A guide to commissioning cardiac surgical services

NHS
NHS Improvement
CANCER

DIAGNOSTICS

HEART

LUNG

STROKE

NHS Improvement Heart
A guide to commissioning
cardiac surgical services

Contents
Foreword 3 Discharge planning 35

Introduction 4 • Improving the patient experience for cardiac
surgery pathways 36
Improvement to the patient pathway -
summary of recommendations 5 • Reducing length of stay of elective cardiac surgical
patients to a one night stay post operatively 39
Access to surgery 7
Quality - the current context 42
Elective pathways 8
Supporting Information 49
• Redesign of the cardiac surgery patient pathway 9
Cardiac Data Dashboard 50
• Ensuring patients are fit for surgery and reducing delays in the
cardiac surgical patients pathway 15 The Sustainability Toolkit 51

• Process changes significantly increase 18 week performance NHS Improvement System 52
in cardiac surgery 18
Good planning can inspire change that
• Tackling change - the teamwork way 20 leads to improvements 53

• Cardiac surgery and 18 weeks - a pan network approach 22 References and supporting information 54

Cardiac surgery trends - the national picture 24 Acknowledgements 56

Non-elective pathways 29 Cardiac Surgery National Project Team 57

• ‘Urgent or non urgent’, that is the question 32

A guide to commissioning cardiac surgical services

Foreword
There has been substantial progress in It is a clinical challenge, since it is, in the
cardiac surgery over the last ten years. end, clinicians that spend the money. So,
Surgeons are operating in a more timely every clinician is required to examine their
fashion on more people with higher levels practice and actively look for ways to
of risk and co-morbidity, yet they are deliver care more efficiently, removing
delivering better outcomes. waste and saving money.

The national audit has been a major In my last foreword (Improving the patient
driver for success and so has the work of experience: Developing solutions to
NHS Improvement where a focus on delivering sustainable pathways in cardiac
systems that deliver high quality care has surgery, March 2009), I pointed out that Professor Roger Boyle CBE
been pivotal. there are still long delays in the non-
elective pathways that lead to heart
Now we face an even bigger challenge. surgery. These delays have not gone away
Over the last ten years, we have benefited and still need to be addressed. Many of
from higher levels of growth in NHS the issues regarding pre-assessment and
expenditure than at any time in its history theatre scheduling are other examples
and cardiac services have been substantial where the priority projects have addressed
beneficiaries. Today, we have to recognise the key efficiency measures over the years.
that it is inevitable that the wider financial Now, we cannot rest on our laurels, there
situation is going to impact on each and remains much to be done.
every one of us. This challenge, to deliver
continuing high quality care while at the
same time delivering it much more Professor Roger Boyle CBE
efficiently, is the biggest challenge that National Director for Heart Disease
has faced us in the history of the NHS. and Stroke, Department of Health

www.improvement.nhs.uk/heart 3


Introduction
A superficial view would suggest that This has increased from 10% in 1999 and The focus of work undertaken by the
cardiac surgery has changed little over the has brought challenges in terms of current project sites considered to be
last twenty years – we still spend most of increasing co-morbidity but results constraints within the management of
our time in theatre grafting coronary following surgery continue to improve. smooth patient flows includes the
arteries and replacing heart valves. Mortality following CABG has fallen from following:
However, closer inspection shows marked 1.9% in 2004 to 1.5% in 2008. The
changes in the type of patient being seen changes in cardiac care set out in the • Pre-admission provision.
by surgeons. The era of operating on National Service Framework have also had • Referral management services.
patients with heart valve disease only a marked effect on the way patients are • Scheduling.
when their symptoms became severe has treated we have found that we are • Discharge and post operative care
passed and now many patients are operating on many more patents on an management. Steve Livesey
operated on specifically to prevent urgent basis as appropriate treatments are
deterioration rather than improve now available much earlier in the time This report aims to share the successes
symptoms. This change means that course of patients’ disease course. with the wider NHS providing a range of
patients having heart valve surgery are not excellent examples of where local teams
having their operations when they have The attention focused on cardiac have delivered innovation in their service
begun to slip down the slope of clinical diagnostics and 18 week pathways as part to improve the efficiency and experience
deterioration when ‘risky’ surgery is the of the portfolio of work led by NHS Heart for patients and staff.
only prospect of survival but when they Improvement during 2007/08 highlighted
are well. a need to shift attention to cardiac surgery
to develop sustainable solutions. Eight Steven Livesey
This change has occurred alongside a NHS Trusts supported by their local cardiac National Clinical Lead
justified increase in the expectations networks have been involved as NHS Improvement - Heart
patient have of what can be done for demonstration sites during 2008/09
them and as evidence of this we are testing out new approaches to care and
operating on an increasingly elderly improvement to frontline patient services.
population of patients. In 2008, 25% of
all patients undergoing coronary artery
bypass surgery were over 75 years of age.

