Transforming care for cancer patients - spreading the winning principels and good practice

65786_NHS_Improve.qxd:Moving Forward 2/7/09 12:41 Page 1

NHS
NHS Improvement

CANCER DIAGNOSTICS HEART STROKE

Transforming Inpatient Care Programme
Transforming Care for Cancer Inpatients
Spreading the Winning Principles and Good Practice


Contents

Foreword 3

Acknowledgements 4

Introduction 5

Why we need to spread the Winning Principles 6

A framework for spread 7
• Understanding spread
• Defining spread
• Capturing the learning to support spread

Winning Principle 1 8




Further evidence supporting spread 43

Transforming Inpatient Framework for Spread: 44
Common themes and practices

Spread is evident 45

Conclusions 46
References and supporting information 47
Roll of honour 48


Transforming Care for Cancer Inpatients Spreading the Winning Principles and Good Practice

Foreword

The Cancer Reform Strategy highlighted the need to Many clinical teams have learned service
focus attention on inpatient care for cancer patients. development techniques and have started to
The “Transforming Inpatient Care Programme” has introduce new ideas to improve their practice.
been established to take this forward. The programme Traditionally in the NHS we have been slow to
is being led by NHS Improvement – Cancer in spread new ways of working both within and
partnership with the National Cancer Team. Forty between organisations.
NHS Trusts are now involved in piloting new
approaches to care. This report provides a range of excellent examples
of where teams have not only delivered
The first aim of the programme is to improve the innovation in their own service but have also
quality of inpatient care for cancer patients by averting spread good practice to others, thus improving
unnecessary admissions and by streamlining care for the quality of care for many more patients.
those who do need to be admitted. Achieving this aim also has the potential to reduce
bed utilisation very considerably. In the year before the Cancer Reform Strategy over
five million bed days were occupied by cancer patients. Work done during the Celia Ingham Clark
development of the Cancer Reform Strategy – and now endorsed by the findings from Colorectal Surgeon, Medical Director, The
pilot sites – indicates that at least a million bed days could be saved. Whittington Hospital London, National Clinical
Lead and Chair Transforming Inpatients Steering
The Transforming Inpatient Care Programme is an excellent example of ‘Quality, Group.
Innovation and Productivity’ in practice. This programme links with the Enhanced
Recovery Programme which goes beyond cancer. It also relates closely with the work
being undertaken by the National Chemotherapy Advisory Group to enhance quality
and safety of chemotherapy services.

I would like to thank all of the pilot sites for their innovative work on developing good
practice. I hope these examples will prove useful to other NHS Trusts in their quest to
improve quality and productivity.

Professor Mike Richards
National Cancer Director

3



Acknowledgements

The Department of Health Cancer
Programme Board, NHS Improvement
and the National Cancer Action Team
would like to thank all the test sites
for their continuing support and
commitment to the Transforming
Inpatient Care Programme. Valuable
learning has emerged from this
important area of work which has
influenced policy, quality
improvement, demonstrated
innovation, efficiency and improved
the patient’s experience.

The learning from cancer
improvement is well recognised and
has been adopted across many other
specialties. This is a credit to the test
sites involved and their ongoing
commitment to improve services and
share their learning across the NHS.

4



Introduction

Testing an idea, then realising what works that if spread could make significant If Winning Principles 1 and 2 were widely adopted by all Trusts in England the combined
and how it can benefit patients is a improvements in quality, efficiency and the impact could mean releasing 25% of bed capacity in most tumour groups. By adding
fantastic achievement. patient experience. Principles 3 and 4 we would see a potential further impact on bed capacity moving
towards releasing a million bed days.
The challenges that follow are: Over the last 12 months it has become
evident that Winning Principles 1 and 2, “The Transforming Inpatient Care Programme will improve quality
“We know what works. The and the following models of care have of care for patients and could save the NHS a million bed days.”
spread significantly:
question is - can we spread this • Communication Rapid Alert systems Mike Richards
across the NHS in 2 years, or reducing unnecessary length of stay by National Cancer Director (2009)

