Assessing palliative care needs for St Ann's Hospice

Bespoke Analytics

Background

Approximately 500,000 people die in England each year. People with advanced life-threatening illnesses and their families should expect good end of life care. It is critical to commission hospice services for the future to ensure these needs are met.

St Ann’s Hospice, a charity providing care and support to patients living with or affected by life-limiting illnesses from across Greater Manchester, appointed the UM Unit to review and update their Palliative and End of Life Care Needs Assessment.

The work aimed to provide the hospice with an understanding of the palliative needs of their local Clinical Commissioning Groups (CCGs) and evaluate how these needs are being met, including:

• Updating their existing palliative care needs assessment
• Understanding and evaluating the internal activity levels across inpatient, outpatient and home-based services
• Predicting future requirements for hospice level care over the next 10-15years

What did we do?

Using a variety of data sources, as well as data from the hospice themselves, the Utilisation Management Unit compared recent data within the original palliative care needs assessment and demonstrated data change over the past 13 years.

Key insights included:

• Based on current service provision, a significant increase in bed-based services will be required by 2041 in order to meet predicted demand.
• It is likely that patients with non-cancer diagnoses will increasingly need hospice care in the future.

The impact

The results of the review allowed the hospice to better plan for the future. This includes how the provision of outpatient and community services can supplement the increasing palliative and end of life care needs of the local population and how needs will change as the population increases and becomes older.

Rachel McMillan,  Deputy CEO St Ann’s Hospice, said: “St Ann’s will be 50 years old in 2021 and we need to ensure that we are still providing world class care in the next 50 years.

“We needed the wisdom and expertise of the UM team to help us update and further understand the palliative and end of life care needs assessment in order to work closely with our commissioners and stakeholders to plan for the future.

“The team were amazing – their attention to detail was helpful and the level of engagement was spot on. We are so proud of the report and we are telling everyone about it.

“It will help us all to shape the future of palliative, supportive and end of life care for the population of Greater Manchester. It’s an excellent example of collaboration and co-production and I have thoroughly enjoyed working with the team.”

Contact: clinicaloffice@healthinnovationmanchester.com

Improving Emergency Department performance

System Improvements

Background

Urgent and Emergency Care is one of the NHS’ main national improvement priorities. Emergency Department (ED) performance, measured as the proportion of patients discharged home or admitted to hospital within four hours, is a key determinant of the whole health and social care system resilience. It is also one measure of the quality of care and patient experience. High ED performance is linked to better patient outcomes, lower mortality, earlier clinical intervention and shorter hospital length of stay.

The Utilisation Management Unit Non-Elective Pressures and Performance Review aims to inform strategic partners as to possible contributions to reduced performance at their local Trusts in order to support focussed action plans to improve and sustain acceptable levels of ED performance, particularly over the winter period.

Our Approach

In our experience, Emergency Department underperformance is rarely attributable only to internal issues within the Emergency Department.

The UM Unit examine, articulate and numerate contributions across the entire patient pathway and the arrangement of services which lead to current and likely future performance challenges.

Our approach uses a blend of national analytics, national SitRep submissions and local data extracts to understand the key contributions to whole system performance.

This is done in conjunction with frontline clinical insight captured over a 2-day observation period by UM Nurses; to provide a robust and complete analysis of reasons behind underperformance.

This combined approach means we can use data to illustrate where opportunities for improvement arise while observation highlights the cause and effect and why systems underperform. The data may show activity and performance but it fails to illuminate relationships, working practices, rotas and arrangements for care.

On completion of these reviews and observations, reports are provided to the health and care system to outline findings and present strategic and operational recommendations to sustainably improve ED performance.

Contact: clinicaloffice@healthinnovationmanchester.com

Bed Modelling at Southern Health and Social Care Trust

Bespoke Analytics

Background

Statistics published by the Northern Ireland Department of Health highlight that demand on hospital beds has been increasing. At Southern Health and Social Care Trust’s (SHSCT) two acute sites – Craigavon Area Hospital and Daisy Hill Hospital – inpatient admissions have been increasing at an average annual rate of 3% between 2013-14 and 2017-2018. There has also been an annual growth of 5% in emergency admissions. Population figures are also predicted to increase by 7.2% by 2024.

What did we do?

SHSCT commissioned the UM Unit to undertake data analysis of the predicted capacity and demand requirements at Craigavon Area Hospital and Daisy Hill Hospital up to 2024.

