CONTINUOUS SERVICE IMPROVEMENT (CSI) PROGRESS UPDATE

1.Background to Continuous Service Improvement (CSI)

NHS Grampian’s vision is to:

  • Improve the health of people in the North East of Scotland and beyond
  • Provide high quality services for our patients
  • Help people choose the best ways to look after their health

The environment and the circumstances we face require a dramatic change in our approach to service provision. Whilst there is a good deal of constructive and innovative change taking place, we need to make these activities more effective, widespread and sustainable. This will be achieved only if change is understood, owned and delivered by all so all staff need to be supported and encouraged to be involved. The aims of implementing our approach to improvement known as CSI are to ensure that:

  • NHSGrampian (NHSG) has knowledgeable and confident staff prepared to lead and engage in CSI activities
  • Pan NHSG service delivery is led, managed, prioritised and improved using lean techniques
  • NHSG establishes its own improvement tools and techniques
  • NHSG approach realises significant benefits

A paper was presented to the Board in June which highlighted the work undertaken with the support of ATOS consulting regarding the whole system analysis and the CSI plan for taking forward the outcomes.

2.Progress to date

There has been much progress over the past three months, in particular around ensuring consistency within the CSI portfolio of programmes and projects. The work undertaken includes the following:

2.1Establishment of the CSI Group (CSIG): this working group was originally set up to work alongside ATOS consulting during the whole systems analysis earlier in the year but has now been formally recognised within the NHSG committee arrangements. CSIG is chaired by the Director of HR and Strategic Change with the membership comprising:

Director of Finance/DeputyCEO

Director of Performance and Improvement

Director of Corporate Planning

Medical Director

Director of Nursing

Deputy Medical Director

Head of Strategic Change and OD

Head of Service Improvement

Head of Performance Management

Head of Health Intelligence

General Manager eHealth

Divisional manager – Service Improvement (Acute)

Acute Sector Clinician – Terry O’Kelly

Primary Care Clinician - Jamie Hogg

CSIG reports into the Strategic Management Team (SMT) and is the strategic leadership group for all improvement. Whilst the achievement of targets and objectives remains the responsibility of operational line management, acting as strategic improvement group with delegated authority from the Chief Executive, the group directs, sponsors and monitors all service improvement and redesign activity and agrees all plans and priorities for improvement. Designated Executive Leads for each of the CSI programmes and projects will be responsible and accountable for the delivery of their respective programme or project.

CSIG has employed lean methodology to develop an A3 which outlines how we will achieve the aims detailed above and how we will measure our progress. This A3 is attached at appendix 1.

2.2CSI Portfolio: Of the 14 programmes and projects which emerged from the Whole Systems Analysis, undertaken from February to May 2009 with the support of ATOS consulting, a portfolio of strategic CSI activity has been agreed. This comprises the following:

  1. AberdeenCity CHP Redesign
  2. Better Care without Delay – to include:
  3. Orthopaedic Theatre Capacity, and
  4. Sustain and further improve outpatient waiting times
  5. Health Campus
  6. Intermediate Care
  7. Long Term Conditions
  8. Mental Health Collaborative
  9. Neonatology
  10. Procurement Best Value
  11. Reduce Length of Stay ARI surgical
  12. Reduce Length of Stay ARI medical
  13. Reduce Length of Stay Community Hospitals
  14. Unscheduled care

In addition, scoping work has begun in Diagnostics which will completed by the end of October and there is also some initial work being undertaken within Prescribing to consider establishing a separate project in this area.

2.3Integration of existing improvement activity:Work is under way to integrate other programmes currently being implemented across NHS Grampian which enhance improvement activity and employ lean tools and techniques. These include “Releasing time to Care” and the Scottish Patient Safety Programme (SPSP). By integrating approaches and defining common tools and techniques, there will be a wider spread of improvement activity – “horizontally” across the organisation through SPSP etc and “vertically” across the organisation through the CSI portfolio.

