18 Week National Cardiac Pilot Project Princess Alexandra Hospital, Harlow

1
18 Week National Cardiac Pilot Project
Princess Alexandra Hospital, Harlow

• Phil Duncan
• Intern Director

2
The good things about 18 Weeks
3
The Project

• Pathway - GP referral to CABG
• Understanding existing data systems
• Manual measurement of individual patient journeys
  clock start and stop
• How long are patients really waiting? -
  calculating indicative waits
• Understanding the impact of service improvement
  on 18 weeks
• Capacity to meet 18 weeks?
• Removing wastage
• Recommendations and solution testing
• Identifying the capacity gap future service
  planning

4
Is the road ahead difficult?
5
Can 18 Weeks be Achieved?

• 50 of patients currently experience less than 18
  Weeks for their pathway of care
• Start the dialogue primary, secondary and
  tertiary care
• Understand patient flow dynamic - mapping
• Determine patient pathways (and parallel
  pathways) and agree on pathway steps keep them
  simple
• Understand demand, capacity, variation and
  process capability
• Review administration processes that add no value
  get lean!
• Capture the right data activity vs. demand
• Manage the source of referral see and treat
  patients chronologically
• Challenge current practice
• Look for new ways of working staff and service
  improvement

6
GP Referral to Angio
7
GP Referral to PTCA
8
GP Referral to CABG
9
So now you have measured the pathway, what next?
10
Outpatients

• Demand remains high (in line with national
  picture) against capacity
• Non-cardiac referrals to cardiology are also high
• Patient clinic suitability is diverse RACPC vs.
  General
• Out-reach clinics (where diagnostics are
  required) can lead to an additional appointments
• Follow-up cancellations
• Multiple clinic slots types and patient queues
• Consultant to consultant referral process

11
RACPC

• No triage of referrals
• Increase capacity vs. strict referral criteria
• Utilisation of slots from general referrals
• Direct referrals from A/E
• Workforce options
• Integrate referral criteria within pathway of care

12
PRISM and Data

• Understand features and benefits of ad-on systems
• Staff training and improve data interrogation
• Integrated information strategy encompassing all
  systems
• Determine measures from agreed patient pathways
• Linking data and tracking outcomes
• Access DH resources

13
Diagnostics

• Local agreements who needs diagnostics?
• Validation of diagnostic referrals
• Improve administration processes (referral and
  booking)
• Diagnostics prior to the decision to refer
• Maximise capacity utilisation
• Understand demand
• DNA management
• Validate follow-up diagnostic requests
• Sustainable backlog management

14
Angiography

• National demand is increasing
• Commissioned activity determines patient waits
• Pre-assessment to maximise capacity usage
• Outcome data from angiography
• Pooled waiting lists
• Clinical guidelines conversion rates

15
Tertiary Care

• National demand for PTCA is increasing CABG has
  levelled
• Develop and agree new pathways of care with
  Essex Tertiary Centre
• Pre-assessment to maximise capacity usage
• Pooled waiting lists
• Linking data for RTT times
• Further work on demand

16
Notes on Data

• Good data management will help achieve 18 Weeks
  establish the baseline
• Butexisting data is limited for the purposes of
  18 Week analysis
• Primary to secondary care analysis requires
  decision to treat PAS field manual collection
• Outcome data from secondary care is limited
• 18 Week pathways including tertiary care may
  require HES / Clearnet analysis
• Linking data may require HES identifier to
  distinguish patient episodes
• Access NHS Institute No Delays Achiever
• Tactical RTT measurement - DSCN 17

17
Summary Recommendations

• An integrated primary, secondary and tertiary
  care approach in developing locally agreed
  pathways of care clearly define clock start and
  clock stop
• A detailed understanding of service demand and
  capacity
• Commission on the basis of need (and demand)
• A strategic approach to data and knowledge
  management that is demand (not activity) led
• An integrated systems approach (to include add-on
  databases) to data capture and analysis
• Managing the source of referrals by improved
  screening within primary care

18

• Improve the utilisation of the workforce by new
  ways of working including out of hours work and
  nurse / GPwSI / physiologist led activity
• Diagnostic tests prior to the decision to refer
• Generic referrals and waiting list pooling
• Rapid access models of outpatient management
• Simplification of clinical slot types to prevent
  multiple patient queues and treat patients in
  chronological order of referral
• Partial booking of follow-up appointments
• Standardise consultant activity where not
  sub-speciality biased by a review of clinic
  templates and also clinic rules
• Develop modelling for 18 Weeks in order to
  identify service gaps

19

• Standardise paper referral systems to improve
  recording and efficiency and where appropriate,
  record by the date of referral
• Pre-assess patients where appropriate to reduce
  DNA rates, develop standby lists and maximise
  slot capacity
• Capture relevant outcome data on additional PAS
  fields in line with the requirements of 18 Weeks
  and DSCN 17
• Develop a process for back log management that
  is sustainable in line with the relevant service
  improvement
• Reduce batching and decrease unnecessary waits
• Implement changes only if there is a clearly
  identified benefit that adds value to the service
• Involve patient and carer groups in any service
  change ideas
• Start the work yesterday!

20
Challenging Current Practice

• Do all patients referred for a cardiac opinion
  need to see a cardiologist?
• Do all patients need diagnostic tests in
  secondary care?
• Do all patients need diagnostic tests following
  an initial consultation?
• Do all patients need diagnostic tests?
• Do all patients need follow-up appointments in
  secondary care?
• Do all patients need follow-up appointments?
• Is current data really describing the patient
  process?

21
Tweak the system or radically redesign the whole
pathway?Its more than measurement

• GP to outpatient referral 5 weeks
• Outpatients to diagnostics 6 weeks
• Diagnostics to angiography 6 weeks
• Angiography to CABG 6 weeks
• Total journey time 23 weeks

22
Next Steps

• Project management input into Colchester and
  Harlow projects
• Begin recommendation testing and implementation
  linking with local initiatives
• Essex Cardiac Network roll-out plus EoE links
• Continue to input potential solutions and
  outcomes - national cardiac network learning set

23
(No Transcript)