The Utilisation Management Unit used information and data from the previous five years and projected future population changes in order to assess the number of beds required at each hospital to meet increasing demand.

The results

Analysis of projected occupied bed demand shows that both Craigavon Area Hospital and Daisy Hill Hospital will have fewer beds than needed to meet requirements by 2024.

In both cases, the greatest deficit in available beds is in General Medicine. The study also found that there is significant variation across month and day of week.

The impact

• Through the use of a data visualisation tool, SHSCT can understand the impact of population changes at a Trust, hospital site, speciality and subspecialty level, including non-acute/rehabilitation bed capacity.
• The ability for managers and lead clinicians to truly understand the projected demand increases over the next five years enables transformation plans to be developed to address future capacity needs.

Contact: clinicaloffice@healthinnovationmanchester.com

Implementation of a Pre-ED Assessment Service

System Improvement

The Challenge:

In August 2020 gtd Healthcare commissioned the UM Unit to support their organisation with their contribution to the Oldham system Urgent and Emergency Care (UEC) by Appointment Programme of work. Specifically the design and mobilisation of a Pre-ED Assessment Service in-line with recent GM regional guidance. This service would be required to rapidly assessment patients who self-present at the Royal Oldham Hospital (ROH) with a requirement for urgent care and signpost these patients to an appropriate service in the Oldham system, other than ROH ED as clinically appropriate.

The Solution:

The UM Unit collaboratively engaged operational, clinical and managerial colleagues from gtd Healthcare, the Acute Trust and the Clinical Commissioning Group in order to map patient pathways and design a clinically safe and effective Pre-ED Assessment Service model. The most recent guidance and available patient activity data was utilised to develop a robust patient assessment process delivered by a team of highly experienced clinicians and administrative staff from gtd Healthcare.

In accordance with GM guidance, the resulting ‘two door model’ of assessment was mobilised which saw patients presenting to the ROH site, being rapidly assessed and directed to the gtd Healthcare Clinicians in the Pre-ED Assessment Service (the Blue Door) or indeed as appropriate signposted directly to ED (the Red Door) according to the acuity of their presentation.

The Outcomes:

The GM regional team had set a standard requirement for Pre-ED Assessment of 25% of self-presenting patients should be assessed and signposted to services other than ED as clinically appropriate.

The gtd Healthcare team in association with the Trust initially completed 3 ‘test of change’ days for the Pre-ED Assessment service model. The data analysis for these 3 days showed a deflection of greater than 30% of patients who self-presented during the 12 hours of service operation on each of these days. The UM Unit provided a analysis report of these ‘test of change’ days and following review of this by Oldham CCG’s Urgent Care Board, the Pre-ED Assessment Service has been formally commissioned from gtd Healthcare.

Discharge to Assessment – Impact of Community Capacity on Hospital Flow

Bespoke Analytics

Background:

Greater Manchester (GM) Winter Gold asked if it was possible to better understand the impact of changes in community capacity on patient flow and acute bed capacity.

This followed recent events where significant amounts of capacity had been lost within the community due to COVID and the high likelihood that this will re-occur.

The ask was to develop a method of testing phase 3 planning assumptions using different scenarios at a locality level.

“Create a modelling tool that would help to support a whole system discussion and improve understanding of how small or large changes in community capacity would affect patients waiting for discharge and acute bed occupancy”

“Keep it simple!”

What did we do?

We developed an iterative tool for localities to run scenarios to see the impact of various changes in the availability of community bed and enablement pathways. These were based on the Discharge to Assess Pathways. We developed a queuing model using R with a front-end Tableau dashboard:

• Acute bed data was taken from Phase 3 planning submissions
• Initially it was developed for Pathway 2 (which can include pathway 3)
• It was then further developed for Pathway 1 (only for reablement)

How does it work?

Users can adjust number of daily discharges for each pathway. Length of stay in community bed (pathway 2/3) or daily caseload and duration of reablement (pathway 1) can also be altered.

Shows impact on:

The number of patients waiting to be discharged from an acute bed and the number of days they will have to wait versus the number of community beds required. It also impacts the predicted number of general and acute beds occupied.

Contact: clinicaloffice@healthinnovationmanchester.com

Testimonial

Zeph Curwen, Divisional Managing Director, HMR Division of Integrated Care & Rochdale Infirmary:

How did this help?

“It helped people to understand the impact of what may seem a small number of beds out of hospital making a big difference to flow in hospital. It helped to support discussions of what if contingencies.”

