As part of its foundation trust bid, Royal Wolverhampton Hospitals Trust embarked on a challenging three-year efficiency programme. Chief executive David Loughton explains what it achieved and how.
How to do more with less. This is the challenge facing NHS organisations as a result of restricted budgets and increasingly demanding performance targets.
At Royal Wolverhampton Hospitals Trust we have always focused on continuously improving patient experience and outcomes, but two years ago we realised we had a few long-standing “pain points” that needed to be overcome.
It was doubly important that these issues were tackled in light of the Royal Wolverhampton’s long term objective to become a foundation trust.
However, due to ever-increasing demand in certain departments we were spending a lot of money on outsourcing to plug gaps, and that was costing us significant amounts without ever actually dealing with the root cause of the problem.
We needed to break that cycle somehow and find a fresh approach to the way we went about delivering our services.
Rather than try to effect a wide-ranging programme immediately we decided to test the water and focus efforts on a specific area, engaging improvement specialist Newton to help map out the path to change. If we could successfully knock off some of the low hanging fruit then we could start aiming higher.
Training and developing local teams
In order to support the outpatients improvement programme we developed the outpatients development team, comprising both internal staff and Newton. It was this group that mapped out what it was that we needed to do to deliver what we needed.
The team was made up of people from all over the trust, not just outpatients, and brought engagement from all levels including consultants, management, nurse, patients, clerical staff, finance, information/IT and Newton. Links were formed between these people, and they had a collective visibility of the “pain points” that needed to be overcome and could highlight areas where improvement could be made.
With the priority of each programme being to ensure that improvements can continue after the project is complete, initially the focus began with a core skills training course for all staff. We were being trained in Newton’s methodology so that we could essentially do what they would normally do once they had left.
This ensured all members had been trained in technical and analytical techniques used to make efficiency improvements – something which is not normally in the scope of their day to day jobs.
This training covered a range of defined areas including an introduction to the developing efficiency programme and setting objectives, measuring efficiency, undertaking clinic studies, process mapping, building an assessment case, analytical IT skills, improvement cycle, stakeholder management and project management.
A further element of the training plan was to ensure that our team could transfer their knowledge to other staff across the trust. The outpatients development team is doing this really well and it is empowering others within Royal Wolverhampton and really driving the culture shift at the trust.
As you can imagine, training staff in skills that were not necessarily their core presented a few hurdles. But, once we were fully capable, Newton’s involvement decreased and they handed over responsibility of the outpatients programme to the team, although their technical support and mentoring still remains.
We are now in a position to use these skills to make further enhancement to the outpatients departments and throughout other areas of the trust.
The whole project was aimed at streamlining processes and improving the patient pathway experience. That partnership exercise delivered £1.25m worth of efficiency savings within our orthopaedic department (see case study, below). Being able to realise such an outstanding result gave us the confidence to really challenge our own perceptions of care for patients.
A delivery team comprising Newton and Royal Wolverhampton staff was established to deliver the efficiency gains throughout the three year project, working in partnership to find solutions that would optimise the trust’s operational performance.
A six-week assessment study was carried out to look at areas such as length of stay and bed use, diagnostic services, coding, procurement and supply chain, staff costs and accident and emergency services.
The information was analysed and used to introduce smarter processes, using the resources we already had at our disposal more efficiently to bring benefits to our patients and our staff.
The key objective was ensuring that improvements – such as creating visibility of information and reporting to streamlining procurement – could continue after the project was complete. That meant staff training was pivotal in sustaining the benefits for the long term future of the trust.
As part of the efficiency project, a training and development programme for staff was put in place, including the creation of a core internal team that could essentially do what Newton was brought in to deliver and could carry the work on after their involvement ceased (see case study, right).
Let me just say that it wasn’t easy. Ensuring clinical engagement at all stages was crucial, and we needed to tap into all the drive, motivation, analytical skill, persistence, and empathy our staff display every day and apply it to this area of our work.