like many NHS initiatives will 25% in most tumour groups recognising
the importance of valuing patient’s time.
Winning Principles
it take 20 years.” • Breast 23 hour model 100% coverage Previous testing identified four winning principles that can improve length of stay
across Pan Birmingham for 80% of management, avert unnecessary admission, deliver care in the appropriate care settings,
Mike Richards
National Cancer Director (2009) patients. Reducing length of stay from improve efficiency, quality, promote value for money and importantly value the patients’ time.
six days.
• Acute Oncology Models being adopted
and adapted across the country to
ensure patient safety and reduce delays.
This publication, the third in a series*, • Applying an enhanced recovery approach
supports the Cancer Reform Strategy’s for elective surgery can reduce Winning Principle 1
(2007) Transforming Inpatient Care unnecessary length of stay by 50%. Unscheduled (emergency) patients should be assessed prior to the decision to
Programme. Its aim is to illustrate ‘how’ admit. Emergency admission should be the exception not the norm.
NHS Trusts are spreading tested Evidence from the case summaries within
improvements. this publication suggests that the adoption Winning Principle 2
and adaption is due to the principles and All patients should be on defined inpatient pathways based on their tumour type
During 2007- 2009, NHS Trusts (40) models: and reasons for admission.
across England tested out ideas to • Being easy to apply
improve the quality of the inpatient • Having a clear purpose and evident Winning Principle 3
experience by looking at valuing patient’s in practice Clinical decisions should be made on a daily basis to promote proactive case
time, shifting care from an inpatient to an • Simple to understand management.
ambulatory care setting, reducing • Meaningful to patients and professionals Winning Principle 4
unnecessary lengths of stay and averting • Bring together quality improvement, Patient and carers need to know about their condition and symptoms to encourage
unnecessary admissions into hospital for innovation and efficiency. self-management and to know who to contact when needed.
both planned and unplanned care.
Testing, identified four winning principles, *www.improvement.nhs.uk/winning_principles

5



Why we need to spread the Winning Principles?

At a time where the economic future is Improving quality is a journey that
uncertain, David Nicholson, NHS Chief Why we need to spread what has no end point; there is always
Executive has stated that: works across cancer inpatients? more that can be done. Spreading the
Winning Principles will be the start
• Inpatients is an area that’s had Most importantly patients have told us
“Now is the time to be little attention they do not want to be in hospital.
of the journey for many as the
summaries in this publication
innovative and adopt and • England has higher bed utilisation
illustrate there is ‘not a one size
diffuse the well-evidenced for cancer than any other country “Been in hospital for five fits all’ approach to spread.
• Emergency admissions have risen
things we should all be doing. by 47% in the past eight years days, it’s cost me over £20 to
We need to look at each system and elective by 8.6% watch the TV and make calls
• 40% of all cancer admissions are
and process to see if it is emergency, but they use 60% of to my family, to kill the
capable of taking us through bed days boredom. Why couldn’t
• Inpatient care for cancer patients
this big challenge” accounts for 12% of all inpatient I have taken the tablets at
beds home and got them from the
David Nicholson • Over half (ie over £2 billion) of the
NHS Confederation (2009) total expenditure on cancer in
GP, would have only cost me
England goes on inpatient care something like £6 for the
Quality improvement can • 60% of all cancer admissions are
elective but they use 40% of beds
prescription and shoe
drive efficiency.
days leather!”
• 2007-2008: 4.7 million bed days
“Quality improvements through were cancer related.
Extract from a patient diary
greater efficiency and
redesigning services can provide
the budget savings necessary to
navigate this crisis"
Nigel Edwards
NHS Confederation Director of Policy (2009)