Has the support made you think differently?

“It has led to other discussions about issue relating to/impacting on flow and what they can do to support for example how to flex IMC capacity, and ensure there is not double count IMC bed capacity when they are pushing community rapid response to step up, as it will mean less beds to step down into.”

Non-elective pressures and performance at Leighton Hospital

System Improvement

Background:

Urgent and Emergency Care is one of the NHS’ main national improvement priorities. Emergency Department (ED) performance, measured as the proportion of patients discharged home or admitted to hospital within four hours, is a key determinant of the whole health and social care system resilience. It is also one measure of the quality of care and patient experience. High ED performance is linked to better patient outcomes, lower mortality, earlier clinical intervention and shorter hospital length of stay.

Emergency Department (ED) performance measured as the proportion of patients discharged or admitted to hospital within 4 hours is a key determinant of whole health and care system resilience and a good measure of quality of care, and patient and staff experience.

The Utilisation Management Unit Non-Elective Pressures and Performance Review aims to inform strategic partners as to possible contributions to reduced performance at their local Trusts to support focussed action plans to improve and sustain acceptable levels of ED performance, particularly over the winter period.

What did we do?

The primary purpose of this review was to identify as far as possible contributions to reduced T1 performance at Leighton Hospital, to support a focussed action plan to improve and sustain the required levels of Emergency Department performance.

Approach

A 2-day ‘walk-through’ approach was undertaken by two senior UM Unit clinicians. This focussed on the” front of house” non-elective pathway, defined as:

• ED (including streaming to the co-located Urgent Care Centre)
• Ambulatory Care Unit (ACU)
• Surgical Ambulatory Care Unit (SACU)
• Clinical Decisions Unit (CDU)
• Assessment Units (Surgical, Gynaecology, Acute Medicine, Children’s)

Contact: clinicaloffice@healthinnovationmanchester.com

Testimonial

Emma McGuigan, Director of Operation at Mid Cheshire Hospital NHS Foundation Trust:

What was the situation like before/what problem did you have and why did you approach Health Innovation Manchester’s Utilisation Management Unit? “At the Trust we were experiencing a significant deterioration in our emergency department performance. The situation was complex and challenging with a range of factors contributing to this, specifically an increasing attendance rate far exceeding the national average. We had a plethora of action plans and improvement projects but really needed support to ensure our efforts were being directly in the most optimal way that would have the greatest improvement for our staff and patients. Like many organisations we were faced with challenges regarding flow right across the system, pre-hospital, in-hospital and leaving hospital; therefore, it was difficult to really understand our hot spot areas and ensure focus.”

What support did you receive and how did it make a difference? “The UM team undertook a significant amount of analysis and helped set this within the context of our system and the national picture. The team were able to dispel some myths that been gathering traction and really highlighted across our data where we were outliers and some of the work that we could do to address this. The team attended on site and interviewed staff, joining the operational site meetings as necessary throughout the day. The really engaged with front line and were very credible in their response. The UM team really understand the challenges of the NHS and come with a sound understanding of how an emergency department works, they have clinical credibility and can really get to the finer details of the problems.

“The UM review has supported a greater focus within the organisation to understand our own data and move to a more predictive analysis and planning culture. The report has been the focus of our Urgent Care Steering Group and will be aligned to our improvement programme for urgent care over the next 12 months. The UM report has established a single and clear understanding of the challenges with our urgent care pathway and a cohesive understanding of the issues is a crucial component to influencing and agreeing the changes required.”

What results did you see? “As above really.”

What was it like to work with HInM/UM and would you recommend It to others in a similar situation/in need of support? “I would strongly recommend working with the UM team again, they really understanding the working of urgent care systems and get into the details. They come with clinical and operational credibility and understand the context in which an emergency department functions and the significant role all the system plan in that. The analytics within the report were really helpful at concisely articulating the issues and the recommendations were valid and achievable. We would definitely welcome further support from UM.”

Dashboard Design Development at Saint Mary’s Managed Clinical Service (MFT)

Bespoke Analytics

Background:

Saint Mary’s Managed Clinical Service commissioned the UM Unit to scope the development of dashboards designs for clinical and operational indicators across 3 of its services areas and the Senior Leadership Team.

To provide requirement documents and system agnostic designs for dashboards in 4 areas:

• · Gynaecology Division
• · Genomics Division
• · Sexual Assault and Referral Centre (SARC) Directorate
• · Senior Leadership Team

What did we do?

