Launch of The General Practice Development Programme Releasing time - - PowerPoint PPT Presentation

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Dr Rachel Duffy and Carolyn Robertson

Sustainable Improvement Team 23rd February 2017

Launch of The General Practice Development Programme Releasing time for care

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#GPforwardview

Welcome & introduction

Catherine Blackaby

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3

#GPforwardview

#GPforwardview

#GPforwardview

#GPforwardview

#GPforwardview

Dr Rachel Duffy and Carolyn Robertson

Sustainable Improvement Team 23rd February 2017

Launch of The General Practice Development Programme

#Gpforwardview

#GPforwardview

Introductions

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• Who you are
• Where you are from
• Your favourite record and why
• Some thing you have in common
• Your biggest challenge in practice
• What you are hopeful about

Icebreaker

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Agenda

12:30 Arrival and lunch 13:00 Welcome and Introductions 13:10 Icebreaker 13:30 Review of the HIA and showcase event & the General Practice Development Programme 14:10 Considering your ambitions and project ideas 15:00 Refreshment Break 15:15 Using prioritisation to select your project 15.45 Making changes locally – working with the Model for Improvement 16.30 Introduction to Measurement 16.40 Actions and next steps 16.50 Evaluation 17:00 Close

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Session Objectives

• To launch the time for care action learning

programme

• To create time and opportunity to think about

your project areas

• To introduce the Model for Improvement as a

structured approach for making changes

• To gain greater clarity of what you want to

achieve and your project to help achieve it

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• On tables think about the showcase event.

Consider:

• What did you get out of it? The takeaways

.…….

• What have you done since?
• What do you want to get out of today?
• What would you like to know more about?

Activity One

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Previously ……….

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www.nhsalliance.org/making-time-in-general-practice/

bit.ly/time4caretool1

#GPforwardview 0% 5% 10% 15% 20% 25% 30%

Getting paid Processing information Keeping up to date Reporting Supporting patients

Most burdensome areas of bureaucracy

www.nhsalliance.org/making-time-in-general-practice/ bit.ly/time4caretool1

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74%

7% 6%

4% 3% 3%

2% 2%

Other in practice Self care/Pharmacy Outpatients Sick notes / appeals Care navigation Continuity/preparation Other

Data from 5,128 consultations

bit.ly/time4caretool1

GPs judged 26%

• f their consultations

to be potentially avoidable … 18% are about how the practice manages its workload

Potentially avoidable GP appointments

(audit by GPs)

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10 high impact actions to release time for care

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10 High Impact Actions

Innovations from around England that release time for GPs to do more of what only they can do. bit.ly/gpcapacityforum

#GPforwardview

10 High Impact Actions

Innovations from practices throughout around England that release time and improve care. bit.ly/gpcapacityforum

#GPforwardview

1 Active signposting

The idea

• Receptionists’ job is to connect the

patient with the most appropriate service (not just book everyone with a GP).

• Train receptionists to ascertain the

patient’s need. Include red flags for medical emergencies.

• Develop a directory of services, inc

services outside the practice, for patients to be directed to.

Implementation tips

• Explain to patients that the aim is not to deny them access but rather to improve it, as well as allowing

GPs to focus on the things only they can do.

• Involve GPs themselves in giving information and explanation, eg through the practice newsletter or

phone system messages. Patients appreciate and respect this.

• Encourage receptionists to ask lots of questions, practice asking about the patient’s need and make their
• wn suggestions for improvement and the directory of services.
• Measure closely at first, to demonstrate impact and identify areas for improvement.
• Keep the directory of services updated. Include hospital outpatient booking offices, voluntary & community

sector services, community pharmacy, dentists, optometrists, welfare rights, housing, etc.

• Replicate the information on the practice website, for patients to find directly.

Impact

• Reduced GP appointments – estimated

at 1,046 per year for a 10,000 patient

• practice. (Eg West Wakefield, 930 GP

hours saved across the 6 practices (64,000 patients) in the first 10 months).

• Patient benefits - faster access to the

right service (one step in the process removed).

• Staff satisfaction – receptionists feel

they’re doing a better job for patients and making bigger contribution to the practice.

Reception care navigation

bit.ly/GPcapacitynet1

#GPforwardview

10 High Impact Actions

Innovations from practices throughout around England that release time and improve care. bit.ly/gpcapacityforum

#GPforwardview

2 New Consultation types

The idea

• The phone is used to consult (not just

triage).

• Patients can be offered an

appointment with their usual GP or with any available GP.

