From Zero to FLS:
Implementation & Beyond
National Osteoporosis Society
FLS Education Programme
October 2010
Size Matters!
Determinants of the scale of your service
Previous fracture
The FLS’ target population
- which fracture groups?
- what age group?
New
Fracture
Non-vertebral
& Vertebral
Non-vertebral
& Vertebral
Size Matters!
Determinants of the scale of your service
Previous fracture
~650 new non-vertebral fractures &
~120 new vertebral fractures
age 50+ per 100K, per year
New
Fracture
Non-vertebral
& Vertebral
Non-vertebral
& Vertebral
NEW FRACTURE
PRESENTING TO
A&E / ORTHO / TRAUMA
FALLS RISK
ASSESSMENT
NEW RADIOLOGY
REPORT OF FRACTURE
EXERCISE
CLASSES
Rx FOR FRACTURE
2Y PREVENTION
PRESCRIPTION ISSUED BY GP
McLellan et al. Osteporos Int 2003;14:1028–1034
PREVIOUS FRACTURE
EDUCATION
PROGRAMME
From Zero to FLS: Implementation & Beyond
Project
Management
From Zero to FLS: Implementation & Beyond
The first steps
• Appointment of project management team & Chair
Membership of FLS implementation project team
Number
Post
x2
Local champion / lead clinician
x1
Chair GG&CHB Osteoporosis Subgroup (clinician)
x3-4
Other HB lead clinician & secondary care clinicians from involved sites
x1-3
CHP GP lead
x2
Osteoporosis Nurse Specialists
x1
General Manager – Medical Services
x1
GG&C osteoporosis exercise service lead physio
x1
Superintendent Radiographer
x1
Assistant General Manager, Radiology
x1
Consultant radiologist (DXA) – local imaging lead
x1
Estates manager
x1
NOS patient representative
From Zero to FLS: Implementation & Beyond
The first steps
• Appointment of project management team & Chair
• Redefine & agree with providers of funding remit of group &
scope of service
Remit of group & scope of planned service
1. To roll out an FLS, to provide systematic post-fracture
assessment to all men & women age 50+ with new fracture
presentations or with new report of vertebral fracture or with
previous fracture age 50+
2. To ensure equitable access of all relevant patients in the region
3. To implement these services within the constraints of the
proposed funding
4. Case-finding for new fracture presentations & for new reports
of vertebral fracture – by the FLS ONS
Remit of group & scope of planned service
5. Case-finding for previous fractures – by primary care
6. Post-fracture, risk assessment based on one-stop consultation
with FLS-ONS incorporating DXA, where appropriate
7. All episodes of FLS-patient care recorded in database
8. To provide this for population of x over y sites and covering
fracture patients from z hospitals
From Zero to FLS: Implementation & Beyond
The first steps
• Appointment of project management team & Chair
• Redefine & agree with providers of funding remit of group &
scope of service
• Work breakdown
From Zero to FLS: Implementation & Beyond
Project
Management
DXA
Work
Breakdown
Personnel
Logistics
From Zero to FLS: Implementation & Beyond
Project
Management
DXA
Work
Breakdown
Personnel
Logistics
From Zero to FLS: Implementation & Beyond
The first steps
• Appointment of project management team & chair
• Redefine & agree with providers of funding remit of group & scope
of service
• Work breakdown
• Schedule work & establish timeline for delivery of service
Dec 2007
ID
Task Name
Start
Finish
2/12 9/12 16/12 23/12 30/12 6/1
1
Scope & Remit – Group
Membership
Jan 2008
Feb 2008
Mar 2008
Apr 2008
May 2008
Jun 2008
Jul 2008
Duration
05/12/2007
09/01/2008
5.2w
2 WB – Personnel Appointments
05/12/2007
15/04/2008
19w
3 WB – DXA procurement to delivery
05/12/2007
14/03/2008
14.6w
4 WB - Exercise class infrastructure
05/12/2007
07/05/2008
22.2w
5 WB - protocols
05/12/2007
07/05/2008
22.2w
6 WB – Induction – training
05/12/2007
04/06/2008
26.2w
7 WB – Communications incl website
27/02/2008
30/05/2008
13.6w
8 Service launch
05/12/2007
01/08/2008
34.6w
13/1 20/1 27/1
3/2
10/2 17/2 24/2
2/3
9/3
16/3 23/3 30/3
6/4
13/4 20/4 27/4
4/5
11/5 18/5 25/5
1/6
8/6
15/6 22/6 29/6
6/7
13/7 20/7 27/7
From Zero to FLS: Implementation & Beyond
Project
Management
DXA
Work
Breakdown
Personnel
Logistics
What do you need to provide a DXA for a FLS service ?