2.4Performance metrics:A sub-group of the CSIG has been established to provide strategic guidance to all programmes and projects within the CSI portfolio with regard to setting measures for achievement and ensuring performance management of activity against these measures. This will ensure that programme and project measures can be linked back to HEAT targets (where appropriate) and strategic objectives and will aid in the prioritisation of work to be undertaken.

2.5Benefits realisation:A further sub-group of the CSIG has been established to ensure that all activity within CSI has strategic guidance and direction for all benefits identification, categorisation and realisation. “Affinity groups” have been identified, categorised as releasing productive time, cost avoidance and cash releasing. An overall plan is being established which will bring together the following:

  • A prioritised register of all potential benefits, by affinity group.
  • A completed dependencies network.
  • Completed benefit profiles, including dates for capture of baseline costings.
  • A mechanism for regular measurement and reporting to the CSIG.
  • A mechanism for scoring the achievement of the benefit against the Sector and (or) Department to which it can be attributed.
  • A mechanism for regular monitoring, review and corrective action by the CSIG.
  • Arrangements for transfer to business as usual at the end of the respective CSI project or programmes scope of activity.

2.6Prioritisation of resource support for CSI activity: While many of the programmes and projects aremovingforward with the support of their ownorganic improvement resource, a number require additional CSI support if they are to deliver the full benefits project leads have predicted.Dedicated CSI resource isfinite andas such needs to be focused on areas either where there is an organisational imperative to extract significant benefits or specialist support is required to deliver rapidimprovements. The following programmes and projects have been agreed as the initial focus for resource:

  • Procurement Best Value: to set the conditions for the extraction of cost-releasing, cost avoidance andreleasing productive time benefits.Similar smaller-scale projects in two other Health Boards recently have yielded recurrent savings of between £1.6m and £1.9m. However it is estimated that the NHSG project will release significantly more than this.
  • Orthopaedic Theatre Capacity: to establish a viableorthopaedic theatres solution following the expiryof the current Vanguard theatre contract. Use of external support for theatres is costly and it is anticipated that lean analysis of demand and supply will highlight a variety of options to progress.
  • Better Care Without Delay (BCWD): to support the delivery of our HEAT target through the elimination of waste. Progress is well underway in this programme however there are still significant additional areas of improvement work to be undertaken which will ensure the sustained achievement of targets.
  • Unscheduled Care: to support the workthat has been directed within the PST report. It is intended to address the approach to achievement of the 4 hour target at three levels; locally within A&E and AMAU sustaining previous improvement work and introducing further recommendations from the PST report; across the Acute setting with greater recognition that the target is not just an A&E target but a systems target; and at the whole systems level including working with external agencies and partners in care provision.

The Strategic Change Team was created earlier this year and is now firmly embedded in all elements of the portfolio, providing support to programme and project teams in addition to driving NHSG wide priorities such as training and communications. The Strategic Change managers are aligned to the sectors and have responsibility for supporting specific programmes and projects within the CSI portfolio.

Despite the relative scarcity of this resource, the team will continue to provide support to all other CSI projectsin addition to those highlighted above fromany residual capacity that might be available. They will work with project and programme teams toensure that they are being supported in delivering improvement activityusing our endorsed NHSG CSI methodology.

2.7eHealth implications: Similarly to the work highlighted in 2.6, the General Manager of eHealth has met with each of the programme and project leads to identify the eHealth implications and related eHealth resource needs. The 4 key areas of focus highlighted above in 2.6 have clear implications for eHealth whereas some of the other projects and programmes either require little or no resource or are still to define the exact implications for eHealth. In light of the imminent procurement and roll-out of PMS as part of a national initiative, it is important that scarce eHealth resource is appropriately targeted against agreed priorities. On-going assessment and prioritisation of eHealth support will be maintained.

2.8Portfolio overview (Gantt chart): All CSI activity has now been brought together in a Gantt chart format which is attached at appendix 2. This highlights the timescales for activity and delivery across the portfolio and details support resource support requirements to enable programmes and projects to maximise the benefits stated. On going achievement against this plan and the inclusion of future pieces of work will be overseen by the CSIG.

