Informatics implications of
the 18 weeks target
Northwest ASSIST
September 11, 2008
12-Jul-16
D. Protti - City University London & University
of Victoria
1
Outline for the Afternoon
•
•
•
•
Welcome and introductions
Setting the stage
Survey of status on the issues
Small group exercise
»Outstanding questions
• 3:30 – Refreshment Break
• 3:50 – Outstanding questions
• 4:20 – Wrap up comments
12-Jul-16
1:30
1:40
2:10
2:25
–
–
–
–
D. Protti - City University London &
University of Victoria
2
The 18 Weeks Target
•
By December 2008, no one will have to wait longer than 18 weeks
from GP referral to hospital treatment.
NHS Improvement Plan, June 2004
•
“We are also going to end hidden waits. The time patients wait for
diagnostics has not traditionally been counted as part of the waiting
time measurement. This can be a worrying and uncertain time for
patients. To them it is very much part of the time they have to
wait.”
John Reid, February 2005
•
“We need to shift our focus from individual stages of treatment. We
have begun measuring waiting times for admitted and non-admitted
patients from referral to treatment. This began at the start of this
year, and May’s data for admitted patients published on 2 August
showed that 53% of admitted patients are currently seen within 18
weeks. We currently have this for seven out of ten patients.
thequarter – Q1 2007/2008
Director General for NHS Finance, Performance and Operations
12-Jul-16
D. Protti - City University London &
University of Victoria
3
September 6, 2007 STATISTICAL PRESS NOTICE
NHS REFERRAL TO TREATMENT (RTT) TIMES DATA
• In total, 285,744 patients, for whom
English commissioners are responsible,
completed their RTT pathway with an
inpatient or day case admission during
June 2007.
• The NHS reported both the clock stop
and the clock start for 224,819 of these
patient pathways.
• Of these, 54% completed their referral
to treatment pathway within 18 weeks,
compared to 53% in May.
12-Jul-16
D. Protti - City University London &
University of Victoria
4
The challenges are different…
1. Long waits &
clearance times
o 18 week pathway is per patient, not per procedure
2. Managing patients
through journey
o Massive cultural change required to shift focus to
3. Ability to measure
pathways
o Need to prove measurement solutions for use in
and so there is a potential for much longer waits
“pulling” patients through whole pathways
operational and performance management
…and we must manage the key risks
1. Finance
o Financial environment puts pressure on activity
necessary to meet milestones within LDPs
2. Capability and
capacity
o Capacity is under pressure from the range of other
3. Wider system
reform
o Delivering 18 weeks must fit within system reform
initiatives already underway
and maximise benefits through integrating with ISIP
The challenge of 18 weeks
The NHS needs to continue to reduce waits to first outpatient and from decision to treat
to treatment. This will require more activity and reform than ever before. In addition the
NHS needs to focus on the time from first outpatient to decision to treat which historically
has not been a major focus.
18 Weeks
GP
OP
GP Visit
1st Outpatient
Appointment
D
OP
IP
Decision
to treat
Treatment
Previously only measured the wait for the 1st outpatient appointments and the wait for inpatient treatment,
once a decision to treat had been made. Now RTT measures the total time. The time from the 1st OP
to decision to treat includes the most significant challenges including all diagnostics and subsequent OPs.
Challenges - diagnostics & specialties
Certain diagnostic tests (Endoscopy and Pure Tone Audiometry) face particularly long waits.
Most significant
challenge to reducing
diagnostic waits to
below 13 weeks
Diagnostic test clearance times
9000
Other Endoscopy
8000
Number of 13+ wk waiters
7000
6000
Pure Tone Audiometry
5000
Non-obstetrics Ultrasound
MRI
4000
3000
Echocardiography
2000
Peripheral Neurophysiology
CT
Diagnostic cardiac
catheters/angiography
1000
Nurse & GPSI led endoscopy
0
0
5
Sleep studies
GI Physiology - manometry
10
Electrophysiology
15
20
25
Clearance time (weeks)
The average referral to treatment time is c21 weeks.