Clinical and analytical colleagues from the UM Unit facilitated scoping workshops with key stakeholders from each Division to:

1. 1. Arrive at a consensus regarding the clinical and operational/management questions the dashboards are addressing.
2. 2. Co-design dashboard specification and dashboard design with each Division/ Directorate and each member of the Senior Leadership Team.
3. 3. Share the principles of good dashboard design with each team.

Scoping addressed the following requirements:

• · What metrics to collect and measure (patient, service, organisational level)
• · Why selected metrics should be included (dashboard development for short term improvement projects is not within scope)
• · Time period to report (e.g. daily, weekly, monthly figures)
• · Recommendations on type of visualisation for each metric
• · How and where the dashboard will be used or displayed
• · Target audience, who will view, act on the dashboards
• · Number of dashboards required for each Division / Directorate and SLT member.
• · Overall design of dashboard

Following the workshops, detailed requirement documentation was produced and mock-ups of system agnostic dashboards were designed.

Shows impact on:

The outputs gave a clear understanding of the data requirements of the service areas and Senior Leadership Team along with recommendations and designs for dash-boards.

Reducing the burden on the Saint Mary’s principle analyst, allowing them to concentrate on the technical and data requirements.

Robust, informative dashboards should lessen the number of data requests from the MCS’s and allow for ‘1 version of the truth’ for monitoring and planning purposes.

Supported preparation prior to the deployment of the MFT electronic patient record in terms of data and reporting requirements.

Contact: clinicaloffice@healthinnovationmanchester.com

Testimonial:

Ian Daniels, Director of Business & Innovation, St Mary’s Hospital Managed Clinical Service:

“Thanks to the unit for the work you have done to produce the dashboards designs.”

Point Prevalence Study of Saffron Ward

Point Prevalence Study

Background:

The CCG commissions 25 community beds on Saffron ward at The Meadows, Offerton, for patients with low level confusion, dementia or delirium who require a short period of assessment and rehabilitation. NHS Stockport CCG commissioned the Utilisation Management Unit to undertake a point prevalence review to understand the nature and level of admissions, the types of physical and mental health issues being managed and to understand the therapy needs of the patients. Length of stay, delayed discharges and alternatives to in-patient care were assessed.

What did we do?

A 3-year historical data set was obtained to understand the flow of admissions and discharges through the ward. Approvals were obtained for all necessary information governance requirements. A bespoke data collection tool was co-designed with key stakeholders. A point prevalence study was undertaken which consisted of a review of each in-patient case note on Saffron Ward at The Meadows undertaken on a specified date. Data collected during the point prevalence study was analysed alongside the 3-year data set to understand: the level and nature of admissions, the nature of therapy input needed and the level of integration with other IMC services. Semi structured interviews were held with the ward manager and the ward therapists.

This Shows impact on:

• Demonstration of the performance, successes, and challenges within the operation of Saffron Ward.
• Recommendations for strategic and organisational change to optimise the performance of Saffron Unit.
• Considering the ‘art of the possible’ in support of admissions avoidance strategy.

Contact: clinicaloffice@healthinnovationmanchester.com 

Testimonial

Melissa Maguiness, Director of Integrated Commissioning, NHS Stockport CCG, May 2022

‘Stockport CCG had the pleasure of commissioning the Utilisation Management Team (UM) at Health Innovation Manchester to undertake a point prevalence review of Saffron Ward in Stockport. The UM team worked in collaboration with the CCG, Stockport local authority and Pennine Care to co-design the methodology. UM Staff supported us through establishing IG and operational processes to deliver an insightful and pragmatic report with helpful recommendations for future developments of the service.

The success of the project would not have been possible without the expertise and dedication of the team. We are very grateful to the UM staff for their input and hard work and look forward to working on future projects together.’

Salford Mortality Review 2

Mortality Review

Background:

A review of 543 deaths was undertaken in 2020 during phase 1 of the pandemic, to identify important learning for the Salford locality to help reduce avoidable deaths during future waves of Covid-19 infection.
The mortality data analysed from this demonstrated that there were excess deaths in Salford compared to 5-year pre-Covid average. Reducing mortality was identified as a key priority for Salford CCG.

What did we do?

