the Kaiser Permanente model was agreed. This included the joint appointment by Carmarthen LHB and the NHS Trust of the chronic disease team.

5. Strategy for change Formation of steering group consisting of Consultants, GPs, nurse advisors, modernisation manager, Nurse directors from Trust and LHB and patient representatives [2005/6].

• Appointment of chronic disease co-ordinator and 8 specialist nurses, 1 physiotherapist & 2 administrators[January 2006]

• Co-ordination of “top up”, clinical assessment skills training for specialist nurses [March 2006]

• Personalised visits to Carmarthenshire GP surgeries, secondary care medical and elderly care teams, A&E, medical admission units, CCU/intensive care teams, district nursing teams and newly appointed admission avoidance teams/services; informing them of the chronic disease service [June 2006]

• Identify link nurses in each GP surgery [October 2006]. • Baseline review of medical emergency admission rates and

QoF data [2005/2006] • Update needs analysis regarding current service and

training needs in primary and secondary care [October 06- Mar 07]

• Produce evidence based diagnostic and treatment algorithms [June 2006]


• Update Heart failure and Diabetic components of Carmarthenshire CHD & Diabetic “tool kits”, designed to facilitate standardised management for CHD and Diabetic patients throughout Carmarthenshire [November 2007].

• Introduction of “Heart Save” heart failure training course [2006/7]

• Introduction of “XPERT” diabetic patient training course [2006/7]

• Development & introduction of integrated COPD care pathway [2006/7]

• Introduction of “COPD” telehealth pilot [2007/8] • Develop standardised clerking and communication

documentation for the service [January 2008] • Establish patient focus groups to evaluate and inform

service development [November 2007] • Develop & test service satisfaction questionnaires

6. Measurement of improvement Collated a directory of each GP link nurse, outlining their method of systematic GP follow up • Medical emergency admission rates from the Trust and QoF

data from each GP surgery was provided monthly to the LHB, and compared quarterly against the previous years data

• Staff questionnaires issued to primary and secondary care, ascertained their local management and training needs

• Evaluation questionnaire regarding the education programmes • Patient focus groups and user satisfaction questionnaires • Comparatives of quality of life scores [Minnesota QoL

questionnaire] • Comparatives in application of evidence based prescribing • Referral waiting times for diagnostic echocardiograms

7. Effects of changes Reduced emergency medical admissions for the 3 chronic conditions by a staggering 28.2%, [nearly 3 times higher than target admission avoidance rate]. • 37% improvement in patients Quality of Life scores • Significant improvement in prescription rates of evidence

based medication [ up to 99% in some areas] • Reduced waiting times for outpatient clinics and diagnostic

echocardiograms • Exceptionally high levels of user satisfaction; patient

understanding of disease process and self care strategies • Exceptionally high levels of carer satisfaction - • Research into the benefit of telehealth to improve patient care

and individual health trends.


• Excellent course evaluations and high pass rates • Improved liaison and shared care between primary &

secondary care, community rehabilitation, acute response services, palliative care and voluntary agencies.

8. Lessons learnt Ensure:-

• Adequate administrative support, office and storage space for clinical staff

• Effective systems of prompt communication between all agencies involved in the patients care

• Service models need to be flexible to suit users needs • Patient involvement in defining service model

9. Message for others By breaking the traditional models/boundaries and working across the interface of primary, secondary, social care and voluntary agencies; patients now have greater continuity and co-ordination of their care. By utilising a flexible continuum of care within a multi professional and multi agency chronic disease model, medical admissions can be significantly reduced; allowing patients to have improved access to care/services either in their homes or local communities.

Therefore, shared goals and collaborative working is the key to sustainable management of change; allowing the NHS to shine and deliver a world class service in the global health care challenge of the 21st century.

References: Wanless, D [2003] Review of health and social care in Wales. HMSO/WAG. Cardiff Designed for Life: creating world class health and social care for Wales in the 21st century [2005]. Wales: Welsh Assembly Government. DOH [2001] Tackling coronary heart disease in Wales : implementing through evidence. HMSO. Cardiff. DOH [2002] Diabetic NSF in Wales. HMSO. Cardiff.

0152 - Citizens at the centre of service design and delivery Formatted: English (U.K.)


Storyboard submissions 1. Storyboard Title Integrated Mental Health Day Opportunities Service 2. Brief Outline of Context A multi agency Task Team was established in 2000 to review historical Day Care Services provided at Cam Cyntaf Day Centre, Glanrhyd Hospital and Ty’r Ardd Social Care Day Centre in the community. The client groups included 170 individuals with severe and enduring mental health to those with mild to moderate mental health problems. 3. Brief Outline of Problem The problem was duplication in provision eg both organisations provided garden projects and institutionalisation was inherent with service users dependent upon these services and not maximising their potential - service users were becoming reliant on the service rather than being empowered to become more independent and function within the community. The services for some had become a hindrance rather than a help to their recovery - service users were living in the community but returning on a daily basis to a mental health institution for support. The existing services were focussed on a maintenance model rather than one of recovery, and so many patients were likely to be in the mental health system for life. 4. Assessment of Problem and Analysis of its Causes January, 2000 a Review of Mental Health Day Services was undertaken by Bridgend County Borough Council and Bro Morgannwg NHS Trust. In 2001 a Joint Consultation Workshop involving staff, the voluntary sector, service users and carers undertook to develop a Model of Day Opportunities. In 2002 the Day Opportunities Sub Group was established involving voluntary sector partners, service user and carer representatives. A graded closure plan of Cam Cyntaf was developed with staff and service users to progress the integration of individuals into one statutory service. The closure of Cam Cyntaf was achieved in July, 2006 and the service renamed ARC (Assisting Recovery in the Community).


5. Strategy for Change The proposed change was a key strategic aim of the local Joint Mental Health Planning Team. Funding was secured to appoint a Joint Health and Social Care Manager to lead the new service. A Day Opportunities Sub Group was established with wide representation from all sectors, including service user and Patients’ Council representatives, patient Advocates and the voluntary sector. Continuous and ongoing meetings were held with staff and service users, both as groups and individual counsellings, to share the vision and provide support. The integration of the service users was undertaken over the period of one year with a staged approach for staff and service users to experience working and attending Ty’r Ardd. The Strategy was supported by the Welsh Assembly Government and funding secured to provide a new purpose built facility in the town centre to be commissioned in December, 2008. 6. Measurement of Improvement In the first year of integration there has been a 30% increase of activities accessed in the community supporting service users towards recovery. The number of referrals into the new service has increased from 103 for the period January, 2006 to December, 2006 to 200 in the period January, 2007 to December, 2007. ARC access in excess of 30 different Community Groups, services or innovative projects in the community. Individual satisfaction is monitored through the personal profile review, processes and the service is planning a formal Service User Satisfaction Survey in the next 12 months. 7. Effects of Changes Service users and staff have embraced the new service and the process of individual assessment and personal profile has significantly supported the process of normalisation within the community. This is enabling individuals to be a part of their local community and not be seen as set apart. The closer working relationships between services has resulted in a whole new way of working, maximising the use of resources. The process of change with this client group is resource intensive and requires substantial support for some individuals to make this cultural shift.


Within a client group of this size there will always be a small cohort who are extremely resistant to change and whose needs will need to be met for the foreseeable future. This needs to be acknowledged and successes and positive gains promoted to foster a change of mindset. 8. Lessons Learnt Change management requires robust and consistent communication to negate the rumours. Not to under estimate the impact of these changes on both the staff and service users involved. The appointment of the Service User Engagement Officer sooner would have assisted the process. 9. Message for Others The benefits of such a major change for service users and staff far outweigh the difficulties in achieving this and provides an innovative and modern service fit for the 21st century.