Total sample size = 100,000
waiters
30
Challenges ~ diagnostics & specialties
The orthopaedics pathway wait is 10 weeks longer that of other specialties
Bedfordshire & Hertfordshire average end-to-end waiting times for key procedures
40
Orthopaedics has
longest average wait
Average total wait (weeks)
30
27
21
Orthopaedics
ENT
Ophthalmology
Urology
17
17
17
Adult medical
General surgery
Gynaecology
16
OMFS
Challenges - diagnostics & specialties
Sheer scale of diagnostics






Hundreds of different tests and procedures
High volumes for some tests and low volumes for others
Imaging: MRI, CT, ultrasound, DEXA, plain film, >30m tests pa
Endoscopy: ~3m procedures annually
Pathology: ~600m tests pa, hundreds of kinds of test
Physiological measurement: ~9m tests pa, >200 kinds test
Many different kinds of skilled staff deliver the service
Patchy information systems locally, some still paper-based
Lack of information and focus on diagnostics waiting times
in the past
Tactical and strategic informatics
challenges of 18 weeks – an acute
Trust perspective…
or…
the biggest thing since Körner
Brian Derry
ASSIST Vice Chair
Director of Informatics
The Leeds Teaching Hospitals NHS Trust
brian.derry@leedsth.nhs.uk
12-Jul-16
B. Derry Leeds Teaching Hospitals
11
Where are we (Leeds) now?
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B. Derry Leeds Teaching Hospitals
12
Waiting times target coverage
X
OP att nurse
GP ref
OP att cons
Decision
To admit
X
2nd+ atts
Admit & treat
Home
X
Any primary care
X
Other ref
X
X
1st att
2nd+ atts
Admit & cancel
Decision
To admit
LTHT Outpatient Attendances
2005/6
Other-NonCons 1st Other-NonCons 2nd+
6%
GP-NonCons 2nd+
1%
4%
GP-Cons 1st
13%
GP-NonCons 1st
1%
GP-Cons 2nd+
26%
Other-Con 2nd+
41%
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B. Derry Leeds Teaching Hospitals
Other-Cons 1st
8%
15
Scope: includes -1
• Referrals from:
–
–
–
–
–
–
–
–
–
consultants to consultants - agreed by “1o care”, unless “urgent”!
GPSIs
General Dental Practitioners
“…from GP
Optometrists
referral to
A&E, Minor Injuries Unit, Walk-in-centre
hospital
GUM
treatment”
National screening programmes
Other primary care profs - when PCTs choose!
“mechanisms locally”
• Referrals to consultants working in community (incl.
employed by PCT)
• Endoscopies - OP or DC!
12-Jul-16
B. Derry - Leeds Teaching Hospitals
16
Scope: includes -2
Clinically complex cases, including tertiary
referrals, Choice & multi-org pathways:
• No suspensions
• No reset for provider cancellations
• % tolerance
“By December 2008 no
• …..audit?
one will have to wait
longer than 18 weeks..”
12-Jul-16
B. Derry - Leeds Teaching Hospitals
17
Scope: excludes - 1
• Direct access:
– Diagnostics pre-decision to refer
– Physiotherapy
– Occupational Therapy
– Speech & language Therapy
• Podiatry & Audiology if not consultant-led
• Referrals to nurse consultants & AHPs
12-Jul-16
B. Derry - Leeds Teaching Hospitals
18
Clock start -1
• At point of booking (no re-start if wrong
clinic)
• Intermediate services (CAS, GPSIs, RMS) –
at GP ref if part of 2o pathway, not of 1o
• Direct access diagnostics (1o&2o) – when
patient books 2o OP appointment
• If planned sequence, new pathway when
medically fit for each stage
• Patient choose “late” appointments –
undecided?
12-Jul-16
B. Derry - Leeds Teaching Hospitals
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Clock stops -1
• Start treatment – “1st curative/definitive
treatment”! (not admission for diagnostics )
• Admission & treatment as IP/DC (not
cancelled ops)
• OP (including AHP) – procedure
• Return to 1o care after OP/diagnostics & no
further 2o care action
• Medical device fitted
12-Jul-16
B. Derry - Leeds Teaching Hospitals
20
Clock stops -2
• Patient declines treatment or dies
• “Watchful waiting/active monitoring” starts
• DNAs
– 1@1st appointment & back to GP….but CAB
– @ follow-up ….in tolerance
• Other patient-initiated delays (e.g.
repeated failures to agree date …but
?“reasonable offers”) - in tolerance
• When in doubt: “will be rules” or in
tolerance!