Salford CCG commissioned the UM Unit to support a further review of 209 deaths specifically from Covid-19 infection, occurring during the third Greater Manchester (GM) wave of the Covid-19 pandemic, to gain further insight and understanding of the impact of the virus on mortality in Salford and to identify any further learning opportunities.
This Shows impact on:
• The outcomes of strategies used to address themes identified in the first wave review.
• Strategies to be developed to address themes associated with covid mortality and learning that could be shared with the wider health and care professions.

Contact: clinicaloffice@healthinnovationmanchester.com

Testimonial

Jeremy Tankel, Medical Director, Salford CCG

‘As clinical lead it was great to work with the team again. It always amazes me how much data a project can collect and how complex the data and I.T. issues can be. Analysing the case files and collating the data of so many people who passed away during the second wave of the Covid pandemic is no easy matter. The data analysis has revealed a wealth of interesting information and the Team kept the clinicians who considered avoidability and themes on task and on time!
I am deeply grateful to them all as the information gathered helps to change services which ultimately saves lives and reduces suffering.’

Hakeel Qureshi, Programme Manager, Quality Improvement

‘Salford CCG had the pleasure of commissioning the UM Team at Health Innovation Manchester to undertake our 2nd mortality review with them, bringing together our multidisciplinary team at Salford who were dedicated to review the insight on the impact of COVID-19 in our locality, which thus enabled us improve our patient safety outcomes. The UM team worked with us through the challenges of the pandemic working digitally and virtually. The success of the project would not have been possible without the expertise and dedication of the team. From the very beginning of the review the UM team provided the guidance and support, helping us establish the process to gain our final outcome. I am very grateful to the team on a job well done and look forward to seeing what we can deliver in the future!’

Salford Mortality Review

Clinical Pathway Review

Background:

In May 2020, registrar data highlighted that there were 543 excess deaths in the Salford locality compared to 5-year pre-Covid average. The deaths were due to Covid and non-Covid causes.  The peak in the number of deaths was between weeks 12-19 of 2020 (20^th March to 18^th May).  As reducing mortality was already identified as a key priority for Salford Clinical Commissioning Group (CCG) a collaborative review of patient deaths by a multi-stakeholder group was commissioned which included:

• Health Innovation Manchester-Utilisation Management (UM)
• Salford Royal NHS Foundation Trust (SRFT)
• North West Ambulance Service (NWAS) 999 and 111
• Public Health Salford Local Authority

The approach developed followed the terms of the NHS Control of Patient Information Regulations for sharing of information in the context of the COVID-19 pandemic due to the review adopting a system safety review process.

• Primary Purpose of the Review

 The aim of this review was  to ascertain  “For Salford residents who died between weeks 12 to 19 of 2020 (the ‘first wave’ of the COVID-19 pandemic), can any phenotypic characteristics of the patients, uncertainty over the diagnosis, or features of the Urgent and Emergency Care (UEC) response to the pandemic be identified that could be modified to mitigate against excess deaths in the future?”

• Objectives

 What are the emerging themes that would inform future UEC policy/protocols/guidelines both for the general population and vulnerable sub-group phenotypes.  

• What did we do?

Outcomes:

A set of core themes with contributing factors were identified across pre-hospital, primary and secondary care. The themes and contributing factors have been widely disseminated across Greater Manchester (GM) and the North West Region and have supported changes to patient pathways for the second or third wave of Covid-19.

Contact: clinicaloffice@healthinnovationmanchester.com

Testimonial

Name: Dr David Ratcliffe
Urgent Care lead for Greater Manchester Health & Social Care Partnership

How did this help?

“This was a unique opportunity to review the comprehensive clinical records of the patients involved in this study, expertly collated, reviewed and presented by Utilisation Management Unit Senior Nurses. This enabled key insights to be fed back to the health and social care leadership in GM to ensure safer care. Valuable, insightful lessons were learned, and actions put into place regarding safety immediately, ensuring clinical assessment, decision making and compensating for social inequalities when planning service change could be actioned. There was also an acknowledgement that this review provided clear demonstration of the value of good, responsive end of life care.”

Name: Dr Martin Smith
Salford Care Organisation Clinical Director for Mortality, and the Emergency Medicine Consultant representative on the Greater Manchester Mass fatalities and Excess Deaths Planning group.

How did this help?

“The team contributed actively to the design of the project injecting learning from their prior experience of pathway review projects.  The project was out of necessity, a lengthy review, but the methodology was consistently applied with extreme diligence. Without the UM senior nurse’s expertise and productive approach to the review limited progress would have been made.”