6



A framework for spread

Through evaluating the learning and looking Data analysis was undertaken using
Fig 1: The Transforming Inpatient
at how the test sites have spread the Winning National Hospital Episode Statistics (HES)
Framework for Spread
Principles, 12 common themes have emerged. (NHS Improvement 2009) A Vision
and cross referenced with local data.
These have been applied to a framework for for Quality Organisations completed a learning diary
Improvement Systematic
reference to support organisations in their Spread
Improvement
that provided an ongoing evaluation of
Strategy
quest to spread “The Transforming Inpatient Approach progress. They provided case studies and
Framework for Spread” (NHS Improvement, took part in completing an electronic
Linked
2009). Fig 1. Strategic & Organisational spread survey (spread planner) that
Culture
Operational
and Fit
assessed spread and coverage, this
Change
The framework was developed drawing provided further qualitative intelligence.
upon Pettigrew’s (1993) receptive context
model, Fraser’s (2002) framework for Continuous Spread Spread The spread survey was also used with
accelerating spread and Rodger’s (2003) Monitoring
Making the
Simple non-test sites to evaluate if the
Progress & Principles &
diffusion of innovations. This builds upon Impact Connections Messages improvements and principles were being
earlier work in cancer improvement by the more widely adopted. This was not about
Cancer Services Collaborative research, but checking how far spread
‘Improvement Partnership’ where Collaboration Leadership had been achieved and how this was
Partnerships Engagement
Williamson’s (2007), work identified the & Team Accountability occurring. Collectively this data provided
Working
critical factors for whole system change the opportunity to undertake a thematic
of a clinical speciality and Driver’s (2008) Alignment analysis to draw out the learning and key
Learning with
evaluation of the factors affecting the & Unlearning Opportunities messages. The organisations involved
achievement of cancer waiting times in
Patient & Levers were predominately NHS Acute Trusts and
Centred
the domains of leadership, performance Foundation Trusts (integrated testing is
and service improvement. underway with Acute, Primary Care and
Social Care, the intention is to evaluate the
learning from these sites in early 2010).
Understanding spread • Spread is often difficult to define rather the exception in our quest/goal to
The concept of spread is often implicit • Successful spread can be active transform the inpatient experience for The selection of NHS Trusts included in
within the large amount of literature (dissemination) and passive (diffusion) cancer patients across England. this publication began testing ideas in
available on change and organisational • The process of spread does need an 2007. To date they have all achieved a
management. Such literature contains agreed spread strategy, time, focus, Capturing the learning to different pace of spread that was
contributions from many different and monitoring support spread culturally and contextually specific. All
academic disciplines. • The pace of spread varies and is The NHS Trusts shared their experience of have spread the Winning Principles and
influenced by many variables. spread covering three aspects: applied them to different tested
From the evidence the key messages 1. What improvements/Winning improvements with a range of impact
appear to be: Defining spread Principle(s) have spread? (detailed case studies are available at:
• Spread has a range of meanings and Spread is the process whereby we see the 2. How has spread been achieved? www.improvement.nhs.uk/cancer).
language four Winning Principles become the norm 3. What impact has been made?

7



Winning Principle 1
WINNING PRINCIPLE 1

1. Unscheduled (emergency) patients
should be assessed prior to the Common themes of spread from the analysis
decision to admit. Emergency
admission should be the exception 6
not the norm.
5
The following five NHS Trusts spread
Winning Principle 1. Four tested and 4

Number of test sites
spread the same improvement
(communication alerts) and approached
spread in different ways. Evaluation of 3
their learning against the spread
framework identified common themes 2
across these Trusts (fig 1).

