18wRTT Delivery - The Pathway Re-engineering

Challenge

Denis Gizzi

Measuring V Delivering

The most defined measurement system will still only quantify a business process.

RTT end-to-end stage recording, tracking & reporting is priceless,

BUT WON’T ,ON IT’S OWN, DELIVER AN 18 WEEK TOTAL CARE PATHWAY EXPERIENCE FOR PATIENTS

Learning So Far (re stage 1)local pioneer work

• Engineering is not difficult – culture change is• 18 week delivery is higher on the commissioner radar• Pragmatic & basic data collection systems are possible• Don’t assume basic systems are in place (e.g. clinic outcomes)• Easier to make changes where systems are owned• Commissioner should drive data specification• Sufficient knowledge in the system to drive through objectives• Diagnostic end-to-end stage measurement is critical• Define generic outcome collection 1st rather than consult• RTT for ICATS/T2 segment of pathway presented NO material problem• Interim IT solutions will have to suffice (until CFH delivers)• Variable understanding of 18wRTT & how fits with broader reform• Clinical engagement (or lack of) is an overused excuse for poor business planning

Learning So Far (re stage 1)Wider Pioneers

• Focus on business process change (define our data)• Get ready for the commissioner challenge (is this defined?)• Technical system change is not feasible (i.e. through PAS)• Easier to make changes because we own the process & system• Very little commissioner participation in RTT measurement• Diagnostic end-to-end stage measurement is critical• Defining generic outcome collection sheets is easy, getting consultants to use

it isn’t• Interim IT solutions will have to suffice (until CFH delivers)• Variable understanding of 18wRTT & fit with broader system and policy reform• Reconciling tactical RTT measures with core business systems is challenging!• Supporting reform products (e.g. ICATS) & wider alignments is vague

Commissioner led Pioneer – the specific challenges

• The PCT does not own or have defined operational knowledge of hospital PAS systems.

• We do not have a direct management relationship with hospital clinicians who are faced with 18wRTT changes.

• Commissioning & contractual levers for change require greater definition.

• Aligning reform programmes with 18wRTT requirements & keep the financial plates spinning in sequence.

• Raising the profile of WIP (re 18wRTT) to the top of everyone's agenda.

• Raising the bar – re Business Processes

• Programme spread throughout Economy

Delivering & Sustaining 18wRTT

The Care Pathway Challenge(Stage 2)

Driving 18wRTT Pathways – The Realisation

• The days of negotiating, cajoling, modernising to improve outcomes has come to an end?

• Specifications & agreed systematic pathways will drive lean outcomes

• Commissioning levers & incentives are critical (harvest local clinical knowledge & capacity) + expect financial penalties

• Drive continuous improvement via market management

• Systemising care processes, moving away from variation & disparate decision management for 80% of care processes.

• Disciplined (objective based) decision management (at each–to-end stage) is critical

The challenge of 18 weeks

The NHS needs to continue to reduce waits to first assessment and from decision to treat to treatment. This will require more activity and reform than ever before. In addition

the NHS needs to focus on the time from first assessment to decision to treat which historically has not been a major focus.

GP IPOP D OP

18 Weeks

GP Visit1st OutpatientAppointment

Decision to treat

Treatment

The time from the first (assessment) outpatient to decision to treat includes the most significant challenges including all diagnostics and

subsequent outpatients

Generic Pathway to be managed – Adapted from (DOH) model

GPCAS

Assessment

CAS Diagnostics

CAS Referral

1stOP

CAS Treatment

Diagnostics2ndOP

DTA1stIP

Treatment in OP

On bookedlist

• Commissioners need to drive delivery across this entire pathway

• Re-define the key stages along the pathway that PCTs need to monitor

• Standard thresholds & accountabilities at each stage to reduce variation

• ICATS / CASs (or equivalent) must be lean & deliver VFM & BR

• So what sort of business intelligence systems are required to enable this?

