Getting Better in Fife
2012-2017
Version 12.10 (12/09/2012)
1
Getting Better in Fife
Contents
1.
CHIEF EXECUTIVES’ FOREWORD ................................................................ 3
2.
NHS FIFE’S STRATEGIC OVERVIEW ............................................................ 4
2.1
Context ............................................................................................................. 4
2.2
The Position in NHS Fife .................................................................................. 5
2.3
Working in Partnership ..................................................................................... 7
2.4
Responding to the Coming Challenges ............................................................ 8
2.5
Moving toward 2020 – NHS Fife’s Vision ......................................................... 9
2.6
Maximising NHS Fife’s Estate .......................................................................... 9
3
MOVING FORWARD – GETTING BETTER IN FIFE ....................................... 9
3.1
What are we trying to accomplish? ................................................................. 10
3.2
Delivering Getting Better in Fife; A Programme of Improvement Projects ...... 11
3.3
Improving Flow and Emergency Access- the Right care in the Right Place at
the Right Time ................................................................................................ 12
3.4
Improving Elective Flow –Care where it counts, care when it counts ............. 14
3.6
Safe and Accessible Mental Health Services ................................................. 18
3.7
Safe and Effective Medicines Management ................................................... 21
3.8
Examples of improvement projects and tests of change ................................ 23
4
IMPROVEMENT APPROACHES .................................................................. 23
4.1
Quality Improvement Methodology ................................................................. 23
4.2
Programme Management Office .................................................................... 25
5
HOW WILL WE KNOW WHEN CHANGE IS AN IMPROVEMENT ............... 25
5.1
Measures for Improvement............................................................................. 25
6
ALIGNING RESOURCES TO SUPPORT THE PRIORITIES ......................... 26
6.1
Building Capacity and Capability for Sustainable and Effective Quality
Improvement .................................................................................................. 26
6.2
Quality Improvement Hub ............................................................................... 26
7
WHAT DOES THIS MEAN FOR THOSE WE CARE FOR AND OUR
STAFF?.......................................................................................................... 27
Appendix 1 ............................................................................................................... 29
2
Getting Better in Fife
CHIEF EXECUTIVES’ FOREWORD
1.
In 2002 Fife Health Board embarked upon an ambitious
programme of service redesign across all the strands of
healthcare in Fife. This plan became known as “Right for Fife”
and anticipated many of the issues which have caused all
healthcare systems to review how services can be provided.
The success of “Right for Fife” has put NHS Fife in a good
position to move forward.
Much of “Right for Fife” was structural and has resulted in
improved in-patient facilities for patients at St Andrews,
Adamson, Stratheden, Lynebank, Randolph Wemyss and
Victoria Hospitals, and new community facilities for example in
Anstruther and Dunfermline and across Fife in respect of dental
access centres. Importantly, it also encompassed new models
of care and patient pathways resulting in reduced lengths of stay, reduced waiting times and
reduced numbers of hospital attendances through developments of increased “one stop”
clinics and services provided on an ambulatory, or day case, basis.
So, ten years on we have achieved much, but there is still more to do. My goals over the
next five years are to:


Recognise the need for continuous improvement and to enable staff to redesign
services they provide while continuing to provide safe and effective care in a
changing environment.
Build on the good work of “Right for Fife”, ensure we finish what we started and
further improve clinical care.
I want NHS Fife to be a place where:





Staff are able and encouraged to make changes to reflect patient needs in their area
and to ensure care is person centred.
The culture is that we are always looking at how we can do things better.
The culture that patients feel safe, valued and well looked after.
Staff feel able to raise issues and suggest improvements.
People are prepared to make changes and to think about the “how to” and not the
“why not”.
This plan – Getting Better in Fife – sets out the processes to make this happen and the
priority areas in which we will invest time and resources to make it happen. We will also
continue to provide the wide range of services to the people of Fife and meet our
performance targets
This plan is not an end product – it is the start of a process which will evolve over time.
John Wilson
Chief Executive, NHS Fife
3
Getting Better in Fife
2.
NHS FIFE’S STRATEGIC OVERVIEW
2.1
Context
NHS Fife works with and on behalf of the citizens of Fife to improve their health and
healthcare.
The Scottish Government set out the national framework for improving Scotland’s
health and healthcare in its Quality Strategy1 which sets out NHSScotland’s vision
to be a world leader in healthcare quality, described through 3 quality ambitions:
effective, person centred and safe. These ambitions are articulated through the 6
Quality Outcomes that NHSScotland is striving towards:






Everyone gets the best start in life, and is able to live a longer, healthier life;
People are able to live at home or in the community;
Healthcare is safe for every person, every time;
Everyone has a positive experience of healthcare;
Staff feel supported and engaged;
The best use is made of available resources.
The Quality Strategy builds on Better Health, Better Care2 and, together with
subsequent supporting publications; they provide the overall strategic context.
Since 2002, NHS Fife Board has been delivering an ambitious programme of
development and modernisation designed to improve the range and quality of healthcare
services and to improve the quality of the premises from which services are provided the implementation in Fife of the Quality Strategy and of Better Health, Better Care.
Within the national framework, NHS Fife has prime responsibility for the protection and
improvement of its population’s health and for the delivery of frontline healthcare
services.
It does this through services it provides itself, through primary care
contractors, through joint working with other agencies and NHS Boards and through
public participation and patient focus. Services are provided in people’s own homes
and from a range of locations and premises across NHS Fife. All NHS Boards work
together for the benefit of the people of Scotland; NHS Fife works principally with NHS
Lothian and NHS Tayside to provide specialist and other healthcare to the people of Fife.
Because social and economic participation is vital to good health and economic growth,
NHS Fife also works closely with its Community Planning Partners - Fife Council, Fife
Constabulary, the Further Education Colleges located in Fife and the voluntary sector, all
of whom come together as part of the Fife Community Planning Partnership.
1
2
The Scottish Government. The Healthcare Quality Strategy for NHS Scotland; Edinburgh 2010
The Scottish Government. Better Health, Better Care; Action Plan; Edinburgh 2007
4
Getting Better in Fife
Fife’s Community Plan and Single Outcome Agreement demonstrate how the
Partnership will contribute towards delivering the Scottish Government’s National
Outcomes in order that:





We tackle the significant inequalities in Scottish society;
Our children have the best start in life and are ready to succeed;
We improve the life chances for children, young people and families at risk;
We live longer, healthier lives;
Our public services are high quality, continually improving, efficient and
responsive to local people’s needs;
We reduce the local and global environmental impact of our consumption and
production; and
Our people are able to maintain their independence as they get older and are
able to access support when they need it.