1

0

Spread Simple
Principles & Messages

& Team Working

& Operational Change
Collaboration, Partnerships

Continuous Monitoring,
Progress & Impact

Linked Strategic
A Vision for
Quality Improvement

& Accountability
Leadership, Engagement

Alignment with
Opportunities & Levers

Patient Centred

Learning & Unlearning

Spread Strategy
Systematic Improvement
Approach

Organisational
Culture & Fit

8



United Lincolnshire Hospitals NHS Trust

WINNING PRINCIPLE 1
Recurring Admission How was spread achieved? What has been the impact?
Patient Alert (RAPA)
“We used a systematic Quality improvements Coverage Efficiency benefits
RAPA is a simple communication solution
approach taking one tumour
that ensures that everyone knows their The patient is on the right Upper GI – 3 x hospital Testing in urology and
patient has arrived at the hospital. The site at a time, demonstrating pathway and seen by the sites (Lincoln County Upper GI in 1 site (Lincoln
improvement benefits known cancer the evidence of why the appropriate clinical team Hospital, Louth County County Hospital) reduced
patients and where admission is required Hospital and Grantham bed days by 96 =
patients go to the right place, on the improvement works and Reduced number of District Hospital) within savings* £19,400
right pathway or the admission is averted measuring the benefits. We diagnostic tests/invasive United Lincoln Hospitals (October – December
and redirected to the appropriate care procedures NHS Trust 2007)
setting. kept the approach simple and
positioned in the Upper Gastrointestinal (GI) Urology – 3 x hospital sites Impact of spread for
The improvement idea was ‘pulled’ have demonstrated a (Lincoln County Hospital, Urology and Upper GI
from Sherwood Forest Hospital NHS organisation. From being reduction in diagnostics Louth County Hospital and (across three hospital
Foundation Trust and adopted locally. It involved with RAPA in tests/invasive procedures Grantham District General) sites) has the potential to
was initially tested on one site, Lincoln from three to two tests within United Lincoln reduce bed days by 499.2
County Hospital, and is now spreading Sherwood Forest I knew the per patient Hospitals NHS Trust per annum = savings
across the four hospital sites of the principle was right, but a *£99,840.00
United Lincoln Hospital NHS Trust. The clinical team that Lung – Pan United Lincoln
lesson learned was that you knows the patient is Hospitals NHS Trust Invest to Save - 5 x
cannot simply ‘cut and paste’ alerted; this is a familiar (Lincoln County Hospital, smart phones purchased
face in time of crisis Louth County Hospital, for key workers to receive
the improvement into Grantham District General alerts at a cost of £870
another organisation; it needs and Pilgrim Hospital) (£175.00 each) + £600
p.a. (£120.00 each) line
to be tested and owned to rental (contract)
encourage engagement
and spread.” * based on cost savings of circa £200 per night per patient

Julie Pipes
Cancer Manager

9


WINNING PRINCIPLE 1

“This is a really important Evidence from testing supporting spread reductions in length of
stay for Urology and Upper GI
piece of work showing
genuine improvement in the
Length of stay - Urology Length of stay - Upper GI
quality of care that we deliver
Length of stay Length of stay Length of stay Length of stay
to an already vulnerable in baseline for test period in baseline for test period
group of patients. It is Minimum 1 Day 0 Day 0 Day 0 Day
important that all patients Maximum 55 Days 28 Days 45 Days 25 Days
receive timely care provided Median 7 Days 2 Days 7 Days 7 Days
by the right person in the Average 10 Days 7 Days 10 Days 8 Days
right place - this is especially
important for cancer patients.
Early assessment is key to this
and ensures that the patient
and family are treated with
dignity. I am pleased to see
that this programme of work
is being extended to cover
other specialties”
Dr Richard Lendon
Director of Performance

10



The Hillingdon Hospital NHS Trust

WINNING PRINCIPLE 1
Through working across • Collaborative and close working with What has been the impact?
boundaries, a palliative care site specific Clinical Nurse Specialties in
three tumour groups, Upper GI,
pathway was integrated into Urology and Lung and with the
Quality improvements Coverage Efficiency benefits
mainstream medical and Community Specialty Palliative Care
Improved communication Organisation Analysis will be completed
surgical care with the aim to Team
amongst teams wide mid July 2009 preliminary
improve the quality of care • Sharing the message and principles
data has shown
• Poster presentation – The Pan Alert notifications Community
for end of life patients.
London End of Life Care Conference regarding cancer patients A& E Specialty Palliative A&E attendances:
awarded joint 2nd prize attendances and any subsequent Care Team Jan/Feb 2008 n = 117
The pathway was triggered • Ongoing monitoring and analysis hospital admissions to community Jan/Feb 2009 n = 99
by alert notifications to the • Active leadership from the Palliative specialist palliative care team and
A&E attendances resulting
community team and clinical Care Consultant. specific tumour clinical nurse
in admission:
specialists
nurse specialists for acute Jan/ Feb 2008 n = 55
Productivity alone cannot ascertain the Junior doctors receive teaching Jan/Feb 2009 n = 45
cancer admissions, to optimise effectiveness of a complex intervention on the palliative care pathway
the appropriateness of like palliative care input/palliative care
admission, place of admission, pathway in the care of a patient (where
management and length of there are so many variables that influence The Hillingdon Hospital Palliative Care Pathway
stay. whether or not patients are admitted and
how long they stay) in terms of directly
influencing variables like length of stay
How was spread achieved? (LOS) or averting admission is extremely
• Increasing awareness: difficult.
• Palliative Care Pathway launched at
the Hospital Grand Round meeting in The key is to focus on integrating the
October 2008 pathway and the quality improvements
• Meetings with A&E and Emergency this will drive the efficiency gains.
Assessment Unit staff
• Attendance at on call handover
meetings
• Junior doctors teaching sessions to
increase awareness and
understanding.