4 www.improvement.nhs.uk/heart


Improvement to the patient pathway - summary of recommendations

one:
Lessons drawn from project 1. Service priorities
demonstration sites suggest that 2. Models of care and idealised 1. Referral management services
quality improvement to elective patient pathways There is often an information gap between referring provider units and
cardiac surgery services requires 3. The approach to the change the tertiary centre:
smarter working, a data driven initiative and the identification • Manage variation in the referral process from provider units and
approach to understanding process of root cause issues and in-house reducing multiple referral points through development of
performance and process variation, solution development agreed referral criteria to relieve pressure on waiting times for surgery.
the enhancement of staff roles and a 4. The methods/approaches to • Develop central systems for optimising referral efficiency by
shared overview of the patients’ change management streamlining administrative process and referral management linking
journey and patients experience • Strategically in gaining clinical teams across secondary and tertiary care to triage referrals and
across referring providers and the agreement to change service advise on appropriate tests/investigations.
tertiary centre. models and contractual • Introduce pooled referrals across consultants as this significantly
arrangements; impacts on waiting times.
Cardiac networks continue to be • Operationally in the application • Use appropriate clinical staff to confirm referrals are complete and
uniquely placed to assist with the of improvements including the discusses work up criteria with referrer.
delivery of the quality agenda by adoption of processes that hold • Introduce a single point of contact at the tertiary centre for referrers
linking clinicians, managers and and sustain the gains. and patients. The role of the trained clinical coordinator is pivotal in
commissioners together in every tracking individual patients and in ensuring the consultant team kept
aspect of the patients’ journey This document identifies a range of informed of significant events.
through primary, secondary and initiatives that have been successfully
tertiary care. employed in meeting the challenge of
18 weeks in elective surgery which
Networks are well positioned to inevitably required the focus to
reflect local relationships between extend to systems and processes that
clinicians across organisational support the whole surgical process,
boundaries to further develop safe elective or otherwise.
and effective surgical pathways of
care for patients by providing an The detailed case studies within the
opportunity for clinicians and publication aim to share the
managers to work together on the knowledge and learning from these
redesign agenda and to gain pilot sites which breaks down into the
agreement on: following four areas:



two: three:
2. Pre admission provision 3. Scheduling
• Manage variation in pre assessment services. • Move toward Day of Surgery admission as the standard of care for
• Adopt investigation guidelines which state agreed timeframes from test to elective surgery as this can improve the patient experience considerably.
planned date of surgery and only carry out investigations which are • Maximize theatre efficiency by reducing waste in the system for
relevant, indicated and likely to alter management. example right staff in place at the right times with the right equipment.
• Introduce ‘one-stops’ for outpatients to avoid wasted clinics for medical • Optimise theatre capacity by reducing slot cancellations (clinical/non
staff and patients. clinical) and by scheduling procedures that assist with patient flow
• Maximize opportunities for multidisciplinary team assessment and through ITU/HDU.
emphasise use of technology an example would be use of video link • Where ever possible pool lists to reduce waiting times.
between hospitals.
• Procedure complexity scores developed to assist with scheduling
• Maximize pre assessment opportunities as they help manage patient health
developed as part of MDT.
and reduce risk.
• Maximize pre admission diagnostics particularly in referring district general
hospitals by establishing agreed pre operative protocols.
• Maximize patient work up prior to admission and agree the schedule for

four:
each clinical scenario for example surgery for coronaries, mitral valve, aortic 4. Discharge and post operative care management
valve and combination. This has a beneficial effect on waiting times. • Manage variation in post operative clinical management practice.
• Train and support key clinical and managerial staff to deliver some of the • Manage variation in discharge patterns reducing length of stay.
work undertaken by junior doctors reconfigure services to develop • Start discharge planning at pre assessment to identify requirement for
opportunities for other health care professionals to widen their skills and support and home aids to reduce requirement for delayed discharge.
scope of relationship with patients. An example is the patient ‘navigator’ • Involve a range of health care professionals for example occupational
role which benefits patients and families by providing information and therapists in discharge planning at pre assessment particularly where
support following attendance at outpatient and pre assessment clinic. patients and in particular the elderly may have complex needs.
• Maximize the scope of extended practice for nursing roles working in pre • Discharge assessment should form part of the central patient record
operative assessment clinics functioning as part of the consultant led team available throughout the patient journey to all staff groups.
to streamline cardiac surgery patient care. • Move toward nurse led discharge.
• Maximize inclusion of different staff groupings for example anaesthetists
involved in pre assessment to ensure that all patients presenting for surgery
will be adequately assessed as this can reduce cancellation rates, improve
operating theatre efficiency and increase patient satisfaction. Note: The resources developed by these pilot sites are available
• Continue to provide information and support. through the web links and NHS Improvement system at:
www.improvement.nhs.uk/heart/sustainability



Access to surgery
The reductions in waiting times envisaged The need for non-medically qualified staff
by the NHS Plan are now a reality and in to play an even greater role in patients’
order to meet the expectations of shorter assessment and treatment is becoming
waits, the way in which patients are apparent as the effects of the reduction in
managed and referred from one junior doctors hours are starting to bite.
department to another as their treatment It is vital that training organisations work
progresses has had to improve. with trusts to ensure the workforce
continues to develop to ensure timely
As a result, the majority of units in the delivery of care in the future.
country have adopted a network-agreed
system of investigating and referring
patients on for further treatment, such as
coronary artery bypass graft (CABG).
The rapid progress of patients through the
system has been greatly facilitated by the
adoption of common protocols for
investigation and agreed timelines for
referral. Many of the steps in the
pathway are now overseen by specialist
nurse practitioners rather than junior
doctors and this has contributed greatly to
the efficiency of the process.