2.2
The Position in NHS Fife
Since 2002, NHS Fife has significantly changed the way it contributes to the health and
healthcare of the population. Over the decade we have transformed a very large part of
the way NHS care is provided. The paragraphs which follow offer some key
headlines from a much longer story.
In terms of health improvement and primary prevention we are for example:
 Strengthening the ability of General Practice
o
By supporting chronic disease management, developing and
strengthening our community and public health nursing, podiatry, speech and
language, physiotherapy and occupational therapy services, increasing direct
access to diagnostic services and through investment in modern premises,
including the refurbishment of Rosyth and Kirkcaldy Health centres, the
redevelopment of Cupar Health Centre and the development of Skeith and
Linburn Health Centres.

Strengthening the ability of General Dental, Ophthalmic and Pharmaceutical
Services
o Through investment in premises- 10 new dental services centres, by further
improving links to specialist care (e.g. the eye care project) and in the
introduction of a range of pharmacy based services including the roll out of
the new community pharmacy contract, and a range of local services based
on need. For example, we have a network of palliative care community
pharmacies, ‘Just in Case’ boxes to meet the anticipatory medication needs
for patients at the end stages of life.

Implementing and sustaining a range of health improvement programmes
o Including smoking cessation, alcohol brief interventions and weight
management, mental health – facilities, therapies, earlier diagnosis and
interventions for dementia and better collaboration across services.
5
Getting Better in Fife
In terms of helping to meet the needs of the most vulnerable members of our community
we have strengthened some services and redesigned others. Examples include:

Children
We have centralised inpatient paediatric services within Victoria Hospital,
increased service provision for the care of children in the community, redesigned
services and health improvement work in the monitoring and delivery of the child
healthy weight programme and developed an integrated care pathway for
vulnerable under 2 year olds. We have further developed and are delivering an
integrated model of care across council and health – pathways and
implementation of ‘Getting it right for every child’ across the Fife partnership.

NHS Fife is one of the first Boards to implement the Family Nurse Partnership
(FNP). FNP is evidence based, preventative programme offered to young
mothers having their first baby. It begins in early pregnancy and is orientated
to the future health and well-being of the child. It is a nurse-led, intensive,
home visiting programme and supports universal services in supporting
teenage families. FNP is a licensed programme with structured inputs and
well tested theories and methodologies. Creating the right environment to
deliver the FNP is important and challenging. The aims are achieved by
maintaining fidelity to the programme license which is essential if the benefits
identified in the research are to be realised.
These benefits of this are:

O
Improving the outcome of pregnancy by supporting women to improve
their prenatal health;
O
Improving child health and development by supporting parents to
provide more competent care of their children in the first 2 years of
life;
O
Improving families’ economic self-sufficiency by supporting parents to
develop a vision of the future, accomplish goals by planning timing of
pregnancies and staying in school/finding work.
People with Learning Disabilities
NHS Fife participates in a national accreditation programme to ensure staff are
highly trained in this speciality area and additional investment has been made in
Community Based Care with additional specialists in post to deliver the care and
enable the development of the Learning Disabilities Unit and the Regional
Learning Disabilities unit at Lynebank.
In terms of improving care, we are for example:
 Strengthening the workforce by
o
Training and developing highly specialised clinicians e.g. Advanced
Nurse Practitioners, Specialist Nurses and other Allied Health
Professionals
6
Getting Better in Fife
o
Using Redesign, Organisational Learning and Development resources,
In-house and external training programmes and organisation-wide
implementation of the electronic Knowledge and Skills Framework to
provide our workforce with the skills required to deliver 21st century
healthcare
 Moving to new ways of delivering care for example by
o
Implementing the Scottish Patient Safety Programme methodology
including the use of care bundles, use of Day Surgery where possible and
appropriate, shorter waits for investigation and treatment, one stop clinics,
state of the art facilities, increasing use of IT e.g. electronic prescribing,
telehealth, telecare and video conferencing including Telepresence,
electronic patient referral processes and ordering of investigations
 Redeveloping premises including
o
2.3
The new wing at the Victoria Hospital, the Learning Disabilities
Assessment and Treatment Unit based at Lynebank Hospital, two new
mental health wards at Stratheden hospital, the new community hospital
in St Andrews and redevelopment of Adamson Hospital and Randolph
Wemyss.
Working in Partnership
Community Planning is a process which helps public agencies to work together with
the community to plan and deliver better services which make a real difference to
people's lives. NHS Fife is a major contributor in this work in Fife. Partners identify
the priorities for joint working and align/pool resources around projects where they
identify an advantage in doing so. The breaking down of barriers between
organisations and the requirement to achieve more with the resources available
should foster innovation and new ways of working in partnerships.
Single Outcome Agreements are an important part of this drive towards better
outcomes. They are agreements between the Scottish Government and Community
Planning Partnerships which set out how each will work towards improving outcomes
for the local people in a way that reflects local circumstances and priorities.
The Fife Partnership is responsible for community planning in Fife and is made up of
representatives from local agencies.
Fife’s Health and Wellbeing Alliance comprises NHS Fife, Fife Council and Fife’s
Voluntary sector and works to reduce health inequalities and improve health and
wellbeing for the people of Fife.
The Fife Health and Social Care Partnership (FHSCP) is a partnership between NHS
Fife and Fife Council and its Social Work and Health Committee. The partnership works
closely together to plan and integrate the care provided for the people of Fife. This closer
joint working enables more effective and efficient use of partnership resources,
maximises opportunities and facilitates the delivery of higher quality and more
7
Getting Better in Fife
responsive services. The FHSCP Service Delivery Plan3 sets out how the joint service
will deliver health and social care for:





Older people
People with learning disabilities or autism spectrum disorder
People with and affected by mental ill health
People with physical disabilities or sensory impairments
People with and affected by drug and alcohol dependency
The processes of continual improvement in our services are ongoing. Working with
Council partners and using the Older People’s Change Fund – a government initiative –
we are changing the approach to the care of older people. Residential care, whether in
a care home or a hospital, is becoming the last resort rather than the first choice. A wide
range of re-ablement rehabilitation services will enable people to stay healthier and stay
at home longer, and the developing “virtual ward” approach will mean even when
actually ill, many people will be able to stay at home.
In May 2012, the Cabinet Secretary for Health, Wellbeing and Cities, Nicola
Sturgeon, launched a consultation document outlining proposals to integrate adult
health and social care across Scotland. The aim is to improve care for patients
by overcoming some of the 'disconnects' between different parts of public sector
services including primary care, social work, community health and some acute
hospital services. While it is recognised that progress has been made across
Scotland, more needs to be done in partnership to meet the future needs of the
population. The specific proposals outlined in the consultation are to establish a
health and social care partnership which will take a joint local responsibility for the
delivery of adult health an social care in each Council area.
We have made significant progress across Fife with the existing partnership
arrangements. We have been at the forefront of many significant service
improvements and have led innovation across services for older people, mental
health services and in the development of community based service for people with a
learning disability. We believe the development of a health and social care
partnership in Fife, working as part of a whole system, will help us take that joint
working a step forward to ensure that we provide seamless care for the people of Fife.
2.4
Responding to the Coming Challenges
While services have changed and continue to change, the challenges facing the NHS
continue to grow. As a society, we are getting older, with more people living longer and
fewer people in the workforce. Lifestyle diseases such as obesity are generating new
healthcare demands and advancing technology, including new drugs, means the NHS
can do more to help more people.
The NHS can only reconcile that growing need with the reality of contained resources by
doing more with less. Our investment programme, in new community facilities as well as
new hospitals, has put us in a strong position already but we need to do more.
3
Health and Social Care Partnership Service Delivery Plan 2012 - 2015
8
Getting Better in Fife
By looking to nationally recognised evidence and best practice we must work to provide
harm free care and identify unwarranted (wasteful or harmful) variation and waste in the
system. We must challenge out dated traditional ways of organising and delivering
services and redesign them to provide an up-to-date and highly efficient and safer health
service. We must identify productive opportunities and use them.
Our vision for 2020 is that everyone is able to live longer healthier lives at home, or in a
homely setting.
We will have a healthcare system where we have integrated health and social care, a
focus on prevention, anticipation and supported self management. Primary Care has a
key role in helping the healthcare system as a whole make improvements. When
hospital treatment is required, and cannot be provided in a community setting, day case
treatment will be the norm. Whatever the setting, care will be provided to the highest
standards of quality and safety, with the person at the centre of all decisions. There will
be a focus on ensuring that people get back into their home or community environment
as soon as appropriate, with minimal risk of re-admission.
2.5
Moving toward 2020 – NHS Fife’s Vision
The narrative above gives an indication of some of the challenges that lie ahead.
Funding increases will be lower and demands for services higher. NHS Fife recognises
the opportunities this offers. We will need to scrutinise all areas of service to ensure they
are efficient, perform to the highest standards and deliver the best possible care.
We share the national ambition for achieving world leading quality in healthcare services
and are committed to realising it.
2.6
Maximising NHS Fife’s Estate
The major infrastructure changes in NHS Fife have largely taken place already, but
we will continue to improve the healthcare environments and deliver the necessary
equipment and technology systems to enable the highest possible clinical care
provision to our patients. Our Property and Asset Management Strategy, (PAMS) will
target the areas of improvement over the next five years and beyond. The work
undertaken as part of this improvement plan will guide the decisions and priorities for
our capital investments.
3
MOVING FORWARD – GETTING BETTER IN FIFE
Getting Better in Fife is the name for our healthcare improvement plan for the next five
years. It describes our priority areas for improvement in the delivery of clinical services. It
underpins our strategic objectives.
9
Getting Better in Fife
3.1
What are we trying to accomplish?
The aim of Getting Better in Fife is to improve the patient experience through reducing
harm, waste and unwarranted variation.
Getting Better in Fife describes our five areas of strategic priority relating to the healthcare
services we provide. Some of these services are delivered in partnership and others by NHS
Fife alone. NHS Fife also has a responsibility to improve the health of the population. This
responsibility is driven by related strategies and action plans developed in partnership with
local council and primary care colleagues who have a significant contribution in improving
the quality of services4. So the focus of Getting Better in Fife is the systematic
improvement of the clinical services delivered to our local population across the whole
healthcare system. Getting Better in Fife builds upon the improvements that were the
subject of Right for Fife and describes our next areas of focus.
Here are some examples of what we believe a quality service looks like for our staff and
patients. These are real examples that already exist and we want everyone engaged with us
to have experiences of this quality.
4
Colin’s Story
Evelyn’s story
Colin was in our Intensive Therapy Unit (ITU)
for extended period of stay. Shortly after
admission he was given the ‘ITU look’ (clean
shaven, short haired), listened to whatever
radio choice the nursing staff made and his
family were only allowed to visit at specific
times. He was receiving good quality clinical
care but as he became able to articulate his
desires it was obvious we weren’t meeting
his personal needs. Colin didn’t like to be
woken early, wanted to keep his facial hair
and his head hair long and preferred to have
peace and quiet rather than music. The
clinical team made these changes and, as
well as seeing Colin cheer up, they also
noticed an improvement in his response to
and compliance with the clinical care.”
Evelyn is an experienced staff member working
in occupational therapy. By working in radically
different way with one client, she discovered
moments of great satisfaction for her and for
the client. Her client lived at home but required
lots of support and had effectively become
house-bound. By enquiring what this person
really wanted she discovered that cups of tea
and chat were as, if not more, important as the
clinical care as this kept her client feeling more
in touch with the outside world. Secondly, her
client really wanted to visit the local shops.
Working with partners in other teams and
organisations, they enabled the client to visit
the local supermarket. This experience was
really positive for her client.
Delivering Quality in Primary care National Action Plan, Scottish Government August 2010.
10
Getting Better in Fife
3.2
Delivering Getting Better in Fife; A Programme of Improvement Projects
In order to meet the aim of Improving the patient experience through reducing
harm, waste and unwarranted variation, five strategic priority areas have been
identified. These areas have been developed by integrating and analysing current
programmes of work across the whole system, reviewing quality and efficiency data
and responding to national strategic drivers.
The priorities within Getting Better in Fife are:





Improving Flow and Emergency Access
Improving Elective Flow
Reshaping Older People’s Services ( Including Integrating Health and Social
Care )
Safe and Accessible Mental Health Services
Safe and Effective Medicines Management
Discussions with staff and public representatives have endorsed the choice of these
priority areas and the detail of activities under each heading will be reviewed and
updated on an ongoing basis.
11
Getting Better in Fife
3.3
Improving Flow and Emergency Access- the Right care in the Right Place at the
Right Time
Jean was admitted to our hospital in January 2012 with a recurrence of a chronic
respiratory condition. She was experiencing shortness of breath and could no longer
walk around her garden. Jean was cared for in the respiratory ward for 2 weeks but 2
days before she was due to be discharged, she was transferred to a ward which did not
specialise in caring for patients with respiratory conditions (boarded) as her bed in the
respiratory ward was required for a more acutely unwell patient. Jean’s family were
really concerned when they came for evening visiting and discovered she was not on the
ward they expected. Although Jean described receiving excellent care in the new ward,
the nurses were new to her and she did not see the physiotherapist every day as she had
done in the respiratory ward. Jean became increasingly anxious that the staff were not
familiar with her or her condition. Jean then experienced a recurrence of her shortness
of breath which was attributed to anxiety around the move between wards. This
resulted in Jean spending an extra 2 days in hospital. Although she did make a good
recovery, she found the experience very difficult. Jean says “I do still remember what
happened and although all the staff in the new ward were very nice, I found it frustrating
and worrying that they didn’t seem to know what I needed’.
What are our aims?
To ensure that patients accessing emergency care receive the Right Care in the
Right Place at the Right Time through:



Meeting the 4 hour emergency access standard which aims for 98% of
patients who attend the Emergency Department having their needs met within
four hours of arrival. This will involve being admitted, discharged or
transferred from the department.
Ensuring that patients who require specialty review in the Emergency
Department are referred to and assessed by that specialty within a clinically
appropriate time scale
Improving the efficiency of the patient journey (Flow) to ensure that patients
who are admitted urgently and who require to stay in hospital do not have to
12
Getting Better in Fife

stay longer than necessary and get access to the appropriate service in the
appropriate place at the appropriate time.
Collaborative working across the health and social care system to deliver an
optimum length of stay for patients with complex care needs
Why will this improve the patient experience and reduce harm, waste and
variation?
Prompt access to emergency care-initiation of appropriate treatment and reduction in
unnecessary moves between wards will help us reduce length of stay and improve
the outcomes and experience of our patients.
Transfers late at night for non clinical reasons leads to staff spending increased time
identifying and following up patients. Moves between wards can also lead to
unnecessary variation in treatment and lengths of stay in hospital and contribute to
the disorientation of frail elderly patients.
Extended length of stay in hospital for non clinical reasons, e.g. patients with complex
discharge planning needs and patients being discharged later in the day, can
negatively impact on the care of new patients through delays in admission,
assessment and initiation of treatment.
13
Getting Better in Fife
3.4
Improving Elective Flow –Care where it counts, care when it counts
Mr Simpson was referred by his GP to see a specialist. He had an initial consultation and
was sent for tests. He was told that he required more specialised tests and had to wait 8
weeks to have these carried out. During this time Mr Simpson had to take time off work
and was concerned about the financial impact of this. He struggled to cope with the
impact of his physical condition which had an impact on his mental health. He asked,
“Why was I treated as an illness rather than a person, with no thought or consideration
given to my personal or professional life?”
What is our aim?
To deliver patient centred care and enable people to maintain their contribution to
society, through prompt assessment, diagnosis, and intervention.
By ensuring that

90% of patients who are referred have their assessment, diagnosis and
treatment within 18 weeks from referral.

95% of patients who are referred with a suspicion of cancer receive
assessment, diagnosis and treatment (if required) within 62 days from referral.