11



Northampton General Hospital NHS Trust
WINNING PRINCIPLE 1

Emergency Admission Unit How was spread achieved?
(EAU) Alert
“Following the initial testing in lung the results were shared
Emergency Admission Unit Alert is an
electronic system developed through the at the clinical nurse specialist meeting with the cancer
existing patient administration system steering group and with all the cancer clinical leads in the
which searches for all known cancer
patients and alerts the relevant Cancer hospital. Clinical engagement was gained as well as the
Nurse Specialist when the patient arrives agreement to rollout the alert principle across the other
in the Emergency Admission Unit.
specialties, using the electronic system.

The cancer steering group reports to the hospital management
team and the clinical quality effectiveness group. The progress
of roll out was reported quarterly to these groups.
This ensured clinical and managerial support.

The service improvement facilitator (from the cancer network)
became part of the Trust service improvement team and
supported the spread of learning from the testing.

A lesson learned which came to light when completing
the spread planner survey was that we could have improved
our communication internally with the wards.”
Karen Spellman
Cancer Lead Manager
Northampton Hospital NHS Trust

12



WINNING PRINCIPLE 1
What has been the impact?

Quality improvements Coverage Efficiency benefits Influenced length of stay

Increased number of Across selected Reduction in LOS for Lung 25
patients receiving clinical teams: cancer patients by 7.4 days
‘Preferred place of care’ per patient
discussion Gynaecology 20
Period of Number of Average
Haematology length
data admissions Yes Not Recorded No

Number of Patients
Proactive referral to the Head & Neck collection alerted of stay
specialist palliative care Lung (days) 15
team Testicular
Thyroid April-June 2006 16 12.5
Early assessment by the Upper Gastro (baseline) 10
specialist team has Intestinal
July 2006- 49 9.7
ensured timely proactive (Upper GI†)
December 2007 5
management of the Urology
(paper fax alert
patients care Skin from EAU)*

April-November 12 5.1 0
Gynaecological Head & Neck Head & Neck Urological
2008 (electronic
alert)** Haematological Lung Upper GI

*Between Dec 2007 and April 2008 the new electronic alert system was being developed and
therefore no data was captured on length of stay.
**Since November 2008 the alert system has been implemented and the evaluation is
currently under review.
†Upper Gastrointestinal (Upper GI).

13



Sherwood Forest Hospitals NHS Foundation Trust
WINNING PRINCIPLE 1

Recurring Admission The Trust won the 2007 Medical What has been the impact?
Patient Alert (RAPA) Innovation Futures Award for this
innovative initiative.
RAPA is a process that supports the co-
The Trust held a RAPA showcasing event
ordination and timely care for patients Defined emergency Organisation wide across Lung tumour site has
May 2008. Delegates came from as far as
admitted as an emergency, alerting pathway nine cancer tumour sites reduced length of stay by
Brighton and Gateshead. RAPA is
members of the clinical teams when their 25%, releasing a potential
currently being tested and implemented
previously diagnosed cancer patients are Patient is assessed to Hospital Specialist 560 bed days per year
at Doncaster hospitals and we have other
being re-admitted to the acute hospital. admit rather than Palliative Care Team
sites still coming for a demonstration on
admitted to assess This equates to a potential
how RAPA works!
Initial testing commenced in Kings Mill Non-Cancer Specialist redistribution of £112,000
Hospital and has now been successfully Timely and appropriate areas, Cardiology, based on £200.00 per day
Along with other service improvements
implemented across Sherwood Forest support/interventions Respiratory, and Diabetes
such as the discharge planning tool and
Hospitals NHS Foundation Trust. Reduced length of stay for
expansion of the Integrated Discharge
Promotes ongoing Infection control alerts - all elective and non elective
Team this allowed our overall average
How was spread achieved? continuity of care known MRSA/CDiff cancer admissions
length of stay to steadily decrease for the
RAPA has now been implemented across patients are alerted to the
trust as a whole despite an increasing
all nine tumour sites at Sherwood Forest Early discharge supported Infection Control Team Reduced length of stay for
number of service users. The graphs show
Hospital NHS Foundation Trust and when they arrive in all elective and non-elective
figures for length of stay in days for the
Hospital Specialist Palliative Care Teams. Supports patient choice hospital admissions across
financial year broken down by elective
and preferred place of organisation
and non-elective admissions.
Showcasing at different hospital forums care Other hospital sites
has enabled non-cancer specialties, outside of trust -
including the Integrated Discharge Team, Doncaster Hospitals
Cardiology, Respiratory, and Diabetes to
benefit from RAPA.