0160 - Citizens at the centre of service design and delivery NHS Wales Awards 2008 Storyboard submissions

1. Storyboard Title Streamlining the Parent Education Programme – Bringing it into the 21st Century. 2. Brief Outline of Context Midwives based in the Birth Centre at Neath and Port Talbot Hospital identified a need to modernise and streamline how parent education was delivered to pregnant women and their families. 3. Brief Outline of Problem Parent Education for pregnant women has traditionally been organised in weekly sessions. Before the 1990’s it was during the day and only for women. Midwives and Service Commissioners realised that the take-up for the session was not optimum and that with many women now working, holding the information programme in the day is not always convenient. The drop out rate becomes high as the sessions progress and continuity of midwife is not available depending on available rotas. Parent Education has since been offered for couples in six weekly evening sessions and is very popular, with demand outstripping supply, but again the drop out rate is high. 4. Assessment of Problem and Analysis of its Causes The high drop-out rates mean that information given out is often missed or has to be repeated at subsequent sessions. It is difficult to ensure continuity of midwife for the six-session programme. With the rise in birth rate and national shortage of midwives, midwifery managers are asking if this service is an effective use of precious midwifery time. At times, women are not receiving one-to-one support in labour and so a more effective use of midwifery time by providing these sessions in a concise one day programme has been implemented. 5. Strategy for Change Two midwives who facilitated the weekly sessions benchmarked with a Maternity Unit in the South East of England who had already piloted the one day Parent Education Sessions. • Aims and objectives were agreed; • Potential measurable standards and outcomes were identified; • Programme for the day was developed; • Pilot sessions (March ‘07 to June ’07) were undertaken and evaluated. 6. Measurement of Improvement • There is now a one day session providing comprehensive education to prepare for

labour and learn about parenting skills to more women than previously; • Comparing traditional sessions (2006) with the one day session (2007):

• 24 couples attended from Jul 06 to Jan 07 • 61 couples attended from Mar 07 to Oct 07

Very often there would be a drop-out rate in the weekly sessions, particularly when instrumental births and breastfeeding was being discussed. There is a 0% drop-out rate on the one day sessions;

0160 - Citizens at the centre of service design and delivery • The process has been streamlined potentially releasing six hours of midwifery

time to provide one-to-one care in labour; • Maximising the number of women giving birth in the Birth Centre by providing

sessions within Neath Port Talbot Hospital – enabling visits to the Birth Centre; • This has helped to maintain the lowest Caesarean Section (CS) rate in Wales of

20%. Women who start labouring in the Birth Centre have between 3.5% and 5% chance of a CS. Team statistics show a reduction in CS rate from 25% to 20% during 2007;

• Numbers attending the session are monitored and evaluation forms analysed; • Data regarding women who change their booking to the Birth Centre is collected; • Women are able to meet other members of the team ‘on duty’ at the time; • Activity is monitored monthly; • Normal birth rates, water for labour and breast feeding rates have increased; • Discussing breast feeding at the session has helped to produce outstanding

statistics for the first nine months of 2007: • 47% breastfeed at birth with 51% of these women still breastfeeding at 28

days; • Impressive team statistics:

• 86% women now receive home assessments; • A team Midwife attended as Lead Midwife for 33% births in Birth Centre; • 18% women used the birthing pool for labour; • 5% birthed in the birthing pool; • 61% women had intact perineum; • 17% women changed their choice for place of birth to the Birth Centre.

7. Effects of Changes Through evaluation, women and their partners have expressed satisfaction with the new service. Comments from women and their partners: “Much preferred doing parentcraft as a crash course on a Saturday as we both work full time and found the idea of 6 separate sessions daunting.” “I feel I have benefited from the well organised parent craft class and appreciated the friendly and professionally honest approach of the staff that ran this. It was especially helpful that this was run in a one day block.” “Excellent, very comprehensive and every issue we had was discussed. Also, lovely to see how personal the Birth Centre approach is and rid any doubts about using the Birth Centre.” 8. Lessons Learnt The change has proved successful for both mothers and midwives. However, the venue is being reconsidered to ensure we can accommodate the full session in one location.

0160 - Citizens at the centre of service design and delivery 9. Message for Others • Head of Midwifery is standardising this approach throughout Bro Morgannwg NHS

Trust with all nine Midwifery Group Practice Teams are moving to provide a full day session;

• This has proved to be an efficient and effective method of providing education in a streamlined process;

• Could be transferrable to other disciplines; • Excellent method of providing health education to the public e.g.:

Diabetes Cardiac problems Obesity

0167 - Promoting better health and avoiding disease


Storyboard submissions 1. Storyboard Title Crisis Resolution Home Treatment Service 2. Brief Outline of Context Bro Morgannwg NHS Trust recognised the need to provide intensive support outside the acute inpatient setting for people experiencing an acute mental health crisis. Bed pressures of 100% occupancy levels were driving the need for change, along with increasing demand on commissioners and Trust staff to find and fund out-of-area placements. This led to the national requirement to establish Crisis Resolution Home Treatment Teams (CRHTs) by March 2006 and to reduce inpatient beddays by 25% by March 2008. 3. Brief Outline of Problem The Project Team set the key goal of identifying viable alternatives to hospital admission which would alleviate the high occupancy levels and reduce beddays used. The aim was to establish CRHTs to provide intensive support at home, in the least restrictive environment with the minimum disruption to people’s lives and to importantly, recognise and facilitate the patient’s ability to recover. The Team was to have three distinct roles: Gatekeeping – patient assessments carried out by the team

freeing-up ward based staff time. Early Discharge – facilitating discharge form the acute

environment, allowing capacity to be enhanced. Delivery of Home Treatment – providing a rapid access, intensive

support package of care at home for people experiencing an acute mental health crisis.

4. Assessment of Problem and Analysis of its Causes Bed occupancy levels were consistently above accepted normal guidelines, usually at 100%. At the start of the implementation phase of the project beddays used at the two acute inpatient sites were reaching 23500 and length of stay was excessive. The inability to avoid admission or to facilitate speedy discharge when needed became a growing problem. The introduction of the CRHTs was seen as the solution to these problems with the vision that admission to hospital must not be seen as the sole option for treating a patient undergoing an acute mental health crisis.


5. Strategy for Change The Core Characteristics of the CRHT role was to deliver one service to patients using two teams. The teams would include staff from a range of NHS and other sector agencies and be available 365 days a year. The aim was to provide an intensive Care Programme Approach service, staying with the patient and family until the crisis had abated. The philosophy was one of mental health recovery, focusing on the potential of the patient to recover - a move from the traditional medical model to one that embraces medico-sociological aspects of treatment and recovery. The Trust monitored the implementation of the CRHT approach and the reduction in beddays quarterly, via the performance review process, to ensure that the deadline of March 2006 was met. 6. Measurement of Improvement As a result of the CRHT model being introduced, the target of reducing inpatient beddays has been achieved (now down to 18000) and the average length of stay for patients has come down by 10 days. Occupancy levels are improved with stability at 86% reached more consistently. 7. Effects of Changes As well as the success noted above feedback from the service users has been positive:

Previously when I have had these problems I end up in hospital. It was good to be cared for at home and have support when I needed it”

“ I have young children and not having to leave them was great”

“ I was able to return to work a lot quicker than I usually do” “ I only needed my tablets changed and that was done within

the first day” And from the service’s largest referrering body (46% come from GPs), praise of the service has included comments such as:

I can now just phone one number and access the help that I need. This makes my job a lot easier and more importantly benefits my patients”

“ I now know that I can get help for people in crisis almost immediately and receive feedback on their progress


8. Lessons Learnt The key messages would be that working in this way has reinforced the principles of contemporary mental health care. Working differently does not always have to cost large amounts of money. Spending to save can be a sensible approach for long-term gain. 9. Message for Others This new service offers choice, is flexible and cost effective. It has improved user and carer satisfaction, and very importantly, has helped to reduce stigma that can be associated with a mental illness.



Storyboard submissions 1. Storyboard Title Improving the health of people with learning disabilities 2. Brief Outline of Context The Welsh Health Check is the centre point of developments within the NHS in Wales for improving access to health promotion and enhancing primary care services through locally enhanced Services. The check was initially developed within Ely Hospital as tool to improve the quality of health care for people with a learning disability. With the rationalization of services and the move to deinstitutionlaisation the check was introduced into Hensol hospital and used to aid communication of people’s health status as they moved out of the institution into primary care services. At the same time as this the pivotal research on the Check as a primary health care intervention was being performed by Professor Mike Kerr and Dr Glyn Jones within the Trust. As the Check has become the National Standard for Wales the directorate has continued to use it as a measure of improved quality health care within all its residential services and has continued to support ongoing research. 3. Brief Outline of Problem There existed very considerable evidence that the health experience of adults with a learning disability was unequal in relation to their peers. This in particular was due to poor access to primary care and a lack of skills in application within primary care as the focus for health moved from long stay institutions into the community. We set out to tackle this by recognising that while skills and experience in the early 1990s existed mainly within the institutional settings but that the future of care must be ordinary services and in particular ordinary primary care services.


We worked on several fronts: (1) addressing and evaluating the effects of opportunistic and structured health screening in a scientific manner, (2) developing an understanding of GPs attitudes to care delivery and (3) further developing the framework to understanding the inequality in care experienced by people with a learning disability. In fact the processes worked in parallel and the implementation of the Wales Health Check owed much to its acceptance from patient and carer groups, in particular MENCAP, backed up by good quality scientific research. 4. Assessment of Problem and Analysis of its Causes We quantified the problem by a series of projects which:

1. Identified the needs in a single general practice: Kerr M, Richards D, Glover G. (1996) Primary Care for People with an Intellectual Disability - a Group Practice Survey. Journal of Applied Research in Intellectual Disabilities, 9, (4), 347-352.

