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Executive Summary

The Impact of Supply Chain Transformation in Health Systems Case Study: National Health Service, England Dr. Anne Snowdon RN, BScN, MSc, PhD, FAAN Chair, World Health Innovation Network Scientific Director & CEO, Supply Chain Advancement Network in Health Odette School of Business University of Windsor

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Executive Summary Introduction This case study is one of a series titled The Impact of Supply Chain Transformation in Health Systems. The following case study examines the implementation of a transformational supply chain strategy across the National Health Service (NHS) in England. This case provides an overview of the progress, leadership strategy, outcomes and impacts of supply chain transformation in six demonstrator site NHS Health trusts (trusts). Foundational is the strategy established by Secretary of State Jeremy Hunt to transform the NHS into the world’s largest learning organization, focused on transparency by reporting safety and quality outcomes across the continuum of care, from primary to acute care trusts and the community.

NHS England Supply Chain Strategy In April 2014, the Department of Health published the NHS eProcurement Strategy (later renamed Scan4Safety), mandating all trusts to adopt GS1 global standards to automate and standardize supply chain processes, as well as Pan European Public Procurement On-Line (PEPPOL) standards to enable digitizing transactions, such as the machine-tomachine exchange of data between trusts and their suppliers. Six demonstrator trusts were selected. The sum of £2 million was provided to each trust to implement the Scan4Safety program. The program began by identifying every room location with a GS1 barcode and every product in inventory with a global trade item number (GTIN) and introducing GS1 barcodes on patient identification bands. These core enablers created the infrastructure in clinical settings to demonstrate three prescribed-use cases: (1) tracking and traceability of all products from manufacturer to patient, (2) automated purchase-to-pay transactions between the trust and its suppliers and (3) an automated capacity to remove products from inventory in the event of a recall. The majority of trusts initiated point of care scanning in high-cost and high-risk clinical settings, such as surgical theatres, cardiac catheterization labs, diagnostic imaging and interventional radiology.

NHS Supply Chain Implementation Strategy The NHS structured a franchise model, based on system-level adoption of GS1 global standards and PEPPOL standards. Implementation is being driven through the NHS eProcurement Strategy – Scan4Safety. Six demonstrator sites were selected as beta sites to fast-track implementation and create opportunities for learning. Each hospital trust is guided by the Scan4Safety strategy based on three enablers and three use cases. The three enablers include patient identification, product identification (GTIN) and global location number (individual room) identification (GLN). The use cases that must be demonstrated include: inventory management, automated replenishment and product recall, in order for funding to flow to each demonstration site. To date, they have implemented point of care scanning in surgical theatres with plans to scale to all clinical

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areas. Phase 2 implementation to another 25 hospital trusts is expected to commence in spring 2018.

Findings Return on Investment (ROI) and Impact of the NHS, England Supply Chain Strategy: The evidence of impact and ROI demonstrated in this case study reveal remarkable progress toward achieving the vision of Secretary of State Hunt: “Making the NHS the safest and most transparent healthcare system in the world.” The Scan4Safety program has established the infrastructure necessary to automate traceability of each product, patient, staff member, care procedure and location of care. Trust teams have achieved greater efficiency and productivity, automation of inventory and product recall processes and full integration of supply chain processes in clinical care settings. Integration of tracking and traceability has enabled full transparency in documenting which patients receive care, from which provider teams, and when and where care is provided throughout the patient journey, linked to outcomes for quality, safety and value for patients. Leadership Strategy—the Driver of System Transparency: The leadership strategy underpinning this case reflects the mandate of publicly funded healthcare systems. Political leaders are accountable to the public for ensuring the delivery of safe, accessible and high-performing health services that achieve value for citizens. In this case, the strategy focused on creating transparency in the NHS system. Transparency is envisioned to enable learning from medical error or adverse events to strengthen quality, safety and accountability in the health system. There is also ample indication of the Scan4Safety program’s capacity to enable a data-driven, evidence-informed health system that links product performance and clinician practice to safety and patient outcomes. System Transparency—the Foundation for Accountability: The key leadership motivation is the government’s accountability to British citizens for safe, high-quality care and confidence in their health system. The transparency generated by the Scan4Safety infrastructure creates a platform to support clinician accountability for safe practice and quality, health system accountability for supply chain efficiency and safety, and supplier accountability for accurately identified products enabling traceability from manufacturer to patient outcomes. The integration of the supply chain data infrastructure with clinical information systems enables a highly cohesive digital infrastructure that generates transparency of every patient, every product used in care processes and accurate case costing, all linked to patient outcomes. This infrastructure produces objective data that, when analyzed, becomes knowledge and evidence to inform clinician practice, operational decisions, supply chain management forecasting and accountability of suppliers to provide trusts with product information that supports safe and effective patient care.

