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SCANH Virtual Case Competition: Second Round


Inter-professional Education For Quality Improvement Program



Introduction 

Core values of the NHS facilitate optimal quality of care and makes it a top healthcare system performer world wide

Francis report: 400-1200 patient deaths from 2005-2008  Poor

decision making and cost cutting

Scan4Safety Initiative proves as a promising solution


Agenda (may modify order) 

Goals and situation

Evaluation of alternatives

Comprehensive implementation plan

Scalability plan


Goals & Objectives     

The DH has mandated that all NHS health trusts adopt global GS1 supply chain standards & PEPPOL standards: 3-5 years “Scan4Safety” Initiative January 2016 - March 2018: Implementation at 6 Trusts, at the cost of 2 million Pounds CURRENT: DH wants expansion of Scan4Safety from 6 Trusts → ALL 148 Trusts Opportunity: For worlds most transparent healthcare system, among patient safety and care improvements, and cost reductions


Goals & Objectives 

Overall Goals of Implementation of the Scan4Safety Initiative:

Return on Investment (ROI)

4:1 return of actual savings from investments

Approx. £1,034,000,000 in savings by 7th year, if scaled to 148 Trusts and savings are recurring

Patient Safety & Care 

Decrease ‘Never’ events: Tracking healthcare consumables & all points of care

Culture shift: from reactive to proactive in eliminating expired products before use in patient care

Staff Impact 

Increase in available clinical time, decrease in time spent with paperwork

Increase job satisfaction….decrease healthcare professional burnout

NHS Reputation 

Strive to be transparent & a leader among healthcare systems


Goals & Objectives 

Goals to Implement Scan4Safety Initiative:

Full tracking of:  All

people (patients, healthcare professionals)

 All


 All

points of care

 All

healthcare processes


Analysis of Alternatives Alternative #1 

Implement Scan4Safety at small trusts first, with individual plans based on best practices, with individual teams 

Criticism: 

Much easier to scale down than scale up

“Start big, learn big”: take lessons from implementation at large Trusts, to those smaller Trusts

Lack of standardization with implementation at small Trusts initially

Deceiving results may make it appear easy to implement Scan4Safety, ignoring potential difficulties when implementing at larger, complex Trusts

Why We Reject: 

In the interest of fulfilling the goals of implementation (costs, safety, care, reputation, satisfaction), starting with large Trusts is better as it will have a larger impact that can be trickled down to smaller Trusts


Analysis of Alternatives Alternative #2 

Implement the Scan4Safety initiative at 3 Trusts/week leading to 148 Trusts by 5 years 

Criticism: 

Neglects proper time for feedback to improve implementation strategies

May lead to chaos: not very organized with many champions at different point sin implementation

Why We Reject: 

It simply neglects time for proper feedback and reflection, to improve on mistakes. An implementation strategy with a long term plan to measure outcomes, learn from mistakes, and adjust accordingly, is warranted


Analysis of Alternatives Alternative #3 

Implement Scan4Safety Initiative at 15 Trusts every 6 months, leading to implementation at all Trusts by 5 years 

Criticism: 

Similar to before; even 6 months is most likely not enough time to measure outcomes, learn from initial implementation strategies, and adjust accordingly

May not be most conducive to the goals of the Scan4Safety Initiative (i.e. improve patient care/safety) 

If Scan4Safety improves patient care/safety, why are we taking the full 5 years to fully implement it?

