Live and direct - how five got ahead

HSJ's GM Live events provided an unprecedented opportunity for trusts not only to share best practice, but to see the benefits for themselves. Alexis Nolan reports

In May and June five events created by HSJ and sponsored by the NHS Institute for Innovation and Improvement, the NHS Integrated Service Improvement Programme and NHS Connecting for Health did something rather unusual: they provided the opportunity for managers to visit trusts and talk to managers and clinicians at the forefront of the innovation and creativity that often earns the NHS such a good local-level reputation.

The Good Management Live events covered areas in which many aspire to be the best, but most have some way to go. Overall, nearly 250 managers attended the five events, each at a trust with success stories to tell:

• Mayday Healthcare - using tools and processes such as an inpatient traffic-light system and e-referrals to create planned care, multi-agency planning and timely discharge to reduce length of stay.
• Good Hope Hospital foundation - using IT and patient information to improve care pathways, eliminating outpatient waiting, cutting cancer waiting times and implementing an infection control surveillance system.
• Derby Hospitals foundation - driving up day cases and pre-operative assessment and improving theatre scheduling and use through streamlined patient pathway and service redesign. It also involves creating new staff roles and better recruitment and retention.
• Luton and Dunstable Hospital - analysing the process of diagnosing performance against the 18-week target, identifying delays and using clinical and management information to drive improvement.
• Bolton Hospitals - explaining how lean thinking, rapid improvement events and cutting-edge management methods are improving outcomes in areas from pathology and trauma stabilisation to laundry and discharge management.

At Mayday, winner of the Acute Trust of the Year category at last year's HSJAwards, a straightforward traffic-light system is used at the heart of many services to improve process and patient experience.

To improve patient flow, a bed predictor tool gives the trust an idea of how many patients are going to be admitted and discharged, provides the hospital escalation status and allows the bed-management team to ensure capacity is created by facilitating early discharges.

Green means up to 5 per cent more capacity than required demand.Amber indicates that there is up to 2 per cent more capacity than demand. Red denotes that there is up to 2 per cent more demand than capacity.

Tracking patients

The trust's patient-tracking system follows patients' progress from admission, through treatment, to discharge or referral to other organisations. Discharge planning starts as soon as a patient is admitted, with a discharge checklist and an expected length of stay for around 80 per cent of inpatients. Red indicates an expected discharge on the day or before; amber means expected discharge within the next three days and green more than three days in the future. There is also electronic referral to ensure services that are in place for when patients are discharged.

At Mayday's emergency assessment unit and short-stay ward, the traffic-light system filters new admissions and streamlines the subsequent patient journey. Green covers up to 11 hours from arrival and initial assessment. Amber, from 12-24 hours, covers treatment and the decision to transfer to a specialist bed or a short-stay ward or discharge. Red, from 20-24 hours, covers time to troubleshoot delays, discharge or transfer.

The trust has also tackled length of stay through its day-surgery unit, operational since the start of last year, and by redesigning processes to introduce admission on the day of surgery.

In Bolton, the adoption of lean principles has produced dramatic results. The two main themes are continuous removal of waste such as staff stress, defects (for example, a leaking tap), inventory and waiting from processes, and having respect for people and society.

Rapid improvement events focusing on specific areas and the members of the team involved in that service lie at the heart of lean thinking. They allow the people 'doing' to shape their own improvements rather than have new processes imposed on them.

Bolton's in-house laundry service, which also supplies businesses in the North West, needed to reduce costs or staffing levels to remain competitive. Through lean methodology the laundry can increase productivity by 25 per cent and potentially reduce its net cost by£300,000 (on a£1m turnover). This improves service, increases employee satisfaction and secures a long-term future for the laundry.

Radiology services at Bolton were unable to turn around film within 24 hours and had a backlog of 7,000 films waiting to be reported. Simpler processes now mean that 90 per cent of radiology reports are available within 24 hours.

Team spirit

At Derby, a better team culture and the introduction of performance indicators are transforming operational performance, staff satisfaction and retention rates.

Scheduling and maximising theatre capacity is being transformed through better management and clinical information in the form of performance indicators. Consultants have agreed to new ways of working, and in a new culture of visibility they even get charged for cancellations they make to their lists.

Derby's theatre teams also suffered from a lack of communication and visibility. There was poor staff involvement, a lack of career structure and poor training and development opportunities.

Turnover and sickness levels are down, vacancies have been eradicated - cutting use of expensive agency staff - and there is greater ownership and better understanding of the need to improve services and productivity to help the organisation.

At Good Hope, process modelling was used to measure the impact of pathway redesign in vascular outpatient waiting times with the goal of reducing waits, improving job satisfaction and helping the organisation hit targets. The introduction of a one-stop clinic model cut 12 weeks of wasted time at no cost and the number of patients that could be treated increased by 40 per cent.

Patient tracking and pathway redesign have also transformed cancer services at Good Hope, which from June last year achieved 100 per cent compliance with the 31-day target. For patients treated on-site, the rate was at least 95 per cent against the 62-day target.

And the work of Luton and Dunstable shows that while the 18-week target looms large, trusts need to act quickly to ensure that they have a clear understanding of their current position before staff work on interpretations of when the clock stops and starts for patient treatment.

The five trusts produced many excellent examples of good practice. But what stood out among them was a mixture of good leadership, clear communication, teamwork between managers and clinicians and creativity in finding a fresh perspective on old problems. Their approaches can be replicated through thorough understanding of processes and the use of technology to support or deliver.

And perhaps the biggest lesson is that in spite of financial problems the improvement efforts have to be done as part of the 'day job' of managers and clinicians rather than relying on service improvement teams. It is the challenge of making service improvement skills part of every manager's armoury and enabling and encouraging clinicians to innovate that also presents the NHS with one of its greatest opportunities.