Elective pathways
Elective care refers to care that is Before cardiac surgery can be carried in advance of cardiac surgery, The detailed case studies included
pre-arranged (planned). Managing out a range of resources have to be including clinical examination, history here demonstrate their progress,
elective and emergency patient flows brought together at the right time taking, arranging radiological and outlining practical strategies for
from decision to admit to discharge and the right place: surgical staff, haematological investigations in continuous improvements in the
can prove challenging for nursing staff, anaesthetist, theatre accordance with Consultant or quality of care which has benefited
organisations as they work to deliver time, beds. Remove any one of these departmental guidelines. The patients in reducing delays, tackling
a number of national and local components and the operation has to development of new roles allows bottlenecks and enabled patients and
quality and performance targets be cancelled. The sharing of staff consultant time to be effectively freed carers to access clearer information
among them 18 week referral to and resources to support elective and up permitting more appropriate use alongside the achievement of targets.
treatment admitted pathways, four non-elective care treatment can place of surgeons’ time. (Staffing
hour A&E target and locally agreed an added stress to elective work as Cardiothoracic Units Developing a The dilemma of balancing both
reduction in length of stay and urgent cases should take precedence workforce for the 21st century. elective and non elective/emergency
interhospital transfer times. Yet resulting in cancellation of scheduled Livesey, S. Bartley, T. April 2007). work led some sites to adopt a whole
looking at the pathway of care from elective surgery causing frustration system approach to their quality
the patient’s point of view making it and delay felt by staff and patients Across the country project sites improvement work due to the
smoother, more accessible, less alike. However, as there is a showed wide variation in their knock-on effects of the provision of
complicated and less subject to delays permanent need to provide for non- achievement of admitted waiting non elective care to planned activity.
is necessary given the volume of elective care contingencies can be times and started their journeys to
patients who receive care. built into the system. improvement from differing baseline
positions based on local
With cardiac surgery often coming at Pre operative assessment ensures that circumstances. In understanding how
the end of a lengthy diagnostic the patient is as fit as possible for the patients flowed through their service
pathway the delivery of shorter surgery and anaesthetic and with a particular focus on referral
waiting times completed within 18 minimises the risk of late management services, pre admission
weeks is increasingly demanding. cancellations by ensuring that all provision, scheduling and post
Specialty beds often occupied by essential resources and discharge operative care management these
medical outliers and a lack of requirements are identified and essential facets have supported
intensive care beds due to coordinated. With appropriate achievement of continuous
emergencies or the clinical status of training nurses can effectively improvements in elective care
patients intensify the complexity of manage the care of patients referred pathways.
delivering smooth patient flows. to the pre operative assessment clinic



St George’s Healthcare NHS Trust and the South London Cardiac and Stroke Networks
Redesign of the cardiac surgery patient pathway reduces length of stay

The problem • Analysis of the theatre diary showed • A small number of patients treated at
In December 2008, the opportunity to cases rarely started on time and often St George’s travelled from Jersey –
take part in a National Priority Project overran. due to flight restrictions imposed by
prompted the St George’s cardiac • There was no policy for theatre the airline these patients were unable
surgery team to address how they scheduling. to fly home until at least ten days
might deal with some of their • Patients were given little notice of after their surgery. This resulted in
longstanding problems to help the unit their surgery date; often less than their stay in hospital being extended
perform at an optimum level, meeting one week. to ten days post surgery as opposed
both national and internal trust to usual routine of five days.
standards for issues such as length of 3.Electronic referral system,
stay, cancellations, and notice period of inpatients and interhospital 4.Admission on the day
surgery date for patients. transfer patients • In Q3 2008/09, only 10% of elective
• The electronic referral system, cases were admitted on the day.
Both the elective and non-elective adult primarily developed for the referral of • An admission on the day project for
cardiac surgical pathways had room for non-elective patients from district ‘second on the day cases’ had been
improvement, particularly within the: The issues included: general hospitals into the tertiary successfully piloted in 2006, but had
• pre-assessment service; centre (interhospital transfers) that not been sustained.
• management of length of stay, 1.Pre-assessment had been implemented in 2006 was
theatre cancellations and slot • During 2007/08 fewer than 60% of not being utilised. 5.Length of stay (LoS)
scheduling; elective cardiac surgery patients • Paper referrals made from referring • In Q3 2008/09, the average LoS for
• referral management processes attended the pre-assessment clinic. sites were frequently mislaid. elective patients was 8.8 days.
internally and from referring district • Anecdotally, this was contributing to • Little and inconsistent • In Q3 2008/09, the average LoS for
general hospitals. difficulties with planning patient correspondence between referring non-elective patients was 15.7 days.
admission, scheduling and sites and St George’s was common • LoS needed to align with the trust
Achieving and sustaining the 18 week anticipating date of discharge. place. target of elective patients being
target for elective surgery and the • Referring centres were unsure of the discharged on day five. Non-elective
requirement to meet the trust’s internal 2.Theatre scheduling work-up required for surgical patients LOS should also be reduced in
priority to reduce length of stay across • In Q3 2008/09, the average number resulting in patients often transferred recommendations with the NCEPOD
both the cardiology and cardiac surgery of non-clinical cancellations was 10% into St George’s unprepared for guidance.
care groups felt challenging. A review of all elective cases. surgery. • The cardiovascular division was
of baseline data, gathered using • These were commonly due to theatre • Length of stay was longer than required by the trust to make a saving
pathway mapping, demand and overruns and lack of beds. optimum for admission to referral, of 10 beds.
capacity analysis, and interviews with • Patients were often cancelled the day referral to transfer, transfer to
staff across their respective work area of before, or on the day of their surgery; treatment and treatment to discharge
the patient journey, highlighted a there was no cancellations policy to or transfer back to DGH.
number of system and process issues. prevent or support the decision.



The solution 3) Compliance with the national and Team members attended the national
A project team was established and local agenda including 18 weeks, cardiac surgery priority project peer