95% of patient diagnosed with cancer receive their treatment within 31 days
from the decision to treat
This program will maximise the use of technology and make effective use of all
resources on all sites. This will reduce unnecessary hospital visits, reduce
unwarranted variation and will deliver a person centred, timely, high quality planned
care service
This programme will also contribute to the delivery of the following objectives:
 Meet the 18 weeks referral to treatment guarantee
 Meet the 12 week treatment time guarantee for patients requiring inpatient and
day case treatment
 Meet the 6 week waiting time target for key diagnostic tests
 Meet the 12 week waiting time target for outpatients
14
Getting Better in Fife
 Meet the 62 day and 31 day cancer targets
 Improve the early detection of Lung, Colorectal and Breast cancers
Why will this improve the patient experience and reduce harm, waste and
variation?
This programme has identified examples of where waste, variation and harm has
occurred across the whole of the patients pathway from referral, through consultation
and diagnosis, to preparation and planning for treatment to the period after
intervention. If waste, harm and variation is reduced this would improve the quality of
experience for patients and bring significant efficiency benefits to NHS Fife.
Examples of benefit include:
Providing GPs with direct access to diagnostic tests improves the patient experience
and reduces the number of visits and steps in a patients pathway
A reduction in Did Not Attend (DNA) and cancellation of appointments and theatre
slots ensures effective use of expensive resources and an improved experience for
patients through quicker access to clinical care.
Ensuring demand and capacity for services are appropriately balanced and managed
reduces the need for additional clinics and theatre sessions and reduces the need for
expensive waiting list initiatives.
Increased use of day surgery means patients do not need to stay in hospital longer
than is necessary and it improves their outcomes.
Maximising the use of available resources and facilities at Queen Margaret Hospital,
in particular day surgery capacity, will allow increased and appropriate use of
resources across sites.
Early detection of cancer facilitates earlier treatment and improves the chance of
better outcomes and experience for patients.
When they are required, ensuring timely access to services improves the experience
for patients.
15
Getting Better in Fife
3.5
Reshaping Older People’s Services (Including: Integrating Health and Social
Care)
Mrs Smith a 90 year old lady was admitted on three occasions from a Nursing Home to
our Acute Hospitals between the December and January 2012. She was admitted initially
with respiratory symptoms (she is known to have a chronic chest complaint) and was
subsequently diagnosed and treated for a chest infection.
On the third admission to hospital Mrs Smith was accommodated in four different wards.
She spent four days in the Admissions Unit, a further four days in the Respiratory Ward,
six days in an orthopaedic ward as there were not enough beds available in her speciality
and a final move to a rehabilitation ward where she stayed for a further 20 days. During
the time Mrs Smith spent in hospital there were issues with continuity of care. Had Mrs
Smith had access to treatment in the nursing home from the outset, her admissions may
have been prevented.
What is our aim?
To meet the needs of the older population now and in the coming years, all Health
and Social Care Services should have a primary aim of maintaining and supporting
independent living and maintaining quality of life. The resources of local people and
communities will be at the centre of social care provision.
Within the context of Getting Better in Fife we aim:
To ensure that older people with complex needs are well supported by all parts of the
care system.
To develop care settings, with partners that will help older people to remain at home;
or in a homely setting; and developing community capacity to enable older people and
their communities to develop local systems of self-care.
To reduce the length of stay for older people in hospital, and avoid any unnecessary
transfers in care.
To reduce falls-related admissions to hospital in the over 65s by 20% through the
implementation of integrated falls and fracture care pathways.
16
Getting Better in Fife
To build relationships with the voluntary sector and private providers to develop
community capacity models, and new models of care.
Develop and invest in support for Carers
And in particular to:
Develop a new Integrated Assessment and Community Support Service (ICASS)
which provides hospital at home, intermediate care and home re-ablement services
that are responsive to need and will prevent admission to hospital as well as
supporting early discharge.
Review the community bed resource, in line with our intention to move to more care at
home and agree a plan of reduced inpatient based care and treatment.
Why will this improve the patient experience and reduce harm, waste and
variation?
Hospitals have generally been viewed as the source of expert care and the public
have become accustomed to receiving inpatient care as the first option when faced
with a crisis or emergency. Hospitals do not always provide the most appropriate
environment in which to provide care that is not of a specialist nature. This is
particularly so for elderly frail patients and other vulnerable groups.
Importantly patients have also expressed the preference to remain in their own homes
and to be treated there if possible.
Smooth transition for patients between health and social care sectors in Fife will
reduce the opportunity for duplication and improve the patient experience
A patient safety approach to developing a “transfer bundle” will improve
communication, and ensure transfers in care are undertaken efficiently and without
harm.
The ICASS model currently being implemented across Fife plans to deliver a fully
integrated service for frail older people who would have otherwise been admitted to
hospital for common conditions.
The re-ablement and Home Care Change Programme will enable patients to maintain
their skills and independence for longer periods.
Developing the use of technology for example using mobile telecare devices can
support people beyond the confines of their own home allowing them to remain in the
community.
Building on our programme of falls and fracture prevention has significant potential to
improve the patient experience and reduce harm waste and variation
A focus on modernising current day services and day hospital models will promote
independence and re-ablement, and avoid unnecessary admissions to
institutionalised based care.
17
Getting Better in Fife
3.6
Safe and Accessible Mental Health Services
Tracey is a 28 year old woman who experiences episodes of depression and thoughts of
self-harm and who has required short episodes of inpatient care in the past few years.
She dislikes being in the ward setting stating that she feels unsafe, that there is a lack of
staff engagement with her, and that there is little meaningful activity throughout the
day. As a result, she does not think the experience is therapeutic and she struggles to
achieve the intended improvement in her health.
.
What is our aim?
To improve the mental health of the people of Fife and deliver prompt, safe and
effective treatment for those with mental illness. We will focus on a range of work
designed to support the key themes and areas of change identified in the recently
published Mental Health Strategy for Scotland and on specific areas of work
identified locally as essential for the effective, efficient and sustainable delivery of
current and future services.
Within the context of Getting Better in Fife we will aim to:
Continue the improvements made in ensuring faster access to specialist services for
children and young people with mental health problems.
Improve the care and treatment options for those with common mental health
problems.
Work in conjunction with Social Work and other partners to develop the range of
community care settings and options available for those with a severe and enduring
mental illness, and so reduce the reliance on hospital care.
Support initiatives to improve the physical health of those with a mental illness and
ensure consistent and effective standards of physical healthcare and treatment in
psychiatric settings.
Ensure that inpatient care and treatment is person-centred, safe and effective, and
delivered in therapeutic environments appropriate to the patients’ needs.
Reduce the length of stay in admission wards and maintain the significant reduction
in readmissions through the development and redesign of community services when
opportunities arise and through the effective crisis response.
Continue the development and delivery of services which ensure early diagnosis,
treatment and support for those with dementia.
18
Getting Better in Fife
Maintain prompt access to services for those with alcohol and drug problems and, in
collaboration with partner agencies, ensure the provision of effective interventions
and support.
Provide appropriate inpatient and community services for those with forensic mental
health needs.
Improve the provision of psychiatric liaison services to the general hospitals and
review other areas of unmet and emerging need.
Why will this improve the patient experience and reduce harm, waste and
variation?
The following are examples of some key programmes of work which demonstrate
anticipated improvements in the patient experience and the reduction of waste, harm
and variation:
Early intervention for children and young people with mental health problems and
developmental disorders is essential to build resilience and prevent problems in later
life. We will continue the significant improvements made in pursuit of the CAMHS
Waiting Time HEAT Target through service redesign with specific focus on areas
with high demand.
Improving the access to a range of ‘talking therapies’ for people with common mental
health problems is a key element of developing better care and treatment options.
We will work towards achieving the Psychological Therapies HEAT Target by
focusing on the referral, assessment and treatment arrangements across mental
health and psychology services, and the identification of service gaps and the
additional training necessary to improve capacity and capability. This will lead to the
more efficient use of existing resources and the development of the required skills to
provide matched therapies for people requiring a psychological intervention, so
reducing waiting times and preventing unnecessary treatments or deteriorating
health.
The Rehabilitation Redesign Programme is a collaborative project with Social
Work designed to develop and provide community care options for people with
severe and enduring mental illness currently resident in Stratheden hospital. The
programme will ensure patients have the opportunity to maximise their own potential
and, with the proper type and level of support, be able to live in a community setting
appropriate to their own needs.
The physical health of people with mental health problems is a priority for the Scottish
Government.
Through the development of core care pathways, clinical practice protocols and the
skills development of staff we will improve the quality and consistency of physical
healthcare and the management of common medical conditions in psychiatric
settings. In both hospital and community settings we will support people to make
better lifestyle choices and so improve their quality of life and general health.
19
Getting Better in Fife
The Scottish Patient Safety Programme-Mental Health alongside Releasing Time
to Care and the AHP Realising Potential strategy are key programmes aimed at
improving person-centred, safe and effective care and treatment for people with
mental health problems, and supporting a recovery based approach. The initial
focus on adult acute inpatient care will improve the patient experience by increasing
staff engagement with patients and reducing the occurrence of incidents, accidents
and adverse events, so reducing the possibility of harm being experienced by
individuals in receipt of care from mental health services.
The provision of therapeutic facilities and environments which offer privacy and
maintain dignity is an essential aspect of good patient care. We will continue to seek
improvements in the quality of the mental health estate with the initial focus on
developing a proposal for the re-provision of the Intensive Psychiatric Care Unit.
Prompt access to specialist services for those with alcohol and drug problems is vital
in reducing harm to individuals and their families. We will maintain the delivery of
services in line with the Drug and Alcohol Waiting Time and the Alcohol Brief
Interventions HEAT Targets in collaboration with partner agencies to improve the
treatment options for people, reduce harm and ensure equity of access across Fife.
We will develop and provide a Forensic Low Secure inpatient unit on the Stratheden
hospital site. This development will ensure NHS Fife better meets its responsibilities
for the care and supervision of patients with forensic mental health needs. It will
enable Fife patients to be cared for in a local facility, improving the patient experience
and service efficiency, and will eliminate the need to purchase services from outside
Fife and so realise expenditure savings.
20
Getting Better in Fife
3.7
Safe and Effective Medicines Management
Mary’s Story
Mary, who is 75 years old and lives in her own home, has a number of chronic health problems and is
taking multiple medications. A community pharmacist carried out a review of the number of medications
Mary was taking. At the time she was on:
1. A water tablet for high blood pressure
2. An anti-depressant for her low mood
3. An anti-inflammatory painkiller for osteoarthritis
4. Treatment for osteoporosis which the lady was having difficulty swallowing and remembering to
take regularly.
Mary had a reduced kidney function and a low sodium level. The pharmacist recommended to the GP
that Mary should stop her water tablet as this could be causing her low sodium and could increase her
risk of having an epileptic seizure. Mary was changed onto another medication for her blood pressure
and her sodium level subsequently improved and her blood pressure was well controlled.
The pharmacist also recommended that Mary should have her anti-inflammatory painkiller stopped due
to her poor kidney function and an alternative paracetamol based painkiller prescribed instead.
Furthermore, the combination of the anti-inflammatory with her anti-depressant put her at risk of having
a bleed from her stomach or intestines. Mary’s pain control was improved as a result of this change and
her risk of having a bleed was significantly reduced.
Mary’s osteoporosis treatment was reviewed by the pharmacist who noted that it could also cause
problems due to Mary’s reduced kidney function and discussed it with the consultant who had initiated
it. An alternative preparation was started which was better tolerated and more suitable for her kidney
function. Mary’s community pharmacist was contacted to arrange support to help Mary with compliance
of her medication, thus reducing her risk of osteoporosis and hip fracture in the future.
What is our aim?
Our aim is to ensure that the use of medicines within NHS Fife is safe, clinically
effective and cost effective
21
Getting Better in Fife
Why will this improve the patient experience and reduce harm, waste and
variation?
Medicines can make a major contribution to people’s health and healthcare through a
variety of mechanisms including curing illness, controlling symptoms and preventing
or containing disease. Next to staff, medicines represent the largest area of NHS
expenditure. There is evidence that patients experience side effects and other
adverse effects from medicines, that resources could be used more efficiently in
relation to medicines management and that there is significant variation in the way
certain medicines are used by both clinicians and patients.
Harm will be reduced by:


preventing or minimising side effects and adverse events and the associated
problems for patients such as morbidity and increased or prolonged
admissions to hospital.
improving communication between healthcare professionals in relation to the
use of medicines for individual patients particularly when patients are
admitted to or discharged from hospital or when their prescribed medicines
are changed
Waste will be reduced by working with patients and clinicians to:



improve compliance with prescribed medicines ensuring that patients derive
maximum benefit from their treatments and that there is no unnecessary
expenditure on medicines that are unlikely to be effective or which are not
being taken.
ensure that medicines on repeat prescription are ordered in appropriate
quantities and only when needed
ensure that when there is a choice of treatments the most cost effective
options is prescribed
Variation will be reduced by:



seeking to identify and explain variations in the way that clinicians prescribe
and patients take medicines.
promoting use of the Fife Formulary which provides guidance on the best
options in terms of both clinical and cost effectiveness.
promoting management plans for people on multiple medications to control
multiple long terms conditions which are in line with best clinical practice.
Medicines and in particular how they are used and how much they cost are the most
obvious manifestations of this workstream looking at medicines management but key
to effective and efficient use are the underpinning systems and processes. The
success of this workstream is dependent on the engagement and leadership of
pharmacists working with other clinical colleagues to look at and optimise the flows
and processes associated with all aspects of the use of medicines and related
products. In parallel with the initiatives outlined above work is also underway to look
at how pharmacists can work most effectively with each other and with other
clinicians.
22
Getting Better in Fife
3.8
Examples of improvement projects and tests of change
Appendix 1 outlines in more detail the worsktreams and projects identified to date
under each of the five programmes. A number of these are transformational
programmes which focus on improving the quality of service to patients and
consequently, will not have an explicit financial impact identified. For example the
Falls project under the older people’s programme. There are however, a number of
projects which are aligned to the strategic efficiency plan, for example prescribing
projects.
The timescale for delivery will vary with some projects anticipated to deliver within one
year and others to take longer to reach maturity. All, however, are expected to return
an incremental benefit throughout the life of the project.
4
IMPROVEMENT APPROACHES
“Efficiency without quality is unthinkable. Quality without efficiency is
unsustainable”.
NHS Fife is adopting two overarching approaches to support the delivery of Getting
Better in Fife: Quality Improvement Methodology and the Programme Management
Office. The combination of these is intended to ensure that we realise the full quality
and efficiency benefits and thus achieve the aim of Improving the Patient Experience
through reducing harm, waste, and variation.
4.1
Quality Improvement Methodology
Improvement is about continually working together to improve the service user’s
experience and outcomes. Mostly we know what we should be doing but consistently
applying that knowledge can be difficult. When things go wrong it is normally because
there has been a problem in applying knowledge. Most problems happen because of
the way things are done, not as a result of who is doing them. Systems need to be
improved so that problems are less likely to happen.
Recognising the need to improve, having the will and ideas is not enough. We need to
ensure that we identify changes that will lead to improvement and effectively deliver
them in order to achieve and sustain the desired outcomes.
There are many change theories and models but experience tells us that choosing a
few and using them consistently is more important than which ones are chosen.
However, whichever we chose they should be based on a simple formula. Having a
clear aim, an understanding of the changes that need to be made and having
measurement embedded will allow us to determine if the changes made are leading
to the improvements required which will achieve the aim.
23
Getting Better in Fife
NHS Fife has chosen to use the Model for Improvement as the framework to guide
our improvement work. The Model for Improvement5 is a simple but effective tool for
accelerating improvement and can be used alongside the organisations’ existing
change models and other improvement tools and techniques.
The Model for Improvement provides a framework for developing testing and
implementing changes which lead to improvement. It is based on a scientific method
and is the framework used by the Scottish Patient Safety Programme. The framework
uses three key questions and a process for testing change ideas.
The three questions are