12-Jul-16
B. Derry - Leeds Teaching Hospitals
21
Issues (sample from you)
• How to get clinical specialties to review their
processes and pathways in a timely fashion?
• How to best develop and implement clinic
templates?
• How to best develop and implement the
Directory of Services?
• What resources are needed to deliver patient
tracking and RTT measurements?
• How to best achieve consensus on the
definition of clock starts/stops?
12-Jul-16
D. Protti - City University London &
University of Victoria
22
Issue Types
1. Service implications
2. Information issues
3. IT issues
12-Jul-16
D. Protti - City University London &
University of Victoria
23
1. Service Implications
•
•
•
•
•
•
•
Clearing the ‘backlog’
Booking & scheduling pathways
Patient flows – 1o, ISTC, 2o , 3o , 4o
Pathway management
Capacity planning & management
Transition & parallel running
Clinical engagement
12-Jul-16
B. Derry - Leeds Teaching Hospitals
24
2. Information issues
• Clinician recording – OP outcomes,
intentions, 1st curative treatment…
• Patient admin processes & recording
• Integrating information along pathways
• Pathway identification & linkage
• NHS data model
• PAS, diagnostics & other systems
12-Jul-16
B. Derry - Leeds Teaching Hospitals
25
NHS Data model
Shifting the focus from
Organisation
Staff group
Setting
Administrative
Process
12-Jul-16
Patient
Clinical
Outcome
B. Derry - Leeds Teaching Hospitals
26
Informatics issues
…just a few…
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B. Derry - Leeds Teaching Hospitals
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3. IT issues
• Current PAS context
– Central returns/admin - centric:
– Retrospective & paper-driven
– Consultant orientated
– Care setting insularity….
• 1990s front-ends, 1980s thinking, &
1970s data & business model
12-Jul-16
B. Derry - Leeds Teaching Hospitals
28
New system requirements
•
•
•
•
•
Patient-centred & pathway oriented
Pro-active scheduling & booking
Integrating “OP”, Diagnostics & “IP”
Cumulative PTLs
Link information across organisations &
professional groups
• By late 2007 at the latest!
12-Jul-16
B. Derry - Leeds Teaching Hospitals
29
From here…
Menta
l
Health
Primary
Care
A&E
IST
C
Outpatients
Administrative
Retrospective
Paper driven
12-Jul-16
Inpatient
s
D. Protti - City University London & University of
Victoria
30
…to here?
Who
Clinical workflow
Where
Booking
Why
Scheduling
When
The patient
What
Real time
By whom
Resource
planning
How
Interactive
Prior risk
Virtual linking of
information (not
systems)
Outcome:
expected &
actual
12-Jul-16
D. Protti - City University London & University of
Victoria
31
Early achievers - pioneers
Derbyshire County PCT
Chesterfield Royal Hospital NHS Foundation Trust
Derby Hospitals
NHS Foundation
Trust
Manchester
PCT
Central Manchester and Manchester
Children’s University Hospitals
Blackpool
PCT
NHS Trust
Blackpool, Fylde and Wyre Hospitals
NHS Trust
Halton and St Helens PCT/ Knowsley
PCT
St Helens and Knowsley Hospitals
NHS Trust
Eastern Coastal Kent PCT
East Kent Hospitals NHS Trust
Walsall Teaching PCT
Walsall Hospitals NHS Trust
Herefordshire PCT
Hereford Hospitals NHS Trust
Medway PCT
Medway NHS Trust
Derby City PCT
Chesterfield Royal Hospital NHS
Foundation Trust
Derby Hospitals NHS Foundation
TrustPCT
Bolton
Bolton Hospitals NHS Trust, Greater
Manchester Surgical Centre
Western Cheshire PCT
Countess of Chester Hospital NHS
Foundation Trust
Somerset PCT
Yeovil District Hospital NHS
Foundation Trust
Taunton and Somerset NHS Trust
Torbay Care Trust
South Devon Health Care NHS Trust
Doncaster PCT
Doncaster and Bassetlaw Hospitals
NHS Foundation Trust
Hampshire PCT
Basingstoke and North Hampshire
NHS Foundation Trust
Top tips for implementing RTT
measurement from the pioneers
• Plan for implementation
• Clinic outcome sheets
• PAS (or alternate system solution)