2. Identifying GP views on care delivery: Kerr M, Thapar A, Dunstan F. (1996) Attitudes of general practitioners to people with a learning disability. The British Journal of General Practice, 46, (5), 92-94.

3. Exploring alternative interventions: Jones R, Kerr M. (1997) A randomized control trail of an opportunistic health screening tool in primary care for people with intellectual disability. Journal of Intellectual Disability Research, 41, (5), 409-415.

4. Evaluating the health checks Baxter H, Lowe K, Houston H, Jones G, Felce D & Kerr M (2005) Previously unidentified morbidity in patients with intellectual disability. British Journal of General Practice 56, 93-8.

5. Defining the inequality of health care experience

Morgan C, Ahmed Z, Kerr M. (2000) Health care provision for people with a learning disability. British Journal of Psychiatry, 176, 37-41. Scheepers M, Kerr M, O’Hara D, Bainbridge D, Cooper S-A, Davis R, Fujiura G, Heller T, Holland A, Krahn G, Lennox N, Meaney J & Wehmeyer M (2005) Reducing health disparity in people with an intellectual disability: A report from Health Issues Special Interest Research Group of the International Association for the Scientific Study of Intellectual Disabilities. J of Policy & Practice in Intellectual Disabilities, 2(3/4), 249-55. 5. Strategy for Change The strategy for change was through the development of accessible, appropriately researched tools that could slot easily into the NHS system, offering people with a learning disability access to ordinary care, which was enhanced to meet their specific needs. The research papers informed a more public debate which placed the integration of The Welsh Health Checks into a broader framework of NHS Wales development.


Throughout we linked closely with the Welsh Centre for Learning Disabilities at Cardiff University to ensure scientific excellence. 6. Measurement of Improvement The Welsh Health Check is now integrated with NHS Wales Local use within the trust have been repeatedly evaluated within Clinical Audit The National Public Health Service for Wales is performing the National Evaluation under a grant held by Professor Kerr 7. Effects of Changes The impact of this work developed within the Trust has been far reaching. From small developments initially started by two junior doctors in a decommissioned institution, a national policy proven to help people with a learning disability now exists. Of course any process needs constant evaluation and improvement and this continues on an AL Wales Level The Wales Health Check has been used extensively in New Zealand and has also been the basis for developments in Health Care within England and Australia. 8. Lessons Learnt Our work really developed into having a national focus when it was recognised by client and carer groups. In particular MENCAP. If we could have turned back time such collaboration should have occurred much earlier in its development 9. Message for Others The national and international success of the health Check work was started with very small incremental projects, always working to a final goal, which we knew could be applicable on a national scale. The work succeeded by putting removing patient inequalities central to every project so a consistent focus could not be lost. Our main message is that persistence and consistency of aim are the key characteristics to success sin achieving meaningful change in the health service.

0188 - Developing a flexible and sustainable workforce


Storyboard submissions 1. Storyboard Title HI-ProFILE – Health Informatics Professional Development 2. Brief Outline of Context

The Health Informatics Professional Development Programme (HI-ProfILE) is a long term initiative to advance the health informatics profession and support health informatics staff professional development across Wales. HI-ProfILE is an integral part of Informing Healthcare, the Welsh Assembly Government programme set up to improve health services in Wales by introducing new ways of accessing, using and storing information.

The focus of HI-ProfILE centres on those staff whose primary function is in the health informatics field and are employed on this basis within and beyond NHS Wales, some 3000+ staff. The nature of the programme is ‘inclusive’ but the following functions form the core: knowledge management; information management including information analysis, clinical audit, data protection and confidentiality, clinical coding, planning and performance management; health informatics managers and directors; information and communication technology (ICT); health records; clinical informatics; health informatics education. 3. Brief Outline of Problem Relevant, accurate, reliable and timely information has always been important to safe and effective patient care and to planning of services, but this is now being recognised as crucial. Historically, core clinical and other information systems have been overly reliant on key individuals, there was little understanding of the informatics function and the human capacity and capability requirements to develop, implement and maintain such systems. Health informatics is a young multi-functional discipline, with no clear entry or career progression routes, little consistency across NHS organisations, and at best, patchy access to education and development.


Informing Healthcare set up Welsh Health Informatics Professional Development Programme in early 2006 to address these issues. A Head of Welsh Health Informatics Professional Development Programme was appointed in June 2006 and a Health Informatics Development Manager appointed in February 2007. 4. Assessment of Problem and Analysis of its Causes Analysis of the problem, its causes, and solutions included: • A series of roadshows around Wales during June 2006 attended

by approx 300 staff • Consultation meetings with national and local health informatics

groups • Three workshops to determine the impact of Agenda for

Change on Health Informatics staff and application of KSF • Learning Audit Workshops with each of 12 subspecialties as

well as in local health informatics departments were run in 2007 to determine knowledge and skills requirements

• A workforce survey was undertaken in July 2006 to determine staffing levels (c3000), current and future staffing requirements, recruitment and retention problems, Agenda for Change perceptions.

Key messages to emerge were:

• Health informatics staff needed to have a professional identity and community

• Leadership was required to develop the profession • Appropriate professional standards should be applied • Staff needed better access to education and development

opportunities • Clear entry route(s) and career pathways were required.

5. Strategy for Change As a result the following interdependent workstreams were proposed. • Managing talent more effectively through improved

recruitment, retention, workforce planning and pay and conditions, career progression, leadership and succession planning.

• Developing and applying health informatics professional standards, professional registration and regulation.

• Providing and increasing uptake of relevant education, training and continuing development opportunities.

• Making available the knowledge base of health informatics. • Promoting the health informatics function by providing health

informatics practitioners with a sense of professional identity


and community and promoting the health informatics function to other healthcare professionals, patients and the public.

A Steering Group was set up and a virtual (www.ihc.wales.nhs.uk/hi-profile ) and physical learning community was established. Within these interlinked streams some short term priorities (one year) with ongoing development were identified along with longer term objectives (five to ten year). 6. Measurement of Improvement The success of the various activities was measured quantitatively, e.g. attendance at events, registrations on the virtual portal, numbers using education products, attaining bursaries etc. Qualitative measures included, structured feedback gathered at every event, steering group quality assurance activities. An evaluation report summarises the outcomes the period Jan 2007 – December 2008. 7. Effects of Changes A Health Informatics trainee strand was established within the Gateway to NHS Wales programme. The first trainee in the UK is now in his 2nd year. • The Health Informatics Career Framework being developed by

NHS Wales is being launched in May 2008 for potential use across UK.

• Learning Audits established learning needs ‘Made me realize where the real blockers are to development’ ‘Great to get time to discuss specific education and training needs

with colleagues – motivating! • HIPro-FILE Higher Education bursaries have provided to 18

individuals ‘With my bursary and chance at HE my horizons have been widened’ • Specialist qualification bursaries available 2007-8 • Confidentiality e-learning toolkit developed and launched June

2007 with more than 200 registered users • Conferences, workshops, seminars are being delivered based

on learning audit outcomes. More than 3000 attendances recorded so far. ‘Hi-ProfILE provides an excellent service with very timely sessions

to meet skill gaps’ • HI-ProFILE physical community has over 600 registered

members. ‘Will ensure I register on HI-ProfILE – I don’t want to miss out!’

Good to network with other health informatics staff’ • HI-ProFILE virtual portal provides staff with a one-stop shop for

professional development ‘Excellent – what a great resource’

http://www.ihc.wales.nhs.uk/hi-profile


Problems encountered mainly involved lack of motivation due to perceptions that that Agenda for Change had disadvantaged health informatics staff; a belief that local managers would be unsupportive; and that time constraints would limit participation. Overall the impact has been very positive:

‘I think the progress made so far is excellent and you are to be commended for pushing forward the programme at such a pace.’

8. Lessons Learnt Senior managers felt they should attend events as ‘representatives’ and should ‘filter’ opportunities. Eventually, more innovative ways of reaching everyone were developed including via the virtual community. In this way perceptions which could have proved a barrier were addressed. Professional development initiatives such as HI-ProFILE are not a ‘one-off’ so momentum needs to be maintained. Careful management of expectations coupled with long term commitment is required. 9. Message for Others Professional development activities benefit from corporate leadership but should be owned and defined by individuals who need and will use the services provided. The programme has been successful due to a truly bottom up and top down approach and its ability to provide immediate benefits which clearly contribute to the achievement of a shared long term goal.