What are we trying to accomplish? (The aims statement)
How will we know if the change is an improvement?
What changes can we make that will result in improvement?
Testing the ideas is achieved by using repeated Plan, Do, Study Act (PDSA) Cycles
Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical
Approach to Enhancing Organizational Performance (2nd edition). San Francisco: Jossey-Bass
Publishers; 2009
5
24
Getting Better in Fife
The four stages of the PDSA cycle are
Plan - the change to be tested or implemented
Do- carry out the test or change
Study- data before and after the change and reflect on what was learned
Act - plan the next change cycle or full implementation
4.2
Programme Management Office
The Programme Management Office (PMO) Is responsible for establishing and
managing the operational framework and processes for the development, planning
and monitoring of service and financial improvement within NHS Fife.
It provides both challenge and support to services engaged in change and
improvement processes and the mechanism that supports governance and reporting
processes.
The PMO approach is the process within which quality improvement, efficiency and
service development plans are identified, implemented and monitored to deliver
realisable benefits.
5
HOW WILL WE KNOW WHEN CHANGE IS AN IMPROVEMENT
5.1
Measures for Improvement
Measures for improvement help us to understand the impact of changes made, share
successes when things go well and learn when things don't go so well. There are
three parts to the process of quality improvement work where measurement is likely
to be most important6 :



When identifying issues or opportunities for improvement and those which
require our attention;
When the improvement team is obtaining baseline measurements and
During the tests of change and after they have been implemented
The measures are tools for learning and demonstrating improvements, not for
judgement. Measures for improvement will be identified for all of the Getting Better in
Fife projects to demonstrate whether changes result in improvement. The measures
will be reported regularly on time series graphs know as ‘run charts' or statistical
process control charts (SPC).
6
Solberg L, Mosser G, McDonald S. The three faces of performance measurement: Improvement,
accountability and research. Journal on Quality Improvement Vo 23 (3), 135-147 1997.
25
Getting Better in Fife
6
ALIGNING RESOURCES TO SUPPORT THE PRIORITIES
There are a number of key supporting processes and services which are critical to the
successful delivery of improvements in the priority areas which have been identified.
These include information services, e-health services and workforce development.
Agreeing the priorities enables these supporting processes and services to prioritise
their work plans accordingly.
6.1
Building Capacity and Capability for Sustainable and Effective Quality
Improvement
Analysis of health care systems that deliver outstanding performance in cost and
quality show that their most common characteristic is a systematic approach to
capability building for improvement 7
Therefore critical to our success will be the need to ensure we have the Capacity i.e.
having the right number and level of people who are actively engaged and able to
support quality improvement and the
Capability i.e. ensuring our people have the confidence, knowledge and skills to lead
the improvement work.
6.2
Quality Improvement Hub
Drawing on the extensive global evidence and the work of the National Quality
Improvement Hub we are developing a plan to build capability in quality improvement
at all levels of the organisation.
The development of the NHS Fife Quality Improvement Hub (QI Hub) is a key step
towards this systematic approach to developing capability.
The hub is both physical - an Improvement Resource Room which can be used by
staff working on the improvement projects aligned to the 5 priority areas and virtual
because it harnesses staff talents and skills from across NHS Fife to drive sustainable
quality improvement. A small number of people work with the QI Hub all or most of
their time; many people work with the QI Hub some of their time.
The aim is to provide a 'one-stop shop' for quality improvement support in NHS Fife.
This support might be provided through for example; initial diagnosis of the need for
improvement support, hands on help with running tests of change, improving
leadership and working relationships, mapping and redesigning processes or
measurement for improvement. Members of the QI Hub have expertise in Model for
Improvement, small tests of change, Lean, measurement for improvement,
consulting, coaching, enabling better quality conversations using the practices of
‘dialogue’ as well as other skills.
7
Helen Bevan, How can we build skills to transform the healthcare system? Journal of research in
Nursing, 15 (2) 139-148, 201o
26
Getting Better in Fife
7
WHAT DOES THIS MEAN FOR THOSE WE CARE FOR AND OUR STAFF?
For the people we care for - our commitment is to develop a culture that is person
centred, addressing individual needs and focusing on improving the persons
experience. We need to learn from experiences so that we understand what works
well and what can be improved.
For carers - we want to involve them and value and respect the role that they have as
an equal partner
For members of the public - it means that we will seek involvement from the outset
and work harder to engage the right people in meaningful work.
For our staff - we want them to feel good about what they do, that they can improve
what they do and feel that their contribution is valued whatever their role in the
organisation. We want everyone to be involved in making our services work more
efficiently for the benefit not only of patients, but also staff themselves.
For our partners- we recognise the contribution that our partners in for example
primary care, the council and the third sector play in delivering the quality
improvements we are striving to achieve. We will endeavour to facilitate constructive
and enthusiastic participation and broad representation from all of our partners where
appropriate in the programmes of work within Getting Better in Fife.
Improvement is not a one - off we need to do it continuously in order to provide safe,
high quality, effective care
Getting this right will mean that we will have many more examples of improved
experience like the ones reported below.
The availability of services to support routine, planned treatments in our community
hospitals is improving patient experience. This is David’s story
“I was overwhelmed when the new community hospital was available to accommodate me
for renal dialysis during my stay. This proved to be a successful visit and very much
accessible to me (as I am registered blind). This hospital is spacious and is located in an
easy to reach position in the town, something that NHS Fife, I believe, would be rightly
proud of. The staff were very professional, cheery and indeed helpful, making my holiday
even better than I could have imagined. May I congratulate you on all the hospital staff
for enabling this holiday to be pleasurable for me. Their dedication was truly evident.”
27
Getting Better in Fife
Julie attended A & E at Victoria Hospital recently on a Sunday afternoon with her son.
She wrote to tell us about her experience
“A&E was extremely busy and the staff were obviously working flat out yet everyone was
brilliant. A member of the ambulance crew saw me waiting to give my details and he
came over to make sure my son was o.k. We were taken through almost straight away
and seen by the triage staff and then the doctor. It is very reassuring when it is your child
that is hurt to feel people care. People are often quick to criticise the NHS, well today
you did a great job”
Sarah became unwell at home with what appeared to be a chest infection. Her GP
contacted the Hospital at Home Team who assessed her that day and decided that she
needed to have antibiotics through a drip. Sarah was admitted to Ward 7 at QMH (in
the ICASS unit) given antibiotics, assessed by the physiotherapy service and the hospital
at home nurse. Sarah was able to go home with the Hospital at Home team (supported
by one of the nurses) after 2 days on antibiotics and provided with physiotherapy and
home care support immediately.
John has Alcohol Related Brain Damage (ARBD) and as a result has a complex range of
needs and exhibit s behaviour which can place him at severe risk of harm but this does not
necessarily justify long term residential or hospital care. The particular nature of his
condition and his needs means that normal community health and social work services are
unlikely to be able to provide a successful package of care for him. The mental health
service developed a small team of nursing staff to provide an ARBD liaison and support
resource. The team are able to co-ordinate the various services that may be required to
ensure the optimum package of care and to determine the most appropriate care
strategies. This has led to a significant improvement in the quality of life for John and
others with similar problems. The work of the team has recently been recognised with
them securing the top award at the Scottish Mental Health Nursing Forum Awards event.
The development of a “one stop shop” in ophthalmology has brought about real
improvements in the patient experience. No longer do delays in the process feature and
feedback from patients is very positive. Mrs Bruce is typical of elderly patients attending.
She has now had both cataracts removed and enjoys an improved quality of life as a result.
She described not having to wait and not having to go back and forward to appointments
as a real benefit.
28
Getting Better in Fife
Appendix 1
Programme
Improving Flow and
Emergency Access
Work stream
Front Door
Projects/tests of change