• DH reporting
• Communications
12-Jul-16
D. Protti - City University London &
University of Victoria
33
Survey of about addressing the
issues – based on findings from
King College Hospital (an early
achiever site)
• Please take a few minutes to answer
each question
• If from a Trust: use a white sheet
• If from a PCT or other: use a pink
sheet
12-Jul-16
D. Protti - City University London &
University of Victoria
37
Trust representatives - White
• Survey of Trust representatives as to the
degree to which their own Trust has
implemented the RTT measurement activities
recommended by the Pioneer sites
• For each question respond:
5 = Most definitely
3 = Some what
1 = Not at all
9 = Don't know
12-Jul-16
D. Protti - City University London &
University of Victoria
38
PCT and other representatives - Pink
• Survey of PCT and other representatives as to
the degree to which their Trusts have
implemented the RTT measurement activities
recommended by the Pioneer sites
• For each question respond:
5 = Most definitely
3 = Some what
1 = Not at all
9 = Don't know
12-Jul-16
D. Protti - City University London &
University of Victoria
39
Small group discussions
1. Discuss your survey responses.
2. What questions would you like
answers to – and from whom?
– If answered in your group, no need to list
it.
3. Trust representatives break up into
groups of 4-5.
– Mix up the groups
4. PCT representatives and others break
up into groups of 4-5.
– Mix up the groups
12-Jul-16
D. Protti - City University London &
University of Victoria
40
Outline for the Afternoon
•
•
•
•
Welcome and introductions
Setting the stage
Survey of status on the issues
Small group exercise
»Outstanding questions
• 3:30 – Refreshment Break
• 3:50 – Outstanding questions
• 4:20 – Wrap up comments
12-Jul-16
1:30
1:40
2:10
2:25
–
–
–
–
D. Protti - City University London &
University of Victoria
41
Questions from Trust representatives
• Will SHA provide scenarios re applicability to
Community
• What exactly is the financial incentive/penalty
to (acute & P.care) to meet individual pathway
targets & general :(SHA&Monitor)
• What is the split in responsibility between
orgs on a pathway e.g. ending in tertiary
care. (DH)
• How will Monitor monitor FTs & what is the
responsibility mix between an FT & its PCT
:(Monitor)
• How will the 100% tgt be hit if its 54% now
& rising slowly (SHA)
12-Jul-16
D. Protti a
- City
University London
&
42
• Has there been
pattern
of
increased
DNAs
University of Victoria
& suspension due to CAB & 18w: (SHA)
Questions from PCTs and other representatives
12-Jul-16
D. Protti - City University London &
University of Victoria
43
Learnings from the Pioneers
12-Jul-16
D. Protti - City University London & University
of Victoria
44
1. Understand Present State
Present state analysis
Stakeholders
Examining processes
2. Redesign and plan change
management and process control
Examining results
Demand & Capacity
Start to re-design
3.Agree Change
Implementation Plan
Internal Feedback
Continued improvements
4. Implement
External Feedback
Best practice
5. Monitor and Evaluate
Benefit realisation
Service Transformation
vs
Service Improvement
12-Jul-16
D. Protti - City University London & University
of Victoria
46
Service Transformation
Vs
Service Improvement
Service Transformation
• Something that looks and feels very different from
when it started
• The objective is to not only influence processes, but to
change mindsets, cultures, activities, and
organisational power bases
• Changing the design of the playing field and rules of
the game
Service Improvement
• Tools and techniques to deliver efficiency and
productivity along the pathway
• Help deliver service transformation
12-Jul-16
D. Protti - City University London &
University of Victoria
47
Service Transformation
Why Service Transformation?