0191 - Improving patient safety


Storyboard submissions 1. Storyboard Title Improving warfarin safety within an NHS Trust 2. Brief Outline of Context This work was led by staff of the Pharmacy Department of a secondary care NHS Trust, and also involved other front line staff (those with direct patient contact on a daily basis), particularly nurses and doctors from the most junior, through to the Medical Director. It aimed to reduce the risk of bleeding for all patients treated with warfarin within the Trust. 3. Brief Outline of Problem Warfarin is an oral anticoagulant with a high risk of adverse events including severe bleeding. This has been identified many times in medical literature and is the subject of a recent safety alert from the National Patient Safety Agency (NPSA). Prescribing of warfarin in hospitals is a complex process; prescribing is traditionally left to junior medical staff with little or no prior experience or knowledge. Patients have unpredictable, variable responses to warfarin, requiring different doses to achieve the same result. Response may also be affected by changes in the patients’ diet and by many other medications which patients may be taking. As a consequence, all patients require regular monitoring of their INR (International Normalised Ratio, a measure of how fast their blood clots relative to a standard) by means of blood tests. Warfarin may be prescribed for a variety of clinical indications which have different targets and durations of treatment. Patients may be treated in any area of the hospital, as well as in primary care, leading to many handovers, each with the potential for error. Patients who suffer a bleed due to warfarin will usually have a prolonged stay in hospital (which increases their risk of suffering other adverse effects of healthcare) and requiring extra blood tests. In severe cases the bleeding may cause permanent harm or even death. We aimed to improve the safety of existing processes (and therefore patient safety) by highlighting the riskiest stages of these processes and improving their safety.


4. Assessment of Problem and Analysis of its Causes A multidisciplinary group including pharmacy staff, junior doctors and nurses of various grades undertook a Failure Modes and Effects Analysis (FMEA) of the existing warfarin management processes. This identified that poor documentation of indication, target INR and duration of treatment was the major risk in the process and that the existing monitoring chart did not provide any guidance for users in these areas. Lack of education or knowledge was also identified as a major contributor to the high level of risk. It was decided to re-design the monitoring chart, and improve the education of medical staff about warfarin management. 5. Strategy for Change The monitoring chart was redesigned using small tests of change where front line staff (doctors and nurses caring for patients on warfarin) used each new version of the chart with one or two patients at a time and provided rapid feedback on usability and potential improvements. A variety of staff in different areas of the hospital tested the form to get a variety of opinions. Only once the chart was accepted by staff with no or minimal but impractical improvements suggested was it submitted to the appropriate committees and implemented Trust-wide. The final chart was promoted at education sessions for staff both prior to and following its launch, and with a Trust-wide safety alert. When the chart was launched, pharmacy staff took copies of the chart to each clinical area (ward etc.) and replaced older versions, providing support with its use at the same time. General principles of warfarin management and details of how to use the chart continue to be repeated at education sessions for each new intake of doctors. The initial FMEA was carried out in June 2005. The small tests of change of warfarin charts were carried out between July 2005 and April 2006, with the final chart being implemented Trust-wide in June 2006. 6. Measurement of Improvement The percentage of all INRs which were above specified levels was monitored on a monthly basis using data from the haematology laboratory’s computer system. This shows what proportion of tests are above the normal target ranges. (The further above the target range, the higher the probability that a patient will suffer from bleeding.) Snapshot audits of the prescription charts of all patients on warfarin were used to assess accuracy and completeness of monitoring charts.


7. Effects of Changes The changes outlined above resulted in a consistent reduction of approximately one-third in the percentage of INRs greater then 6 (2 to 3 times the target value). Better documentation of the indication, target INR and duration of warfarin treatment within the organisation was seen, with complete documentation of all these details for 75% of warfarin patients four months after the new chart was introduced.

8. Lessons Learnt Redesigning a form using small tests of change and rapid feedback from users was an effective way of implementing change and, combined with staff education, improved the safety of warfarin use within the Trust. It was time-consuming however and with wider use a few minor additional changes to the monitoring chart have been identified. This is probably unavoidable and shows the need for regular review of all clinical documentation and a clear user feedback mechanism to highlight potential improvements to the relevant individuals or committees. There is also potential for more education and training for nursing staff and more patient involvement in the improvement process. 9. Message for Others The safety of complex systems and processes can be improved by using the expertise of those involved in the process on a regular basis. FMEA and small tests of change are relatively new techniques utilised within the NHS and appear to an effective method of identifying system deficiencies and sustaining quality improvement.



Storyboard submissions 1. Storyboard Title Health Challenge Newport, Going for Gold: More People, More Active, More Often. 2. Brief Outline of Context In order to raise levels of physical activity and promote physical activity to a wider audience, particularly focussing on the sedentary population, a co-ordinated, sustained and highly visible programme was needed for Newport. The Going for Gold (G4G) partnership led by Newport Local Health Board and Newport City Council harnesses the activity of the public sector, commercial sector and voluntary sector, linking to the Health Challenge Wales brand and bedding into Newport’s response to the London Olympic 2012 legacy. 3. Brief Outline of Problem In Newport, only 23% of adults are active enough to benefit their health. This demonstrates that the residents of Newport are less active than other areas, and that an intervention to increase physical activity is required. Going for Gold targets sedentary adults, whose lifestyle means they are at risk of developing chronic health problems. Going for Gold aims to reach people who have not taken any regular exercise for a long time and helps them regain confidence, widen their social network, learn health skills, increase physical activity levels and develop healthy lifestyle habits. 4. Assessment of Problem and Analysis of its Causes The target group for G4G is the sedentary population whose lifestyle means they are at risk of developing chronic health problems, there will be a focus on the unemployed, disadvantaged and socially excluded. G4G aims to reach people who have not taken any regular physical activity for a long time and aims to help them regain confidence, widen their social network, learn health skills, increase physical activity levels and develop healthy lifestyle habits.


In order to reach the sedentary population communities, businesses, charities, and non sporting voluntary groups were targeted. In addition to this a Newport wide marketing plan was planned and is being implemented. This project is also designed to facilitate access to cycles and suitable cycle routes throughout the City, promoting interest to help to reverse car travel trends. 5. Strategy for Change A project manager was employed in January 2007 and led a stakeholder meeting to shape and develop the project. The day was used to gain consensus from the partners on G4G Challenges, and also addressed the equality issues surrounding G4G in an attempt to make the scheme as accessible as possible from the outset. The scheme was launched in April 2007, with the following aims agreed by the partnership:

• get more people, more active, more often • enhance physical and mental health and activity levels of

participants • reduce unnecessary demand on health services • encourage people to take more responsibility for their own

health • appeal to hard to reach communities and the sedentary

population • co-ordinate the efforts of Newport’s existing physical

activity providers • link to and compliment other existing and proposed

physical activity interventions • raise the profile of physical activity opportunities in

Newport • motivate and reward Newport residents for being active

and improving their health knowledge and understanding The partners all formally committed to the project, and agreed to support the scheme until 2012. A high level steering group was established with members representing all relevant organisations, from the voluntary, statutory and commercial sector. In addition to this there is a working group, acting to collectively deliver improvements locally, for example this has resulted in collective partnership bids for 3 schemes to date linked to G4G aims.


Year 1 of the project, April 2007- March 2008 includes three activity modules: Walking, Cyclingand Swimming, two health literacy modules: Healthy Living, and First Aid, and an additional associated Module of Gardening. Further physical activities will be added to the scheme over the following four years, up until 2012 the Olympic year. 6. Measurement of Improvement The scheme is a membership scheme and therefore the number of people who are actively involved in the scheme is monitored. Measures of success for the project include:

• Increased physical activity levels measured by Sports

Council for Wales, Adult Participation Survey, and Welsh Health Survey and data on participation levels at a local level.

• Enhanced mental health levels of participants, measured using SPF 36.

• Enhanced physical health of participants, using fitness assessments where appropriate, (samples only).

• Percentage of those who sign up from the Communities First Communities annual ward analysis).

• The numbers who attain, bronze, silver and gold level accreditation each quarter.

• Partnership Working success measured using in depth interview techniques with all partners.

• Comparative information from the Leisure Services database, on numbers signed up to cards or membership and physical activity frequency data to be conducted annually in addition to quarterly.

A research bid to the Welsh Office for Research and Development has been successful, this will allow a formal independent evaluation of this project over a substantial period of time. 7. Effects of Changes The citizens of Newport now have a co-ordinated and comprehensive package of information surrounding physical activity. All of the local physical activity providers have benefited from the promotional campaign which has been far reaching to promote G4G and a more physically active lifestyle. G4G is designed to persuade people who are not undertaking regular physical activity to recognise the benefits that can be gained from a healthy lifestyle and to facilitate their sustained participation in regular activity.