• Space for DXA (may require building works!)
• DXA scanner/s
– DXA (VFA) site visit to inform choice
– DXA procurement
• Radiographer/s
• ONS clinic space - near DXA
• Database - reporting system
• Patient transport issues
From Zero to FLS: Implementation & Beyond
Project
Management
DXA
Work
Breakdown
Personnel
Logistics
Personnel
• Overview
–
–
–
–
Banding & Grades of Staff
Job descriptions
Appointments processes - job descriptions - adverts – interviews
Consultant Sessions
• How are Consultant sessions best deployed?
• Osteoporosis Nurse Specialist/s
– Band 6/7 Osteoporosis Nurse Specialist
– ONS line management
– ONS where & how will they work?
Personnel
• Administration & Clerical Staff
– Band 3 A&C
• Physiotherapist/s for exercise services
– Band 6 Physiotherapist
• Radiographer/s
– Band 6 Radiographers
From Zero to FLS: Implementation & Beyond
Project
Management
DXA
Work
Breakdown
Personnel
Logistics
Logistics
• Pathways of care
– New fracture presentations in which hospitals & FLS in which centres
– New reports of vertebral fractures in which hospitals & FLS in which
centres
– Past fractures from across region referred to which centres
• Protocol development
• Access to Mineral Metabolism clinic for those who don’t fit with
management protocols
• Liaison re exercise classes
• Liaison with falls service
Logistics
• Communication within secondary care & with GPs
• Standardisation of forms
• Website development to facilitate communication
• Patient education materials
• Patient education classes
• ? Nurse telephone follow up (? Telephone BPR tariff)
• Training & induction
• Launch meeting
What do you need to provide exercise classes?
• Access to health service physio gym
– Identify exercise class locations
• Access to leisure centre gyms
– Identify exercise class locations
• Patient transport issues
If at first you don’t succeed…
If at first you don’t succeed…
you’ve failed!
Pathway to success…
& it will be incremental!
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What changes can we make to
effect improvement?
Plan
Do
Act
Study
Pathway to success…
& it will be incremental!
PDSA & the Evolution of the Glasgow FLS
for new fractures
Cycle 1
Objective 1
Objective 2
Case-finding all new
fx F&M age 50+ by
GP
Fracture risk assessment by ONS at one-stop clinic with DXA
Outcomes
audit
Only 5% wrist fx &
11% hip fx
identified / referred
for assessment
Essential
change
Case-finding must
be by ONS in
secondary care
PDSA & the Evolution of the Glasgow FLS
for new fractures
Objective 1
Objective 2
Cycle 1
Cycle 2
Case-finding all new
fx F&M age 50+ by
GP
Case-finding all new
fx F&M age 50+ by
ONS in secondary
care
Fracture risk assessment by ONS at one-stop clinic with DXA
Outcomes
audit
Only 5% wrist fx &
11% hip fx
identified / referred
for assessment
~all fx patients
identified & assessed
– but only 4% of fx
were vertebral
Essential
change
Case-finding must
be by ONS in
secondary care
Need for new
approach to identify
vertebral fx
PDSA & the Evolution of the Glasgow FLS
for new fractures
Objective 1
Objective 2
Cycle 1
Cycle 2
Cycle 3
Case-finding all new
fx F&M age 50+ by
GP
Case-finding all new
fx F&M age 50+ by
ONS in secondary
care
Case-finding all new
fx F&M age 50+ by
ONS in secondary
care
& all new radiology
reports of vertebral fx
Fracture risk assessment by ONS at one-stop clinic with DXA
Outcomes
audit
Only 5% wrist fx &
11% hip fx
identified / referred
for assessment
~all fx patients
identified & assessed
– but only 4% of fx
were vertebral
Essential
change
Case-finding must
be by ONS in
secondary care
Need for new
approach to identify
vertebral fx
~all fx patients
identified & assessed
– now 12% of fx are
new vertebral fx
‘The only place success comes
before work is in a dictionary!’