“
chaired by the unit’s general manager cancellation on the day and support meetings which inspired
with clinical and managerial reduction in length of stay. members to share existing good
Working together on this project membership including service 4) That the cardiovascular service is as practice within the unit and to develop
managers, heads of nursing, matrons, efficient and forward thinking as any solutions to challenges shared across
has brought the team together and clinical nurse specialists, clinical audit, other tertiary centre in the country. the peer group.
I’m so proud of what we’ve transformation project manger, 5) That the staff within the unit are
consultant cardiologist and cardiac proud to work in the unit and feel The new pathway featured:
achieved. We were all sceptical surgeon. Project management support valued and part of a team. • The pre-assessment of all elective
to begin with and I was was provided by the South West cardiac surgery patients by September
uncomfortable admitting we had London Cardiac and Stroke Network. Highlight reports were produced for 2009.
each team meeting and provided the • A theatre scheduling policy
problems with our service, but Baseline data was collected to identify mechanism for monitoring each introduced in October 2009,
hearing from other colleagues areas for improvement work. It was workstream against key goals, actions, including improving notice to patients
clear the project had developed into a risks and progress against timeline. of their date for surgery.
around the country reassured me whole pathway redesign and was Analysis of the data to show evidence • Regular monitoring of theatre
that we were not any different and subdivided into five key workstreams. of the improvements was supported by cancellations to reduce the number
Project team meetings were held every the trust transformation manager and non-clinical cancellations
we all had the same issues.
fortnight and leads were nominated for clinical audit staff members on the • Implementation of the use of
Working on this project with the each work-stream to be responsible for team. electronic referrals for non-elective
Network and the Heart the work. cases by January 2010.
The work was also informed by the • Implementation of admission on the
Improvement Team has encouraged A set of key values that reflected the analysis of qualitative data from patient day as normal practice.
us to start a similar project trust’s own strategic vision were agreed and carer diaries which were used by a • The recruitment of two additional
and integrated within the team’s vision number of patients and their family staff; a pre-assessment nurse and a
addressing issues in cardiology – established to deliver the improvement members from the time they attended cardiothoracic nurse practitioner:
we’re now looking forward to a work across the patent pathway: their pre-assessment, throughout their • Whilst these new posts required

”
similar success story! stay in hospital, and for a few weeks funding overall the project was cost
1) To ensure that all patients have after their discharge. neutral – as savings were gained
equal access to the service. due to the improvements made by
2) That the patient journey is safe and each work-stream, in particular,
Jane Fisher free from complications. reductions in LoS and cancellations.
General Manager



• Implementation of new discharge • Locum theatre manager in post. • Electronic referral system used for IHT 4. Admission on the day
planning for Jersey patients. • Annual/study leave booked a non-elective patients. • 2006 pilot reviewed.
minimum of six weeks in advance. • All in house and IHT non-elective • Admission on the day exclusion
Below is a summary of the work and • Consultants’ rota set at six weeks referrals addressed to ‘dear surgeon’ criteria agreed.
achievements in each workstream: ahead. and managed by cardiothoracic nurse • Policy agreed and signed by all
• Improved theatre start and finish practitioner, rather than to a named cardiology, cardiac surgery and
1. Pre-assessment times. surgeon. anaesthetic care groups.
• Reviewed demand and capacity • The notice period given to patients • All referrals also processed through • Commenced 31 July 2009.
within pre-assessment clinic. about their surgery date increased nurse practitioner, who then contacts
• Employed second clinical nurse from one week to three. referrer to confirm receipt and discuss 5. Length of stay (LoS)
specialists to increase capacity. • Outpatient referrals pooled for first work-up criteria. • Analysis of LoS compared with peers
• Converted all pre-assessment clinics time CABG to ensure equity of • Nurse practitioner liaises with and national standards was used to
to nurse only clinics. waiting times – this had an impact on pathway co-ordinator to arrange estimate where beds could be saved.
• Worked with admissions co-ordinator general 18 week waiting times. dates for surgery, keeping referring • The transformation project manager
to formalise process between • Implementation and enforcement of hospital informed. worked closely with each workstream
acceptance onto waiting list and theatre scheduling policy. • The matron and nurse practitioner to measure where LoS was saved.
admission to hospital. also worked with the Jersey Hospitals • Alignment of the project to the
• Developed patients information sheet 3. Electronic referral system, and staff at St George’s to develop strategic direction of the trust to
to explain process, now sent to all inpatients and interhospital transfer and implement a new discharge specifically save 10 beds increased
patients when added to the waiting patients routine for Jerseys patients – the team engagement at senior level.
list. • Cardiothoracic nurse practitioner post designed a clinically safe and practical
developed and recruited to. protocol to discharge patients on day
2. Theatre scheduling • Met with referring hospitals to discuss five to stay in a local hospital with
• Theatre lists published weekly, ten new cardiothoracic nurse practitioner regular nurse check-ups until day ten,
days in advance and with slots role, established direct contact of before flying home. This was done in
available for emergency or inpatient individual who would take collaboration with the Jersey referring
cases. responsibility for each referral. hospital, who were pleased with the
• Set up weekly MDT meetings to • Training sessions delivered to staff (at team’s dedication to safe practice and
review lists for following week and each site) on how to use referral clinical effectiveness.
identify possible issues/over runs/ system.
resources. • Electronic referral system used for in-
• Implementation and enforcement of house in-patients between
cancellation policy. cardiologists and cardiac surgeons at
St George’s.



The results Increase in admission on the day
The new pathway has resulted in: Theatre Scheduling - Cancellations (non clinical) from an average of 9.9% of cases per
The improvements have lead to an month in Q3 2008/09, to 24.6% of
20
overall increase in productivity – theatre Cardiac Network cases per month in Q3 2009/10.
project commenced
scheduling, increased pre-assessment 18
Cancellation policy implemented
and admission on the day, reduced This equates to 69 patients admitted on
16
cancellations and length of stay have all the day in 2009/10 to date; at £200 per

Number of cancellations
contributed towards an increase in 14 bed day this makes a saving of
Surgical pathway
activity by £103k to date. coordinator in place £13,800.
12
Rota set at Transformation
six weeks team involved
Reduction in non clinical 10
cancellations from an average of 8
10.1% of cases per month in Q3
2008/09, to 2.3% of cases per month 6
in Q3 2009/10. 4
Improved start/
finish times
2
AoD commenced
0
Apr08 Jun08 Aug08 Oct08 Dec08 Feb09 Apr09 Jun09 Aug09 Oct09 Dec09
May08 Jul08 Sep08 Nov08 Jan09 Mar09 May09 Jul09 Sep09 Nov09

Non-clinical (actual) Non-clinical (target) Linear (non-clinical actual)