The marketing campaign that has promoted Going for Gold to the public has been extremely effective. With 1 in 5 of Newport’s residents signing up to G4G in the first 9 months of the scheme, (31,000 people). People understand the concept of the reward scheme and the simplicity of the concept has proved a real winner, with a mixture of adults, children and older people signing up to the scheme. 8. Lessons Learnt The project has been a great success, but when considering improvements to the scheme, but relies solely on one Project Manager. Work is ongoing to ensure that the scheme remains sustainable in case of unexpected absence. 9. Message for Others This model of working, collaborating with many partners and developing synergy has proved successful. The scheme is unique, but could be replicated across Wales and the UK in the build up to the 2012 Olympic and Paralympic Games to ensure a healthy legacy.



Storyboard submissions 1. Storyboard Title Skills Development Programme 2. Brief Outline of Context The programme was initially undertaken as a pilot based in the classroom to deliver underpinning knowledge based on the Fundamentals of Care (Welsh Assembly Government 2003) and Skills for Health (2004) to Healthcare Support Workers (HSW). This was then transferred to the ward setting where individual competencies based on Designed to Work (WAG 2006) which were assessed and then cross referenced to the KSF and Key Skills. The setting used was within the wards of an acute hospital but the programme also encompassed staff from within the community hospitals. 3. Brief Outline of Problem The problem that needed remedying within the Ceredigion and Mid Wales NHS Trust was to improve and standardise the knowledge and skills of HSW’s. It was anticipated that this would lead to an improvement in patient care standards and raised confidence and self-esteem within this workforce based on the Modernising Nursing Careers (WAG 2006). The initial problem:

No local standards set for HSW No competency based assessment of skills leading to varying

skills and knowledge levels No assessors and mentors specifically allocated to HSW HSW were lacking in confidence and unable to act on patient

care issues and unable to assess the need to report findings of care to a qualified nurse.

Patient care appears to be compromised. No training programme for HSW Difficulty of HSW responding to patient’s simple questions due

to lack of knowledge. No educational/progression mapping for life long learning of

the HSW and preparation for nurse training entry.


4. Assessment of Problem and Analysis of its Causes On initial survey it became clear that the Trust had no set standards for the education of HSW’s, which was felt to compromise patient care, that led to an unfulfilled role and poor job satisfaction for HSW’s. Changes made that helped rectify the problem included:

Baseline standards and competencies set Knowledge based understanding of care modules developed Multidisciplinary involvement in training Development of training packages for the HSW New staff trained by competent mentors/assessors

Improvements noted following the programme included:

Improved standard and consistency of patient care by HSW Greater understanding of care needs Improved patient safety Fewer complaints regarding patient care Improved communication between staff groups Increased job satisfaction and motivation of HSW Learning route for HSW established Initial preparation for career pathway for HSW

5. Strategy for Change Proposed change discussed with ward managers greeted with enthusiasm. Project initiated by Director and Deputy Director of Nursing who successfully gained funding from the Individual Learning Account Bid from the Welsh Assembly Government. This led to the employment of a Skills Development Coordinator post. Skills Development Project Coordinator implemented the project, established the programme and devised this based on the Fundamentals of Care (FOC) and Skills for Health, with taught and ward based components. First cohort of HSW established, an enthusiastically completed the programme. No problems were encountered and initially the programme was over subscribed. Pilot programme ran over two sessions with changes made accordingly, now in the process of running the programme over eight months with Open College Network (OCN) accreditation. All Trust HSW to be enrolled and complete competences over the next two years. Current status – 56 HSW undertaking the programme. 20 HSW about to complete the programme.


Eighty Units have been written for the HSW by the Skills Development Coordinator which has been accepted by OCN. NLIAH is currently completing the accreditation process of theses Units. 6. Measurement of Improvement

Evaluations following each teaching session Role satisfaction survey three months following course Greater knowledge of care needs by HSW – pre and post

course questionnaires Continuous review of complaints relating to FOC since

programme (ongoing) 7. Effects of Changes

Knowledge gained by HSW has improved patient care and reduced complaints in particular in relation to FOC

Standards of patient care more consistent, with all HSW able to provide and deliver the same level of care

The HSW has always been a valued member of the care team but the course has provided more evidence to this group and has started, for many, on a lifelong learning programme, motivated many to consider pre-registration nurse training

Communication between HSW and registered nurses has improved

Changes were welcomed by all staff groups and although minor fluctuations in care still occur, in general the problem has been resolved. Until mentors had been identified and their role made clear, problems arose with an inability to sign of HSW competencies. Minor changes continue to be made following each cohort to ensure the programme meets the needs of those it is aimed at. 8. Lessons Learnt

The need for multidisciplinary team involvement is crucial to assessing the educational needs for each individual prior to commencing each module

Essential for the programme manager to have the correct skills prior to commencement

Ensuring skills of all professional groups are used to provide the education

To undertake a coordinator approach in planning the sessions to stop duplication of training days. Ensure mentors/assessors are recruited and role clarity is established prior to commencement of programme


Ensure good matching of HSW to mentors from the beginning 9. Message for Others It became apparent that by providing this programme patient care was improved and additionally, increased the abilities, self-confidence and knowledge of HSW. This linked well into the KSF enabling HSW to pass through the gateways accordingly. Patient care delivered by HSW became less erratic and a standard pattern of care has evolved across the Trust. Relations between staff groups have improved with greater understanding and confidence in each others roles. ‘Celebration Day’ have created a sense of achievement and reward for the HSW that was previously missing.

0209 - Citizens at the centre of service design and delivery


Storyboard submissions

1. Storyboard Title The development of a vocationally-based Occupational Therapy service in adult mental health with service users to the fore of design and delivery, offering occupational and vocational assessment, advice and guidance leading to individualised vocational opportunities across a range of interagency settings. 2. Brief Outline of Context

Over six years, the Occupational Therapy service re-designed in the context of hospital closure and community mental health service development, within a climate of political, economic change.

Occupational Therapists’ desire to utilise and promote key core skills to develop a mental health service which celebrates the potential of service users as active, productive members of the community.

Strong historical commitment to service-users at the heart of developments.

History of collaboration between the Occupational Therapy service and nursing in Cardiff and Vale NHS Trust and of strong partnership working with other agencies from the Voluntary, Employment, Education, Training and Local Authority sectors to design and develop vocational pathways as an integral part of adult mental health service delivery.

3. Brief Outline of Problem

The persistence of institution-based care designed for medical-model based interventions with outmoded emphasis on patient problems and limitations.

The need to develop a recovery-based service model to reflect the centrality of service users, their needs and potential, reducing stigma and normalising ‘care’, enabling them to be in charge of their own vocational pathways .

The need to expand the number of community – based vocational routes whereby a greater range of productive opportunities could be offered in partnership with other organisations.

Limited strategic arrangements between mental health services and Department of Work and Pensions looking at


both the needs and potential of service users in a changing, more demanding economic climate.

4. Assessment of Problem and Analysis of its Causes

Historically, mental health care delivered in institutions. Service users perceived as passive recipients, possessing few aspirations beyond the hospital. Occupational Therapists regarded as providers of diversional activities, their core skills of promoting productive occupation serving a limited purpose.

The self-assessed needs of service users include participation in meaningful activities as part of mainstream community living (Sainsbury Centre 1997).

Large range of studies support the concept of the importance of work as an adjunct to good mental health {two thirds of young men with mental health problems who die in the UK by suicide are unemployed (Social Exclusion Unit report, 2004)}

The burden of mental ill-health has significant impact on the economy. Only 24% of adults with mental health problems are in work.

Government policy strongly promotes the development of vocational opportunities in mental health {revised NSF ‘Raising the Standard’ (2005), NICE guidelines for schizophrenia (2002)} and of involving service users in the design and delivery of services.

5. Strategy for Change

Workforce re-design:- (1) The promotion of vocational knowledge and skills amongst the OT workforce (2) The recruitment of skilled OT technicians with a variety of practical vocational backgrounds (engineering, catering, adult education) to match clients’ needs.

Structures developed for multi-disciplinary, interagency vocational planning at strategic and operational levels. Partners include health, social services, voluntary organisations (e.g. MIND, Hafal), DWP management, Disability Employment Advisors, Educational and Training providers (DART, OCN).

Service users invited to join planning mechanisms and to help develop a vocational tool (the Vocational Profile) owned by the service user, used across agencies to promote the vocational needs, aspirations and pathway of the individual.

Local organisations approached as potential partners for development of joint vocational projects and training courses.

Individual service user vocational pathways developed as part of the Care Programme Approach with discharge routes into other agencies, services.


Service users promoted as NHS honorary contract volunteers and skills-share workers, offering skills and expertise whilst furthering personal vocational development.