2.9CSI training and awareness: Awareness sessions, including a half-day workshop and a 1.5 hour on-line session, are being developed. The half-day session will be rolled out to staff in line with the planned activity in the Gantt chart (as in appendix 2) and will comprise an introduction to the background of CSI and some of the most common lean tools and terminology. This will not only enable staff to participate more knowledgably in the planned CSI activities, but also to identify local areas for improvement and initiate change for themselves.

Lean training for the Strategic Change team and other dedicated improvement staff has commenced. Whereas the budget is not available at present to implement an accredited training programme, there are plans in place to work with the local universities and NHS Education Scotland to retrospectively accredit the in-house training undertaken and develop an NHS Grampian programme of accreditation for the future.

2.10CSI communications and engagement strategy:A communications plan for CSI is being completed with support from the Corporate Communications team. The first step in this plan is the inclusion of an introduction to CSI in the Face2Face sessions running throughout September and October.A CSI web-page is also being developed on the intranet.

In January this year the Executive Team embarked on a development programme on Engaging Leadership. CSI has provided an excellent vehicle for the team to evidence this approach and their own personal development through Executive sponsorship of activities within the CSI portfolio. A programme for clinical leaders also commenced in August with a session on Engaging Leadership delivered by Professor Beverley Alimo-Metcalf. This programme is sponsored and lead by the Medical Director and the next session is planned with a broader clinical audience for early December.

One of the potential issues rehearsed from the concept of CSI in NHSG has been how to tackle the language and terminology used in lean. The CSIG at a recent development day agreed a way forward with this; namely that there should not be an attempt to “dumb-down” some of the important principles and terms but rather an appropriate mechanism for communicating in simple language be adopted. This approach allows for lean terminology to be proceeded by a simple definition which should be easily understood by all staff across NHSG and, where appropriate, by the public and our partner organisations. This approach will be piloted at the Face2Face sessions and example is described below.

2.11Evaluation:the CSI Group has commissioned an evaluation process to be established, the aims of which will be to undertaken evaluation on two levels. The first level will focus on CSI Leadership activities, seeking to answer questions such as ‘how effective was our strategy?’; ‘how well did we organise ourselves?’ and ‘how valuable were our inputs and support?’. Assessment will include for example:

  • Organisational priorities and integration of projects
  • Phasing of projects – enabling steady progress in all projects
  • CSI organisation and project management – effective communication and planning
  • CSI training plan – reaching and equipping target audience
  • Performance management and governance – effective monitoring for improvement and delivery
  • Extent and levels of capability – good understanding of techniques and their application
  • Quantification and effectiveness of additional or enhanced inputs and staff

A second level of wider evaluation is also being considered to understand the cultural impact of CSI, looking at how well staff are aware of CSI and their preparedness to engage in and initiate service improvement activities. This element of evaluation will also measure general understanding and the demonstration of the application of the CSI philosophy and values.

3.Summary

A dramatic change in our approach to service provision is required to meet both the challenging environment NHSG is operating within and the organisational objectives, building on the constructive and innovative change activities already taking place. The strategic deployment of CSI aims to ensure that all NHS Grampian staff are knowledgeable and able to engage in improvement activities, using NHSG improvement tools and techniques. In so doing, NHSG will be able to realise significant benefits for the organisation by improving service delivery using lean principles and techniques. The CSI Portfolio of Programmes and Projects has now moved beyond planning into the implementation phase with initial key areas for focus having been identified.

Benefits of improvement activities are being quantified, helping to assess the cumulative potential return on investment. A performance management matrix and reporting process has been established. A pragmatic approach to training is being rolled out employing a blended approach of face to face and e-supported learning. An engagement strategy including communication messages and information about CSI is being developed, with the Face2Face sessions as the start point. An evaluation plan is being developed, aiming to assess the direct contribution of the CSI Leadership and support with an assessment of the wider, cultural impact of CSI also being planned.

The strategic deployment of CSI is dependant upon the creation of a culture of engagement in improvement and change activity across all staff within NHSG. A key driver in this is the creation of a style of engaging leadership, consistently demonstrated at Executive team level and embedded in the successful delivery of the CSI portfolio.

1