Why We Reject: 

Length and negation of crucial feedback period. If the initial implementation results are positive again, then the time to implement at the remaining Trusts should be expedited, to rapidly present the same benefits to all patients and healthcare professionals. This is more in tune with the goals of the Scan4Safety initiative


Strategic Action Plan How to scale from 6 trusts to 148 trusts + HOSPITAL SELECTION (NOTES)





+25 Sites

+40 Sites

+40 Sites

+40 Sites

April 2017 – April 2019 Phase I, II, III

April 2019 – April 2020 Phase I, II

April 2020 – April 2021 Phase I, II

April 2021 – April 2022 Phase I, II


Strategic Action Plan – STAGE ONE  PHASE


 Pre-Phase

I: NHS Message

 Supplier


 Establish

3 Core Enablers

 Champions

– Selection and Training

 Administrative

Training for Inventory Management Systems


Strategic Action Plan – STAGE ONE  PHASE


 Nurse

Training 1 – People & Place  Begin Using People & Place  Integrity Checks  Feedback  Nurse Training 2 – Product & Process  Begin Using  Feedback


Strategic Action Plan – STAGE ONE  PHASE


 Feedback

& Modifications


practices, implementation timelines, steps, requirements, critical path, resources etc. IMPLEMENT


Strategic Action Plan – STAGE TWO, THREE AND FOUR 

PHASE I: 3 months

PHASE II: 9 months

+40 sites per year for STAGE TWO, THREE, FOUR

NO PHASE III (Feedback & Modifications)



Implementation Plan Details by Phase PRE PHASE I STEPS NHS




for all stakeholders



communicate and ensure compliance


Implementation Plan Details by Phase PHASE I STEPS 


Management, Location Numbering, Patient Identification


per site, scaled up or down


savings from implementing eProcurement


Implementation Plan Details by Phase PHASE II STEPS  NURSE











18 Outcome Measures: Is the NHS experiencing the benefits of Scan4Safety? 

Goal: Acquisition of IHI Triple Aim  Improve

patient experience of care

 Improving

health of populations

 Reducing

per capita cost of care

3 Key Areas to Measure 1.

Quality of care & staff impact


Safety & legal fees


Financial performance

Process Measures: Is Scan4Safety being 19 used appropriately and is implementation on track? ď ľ

3 Key areas to measure as important in implementation of Scan4Safety Initiative 1.

Location numbering


Patient identification


Catalogue management

Balancing Measures: Has the implementation of Scan4Safety caused new issues in the NHS? ď ľ


2 Key areas to measure to ensure that changes due to Scan4Safety do not lead to new problems in existing health care system 1.

Service staff time devoted to patients


Change in quality of care since implementation of Scan4Safety

Scalability of Solution Scalability 

Scalability is a desirable property of a system, a network, a business, or a process, which indicates its ability to handle growing amounts of work.

A service is said to be scalable if, when we increase the resources in a system, it results in increases performance in a manner proportional to resources added.

Methods 

To develop our framework, we first reviewed the extensive literature on scale-up and spread and identified three core components for achieving results at scale: 

A step-wise approach from an idea to full-scale implementation

Environmental factors that foster adoption

Infrastructure required to support scale-up

We then re-examined the work of the quality improvement community – primarily associates in process improvement and the Institute for healthcare Improvement – that included a series of evolving ideas on sequencing, adoption mechanisms, and infrastructural support of scaleup initiatives.



Scalability of Solution: Our Framework ď ľ

ď ľ

From our literature review we determined that the IHI Framework for Going to Full Scale was the best guideline for developing a scalability plan with a healthcare system. The framework for going to full scale defines four phases required to get to full scale: 1.

Set-up, which prepares the ground for introduction and testing of the intervention that will be taken to full scale


Develop the Scalable Unit, which is an early test and demonstration phase


Test of Scale-up, which spreads the intervention to a variety of settings that are likely to represent contexts that will be encouraged at full scale


Go to Full Scale, which unfolds rapidly to enable a larger number of sites to adopt and/or replicate the intervention.


Scalability of Solution: Our Framework ď ľ

The framework is organized into two broad parts:


A sequence of activities required to take an idea from concept, through early testing, to broader testing, and finally rapid scale-up


The properties that facilitate adoption of the new idea and the infrastructure required to support the scale-up


Scalability of Solution: Setup 

This starting phase is where the NHS would establish an entry point for the action plan into the existing health system.

