Aims and objectives:
Nottingham City Hospital is the only Coronary Heart Disease tertiary centre within the Trent Network serving a population of 1.2 million and has seen a Sharpe increase in demand for non elective work. In addition, faced with meeting the challenge of reducing the wait time for elective work to 3 months by March 2005, the specialty did not have a structure or process to manage the scheduling of the work to meet this demand. The role of a Nurse Practitioner was redesigned to develop the system and processes to manage the non-elective demand without compromising the elective workload. The key objectives were:
Develop a system and process for access at a central point.
Reduce the tertiary transfer wait time.
Reduce the wait time from transfer to procedure being carried out.
Streamline the process to eliminate administrative delays.
Increase capacity utilisation with no increased resources.
Produce an accurate scheduling framework for all elective and non-elective workload.
The project has contributed towards the Trust being able to meet national waiting times targets for coronary intervention and the local target for non-elective work.
Support for the change:
The process change has been driven from within the Cardiology specialty with support of the Lead Clinician for CHD services, Service Improvement manager and the Coronary Heart Disease Collaborative. Methodologies and techniques were brain-storming, non-elective data collection and analysis using statistical process control charts, Plan-Do-Study Act cycles and flow charts, plus process mapping. Fundamental elements to the success of the work involved the key people within the Trust, but also meeting with Lead Clinicians within the referring Centres across the CHD Network.
Patient and public influence:
The project team worked with the CHD Network and local commissioners in encompassing the needs of patients and service users by developing local flow charts and targets. A more recent approach (particularly as Nottingham City Hospital is preparing to move into a new build) has been to further develop the needs of the patients by using patient discovery interviews.
Measuring the results:
Data collection has enabled us to gather the information to give an understanding of the variation in demand pre- and post-implementation to evidence benefits. Data (SPC), written reports and presentations have been presented to the Trust's Clinical Strategy Committee and Integrated Service Improvement Programme Board, as well as through the directorate framework and clinical Network forums.
National data is available for comparison through the CHD Networks.
Improved performance:
Data from the National Interhospital Transfer Audit Summary shows that the average wait from admission to intervention for the Midlands was 18 days in March 2004. Local data suggests an average wait of 4.9 days to transfer and a further 1.8 days to procedure (6.7 day total)
Waiting times for the elective workload have not suffered in that the average wait time for intervention is 4 months. Further capacity modelling through 'checklist' has shown that a continuation of the current activity levels will result in achievement of the 3 month waiting time target for revascularisation.
With no increase in workforce including interventionists and a net decrease in dedicated beds, the service has seen a substantial growth in interventional procedures (661 in 2003/2004 against a forecast of 950 for 2004/2005) of 44%.
Reflecting diversity:
By utilising all available data from patients and working with the Coronary Heart Disease Network and local commissioners, we have been able to base the change in response to local need. As the project meets the strategic direction for the local health community it then also complies with needs of the population served.
The specialty will continue to utilise the information gained through Discovery Interviews as a tool to reflect upon our current patient and carer experience in the Trent region. This will enable us to manage this dynamic service in the future.
Sharing the learning:
Using spread strategy, this project development has been reported through the Coronary Heart Disease Collaborative reporting system - Rapport.
Internal data collection has been shared with major stakeholders through the Network Clinical forum as well as to the Trust Board internally and the Strategic Health Authority.
Outstanding features:
Some of the issues and challenges that have been highlighted in this short submission document may not tell the reader the full story in that this problem has been complex. The outstanding feature overall has been that the service providers have aspired to "raising the bar." This has been the lever to challenge and work with working patterns across traditional boundaries.