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Clinician Accountability: Transparency arises from system infrastructure that creates objective data and evidence of the care that is delivered, by whom, for which patients and under what conditions. Data emerges in clinical settings, in near “real-time,” to enable clinical programs, such as the surgical theatre, to objectively measure variation in surgeon preference, surgical practice (operating time) and cost. In each of the trusts, the data is leveraged to identify opportunities to reduce variation, eliminate waste from products that are discarded or never used and inform best-practice standardization. The data is also used by program and supply chain teams to inform staff and clinicians with evidence of outcomes. The transparency of data-informed strategies enables clinicians to streamline clinical processes, reduce product and preference tray costs by removing waste and standardize high-cost products informed by value outcomes for patients. Supply Chain Team Accountability—Return on Investment (ROI): Supply chain teams across the trusts are able to account for which products are purchased and at what price, informed by utilization and care demands to ensure that products are available when and where needed for patient care. The return on investment that emerged is an outcome of inventory savings from managing product waste and minimizing variation. Inventory savings achieved a 4:1 ROI, exceeding the Department of Health’s projected outcomes. Each trust demonstrated an average savings of £2.4 million, realized from operational efficiencies and clinician time savings, redirected from managing supply chain processes to patient care—on average, the equivalent of 16 full-time equivalent (FTE) staff per trust. The Department of Health plans to implement the Scan4Safety program in all 154 trusts. It is anticipated that this program will yield £1,034 billion in savings by year 7. The return on investment would suggest that it may be possible for the Scan4Safety program to be “self-funding.” Trusts may be able to generate the savings from inventory management to fund the implementation and scale of the program without further government investment. Supplier Accountability: Suppliers of products to the NHS must now adopt global standards to communicate accurate information about products in order to enable successful scanning at the point of care. When a product barcode cannot be successfully scanned in a surgical theatre, the case is delayed and the surgeon is directly affected by the inaccuracy. The impact of inaccurate barcodes on both supply chain teams and surgical team outcomes is a powerful motivator to engage and hold suppliers accountable for barcode accuracy. Supplier adoption of global standards and data accuracy is identified as a “rate-limiting step” to achieving the Scan4Safety deliverables, and a very significant accountability that suppliers must demonstrate in order to continue to sell products to the NHS.

Conclusion Implementation of the three core enablers resulted in significant reduction in product waste, and clinician time was released and redirected to patient care. Transparency may be the new currency that achieves an accountable, continuously learning, safe and sustainable health system—one in which decisions are informed by real-world evidence

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that is foundational to accountability of clinical teams working with supply chain teams to support the delivery of the best patient care. The NHS case demonstrates impressive findings of the opportunity to leverage supply chain transformation to achieve transparency. This transparency, in turn, drives accountability that incentivizes rapid and highly impactful change in health systems. This case demonstrates the importance of transparency in creating the foundation for system accountability informed by data and evidence. The data and evidence contribute to enhancing system efficiency, improving safety and quality of clinical care and real-world evidence of product and process performance linked to patient outcomes. The outcomes of this case reflect the early implementation of the Scan4Safety program infrastructure in highly specialized, high-cost settings, such as surgery and cardiac programs. As the program scales, further evidence of the impact and the value of system transparency and accountability can be empirically examined. Building the evidence and documenting the key lessons learned will inform global health systems of the value, impact and capacity of a highly transparent health system to enable improved clinical decision-making, proactive risk-reduction, improved safety and quality of care, and enhanced system performance that achieves value for the population served.

Produced by: Dr. Anne Snowdon, Academic Chair, World Health Innovation Network, and Scientific Director & CEO, Supply Chain Advancement Network in Health, Odette School of Business, University of Windsor Original release date: February 2018 World Health Innovation Network T: 519.253.3000 x6336 E: winhealth@uwindsor.ca Windsor, Ontario