Baseline figures Percentage of non-clinical cancellations

Mean Median Range

April - March 2008/09 8.3% 9.0% 3-15%
April 2009 - present 3.7% 4.0% 1-7%
Oct - Dec 2008/09 average 10.1% 10.3% 5-15%
Oct - Dec 2009/10 average 2.3% 1.9% 1-4%



Reduction in length of stay for elective cardiac surgery patients, reduced from
Admission on Day of Surgery an average of 8.8 days in Q3 08/09, to 7.6 days in Q3 2009/10.
60

Length of Stay - Elective Cardiac Surgery
50
11
Surgical pathway Cardiac Network
coordinator in place project commenced
40 10
Percentage

Transformation Surgical pathway
team involved coordinator in place

30 9
Transformation
Cardiac Network team involved

Days
project commenced
8
20

7
10
AoD commenced 6
AoD commenced
0
Apr08 Jun08 Aug08 Oct08 Dec08 Feb09 Apr09 Jun09 Aug09 Oct09 Dec09 5
May08 Jul08 Sep08 Nov08 Jan09 Mar09 May09 Jul09 Sep09 Nov09 Apr08 Jun08 Aug08 Oct08 Dec08 Feb09 Apr09 Jun09 Aug09 Oct09 Dec09
May08 Jul08 Sep08 Nov08 Jan09 Mar09 May09 Jul09 Sep09 Nov09
% CS AoD (actual) % TS AoD (target) Linear (% CS AoD)
Cardiac Surgery Elective LoS Linear (Cardiac Surgery Elective LoS)

Baseline figures Percentage of admitted on the day Baseline figures Length of stay for elective cardiac surgery

Mean Median Range Mean Median Range

April - March 2008/09 8.5% 8.0% 1-15% April - March 2008/09 8.8 8.8 8-11 days
April 2009 - present 20.9% 21.1% 10-31% April 2009 - present 7.4 7.7 6-8 days
Oct - Dec 2008/09 average 9.9% 7.7% 2-20% Oct - Dec 2008/09 average 8.8 8.3 8-9 days
Oct - Dec 2009/10 average 24.6% 25.0% 19-30% Oct - Dec 2009/10 average 7.6 7.8 7-8 days



Reduction in length of stay for non-elective cardiac surgery patients, from an Top tips b.The core team held the five points
average of 15.7 days in Q3 2008/09, to 13.3 days in Q3 2009/10. 1. Engagement at senior level and outlined as a shared vision of
alignment of the project to the change, and worked together to
strategic direction of the trust achieve these goals.
specifically saving 10 beds. c. As well as for planning purposes,
Length of Stay - Non-Elective Cardiac Surgery
2. Regular reporting to senior the team meetings were important
23 management supported by robust for boosting morale for when the
21 data across a defined set of work was facing opposition or
Cardiac Network
project commenced measures agreed early on in the difficulties.
19 project to ensure focus. d.As a result of the project,
Surgical pathway
coordinator in place
17 3. Access to data. A member of the relationships and communications
team with access to data was vital to throughout the team and across
Days

15
measuring improvement as the the pathway boundaries have
13 network project manager struggled been improved.
11
to gain access to data, being 5. Keep in the forefront that
perceived as an ‘outsider’. The improvement does not need to come
9
Transformation internal data manager was able to at a financial cost – but that by
team involved AoD commenced
7 retrieve and analyse data shared working more efficiently and more
Apr08
May08
Jun08
Jul08
Aug08
Sep08
Oct08
Nov08
Dec08
Jan09
Feb09 Apr09
Mar09
Jun09
May09 Jul09
Aug09 Oct09
Sep09
Dec09
Nov09
across the project team to drive the productively, patients can receive
work. better care that is value for money.
Cardiac Surgery Non-Elective LoS Linear (Cardiac Surgery Non-Elective LoS)
4. Interdisciplinary core project team
was reflective of the key staff vital to Contact details:
implementing and maintaining Jane Fisher,
changes being tested. General Manager, Cardiovascular,
Baseline figures Length of stay for non-elective cardiac surgery a. The core team consisted of the St George’s Healthcare NHS Trust
lead for each work stream; these Jane.Fisher@stgeorges.nhs.uk
Mean Median Range individuals were the people who
would plan and measure the Laura Gillam,
April - March 2008/09 15.5 15.4 10-21 days Senior Project Manager, South London
changes – they were the people
April 2009 - present 13.2 13.3 10-16 days who could really make a Cardiac and Stroke Networks.
difference. Laura.Gillam@slcsn.nhs.uk
Oct - Dec 2008/09 average 15.7 16.0 14-17 days
Oct - Dec 2009/10 average 13.3 13.1 12-15 days



University Hospitals Birmingham NHS Foundation Trust, Heart of England NHS Foundation Trust
and Birmingham, Sandwell and Solihull Cardiac and Stroke Network
Ensuring patients are fit for surgery and reducing delays in the cardiac surgical patients pathway