The principles have been adopted in
alerting specialties/wards to patients
being admitted to the hospital who are
known to be MRSA or C Diff positive.
This will inform staff of the need to
follow trust protocols and provide most
appropriate care to patients.

14



WINNING PRINCIPLE 1
A snapshot analysis in April 2009 showed
Reduced length of stay for all elective & non-elective admissions across organisation sustained length of stay in the original
Elective Inpatients Non-elective Admissions four test tumour sites, Breast, Lung,
Average Length of Stay Average Length of Stay Upper GI and Gynaecology
5
Comparison of median LOS for the
4 4.53 4.53 4.44 original test sites, pre, during and
Average Length

post RAPA.
of Stay (days)

3.89
3 3.43
3.3
2.77 2.76 Comparison of median LOS for non-elective Comparison of median LOS for non-elective
2 breast patients, pre, during and post gynaecological patients, pre, during and
implementation of RAPA post implementation of RAPA
1
15
0

Time (days)

Time (days)
2005/06 2006/07 2007/08 2008/09 2005/06 2006/07 2007/08 2008/09
Financial Year
6 6 6
4
3
Reduced length of stay for all elective and non elective cancer admissions Pre RAPA Feb 07 Apr 09 Pre RAPA Feb 07 Apr 09
RAPA Trial Post RAPA RAPA Trial Post RAPA
Elective Cancer Patients Admissions Non-elective Cancer Patients Admissions
Average Length of Stay Average Length of Stay
12
11.8 11.9 Comparison of median LOS for non-elective Comparison of median LOS for non-elective
10 lower GI patients, pre, during and post lung patients, pre, during and post
Average Length

10 10 implementation of RAPA implementation of RAPA
of Stay (days)

8
6

Time (days)
Time (days)

4 5.1 4.3 9.5
4.1 4.1 8
2 6
5 4
0 3
2005/06 2006/07 2007/08 2008/09 2005/06 2006/07 2007/08 2008/09
Pre RAPA Feb 07 Apr 09 Pre RAPA Feb 07 Apr 09
Financial Year
RAPA Trial Post RAPA RAPA Trial Post RAPA

15



The Christie NHS Foundation Trust
WINNING PRINCIPLE 1

Preferred Priorities of Care • Raise awareness of the potential risks 260 (91.87%) of these patients have subsequently died and 211 (81.15%)
(PPC) Implementation / to the organisation, staff and patients if achieved their end of life care
end of life and advanced care planning
Advanced Care Planning (ACP) is not implemented
• Giving feedback to each ward area of Total PPC discussions
Spreading the Gold Standards the results from base-lining testing
Framework, Preferred Priorities of Care identifying the actual and potential 300
and the Liverpool Care Pathway in order benefits 283
to reduce length of stay and avert • Ward and medical staff are encouraged 250 260
unnecessary admissions. This is to use the surprise question amongst
integrated work with the National End staff to identify potential patients in 200 211
of Life Care Strategy. their last year of life. "Would you be
surprised if this patient were to die in 150
How was spread achieved? the next 6-12 months?“
Raising awareness – Poster Campaign • Working collaboratively with 100
(including on the back of toilet doors). identified medical teams to facilitate
Increased staff awareness of the active decision making and improve 50
importance of identifying patients in their 49
end of life care. 23
last year of life. 0
Total PPC Deceased Still Alive Achieved PPC Not Achieved
Challenges Discussions Patients PPC
New learning and feedback • The biggest challenge has been
• The communication department changing the mindset of health care
developed a new two day enhanced professionals regarding end of life care
communication skills training for • Importance of promoting the principles “The link between hospital and community services has been
frontline staff (Level 2). Five training and gaining high level management
sessions have been allocated for this support and awareness.
invaluable and has led to a much smoother transition to shared
year and will be co-facilitated by End of • Internal and external sharing of care with the community health team and oncology services.
Life Project Manager and key members information through various means
of the Palliative Care Team including e-mail, intranet, phone
The patients and their relatives involved have expressed a great
• A teaching programme has been contact, letters and updates in the deal of satisfaction with the level of care and support, both
developed for all ward staff to raise hospital bulletin.
awareness of recent National physical and psychological, that they have received.”
developments regarding care at the end
of life. The North West End of Life Care Dr Sacha Howell
Honorary Consultant in Breast Medical Oncology,
Model (NHS North West 2008)
The Christie NHS Foundation Trust
has been adapted and developed into a
checklist for all ward staff to use