6. Measurement of Improvement

The Vocational Profile tool evaluated through questionnaire by service-users and staff.

Training in use of the Profile rolled out to other disciplines and agencies and this also evaluated.

Over the past five years, audits employed to measure levels of vocational activity of service users within the Trust

Case study presentations used to demonstrate the vocational journeys of service users.

7. Effects of Changes

The Occupational Therapy Service has developed a strong vocational identity. Achieved in conjunction with other services and agencies. Largely achieved on a cost-neutral basis, through an internal re-focussing.

The Vocational Profile endorsed by Cardiff and Vale Trust, used to map and promote an individual’s vocational needs and aspirations. The service user, owning the Profile, is at the centre of the pathway. Used across agencies and adopted by a neighbouring Trust, it has yet to be fully embedded within the CPA process.

Vocational activity levels of service users have increased dramatically, e.g., in the past eighteen months, 200 individuals have gained accreditation on a range of IT, well-being and creative courses run by the Workers Education Association (WEA).

Partnership working helping to promote mental health awareness in wider community contexts, thereby reducing stigma and ‘normalising’ the service-user experience in everyday life.

The appointment of service-users as Trust volunteers and skills-share worker is contributing to a ‘culture-shift’ within the Trust whereby service-users are perceived as being productive service contributors.

8. Lessons Learnt

Incremental, opportunistic ‘bottom-up’ change can bring about powerful service shifts without always requiring extra resourcing

Developing services in conjunction with users is at the heart of such change.

Working with other agencies to access a greater resource pool.


The importance of communication with other services in sustaining and progressing change.

Mental health awareness training as a vital adjunct to community service development.

Need to build up a substantial evidence base on the impact of vocational rehabilitation on the quality of life of service users plus the economic impact on the country.

9. Message for Others

Service change has been based on the ultimate value of regarding mental health service users as individuals with huge potential with a right to access opportunities which can bring a much improved quality of life and well-being whilst enriching the community.



Storyboard submissions 1. Storyboard Title Radiology & Endoscopy – Quick Hits have an Impact 2. Brief Outline of Context Bro Morgannwg NHS Trust Radiology and Endoscopy Departments at Princess of Wales and Neath Port Talbot Hospitals All groups of staff were involved – Consultant Radiologists, Radiographers, Ultrasonographers, Radiographic Helpers, Clerical Officers, Secretaries, Endoscopists and Nurses As well as staff, General Practitioners and patients were involved. 3. Brief Outline of Problem 3 years ago there were major problems with the length of waiting lists:

• Endoscopy, especially routine Gastroscopy was over12 months

• Routine Non-Obstetric Ultrasound was longer than 20 weeks • Routine MRI was longer than 36 weeks

As part of the Welsh Assembly Government Designed for Life strategy (maximum wait of 26 weeks from referral to commencement of treatment by December 2009) waiting times for diagnostic investigations were introduced for the first time, the targets were:

• Endoscopy no patient should wait > 13 weeks • Radiology no patient should wait > 36 weeks by April 2007 • Radiology no patient should wait > 14 weeks by April 2008 • Radiology no patient should wait > 6 weeks by December

2009 • 4 hour and 8 hour A&E targets also had an impact on

radiology as there was the expectation patients would have their investigations quicker.

Also, patient and GP expectation had increased. The Directorate had major recruitment problems and was unable to appoint Consultant Radiologists or Ultrasonographers due to national shortages. The capacity was based on the sessions during the normal working day 9:00am – 5:00pm.


4. Assessment of Problem and Analysis of its Causes The length of the waiting lists was clinically unacceptable and contributed to an inequality in the service where waiting lists for individual clinicians varied in length. There was a high risk of inappropriate referral criteria leading to mispriorotisation of the referral. The inability to recruit staff in certain specialities impacted on the ability to reduce the waiting lists and achieve the targets set by the Welsh Assembly Government. The Directorate had two consultant radiologist vacancies which remained unfilled due to a national shortage of radiologists. The was also a national shortage of ultrasonographers so the Directorate had to invest in training two existing staff members over a two year period. 5. Strategy for Change Due to the excessive waiting lists, new targets and recruitment issues it was decided to form a project group consisting of all staff disciplines, General Practitioners and patients with a view to modernising and streamlining the service. It was quickly acknowledged that roles would need to change and be enhanced wherever possible to address many of the capacity and recruitment issues facing the department. In Endoscopy following process mapping some quick hits were implemented which involved pooling of lists, aggressive backfilling, ongoing validation, and the implementation of strict referral guidelines, waiting list management, list utilisation, patient focussed booking and the role of the outreach nurse. The endoscopy nurses were trained to perform the extended role of cannulation pre-procedure which has freed up capacity within the endoscopy procedure room allowing quicker throughput. The role of the Outreach nurse for endoscopy has changed to incorporate nurse consent and ensures ward patients are fully assessed and prepared before arriving at the unit. This prevents delays within the list and releases extra capacity to allow full utilisation of each session. The role of decontamination assistant has been enhanced to ensure all equipment required is readily available and maintained to a high standard to prevent breakdown and so decrease delay in lists. The introduction all of the changes to nursing roles has resulted in an increase of 2 patients per endoscopy session. Similar work was undertaken in radiology resulting in extending the working day in certain specialties to increase throughput per session. In order to accommodate the extended sessions staff roles


were evaluated and new extended roles were developed supported by accredited training courses. One Radiography Helper has successfully completed the Assistant Practitioner course enabling them to perform plain film radiography. This has permitted radiographers to train in the specialist areas with the longest waiting times, in particular CT, MRI and Non-obstetric ultrasound. By increasing the core staff group in certain areas has facilitated the existing staff to develop their role further, allowing individual sub-specialties with long waiting times to be targeted. Ultrasonographers now perform musculoskeletal ultrasound. Three radiographers were trained to report on plain film images (appendicular and axial skeleton). This allowed the consultant radiologists to concentrate on the more specialized work. These radiographers report on 250 – 300 examinations per week each which has reduced delays in reporting and increased turn-around times – this is monitored in quarterly Performance Review meetings with the Executive Directors. 6. Measurement of Improvement Capacity of Modality assessed pre and post changes: CT Previous opening hours = 35 hours per week. Current extended hours = 47 hours per week. Non Obstetric Ultrasound Previous opening hours = 38 hours per week. Current extended hours= 43 hours per week. MRI Previous opening hours = 35 hours per week Current extended hours = 40 hours per week. Impact on Activity of Modality pre and post changes: CT Pre changes 8,020 examinations per annum. Post changes 9,911 examinations per annum. Non Obstetric Ultrasound Pre changes 12,951 examinations per annum. Post changes 14,692 examinations per annum. MRI Pre changes 3,859 examinations per annum.


Post changes 4,973 examinations per annum. Impact on Waiting List of Modality pre and post changes: CT Pre changes (October 2006) 853 patients on waiting list – longest wait 20 weeks. Post changes (January 2008) 377 patients on waiting list – longest wait 5 weeks. Non Obstetric Ultrasound Pre changes (March 2007) 1,596 patients on waiting list – longest wait 19 weeks. Post changes (January 2008) 1,297 patients on waiting list – longest wait 14 weeks. MRI Pre changes (March 2007) 1,265 patients on waiting list – longest wait 24 weeks. Post changes (January 2008) 764 patients on waiting list – longest wait 14 weeks. 7. Effects of Changes As noted above the changes put in place along with a drive to enhance roles to meet the directorate’s agenda has resulted in the achievement of waiting times within current resources – a significant outcome being that endoscopy routine waiting times are currently stable at three weeks; lists are used to full capacity, pooling maintained and validation is ongoing. 8. Lessons Learnt Possibly would have implemented changes sooner as short waiting lists are easier to manage and workload is streamlined. 9. Message for Others Looking at what needs to be done not at who does what, many small improvements lead to overall improvement. Staff morale increases with shorter waiting times and staff become committed to maintaining the throughput that has achieved these results. Short waiting times lead to increased patient satisfaction, less complaints and greatly improved clinical outcomes and diagnosis.