Knowledge System Challenge for Pathways

The 3 essential components

High Level - Strategic Consumer FacingReal Time -

Operational (WIP)

Enabling High-Level Performance Reporting

By Provider & Specialty (inc ICATS, IS Diag)

By HRG / Procedure Pathway

(inc ICATS, CAS)

CPA & Optimisation Reports

Enabling Dynamic / Real Time WIP Review

By Provider & Specialty (inc ICATS, IS Diag)

Aligned & Integrated BIS Solutions

CAB-CAS-OP-Diag-Therapies-Surgery-Financial & Output

Reporting

The focus for continuous improvementUnique tagging & tracking – Know the

Work in Progress (WIP) at any point in time

Enabling the Informed Service

User

100% planned, ordered, timed &

structured 18wRTT journey

Care Pathway Management (CPM) – Objectives

Defining the High-Level Objectives

• Remove variability in consumer experience

• All consumers have a structured and ordered care experience

• Accountabilities are described for each step within the pathway

• Resources are available at each step of the pathway

• Fixed standards (performance & outcomes & metrics) are clearly described

• 18w pathways are policy compatible & deliver value for money

• All 18w service providers work to a common set of standards

• Consumers and clinicians as equal partners in pathway design

Care Pathway Management (CPM) – Outputs

Defining the Core Outputs

• All consumers complete their RTT experience within 18weeks

• All consumers feel empowered and informed

• All CPM navigators (e.g. GPs) feel empowered and informed

• Zero consumer complaints concerning RTT experience

• Financial aspects of 18wRTT Care Pathways are described, structured, agreed and reportable.

• Performance of 18wRTT Care pathways is measurable and reportable.

• Standards for 18wRTT Care Pathways are stated, agreed, costed & reported

Our Approach in Oldham Commissioner Led - Lean Pathway Engineering

8 Stage Process

1. RTT Measurement Systems (define the Work in Progress)2. Systematically analyse all (18wRTT) pathways & inefficiencies3. Engineer-out the sub optimal / non value adding aspects4. Re-define the optimal pathway (cement the lean process)5. Specify the optimal pathway as the (commissioners) product

requirement6. Procure the product to the specified quality & capacity standards (via

the market & commercial processes)7. Performance manage (know the WIP & expected outcomes)and

assure delivery8. Continuous improvement (re-engineer the variations)

Our Approach in Oldham Commissioner Led - Lean Pathway Engineering

The Plan

1. Assess baseline current RTT performance for top 13 specialties2. Select top 25 high volume symptom / procedure pathways3. Undertake research on well-grounded pathway for each4. Undertake clinical consultation regarding efficiencies5. Overlay generic 18wRTT commissioning standard6. Describe standards to provider market (inc plural pathways)7. Undertake real capacity planning to ensure financial & PH probity8. Gauge views from clinical “firms” regarding their views on

opportunities9. Cement pathway maps into local prospectus & contracting regimes

Commissioning Pathways Summary

Risks & Challenges

• RTT tactical measurement solutions (for all 18w pathways) are required now.

• Work within clinical partnerships to re-engineer systems now.

• No slack time in the system (strategic IT solution won’t deliver in time)

• Assurance systems – embryonic at best (trust professional knowledge)

• RTT & data systems – specified for each pathway deliverer

Next Steps

• DSCN compliant processes

• Real demand & capacity planning

• 18wRTT systematic pathway reviews

• Capacity & Specialty engineering

• Specifications & Commissioning

• Performance & tracking & Incentives

• Clinical ownership of pathway maps

• Disciplined thinking, planning & operational execution (J.Coultard HSJ 29/06/06)

18wRTT & PTL

A Commissioners Approach

PTL & the Commissioner

Has to add value Has to be deliverable (with little or no added investment) Has to be accurate & timely Can not be merely Old School WL systems Has to be core product within business cycle Applies to all segments in the supply chain

Is critical to market management, therefore has to be a dynamic & timely product with correct design features

Capacity= what we could

do

Traditional Elective System

Activity = what we did

Demand = All requestsfor a service

= what we should do

Waiting list, queue= what we should have done

Not enough attention, therefore ill defined, variable & unregulated

PTLs are fixed points in systems (OP & IPE) – Risk of breach is mitigated by supply chain data

capture

Waiting list is a tool used to store WIP until a ‘do something critical’

point’ is reached.

Core business planning for service operators – should commissioners

describe it for them?

PTLs convert to activities – but little commissioner input &

insufficient assurance

Capacity= defined turnaround

requirement

Care Pathway Management Approach

Activity = what we planned to

undertake

Demand = All requests

Meet defined standards & are UBRN controlled

Scheduled & Organised Assessment Control= Available Diagnostics & Measured Outputs (RTT)+ Alignments to physical (community) resources

For PCT & PBC Partners to define, reduce variability.