16



WINNING PRINCIPLE 1
What has been the impact? Raising awareness poster

The Christie NHS
NHS Foundation Trust
Improved patient choice and One organisation Over 15 months released
experience. 283 preferred started with ovarian capacity of 1,134
priorities for care discussions and lung cancer inpatient bed days for
facilitated Manchester patients active anti-cancer
only treatments. This equates
260 (91.87%) of these patients to 76 bed days per
have subsequently died and 211 Known patients from month
(81.15%) achieved their end of palliative care team
life care wishes This equates to a
Ward 1 – ovarian and redistribution of
Averted inappropriate admissions breast cancer patients - £226,800 based on £200
15 consultants per day
Moved care out of the hospital to involved
another setting (shifting care) 59 re-admissions were
Spread strategy to averted over 15 months,
Facilitated rapid discharge systematically address this equates to four
each tumour site and patients per month
Improved clinical decision making
ward
(end of treatment decisions)

Increased staff awareness of the
importance of identifying
patients in their last year of life

Timely and effective
communications across all sectors
and disciplines

Developed teaching programmes

17



National overview: Spreading Winning Principle 1 towards a million bed days
WINNING PRINCIPLE 1

Winning Principle 1 National Overview (HES 2006/7) Winning Principle 1 is being adopted
Unscheduled (emergency) patients • Emergencies inpatient episodes and adapted into rapid alert systems,
should be assessed prior to the have increased by 51% over nine defined emergency pathways and
decision to admit. Emergency years acute oncology approaches. Reducing
admission should be the • Emergency admissions via A&E have length of stay and averting
exception not the norm. increased particularly rapidly unnecessary admissions. This has the
(144%) potential to reduce emergency bed
• There are nearly 200,000 days by 25%.
admissions pa via A&E
• The equivalent to 540 per day. This National cancer emergency
equates to three patients per day, bed days total number
per average size NHS Trust Releasing 25% = 740,996 bed days
• Emergencies use 60% of bed days
(almost three million)
• Emergency bed days have increased
by 14.5% over nine years
• In 2006/7 there was 417,646
emergency inpatient episodes
= 2,963.987 bed days
• Average length of stay for
emergency admissions is 7.1 days.

18



Winning Principle 2

2. All patients should be on defined
inpatient pathways based on their Common themes of spread from the analysis
tumour type and reasons for
6
admission.

5

WINNING PRINCIPLE 2
The following five summaries focus on
4

Number of test sites
spreading Winning Principle 2. They
illustrate the spread of change in clinical
practice, new care pathways and shifting
3
care from an inpatient to an ambulatory
setting. All five NHS Trusts have been
successful in spreading the improvements 2
to the places they wanted them to go,
across clinical teams, organisations and 1
cancer networks. The learning applied to
the spread framework shows the
common themes. 0

Spread Simple
Principles & Messages

& Team Working
Collaboration, Partnerships

Continuous Monitoring,
Progress & Impact

& Operational Change
Linked Strategic
A Vision for
Quality Improvement

& Accountability
Leadership, Engagement

Alignment with
Opportunities & Levers

Patient Centred

Learning & Unlearning

Spread Strategy
Systematic Improvement
Approach

Organisational
Culture & Fit

19

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