Storyboard submissions 1. Storyboard Title Is 95% Hand hygiene compliance, an achievable target? 2. Brief Outline of Context Staff’s compliance with hand hygiene is the most important aspect of preventing the spread of infection. At the Royal Gwent Hospital, Newport a general medical and surgical ward has successfully implemented compliance and the initiative is now spreading to other wards within the hospital. As part of the Institute of Health Improvements, Safer Patient Initiative, interventions have been implemented on the pilot wards, increasing hand hygiene compliance to over 95%. Weekly hand hygiene audits indicate that the wards are maintaining this remarkable compliance figure. Using Safer Patient Initiative methodology, the initiative targeted the multi-disciplinary team. Over a three month period compliance improved on the pilot wards from 16% to 95% and is being maintained. 3. Brief Outline of Problem Hand hygiene is considered the corner stone of infection prevention yet it is undertaken with varying degrees of rigour and compliance. National studies have indicated compliance rates averaging 40% amongst all healthcare workers. It is well documented that hand washing can result in reductions in patient morbidity and mortality from HCAI. It has been estimated that up to 10% of hospitalised patients suffer from a HCAI at any one time with around 1% of deaths primarily attributable to HCAI. The cost of HCAI is estimated at 1 billion pounds per year. It is clear that new and innovative techniques are required to significantly improve poor hand hygiene compliance rates nationally. In 2006 Gwent Healthcare NHS Trust successfully applied for Health Foundations Safer Patient Initiative. Based on the saving 100,000 lives campaign in the USA. The Trust has implemented a number of drivers with the aim of saving lives and promoting a safe patient culture. Increasing hand hygiene


compliance to reduce the incidence of HCAI, in particular MRSA bacteraemia has been an integral part of the initiative. The aim of the initiative is to improve patient outcomes by reducing the incidence of MRSA bacteraemia to none or 300 days between infections on the pilot wards, in the first instance, and then throughout the Royal Gwent Hospital by October 2008. 4. Assessment of Problem and Analysis of its Causes Trust wide hand hygiene audits over a three year period indicate compliance rates of only 38% replicating results from other hospitals in national studies. Despite educational packages and hand hygiene campaigns within the trust, audits indicated compliance had hit a plateau. MRSA Bacteraemia data within the Trust indicated a welcome decrease, however studies from the USA suggest that a zero rate of MRSA bacteraemia is achievable, through rigorous hand hygiene compliance and sound infection control practice. Safer Patient Initiative methodology has given the Infection Prevention and Control Team the tools to increase compliance using Plan, Do Study and Act (PDSA) cycles. These cycles are based on the introduction of small tests of change, ensuring the change becomes habitual and embedded within ward culture. While the tools contribute greatly to the increase in compliance, new and innovative ideas were required. Using a multidisciplinary approach the Infection Prevention and Control Team devised interventions based around the “hands on” care given to patients. Breaking down care interventions has given clarity to healthcare workers with regard to when hand decontamination should be undertaken. 5. Strategy for Change All healthcare workers on the pilot wards were targeted and PDSA cycles introduced around simple interventions, such as checking that alcohol gel is available on bed ends throughout the wards. As the intervention is embedded within the ward culture, other interventions are introduced, such as allocating a hand hygiene monitor on a daily basis and prompting doctors to use the gel before and after patient contact.


6. Measurement of Improvement The hand hygiene monitor feeds back five hand hygiene observations on a daily basis. Poor compliance is discussed at patient hand overs. Weekly hand hygiene audits are conducted and fed back to staff using run charts. The results are highly visible. MRSA bacteraemia (outcome measurement) rates are fed back to ward staff via Statistical Process Control Charts on a monthly basis. All data is displayed on the staff room wall. To date, 300 days have passed on the one pilot ward without any MRSA bacteraemia. The second pilot wad has passed 211 days Run charts are indicating hand hygiene compliance rates are being maintained at over 95%. Anecdotally, patients and relatives are noted the significant increase in hand decontamination. 7. Effects of Changes The culture around hand hygiene compliance has changed significantly. Hand hygiene is now habitual amongst staff of all disciplines and where hand decontamination is lacking, staff are prompted in an encouraging and unthreatening manner. Anecdotally, patients and relatives are noting the increase in hand hygiene. Most importantly, surveillance is indicating that bacteraemia is prevented thereby decreasing mortality. 8. Lessons Learnt This work is now spreading to other wards. It should not be assumed that the interventions implemented on the pilot wards will work for a different area. Other solutions may be needed which are tailor made for specific wards. 9. Message for Others To date the initiative appears to have succeeded where others have failed. Achieving 95% compliance is a remarkable. Maintaining this rate is a challenge itself, but as the data is fed back regularly, any drop in compliance is acted upon immediately. Ultimately, this initiative will contribute to decrease in patient mortality across the Trust.

0267 – Working Seamlessly Across Organisations


Storyboard submissions 1. Storyboard Title Working in Partnership Locally to develop a Condition Management Programme for People with Long Term Health Problems 2. Brief Outline of Context The Swansea/Neath Port Talbot Condition Management Programme (CMP) has strengthened partnership working internally between Bro Morgannwg and Swansea NHS Trusts and externally with the Department for Work and Pensions, Jobcentre Plus and community/ voluntary organisations. A multi disciplinary team of health practitioners (occupational therapists, physiotherapists, support workers) seconded from Bro Morgannwg NHS Trust, work with people referred from local Job Centres helping them overcome health related barriers preventing their return to work. The service commenced in August 2006 and has already received 866 referrals. The programme is delivered in local community venues, aiming to break down traditional barriers preventing people from better managing their health condition. 3. Brief Outline of Problem The service received a higher than predicted volume of referrals (25% above planning assumptions), this resulted in unacceptable waiting times for clients and began to place pressure on staffing resources. The team looked at different ways in which they could deliver a Condition Management Programme, using staff resource effectively 4. Assessment of Problem and Analysis of its Causes Within six months, referrals exceeded planned assumptions. Capacity of the service was constrained by the staff resource. To increase capacity, the use of group work to deliver the programme was discussed, and 70% of clients already assessed said they would consider working within groups. Team members visited a project in Yorkshire where similar problems had occurred and they developed a Condition Management Course to overcome them. We developed a seven week ‘Condition Management Course’, which would meet local needs and is the first of its type in Wales.


5. Strategy for Change February 2006: Recognition that service delivery within a ‘one to one’ model was not sustainable long term and there were clear client benefits of working within groups. March 2006: Mapping services in England that had creatively addressed this problem. Identified area of best practice in Yorkshire April 2006: Visit by members of the team to Yorkshire Condition Management Team April 2006: Plan of action agreed to develop seven week course to meet the needs locally. June 2006: Cognitive behavioural therapy training delivered to the team. July 2006: Three day internal planning to develop the condition management course and have a “dry run” of delivery. Development of initial systems, structures and processes to enable the course to be administered/delivered simultaneously across four localities.(Morriston, Swansea, Port Talbot and Neath) September 2006 – Four condition management courses commence across the area. Throughout the planning phases, stakeholders were consulted on the proposed changes to service delivery: formal presentations to the project’s steering group; Jobcentre staff including senior management and personal advisors and local GPs. 6. Measurement of Improvement Client evaluations, capturing both quantitative and qualitative information are completed. Standardized outcome measures are used pre and post intervention. The cost effectiveness of delivering the course compared to ‘one to one’ interventions is currently being analysed. Formal research is being planned with Cardiff University to understand the effectiveness of the Programme using the above outcomes along side in-depth interviews with clients. 7. Effects of Changes Ten Condition Management Courses have been delivered, this has enabled the service to more effectively manage practitioner-client time. The overwhelming benefit reported from clients is the ability to learn new self-management skills in an environment amongst people with similar issues, reducing the sense of social isolation.


People have reported increases to self efficacy, quality of life and improved confidence to return to work. Clients report an increase in social inclusion and increased use of community facilities (e.g. community education, leisure environments) which until recently, they had felt prevented from doing. Clients from early cohorts who have now found work return to the final week of current courses to talk about their experience since participating. Problems encountered include anxieties about attending the course. To address this a pre-course informal coffee morning has been introduced to allow people to meet the facilitators and each other beforehand. There was some resistance initially from practitioners as to whether service delivery would translate effectively to group work. This appeared to be influenced by anxieties of undertaking a new approach. Within team meetings this was discussed and a ‘facilitation skills workshop’ delivered to improve practitioner confidence. Practitioners now report increased ability to deliver and an increased confidence to promote the course due to the positive experiences gained to date. It is hoped that the service reduces dependency on traditional secondary health services by enabling more effective self management. Feedback includes:

• Finding the sessions more and more helpful and finding that people are starting to notice a change in me for the better (so I’m told).’

• ‘I have found this 7 weeks has built up my confidence to feel more positive about life. Life is to be enjoyed.’

• “Customers have a lot of respect for one another – allowing people time to talk & listening /problem solving as a group with no need for prompts from facilitators”.

8. Lessons Learnt Time/resource commitment to planning this service change, though intense at the time, was invaluable for the detail and associated problems to be resolved before delivery.