This phase includes a clear articulation of the Scan4Safety initiative, and how it will be used to transform supply chain processes (i.e. inventory management, traceability of all products used in patient care, and digital eBusiness exchange services) to reduce product and practice variation, improve financial performance, and strengthen patient care, quality, and safety.

During this phase, the next 25 Trusts will be identified, early adopters, as well as the 15 champions from those sites.

The 15 champions at each site will be responsible for spearheading the implementation at each of the Trusts, training staff members on the new system, and establishing the 3 core enablers (location numbering, catalogue management, and patient identification).

Scalability of Solution: Develop the Scalable Unit


This phase develops the “scalable unit”- the smallest representative copy of the system targeted for full-scale implementation.

The purpose of this phase is to intensively test local ideas for best-practice implementation so that the interaction among all parts of this representative sub-system can be understood.

An important outcome is the generation of a set of context-sensitive strategies and interventions that can be further tested and refined in a broader range of Trusts within the NHS.

These strategies and interventions will help to drive rapid improvement of performance during the Go to Full Scale phase.

Scalability of Solution: Develop the Scalable Unit


The first scalable unit will include the 25 initial Trusts that have been selected for implementation of the Scan4Safety initiative.

It is important for each of these 25 Trusts to include infrastructural components and relationship architecture that are likely to be encountered in the system at full-scale.

At these 25 Trusts the 15 chosen Champions will train the administrative staff on how to use the new inventory management systems (products), purchase-topay (automated inventory), and product safety recall (products), so that in 3 months when nurses begin scanning, they will be well versed in using the new software.

Nurses, practitioners, and other relevant staff members will also begin training on how to utilize the patient, place, and equipment scanning, which will include videos, manuals and hands on modules.

27 Scalability of Solution: Develop the Scalable Unit 

Due to the large scalability of this project, it is also advised that the Scalable Units utilize rapid-cycle testing, using the Plan-Do-Study-Act (PDSA) cycle commonly advocated for by the Institute for Health Care Improvement.

Based on a theory about what change will lead to improvement, a change is first tested at a very small scale, e.g. implementing the previously mentioned Core Enablers in one unit of each of the first 25 Trusts before spreading to all units.

Based on the results of each cycle, further tests are planned or the change may be abandoned.

Utilizing the PDSA method will allow the Trusts to rapidly develop strategies that will lead to quicker adoption and less errors when scaling the system to other Trusts.

Scalability of Solution: Test the Scale-up (i.e., testing the set of interventions to be taken to scale) 

The underlying theory of change and the strategies for implementation developed by the initially chosen Trusts need to be tested in a broader range of settings before going to full scale.

Also, during this phase, we test necessary infrastructure (e.g., data systems and supply chain) required to support full-scale implementation and build the human capacity and capability (e.g. leadership, managerial, and frontline capacity needed to support the method being used to scale-up).

This phase is an important opportunity to build the belief and will of leaders and frontline staff to support the changes.

It is anticipated that the initial 25 Trusts chosen for implementation of the Scan4Safety program will take 2 years, which will provide ample opportunity to test and analyze the necessary infrastructure that will be needed for full-scale implementation.



Scalability of Solution: Go to Full Scale 

This is a rapid deployment phase in which a well-tested set of interventions, supported by a reliable data feedback system, is adopted by frontline staff on a larger scale.

The focus is on rapid uptake of the intervention through replication.

While some adaptation of the intervention to local environments will always be required, there is less emphasis on new learning in this phase.

Significant will, knowledge, experience, and well-tested infrastructural support and capacity need to be in place before moving to this phase; the determinants of adoption as reflected in the IHI Framework for Spread (i.e., intrinsic properties of the change, the social environment, and the network properties) are well established.


Scalability of Solution: Go to Full Scale 

The rate of expansion for this initiative is proposed to be over a period of five years, providing enough time to implement the Scan4Safety program at all of the 148 Trusts across the NHS.

The largest Trusts will be chosen for the first 25, with the idea that they will have the necessary resources to develop the best strategies for implementation at the subsequent sites.