However, through close working between hospital staff across all levels, we are able to adapt the existing systems and processes to make improvements with tangible results, and ensure the necessary skills and knowledge are embedded within our trust in order to continue delivering these benefits in the years ahead.
Our overriding vision has been to transform the operational efficiency of the hospital and be a patient-led hospital, and I am pleased to say we have achieved what we set out to do.
Royal Wolverhampton is on track to make savings of £10m over the next four years and we are also fulfilling our strategic objective of being ranked among the best performing trusts in the country. We absolutely believe this approach will allow us to continue to improve the quality of the care we deliver, and meet our targets at the same time, in the testing years ahead.
Sometimes less really does mean more.
Case Study: bringing theatre sessions back in house
Because of a lack of in-house capacity, we were regularly outsourcing six of our orthopaedic elective theatre sessions each week to another acute provider. These sessions were not as popular with patients, and were not as well utilised as those carried out in-house, and represented a significant loss of income for the trust.
We appointed Newton to work with the local team to create the capacity required to bring in all of the outsourced sessions. To be able to do this required optimising the current theatre facility usage, increasing the utilisation of day case theatre sessions, and reducing the number of cancelled sessions.
The project began with a detailed assessment of the operational performance of theatres within the trust. Historical data, live studies and discussions with clinicians, nursing staff and management enabled all losses to be identified, quantified and prioritised.
Three key areas of opportunity were identified:
- unallocated sessions, inaccessible due to a multitude of complex and interdependent timetabling constraints;
- reduced day case theatre utilisation due to late starts and early finishes;
- lost sessions due to cancellations.
A detailed project plan was agreed with all stakeholders to deliver improvements in these areas and realise the benefits.
A detailed analysis of theatre utilisation identified permutations of theatre timetables that would free up six sessions per week, working within constraints such as theatre clinical suitability and physical configuration, staff external commitments, surgeon and anaesthetist working partnerships and consultant job plans.
The problems solved included theatre preparation, communication, rota planning and synergy.
A reduction in early finishes was achieved through decreasing inpatient cancellation rates and increasing theatre list booking efficiencies.
Working across a number of specialties, with managers, clinicians, nurses and clerical staff, the Newton team quantified true capacity and demand in all types of theatres, understanding all constraints associated with possible moves and validating all opportunities to increase orthopaedic elective capacity.
Forty-six session moves were agreed and implemented, making use of sessions previously inaccessible and cascading case-mix down from main theatre to day cases, and from day case to treatment rooms. Within weeks of the project commencing, all stakeholders involved were so confident that the capacity was available in-house, that they terminated the contract for the outsourced theatres.
Increasing session uptake was achieved by simplifying the process of cancelling and reallocating theatre sessions. The new process, created with input from all levels of the administration and management team, improved the visibility of cancelled theatre sessions and simplified the process of cross-specialty list reallocation. To ensure sustainability, an owner was allocated to manage and review each part of the process.
The whole programme was aimed at streamlining processes, improving the patient pathway experience and fulfilling the objective of being a patient-led hospital.
Additional focuses of this strategy were targeted reduced infection risk, streamlined patient pathways, greater patient choice, increased theatre utilisation, reduced waiting times and improved use of valuable resources.
The improvement of patient pathway experience has also delivered annualised savings of £1.25m, a key objective amid increasing patient demands and budgetary pressure.
Breaking this down, all six outsourced sessions were successfully repatriated and are now being carried out in-house – bringing a 14 per cent increase in the number of orthopaedic theatre sessions being run in house, saving the trust £744,000 per annum.
Improvements made in day-case theatres have driven a 15 per cent increase in utilisation over all specialties, recovering £303,000 per year. We have also been able to deliver 2.4 additional sessions every week through improving the visibility of cancelled sessions and the process by which they were booked, cancelled and re-used. This has delivered annualised savings of £197,000.