Involvement from Jobcentre staff at the final session would be useful to ‘signpost’ people to employment resources as they complete their health management course. Weekly written feedback from participants/ practitioners has been extremely useful for service improvement after each cohort. It would be useful to gain more discursive evaluation using methods such as focus groups to further understand the benefits/ limitations of the course. 9. Message for Others Upon reflection, the team has learnt how to deliver health based interventions within an evidence based framework that diminishes dependency on staff, enabling people to overcome barriers to health and work. Most of the team has worked in secondary health settings delivering interventions on a ‘one to one’ clinical appointment basis from traditional health/clinical settings. Working within a ‘psycho-social model’ of health in partnership with Jobcentre staff has allowed the team to use their core-skills in rehabilitation with clients in a non-clinical setting, seeing, at times, tremendous heath, social and vocational gains for the clients with whom they work.

0269 – Leading on Service Improvement


Storyboard submissions 1. Storyboard Title Redesigning SLT services to effectively meet need 2. Brief Outline of Context Growing demand and shorter access targets for Speech and Language Therapy for children led staff from the Directorate of Speech and Language Therapy at Gwent Healthcare NHS Trust to recognise that traditional one-to-one/direct intervention by a therapist was unsustainable. A process to redesign is described. 3. Brief Outline of Problem The traditional care pathway for a child receiving speech and language therapy was organised by sector structure (Fig 1).

Child referred to

SLT i

Specific Language

Impairment Service in School

Community Clinic Service

Paediatric Special Needs Service

Individual therapist caseload






Figure 1: Service sector led pathway This led to:

• lack of standardised clinical pathways across the Trust • Clinical experts remained in their sector silo. • The child may or may not be seen by the right person at the

right time, doing the right thing • The number of follow up treatment sessions varied by

therapist not by child’s diagnosis and functional need


• Referrer’s and parent’s expectation were influenced by their relationships with individual therapists sometimes leading to a culture of dependency on the service

• Waiting times for access were long

A service redesign model was implemented facilitated by the Access Partnership (fig 2).

• ACCESSING SERVICE

• PREVENTATIVE

• REFERAL CRITERIA

• SERVICES ON OFFER

• ASSESMENT

• PACKAGES OF CARE

•GOVERNANCE

• EXIT/INDEPENDANCE

• ALTERNATIVES?

• APPEALS/COMPLAINTS

• LOCATIONS / FACILITIES• MANAGERIAL AND CLINICAL ARRANGEMENTS• ADMINISTRATIVE AND CLINICAL PROCESSES

• PUBLICITY / PROFILE• SYSTEMS

• MEASUREMENT (DEMAND & CAPACITY)

PATIENTS JOURNEY

Access Redesign ModelAccess Redesign Model

WHAT CAN BE DONE HERE?

4. Assessment of Problem and Analysis of its Causes Problem Quantified: Access times - 593 children waiting for a Speech and Language Therapy Assessment 91 children were waiting over 24 weeks. Clinical coding- Codes for differential diagnosis were not internationally standardised Follow-ups- Number of follow up treatment sessions highly variable Process adopted to analyse the problem:

• All sector staff (n=89) were engaged in problem identification workshop

• Top 5 reasons for children to be referred were identified • Redesign clear evidence based packages of care for the top 5

referrals, checked against current evidence • 60% of children referred would benefit from one evidence

based package of care, Hanen®


Changes needed to make improvements:

• Redesign services around pathways of care • Clarify clinical entry and exit criteria • Standardise pathways of care using ‘Sounds so simple’ and

approved programmes including Hanen® where clinically indicated.

5. Strategy for Change 5 LEAs and 5 LHBs approved the redesign timetable, via WAG funded Joint Pilot Projects. Figure 3: Timetable for change Tasks Time line 2007 08

J F M A M J J A S O N D J

Strategic engagement of partners x

Information gathering x

All SLT Staff engaged x

Core volunteers identified x

Workshop understand present state x

• Examine current position x x

• Examine core purpose x x

• Examine patient journey x x

• Demand capacity analysis x x x

Stakeholder interviews x

Workshop findings and redesign x

• Examine results x

• Develop ideas for redesign x x

• Choose areas to redesign first x x

Internal feedback x x

Workgroups develop new care packages with EBP

x x x x

Workshop agree changes x x

• Critique areas of change x

• Implementation plans x x x

Consultation event x

Implementation x

Evaluate benefits x

• Volunteer staff for service redesign work identified (n=20) • 3 redesign workshops


6. Measurement of Improvement Figure 4: New Pathways of Care Model

Complex Child

Further assess

Hanen Parent

Program groups

Advice home / school prog

Early Signing session

1:1 therapy

with SLT or SLTA

Sounds So

Simple groups

1:1 Review

May go directly to next package without another review

Hearing Impaired pathway

ASD path-way

Discharge

Child referred and

triaged

Impact of Service Delivery: Triage of referrals changed from directing child to service sector to triaging child according to need, with assessment directing to a standardized pathway of care. Triage categorised referrals as Acceptable Unacceptable Likely care package required on the pathway Number of children waiting has reduced by 60% (593 to 239) Access times have reduced from 91 children waiting over 24 weeks before service redesign process to 4 over 24 weeks


Benefits to patient:

Shorter waiting times, rapid access to triage to make sure children with significant problems are being seen quickly by an appropriately skilled therapist

Literature evidence for the chosen approved pathway Hanen® show

Speech and language outcomes improve, establishing effective functional communication skills 1

Enables parents to become their child’s primary language

facilitator2

Provides early language intervention3

“I have just completed the Hanen® sessions. What a difference this has made to the quality of life for my little girl. She is more confident and will initiate a conversation and join in activities. Several weeks ago she would not have done so. The skills I have learned I will have for life and I know I will be able to help my three children now and in the future. They will no longer have to feel frustrated when communicating with me. Thank you Hanen®. You have changed my life and my child’s.” parent’s view from literature

Benefits to service:

Appropriate match of clinical skills to client’s need (reduce waiting times, improves clinical effectiveness and delivers improved clinical outcomes)

Allows workforce plans to be aligned with service demand

Band 4 workforce has increased to support care package

delivery


Workforce shape change 2006 to 2008

0 5 10 15 20

1

2

3

4

5

6

7

8St

aff b

and

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20062008

Facilitates the sharing of skills and knowledge for clinical staff who are pathway not sector focused

Delivering structured programmes like Hanen® increase the opportunity for multiagency working, with programmes delivered through multiagency facilities close to parents and children.

Reduction in variance achieved by implementing care pathways

Service is sure evidence based practice4 is being delivered Staff development improved; accredited training Standardised clinical pathways facilitates research in clinical

practice 7. Effects of Changes The service redesign process has seen children, following triage, streamed into care pathways. Some of these pathways are delivered through accredited programmes like Hanen®, that increasingly see therapists as enablers of parents and significant others (e.g. teachers) to be the prime communication facilitators for up to 60% of the services caseload. The service continues to develop pathways where formal programmes have yet to be developed. Work to date has given a robust indication of the capacity required to deliver the Hanen®

programme to those it is appropriate for and the impact that has on the service overall in terms of generating additional capacity to divert into other care pathways. New system 41 Hanen® groups a year x 5 children (parents) =205 cases


Old system at 1:10 new/treatment by individual therapist would have used 2050 slots New Hanen® system = 984 slots Therefore frees up 1066 appointment slots in one year. These will facilitate reduced waiting times targets and improve efficacy of intervention 8. Lessons Learnt

• Engagement of all staff with a volunteer workgroup feeding back regularly was a successful model to manage retention during change.

• Focussing on the patient journey through the service was a successful focus.

• Make changes where the most benefit can be had • Parallel workstreams (e.g. migration of Patient Admin

Systems) timescales may conflict • Data systems may not move at the same pace • Tools to measure variation from clinical pathway

underdeveloped • Stakeholder’s expectation cannot always be met but

engagement is essential • Time lines can slip; e.g. there was slippage in the timescale

for stakeholder interviews • A better communication strategy could have improved with

earlier and wider dissemination of vision 9. Message for Others Clinical pathway standardisation ensures effective treatment, efficient use of finite resources and contributes to waiting time reduction. References 1. Girolametto (1996) The effects of focussed stimulation for promoting vocabulary in children with delays. Journal of Childhood Communication Development 2. Gibbard,D , (1994) Parental-based intervention with pre- school language delayed children . European Journal of Disorders of Communication 29 (2): 131-50 3. Gibbard D, Coglan L, MacDonald J (2004) Cost-effectiveness analysis of current practice and parent intervention for children under 3 years presenting with expressive language delay. Internal Journal Language and Communication Disorders 2004 39 (2): 229 - 44 4. McCauley and Fey (2006) Treatment of language disorders in children.

Contents page Storyboard Storyboard Title Organisation Citizens … Wales Awards 200… · Contents...

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