The problem clinics and with some patients attending
Achieving the national target of 90% of a further appointment at pre-
admitted cardiac surgery patient assessment clinic. The pre-assessment
pathways being completed within 18 clinic workforce did not have the
weeks was proving a challenge across required skills to support a full
organisations within the Birmingham, assessment, including history taking,
Sandwell and Solihull Cardiac and patient examination and assessment.
Stroke Network. One of the most Therefore, an SHO was required to
common delays in the patients’ review all patients.
pathway at Good Hope Hospital was
the time between angiography and case Attendance at pre-assessment clinic was
review by the multidisciplinary team often more than four weeks before the
(MDT). On average the wait was four date of surgery which resulted in the
weeks but at it’s longest nine weeks, need to duplicate chest x-rays and
particularly if the MDTs were cancelled. blood tests on admission. This created
Surgeons from the tertiary centre were unnecessary expense to the Trust and There was also some pressure to reduce A patient progress tracker was
required to travel across the city to inconvenience to the patient the overall length of stay and improve appointed by the network to track the
attend the MDT meetings held at the efficiencies in the patient pathway, as patients through their journeys using a
referring provider centre to review There was no anaesthetic service in the the tertiary centre is reducing its overall live database to help map the pathway
individual cases requiring surgical pre-assessment clinic, resulting in number of beds on the cardiac surgical and identify delays in the journey.
opinion. Clinical commitments often clinical problems often identified late in ward from 39 to 32. Tracking patient pathways also helped
meant that attendance at these MDTs the patient pathway; on admission to to demonstrate that patients sometimes
was not possible. Not all patients were the tertiary centre problems had been The solution attended more than one surgical/
discussed at MDT and the process of identified following assessment by the A surgical steering group was set up cardiology appointment.
ensuring that patients were fully anaesthetist. This often resulted in the which included cardiologists
worked up for surgery prior to referral patient being declared unfit for surgery representing the tertiary centre and A new pathway to support the
to the MDT was not supported by an and the operation cancelled. The clinic district general hospital, a cardiac achievement of 18 weeks was
agreed protocol. was not working to full capacity, flow of surgeon, an anaesthetist, management developed and agreed by all key
patients through the clinic was low and representation from both trusts, a stakeholders. Baseline data was
The system of ensuring patients were a review of the pre assessment services cardiothoracic nurse practitioner and collected to help define the problem
fit for surgery was characterised by illustrated that not all slots were being tertiary centre cardiac audit clerk. The and scope of the project.
inconsistency and variation across the fully utilised. Birmingham, Sandwell and Solihull
surgical teams with pre-screening not Cardiac and Stroke Network provided
carried out in all surgeons’ outpatient project management support.



The project objectives were: potentially adding weeks to the
• Introduction of weekly electronic pathway and unnecessary waits for
Cardiac Surgery Pathway - RTT 18 Weeks
MDTs using: the patient.
• telemedicine to allow the transfer 2 WEEKS 5 WEEKS 2 WEEKS • An increase from 0% of patients
of images between referring units Referral Received in Rapid Access Diagnostic MDT (referral previously reviewed by an anaesthetist
and the tertiary centre; Rapid Access Chest Chest Pain Clinic Tests to tertiary in pre-assessment to72% over a short
Pain Clinic Appointment centre)
• teleconferencing between the period of time. We are working
referring consultant cardiologists 9 WEEKS towards 100% of patients being
and tertiary centre surgical teams assessed by an anaesthetist in pre
Surgical Diagnostic Pre-Assessment Cardiac Surgery
for the purpose of weekly MDT Outpatient Tests Clinic
assessment clinic.
case review. Use of technology was Appointment • Clinic nurses undergoing practitioner
thought capable of reducing MDT training to enable implementation of
Secondary care to tertiary care - 9 weeks
cancellations and increasing the Tertiary care to definitive treatment - 9 weeks
a cardiothoracic advanced nurse
number of patients discussed at practitioner role in the pre-assessment
MDT; clinic and to help address demands
• introduction of a pre-referral on clinical service brought about by
protocol to ensure patients are fully Progress • Development of the pre-referral EWTD.
worked up prior to referral to the The tertiary centre has four core protocol to support the referring • Capacity at pre-assessment clinic has
tertiary centre. purposes. Therefore, it was imperative cardiologist. This will ensure that all increased from approximately 12 to
• Redesign of the pre-assessment that any project undertaken to improve the required information is available 30 available slots per week, resulting
process with patients: services should be underpinned by the at the point of referral including in increased activity. This has been
• attending the clinic no more than following four principles. presenting history, past medical achieved by increasing the number of
four weeks before the date of history and a summary of appointments, and reducing time pre-
admission for surgery at the tertiary i) Excellent patient care investigations and outstanding assessment staff spent on
centre; ii) Clinical quality outcomes results. It also specifies the indications administration duties, to enable them
• being assessed in pre-assessment iii) Research and innovation for undertaking core investigations to focus on clinical duties.
clinic by a cardiothoracic advanced iv) Education and training. such as trans-thoracic echo, carotid • Telemedicine system is in the process
nurse practitioner and an duplex scans and lung function tests. of being installed.
anaesthetist to ensure they are fit These have been achieved in the Implementation of this protocol will • Development of a patient
for surgery on admission to the following ways: ensure all necessary investigations are questionnaire survey to gather an
tertiary centre, with a view to completed before referral to the understanding of the patients’
reducing the cancellation rate and tertiary centre, reducing the risk of experience from referral for cardiac
optimising use of inpatient beds. the patient being referred back to the surgery to admission for surgery.
DGH for the tests to be undertaken,



Top tips Contact details:
• Mapping the existing pathway is Emma Billingham
essential in understanding timelines Group Manager
and delays in the system.

“
University Hospitals Birmingham
• Strong clinical leadership (cardiology NHS Foundation Trust
and cardiac surgeons). emma.billingham@uhb.nhs.uk
University Hospitals Birmingham is still in the process of fully rolling out • Obtain baseline data to identify if a
problem exists and build in robust
the project. However, we have already seen benefits to patients with the data collection mechanisms to
expansion of pre-assessment and pre-screening clinics as well as the support improvement work.
• Understanding the funding
development of anaesthetic-led pre-assessment clinics. We look forward implications and identifying who is
to receiving comments from patients about their pre-operative pathway going to fund what (things like
annual service costs for a piece of kit
so that we can evaluate our success so far and identify any further etc) as early as possible in the project
improvements to be made. We also welcomed the opportunity to work to avoid issues later on.
• Develop a communication plan to
with a local referring cardiology centre to identify bottlenecks in the facilitate the dissemination of project
patient pathway and are currently working to resolve these. information to all admin and
clerical/managerial and clinical staff
involved in the pathway as this helps
I feel the project group has benefitted from networking with other to foster support and buy in to the
centres who have identified similar issues and we have learnt from improvement work making it
everybody’s business.
their experiences how to overcome these to ensure the overall • Bringing together key stakeholders

”
success of the project. from the referring provider unit and
tertiary centre together to identify
issues and problems and develop joint
solutions.
• Understanding the patient/carer
Emma Billingham, Group Manager experience is fundamental to the
success of any quality improvement
work.