After appropriate testing, infrastructure and frontline capacity are established to support full-scale adoptability, then the system will be spread to the remaining Trusts over a 3 year period.

Utilizing the sequential Framework for Going to Full Scale method will provide the NHS with a way to rollout the Scan4Safety program to all 148 Trusts in the health system.


Scalability of Solution: Contingency Plan 

The environment for change and buy-in from the front line staff members and relevant stakeholders are crucial factors that will foster or hinder the pace and extent of adoption of the Scan4Safety program.

Rapid scale-up will not occur in an unreceptive environment. At each step of the scale-up process, the design of the intervention needs to be closely attuned to the social beliefs and health system practices, taking into account the individual policies and protocols at each Trust.

This is why our team has chosen to establish Champion leaders at each site that will be able to identify the necessary actions needed for adoption.


Scalability of Solution: Trust Champions 

The Champions will identify factors that affect adoption by understanding the health system’s infrastructure, culture, size, and strength of its underlying social system.

Understanding the psychology of change and whom to target in the different phases is crucial to success of the scale-up initiative; during the set-up phase, the champion will identify the different segments of the target adoption population (e.g., leaders, caregivers, population) and early adopters.


Scalability of Solution: Trust Champions 

The crucial role of the Champions is to lead the large-scale change needed for the adoption of the Scan4Safety program.

Champions will be coached to understand the difference between simply raising awareness of a new practice and what it takes to lead and ensure its broad adoption.

To get these results, there are a number of systematic approaches that the Champions can use to engage leaders in their key role of guiding and supporting the large-scale change.


Scalability of Solution: Communication 

The early demonstration phase (Develop the Scalable Unit) is a crucial time for communicating the value of the Scan4Safety program to both leadership and the implementers (frontline staff).

Providing real-time data is a powerful way to draw attention and garner support for the next phase of the scale-up process.

Early adopters and eager frontline staff who have successfully implemented the intervention in this phase become powerful advocates for the merits of the program to their peers.

The Champions need to be able to communicate quantitative results and the underlying stories of success and challenges with the program to enhance the level of buy-in from frontline staff members.

Scalability of Solution: Culture of Urgency and Persistence 

The Champions will need to consider several key questions when they begin their initial planning, including why others would want to join the effort and whether there is a glaring gap in performance or an urgent need.

Responses to these questions serve as a benchmark for the amount of will and energy needed to stay the course in bringing interventions to – and achieving results at – full scale.

Having reliable systems that track and provide feedback on the performance of key processes and outcomes is essential in adding to the urgency and the substance of the change initiative.

In addition, data that tracks key processes and outcomes that are targeted by the intervention need to be shared frequently with frontline staff and system leaders to inform ongoing improvement and persistence.



Conclusion ď ľ

The framework we have proposed for scalability and contingency integrates key themes from quality improvement research and a number of existing scale-up frameworks: a sequential approach to getting to full scale, the factors that enhance the receptivity of the environment into which the program is being scaled, and the system level factors that are required to support scale-up.

ď ľ

We believe that this sequential approach will allow us to implement the Scan4Safety program at all of the 148 Trusts of the NHS over a 5 year period, and will also ensure that each Trusts will have full buy-in for system success.


References 

Barker, P.M., Reid, A., & Schall, M.W. (2016). A framework for scaling up health interventions: lessons from large-scale improvement initiatives in Africa. Implement Sci, 11(12). doi: 10.1186/s13012-016-0374-x

Institute for Healthcare Improvement. (2017). Plan-do-study-act (PDSA) worksheet. Retrieved from:

Levinson W, Lesser CS, Epstein RM. Developing Physician Communication Skills For PatientCentered Care. Health Affairs 29: 1310–1318, 2010.

Richard G Evans, Adrian Edwards, Sean Evans, Benjamin Elwyn, Glyn Elwyn; Assessing the practising physician using patient surveys: a systematic review of instruments and feedback methods, Family Practice, Volume 24, Issue 2, 1 April 2007, Pages 117– 127,

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