PBC to determine regulatory (governance) framework

The commissioner should determine & direct “what should

be done” via specifications & commercial rigour

Waiting list is obsoleteScheduling & segmentation &

tracking is the keyPTL Control is critical!!How are we assured?

Core business planning for service operators – commissioners should

define a slot based procurement model

This should align with commissioner specification & assurance processes (PTLs)

Real Capacity Plans & tracking & assurance

process (PTLs)

18wRTT – Pathway & PTL

GPCAS

Assessment

CAS Diagnostics

CAS definitive decision

Consent & Pre-op

CAS Treatment

Booked theatre slot TCI

Action Discharge &

Charge

Via CAB & UBRN generated

Total End-End Stage has defined parameters

Total End-to-End Stage has defined parameters

These stages will require significant culture change

Non Admitted PTL

Admitted Pathway PTL

RED = Do something significant points

PTL Principles – For Commissioners

The Basics Rules for assessment control have to be set Rules for differentiating Admitted V Non Admitted Rules for Clinical outcome (decision recording) No patient added to list without booked TCI slot Trigger “assurance” points defined for each Standard Data collection items defined Patients enter APP after DSCP is reached (not before) Core business processing “cemented” in SLAs Shared customer & supply chain knowledge system

Generic 18wRTT Pathway Commissioning Template

Decision Threshold•Define minimum referral management standards •Define minimum work-up (the diagnostic pack)•UBRN based ordering •Slot based capacity matching

Via Clinical Partnership agreementsIncluding internally generated demand (con-to-con)

(led by PBC)

Assessment Control•Agreed set of pathways •Defined set of diagnostic capacity•Objective based decision management•Lean process management & UBRN based ordering•Time defined outputs•Integrated pathway management (direct listing)•Contractual performance metrics, incentives & penalties

Re-engineered services and/or re-procured Outpatient as

ICATS(outputs within 4 weeks average

6 weeks maximum)+ RTT recording & PTL tracking

Decision to Treat & Action•Define minimum direct listing standards •Define minimum work-up (1st & 2nd line diagnostic pack)•UBRN based ordering •Slot based capacity matching•Contractual performance metrics, incentives & penalties

Consistent standards for all providers

(outputs within 9 week average 14 week maximum)

+ RTT recording & PTL tracking

Capacity m

aps for each delivery component &

stage

RTT CLOCK STARTS

Provider Choice & Dynamic Market Management

Driving Faster Reform via Standardised (transferable) Processes

Weekly 18 week PTL

xxxxxxxxxx Primary Care Trust

Reporting period is as at midnight on (Sunday)Collected

number of patients who (from UBRN) will breach 3 days clinical triage standard if not dated & cleared in 24 hours

number of patients who (from UBRN) will breach 1st clinical assessment (14 day standard) if not dated & cleared within 5 days

number of patients who (from UBRN) will breach diagnostic clearance stage (30 days from UBRN) if not dated, reported and cleared within 5 days.number of patients who will breach assessment control total stage clearance time (42 days from UBRN) if not dated seen and cleared within 5 days.- DO SOMETHING SIGNIFICANT STAGEnumber of patients listed for 1st definitive treatment (within CATS) who will breach CATS standard (56 days from UBRN) if not dated & cleared within 5 days

Number of patients who will breach target in 29-42 days who do not have a TCI date within the target timeNumber of patients who will breach target in 15-28 days who do not have a TCI date within the target timeNumber of patients who will breach target in 1-14 days who do not have a TCI date within the target timeNumber of patients treated within the last 7 days who were not treated within 18 weeks of referralNumber of patients treated within the last 7 days who were treated within 18 weeks of referralTotal number of patients whose breach date has already passed

Number of patients who passed their breach date within the last 7 days

Commentary

LDP trajectory for Non-Admitted

LDP trajectory for Admitted

Number of clock starts (Weekly figure could be estimated from monthly RTT return)

18 WEEK - WEEKLY PTL - PATI ENTS WI THOUT A DECI SI ON TO ADMI T (within assessment control)

18 WEEK - WEEKLY PTL - PATI ENTS WI TH A DECI SI ON TO ADMI T (convert DTT & Action)

Reference Data

PTL sounds OK – the catch!

PCTs can’t own PTL production PTLs act as assurance / mitigation / tactical tools Supply chain owns WIP & therefore PTLs Model contracting for PTL production & access DSS = do something significant = triggers Currently no reference spine for UBRN across path PCT charged with assurance & customer navigation PTLs need careful specification & production What would PCTs do with them & how often?