• Because more of the same faster won’t
work!
• Sustainability of service improvement on
stages of treatment
• Shift from stages of treatment into whole
pathway
12-Jul-16
D. Protti - City University London &
University of Victoria
48
…via…
• Agility – policies, organisations, patient
wants….
• Business disciplines in a political world
• Informatics integral to policy development
• Business process redesign, ICT-enabled
• Supplier capacity & partnership
• Financial investment & affordability
• HI workforce planning & professionalism
12-Jul-16
D. Protti - City University London & University of
Victoria
49
Key lessons from 18 weeks
• Excellent intent
• Spotlights long-recognised weaknesses in
the NHS data model and core system
• Major strategic informatics challenge to
CFH, the IC, suppliers and the NHS
• Informatics a policy afterthought
• Focus on monitoring not delivery
12-Jul-16
D. Protti - City University London & University of
Victoria
50
East Kent Hospitals NHS Trust
18 Week Early Achievers
Matthew Kershaw, Chief Operating Officer
Tracy Rouse, 18 Week Project Manager
East Kent Hospitals NHS Trust
Key Learnings
• Clinical leadership is critical
• Only the clinician treating can determine the treatment status
and relevant pathway
• Admitted clock stops easier to capture and easier to define
• Non admitted clock stops difficult to capture and are more
difficult to define
Achieving the 18 Week Target
• Development of clinical pathways and new service models
including:
− early triage and primary care and self management
− diagnostics earlier in the patient pathway
• Improved productivity
– waiting list management
– hours of operation
– booking systems and management
• Workforce redesign
• Patient and public awareness
• IT
Early Achiever Planning
• Emphasis on speed and momentum
• Need to see early wins and rapid improvement
• Project needs to gain early credibility and build confidence across
our locality
Early Achiever Planning
Business Planning
•
•
•
•
•
18 week activity planning integral to the current LDP and
business planning process
There is a recognition that new pathways will require us to
plan activity differently but no model to support this process
as yet
Setting local trajectories by directorate
Backlog / waiting list initiatives to maximise theatre capacity
and minimise the constraints of theatres
Clock stop - first treatment not always end of pathway
Early Achiever Planning
Clinical Pathways
•
•
•
•
•
– Challenge existing practice
– Maximise opportunities for transformational change across
the health economy
– Deliver 18 weeks
Needs to be clinically led
Clinical pathways to be developed and agreed and implemented
across our locality
Development of service models to support pathways
Agreement with commissioners via contract
Audit of agreed pathways
Early Achiever Planning
Communications
•
Initial awareness utilizing existing locality communications
systems:
– Email, trust magazine, chief executive forum
•
Long term communications to continue through traditional
methods. Monthly communication forum to be agreed
•
PPI – patient representatives will continue to be invited to the
steering group, supported by regular briefings and consultation
requirements
•
Staff drop in sessions to be set up across the locality
Early Achiever Planning
RTT
To continue with development of referral to treatment data collection.
Specific work streams include:
•
•
•
Inter-organisation data collection and data pathway
implementation
PTL development and SUS
Begin to work with Fujitsu re RTT solution
Early Achiever Planning
Translating the rules into practice
Review of current administrative rules to reflect 18 week
principles and definitions
•
•
•
•
•
•
Reduction in suspension and tolerances
Reasonableness needs to be defined and its impact qualified
on outpatients, diagnostics, inpatient
Reasonableness and outpatient timescales to be defined and
planned within choose and book
PCT and GP support to sustain implementation
Need to quantify impact on our lower waits and demand from
other localities
Patient perception of a no waits system
Early Achiever Planning
Governance
• Nominated Executive, Managerial and Clinical leads across
locality
• 18 Week Steering Board. Membership includes managerial and
clinical leads from PCT and Acute Trust, PPI members. Chaired
by Executive Lead
• Project groups will be accountable to the steering board
Summary
• We are clear on the challenges that we face
• We need to win hearts and minds early in the
process
• Can only achieve as a health community
• We are confident that it can be done