Acute Admissions and
Speciality Flow







Community Flow



Implementation of GP ‘hot
line’ to senior A&E Doctor
with a proposal to provide
‘hotline’ to NHS 24 and
SAS
Fast track process for
patients with minor
injuries to decrease
overall length of stay in
A&E
Redirection of patients,
who do not require the
services that A&E
provide, to alternative
care providers
Focus on achieving 50%
of discharge activity
before midday
Reducing variation in
daily discharge numbers
Elimination of boarding
Reintroduction of
discharge lounge
Nurse facilitated
discharge
Improved access to
specialty beds
Predicted Date of
Discharge
Increased number of
patients who retain their
existing care package
following an admission to
hospital
Reduction in waiting time
for patients who require a
new social work care
package
Increased number of
patient transfers to
community hospitals and
community teams at the
29
Getting Better in Fife



Improving Elective
Flow
Inpatient/Day case




Outpatients and
diagnostics







Detect Cancer Early

weekend and on public
holidays
Increased number of
patients with a Predicated
Date of Discharge (PDD)
in Community Hospitals
Standardisation of nursing
documentation across
acute and community
Increased number of
patients discharged
before midday in
Community Hospitals
Optimising waiting list
management orthopaedics – in
development
Reducing Length of Stay
for Vascular Patients- test
of change –managing
patients as a day case
rather than inpatients
Review and reduction of
cancellations of
operations on the day – in
development
Maximising day surgery
capacity and 23 hour stay
in QMH- underway
Telephone clinics- GI
nurses- in development
Evening clinics- in
development
Using visual data in
outpatients to manage
DNA rate- in development
Development of accurate
utilisation data- underway
Roll out of appointment
reminder system to
community- in discussion
Detailed Capacity
management –
ophthalmology GI
Gynaecology
E-advice for GPs
Direct access to
diagnostics- under
30
Getting Better in Fife



Reshaping Older
Peoples Services
Reducing Falls in
community and acute
hospital in people over
65
ICASS and Hospital at
Home
Introducing and testing bundles
of care to reduce falls specifically
 a trigger bundle
 an assessment bundle
 an intervention bundle
 a monitoring bundle




Safe and Accessible
Mental Health Services
Safe and Effective
Medicines Management
discussion
Enhanced recovery for
Colorectal patients- being
developed
Electronic referral
management for referrals
suspicious of cancerunderway
Demand and Capacity
review and modelling for
Colorectal, Lung and
Breast sites
Early supported discharge
– in reach from
community teams to VHK
and QMH
Direct referral and fast
track home care
assessments for patients
in hospital at home virtual
ward
Referral pathway to
ICASS from minor injuries
unit at QMH
Single points of access
Community hospitals
Work currently being scoped
Patient Safety in Mental
Health
National Programme of workunder development
Improving access to
CAMHS and
Psychological
Therapies
Focus on redesign of high
demand specialist services and
scoping work in psychological
therapies
Streamlining processes
to improve medicines
reconciliation and
patient flow across
primary and secondary
care.
Work underway to identify
31
Getting Better in Fife
Minimising medicines
waste and maximising
efficiency within the
pharmacy service.
Work underway to identify
Reducing multiple
medication use
(polypharmacy) in frail
elderly people with
multiple long term
conditions.
Work underway to identify
Improving patient safety Work underway to identify
through the redesign of
medicine governance
processes (initial priority
being safety messages)
32