Royal Brompton & Harefield NHS Foundation Trust in collaboration with North West London Cardiac and Stroke Network
Process changes significantly increase 18 week performance in cardiac surgery

Overall there was a considerable amount These meetings also highlighted
of incomplete data on the inpatient concerns around how the IPTMDS forms
waiting list (KH07). The position of were being completed. These
patients along their 18 week pathway discussions resulted in a revised surgical
was not known due to clock starts being patient pathway and process changes
found/given/used too late. Data flow of featuring:
patients after going on KH07 was not
recorded accurately. These • Patients seen at the pre-operative
inconsistencies meant that Royal assessment clinic (POAC) being
Brompton & Harefield NHS Foundation declared ‘fit for surgery’ before being
Trust had little chance of achieving the added to the surgical waiting list.
18 week admitted referral to treatment • Agreed and standardised use of the
pathway target. 18 week suite of rules across referring
The problem • Clinic outcomes were often not providers and the tertiary centre.
The trust performance for referral to documented following the patients The solution • Inter-trust contacts for administrative,
treatment pathways for cardiothoracic attendance at the pre operative The trust employed 18 week clerical and nursing staff were
surgery, within 18 weeks between assessment clinic (POAC), a crib sheet co-ordinators to assist the 18 week exchanged so that in future clock
April - August 2008 had remained was developed for the clinic staff to project manager and received project start requests were sent to the right
consistently below the 90% national show what rules can/cannot be management support from the North people.
target, sitting in the low 30-50%. A applied in different situations. West London Cardiac and Stroke • Support and training on application
review of the elective surgical pathway • 18 week clock stops were not always Network to focus on the cardiac surgery of the 18 week rules for key admin
for planned care illustrated the following used appropriately, for example pathway. personnel and nursing leads of the
issues: patients requiring referral for pre-assessment service to help reduce
conditions on a new clinical pathway The surgical pathways were mapped variation and ambiguity in their
• Patients were typically added to the such as haematology often resulted in from the point of referral made by the application.
surgical waiting list before they had an inappropriate continuation of the secondary care provider through receipt • Patients at other trusts who were
been assessed and declared ‘fit for 18 week clock. of referral to treatment by tertiary care under investigation were recorded on
surgery’ which resulted in extended • These patients were not recorded on centre which helped to identify RBHfT PAS as ‘active monitoring’,
wait times for definitive treatment a central list and were at risk of bottlenecks in the surgical pathway. effectively stopping the clock on their
well beyond 18 weeks. getting lost ‘in the system’. cardiac surgery pathway. The cardiac
• The understanding and application of • A number of patients had already A series of meetings with the referring nurse practitioners would follow the
the 18 week suite of rules varied breached their 18 week pathway by trusts and the tertiary centre helped gain progress of the patient through their
among staff within administrative, the time the referral was received by a common understanding of how to appointments and tests ensuring that
clinical and managerial roles at the the tertiary centre, this was partly due apply the 18 week rules suite and there were no unnecessary delays,
tertiary centre and referring providers. to the accompanying Inter Provider develop a shared agreement for applying once declared fit for surgery they
Transfer Minimum Data Set (IPTMDS) clock-starts and stops across providers. would be added to the waiting list.
form being incomplete or incorrect.


• Redesign of the clinic outcome form week rules and how to apply them Comparative data of performance for a four month period year on year
with fields developed to show a range effectively.
of scenarios and how the clock rules • There has been an improvement in
apply. both the number of IPTMDS forms April - August 2008 Performance
• The integrity of data on KH07 was sent through and their data
closely monitored. Appropriate and completeness. Apr May Jun Jul Aug Average
effective data management and • Improved communication between
communication significantly improved staff has also helped reduce delays in Wexham Park 71% 80% 79% 44% 50% 64.8%
the accuracy of the data used to referrals, transferring and sharing of Lister 60% 66% 41% 46% 12% 45%
monitor performance. information and the booking of
• Where possible clock starts were appointments. Luton and Dunstable 0% 16% 20% 25% 21% 16.4%
found prior to booking POAC. The
18 week database was used by pre-
Top tips
operative administrative staff to plan April - August 2009 Performance
• Communication between providers
the patients clinic attendance date in
and across staff groups including
line with trust targets and appropriate Apr May Jun Jul Aug Average
administrative and clerical, clinical and
to breach date.
• Through discussion over the 18 managerial is key to ensuring full
Wexham Park 86% 100% 97% 100% 96% 95.8%
week rules and the use of medical understanding of the 18 week rules
management it transpired that and effectively applying them. Lister 70% 88% 74% 70% 86% 77.6%
referring trusts treat the majority of • Developing and strengthening
Luton and Dunstable 100% 92% 86% 84% 96% 91.6%
their patients before referring working relationships between the
them on. cardiac nurse practitioners and the
surgical medical teams helped pool
Results the expertise to support a full • A thorough understanding between Contact details
• By December 2008, the trusts 18 pre-operative assessment clinic. how the information systems and Gemma Snell
week admitted performance met the • Access to the 18 week co-ordinator operational processes correlated by Service Improvement Project Manager
minimum 90% which continues to be contactable by bleep increases their the 18 week co-ordinator had a huge North West London Cardiac and
sustained, often peaking above the accessibility for staff to flag queries impact on improving data quality and Stroke Network
95% target. Pro-active tracking of and problems regarding interpretation hence performance issues. Email: gemma.snell@nhs.net
patients along their pathway has of the rules. • Building relationships and improving
ensured there have been no • Meeting regularly with teams along communication channels with
unwarranted delays. the surgical pathway for example the referring trusts had a considerable
• There has been a far greater theatre scheduler who booked impact on improving performance as
understanding within the hospital staff elective and non-elective cases, there was a sense of shared
and between referring trusts of the 18 helped reduce avoidable delays. responsibility.



Essex Cardiothoracic Centre, Basildon and Thurrock University Hospitals NHS Foundation Trust
in collaboration with Essex Cardiac and Stroke Network
Tackling change - the teamwork way

The problem 1.Collegiate system for review of
The Essex Cardiothoracic Centre (CTC) is patient referrals.
a relatively new unit which opened in 2.Process for allocation of ‘pooled’
July 2007, with many of its clinical patients to consultant surgeons
pathways and their supporting systems resulting in longer waiting lists for
and processes having been developed certain procedures.
early in the organisations history. The 3.Pre-assessment clinic not working to
trust faced challenges with meeting its full potential due to the skills of
the national target of 90% admitted staff carrying out the clinic.
pathways completed within 18 weeks of
referral to treatment with performance Baseline audit of the current service was
often running between 30-40%. carried out in relation to theatre
Review of the surgical pathway was cancellations and theatre day/time. An
seen as paramount to the continued audit tool was developed which allowed
success and growth of the unit, all sections of the theatre to be
evidenced by internal audits that had measured, for example time taken to
identified areas for development and call for patient, time in anaesthetic
improvement. room, knife to skin time. This audit
• Patients often needed to make more The solution helped to identify timing delays and
The elective cardiac surgery pathway than one visit in the pre operative A Surgical User Group (SUG) was identified sections of the theatre day
was seen as a key area of focus to part of the surgical pathway as a established with members drawn from where improvements to efficiency could
review systems and processes in the result of surgical outpatients and across the multidisciplinary team to be made in order to optimize theatre
following areas of the pathway: pre-operative assessment clinics spearhead the development of the usage and reduce surgical cancellations
(POAC) being held separately. surgical service. An action plan with as a result of clinical and non clinical
• Surgical collegiate system, a process clear timescales was produced, the matters. The picture of theatre
of clinical review to ensure correct ECTC were able to focus on problems current service was discussed and ideas cancellations was broken down into the
procedure and surgeon determined several audits were carried out which generated for future developments and following:
for all cardiac surgery referrals, carried identified areas where improvements improvements planned. All changes to
out by surgeons prior to the patient were required in order to streamline the the service were approved by the SUG. • Interhospital transfer patients
attending an outpatients’ appointment. service, improve patient experience and Additional project support was provided received at the unit were often not
Challenges in sustaining the collegiate improve efficiency and effectiveness. by the Essex Cardiac and Stroke fully optimised.
system, based on two surgeons The unit were keen to maintain high Network. • Unfit elective patients.
reviewing each referral on a bi weekly patient satisfaction levels whilst • Anaesthetic cove.r
basis, were related to ‘buy in’ and maximizing the use of in patient beds Mapping of the current pathway • Availability of intensive care beds.
agreement from the surgical teams. and theatre utilisation. highlighted issues with: • Theatre over-runs.



A retrospective audit of 40 case notes • Improve 18 week referral to treatment • Reduction in unnecessary duplication Contact details:
was carried out across six consultant times for admitted pathways. of tests. Tests performed at POAC, Jenni Brown
surgeons during a three month period – • Improve efficiency within theatre day. CXR, blood tests and ECGs now Matron, Essex Cardiothoracic Centre -
this illustrated the problem of delay remain valid from time performed Basildon and Thurrock University
patients experienced between being The new service now provides: until admission into ECTC. Hospital NHS Foundation Trust
seen in pre operative assessment clinic • Same day outpatient clinic and pre- • Reduced waiting times for cardiac Jenni.brown@btuh.nhs.uk
(POAC) and their admission for surgery assessment. surgery from nine weeks to six weeks.
which often resulted in tests being • Dedicated lead pre-assessment nurse. • Timely POAC to admission has
repeated, an unnecessary expense to • Forum for monitoring and auditing reduced length of stay by one day for
the Trust. The case note audit measurables to improve service. some groups of cardiac surgical
highlighted in some cases the time • Same day admission for cardiac patients with same day admission.
interval was 10 weeks between POAC surgery.
and admission for surgery which • Super multidisciplinary team (MDT) for Top tips
invalidated the tests necessitating them review of complex cardiac surgery • Working together in a
to be repeated on admission. cases with joint cardiology and surgical multidisciplinary team and
assessment of the patient presented. collaborating with key stakeholders
Understanding our cardiac surgical within ECTC and with referring
pathway by using service improvement Results District General Hospitals (DGHs)
techniques and data helped us to 18 week admitted pathways are now meant everyone understood each
identify service improvements and areas performing consistently at 90% as a others perspectives.
where patient experience could be result of: • Engagement with staff across a range
improved. • Improved working relationships and of disciplines and at all levels
MDT working have developed as a including consultant surgeons,
Our overarching aim was to: result of the involvement of all anaesthetists, nurses, perfusionists
• Reduce the time frame between disciplines within ECTC as a result of and management team.
attendance at pre operative the development of Surgical User • Strong leadership and senior
assessment clinic and admission for Group. management support.
surgery by four weeks. • Reduction of in -hospital theatre • Schedule meetings to meet the needs
• Reduce theatre cancellations to cancellations from 20% to 10%. of all disciplines to ensure attendance.
below 10%. • Reduction in wait from pre operative • Production of robust data collection
• Reduce waiting times from nine assessment clinic (POAC to admission and analysis to support the project,
weeks to six weeks for cardiac for elective cardiac surgery from nine drive key changes and ensure the
surgery. weeks to six weeks. work remained focused.


A guide to commissioning cardiac surgical services

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A guide to commissioning cardiac surgical services