• Many follow-ups can be done on the

phone as well as new problems. Implementation tips

• Measure actual demand and adjust supply of appointments as it varies during week

(Monday often 40-60% busier) and year.

• Provide training in clinical skills to ensure safety and productiveness of phone consultations.
• When moving to a ‘demand led’ rather than ‘supply led’ approach, plan how to account for

current unmet need.

• Use alongside ‘active signposting’ to reduce demand.

Impact

• 60-70% of consultations can be handled

entirely on the phone, in an average of 4- 6 minutes.

• Where face-to-face consultation required,

GP usually decides in first 2 minutes. Some face-to-face consultations are then much shorter (eg examine rash).

• Access improves, especially for carers &

people in work.

• DNAs fall up to 80%.
• Interpreters usually don’t need to be

prebooked for telephone consultations.

Phone consultations

bit.ly/GPcapacitynet2

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2 New Consultation types

The idea

• Patients make the practice website

their first point of contact.

• Options:
• find out more about symptoms, a

particular condition or treatment

• request a call back from 111 nurse
• send details of problem / query to

GP

• GP surgery includes “slots” for online

consultations (three per typical face to face slot) Implementation tips

• Careful & persistent marketing. Personal recommendations from staff.
• Don’t expect it to suit every patient
• Design GPs’ sessions to provide a prompt response. Audit to spot any problems. Training &

support helpful for some GPs

• Use released time to offer longer face to face appointments for patients with complex needs

Impact

• 91% patients ‘extremely satisfied’
• 90% users don’t contact practice:
• 60% symptom checker / self help
• 20% visit pharmacy
• 10% request 111 nurse call back
• 10% users have ‘online consultation’
• 40% completed by GP remotely -

2.9mins ave

• 20% GP phoned patient - 5.5mins

ave

• 40% face to face appointment –

10mins ave

Online consultations at Docklands Medical Centre

bit.ly/GPcapacitynet2

#GPforwardview

10 High Impact Actions

Innovations from practices throughout around England that release time and improve care. bit.ly/gpcapacityforum

#GPforwardview

3 Reduce DNAs

The ideas

• Make it easy for patients to cancel.
• Send appointment reminders (text/email) 

10% reduction.

• Patients write their own booking  18%

reduction.

• Patients read-back appointment details 

4% reduction.

• Report how many appointments were kept

last month rather than DNAs  14% reduction.

• Reduce 'just in case' booking by improving

same day access  up to 70% reduction.

Implementation tips

• These are additive - implement several of them for best effect.
• Measure DNAs periodically to identify any needs for additional solutions.

10 High Impact Actions. Quick facts 1.2

bit.ly/GPcapacitynet3

#GPforwardview

10 High Impact Actions

Innovations from practices throughout around England that release time and improve care. bit.ly/gpcapacityforum

#GPforwardview

4 Develop the team

The idea

• Approx 20% of GP appointments are for

musculoskeletal complaints

• Patients presenting with a new

musculoskeletal problem from a predetermined list are offered an appointment with the physio rather than a GP.

• Physio has 15 minute appointments with
• patients. Full access to GP record.
• Assessment of the problem and advice on

exercises and self management. If required,

• nward referral for longer therapy /

prescription request / refer to GP

Implementation tips

• Ensure the service is provided by appropriately experienced physiotherapists, confident in

making rapid assessments of musculoskeletal problems in primary care. This usually also means using senior staff.

• Training for receptionists helps them to make appropriate judgements about signposting

patients to a service like this. In West Wakefield, training increased use of the physiotherapy service by 40%.

Impact

• 70% of presentations fully dealt with in

a single 15 minute appointment.

• Waiting time for physio reduced by at

least 4 weeks.

• Reduced pressure on GP appointments

(at least 5%)

• Patient satisfaction very high (100%

'good' / 'very good‘)

eg Physio first, W Wakefield

bit.ly/GPcapacitynet4

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4 Develop the team

The idea

• Train clerical staff to read, code and

action incoming clinical correspondence according to a standard protocol.

• The aim is to reduce the number of

letters requiring processing by a GP. Implementation tips

• During training, allocate a GP to provide advice to staff.
• Standard protocols are helpful, but can also be adapted to your own needs/preferences.
• Consider starting small, eg processing just one GP’s letters. Measure the benefits. Others

will become interested quickly.

Impact

• GPs typically save 30-60 minutes per

day (eg mean of 45min in Brighton)

• With training and a standard protocol,

safety is very good (eg zero adverse events in 15,000 letters, Brighton)

• Coding improves.
• Staff satisfaction improves: enhanced

role and greater contribution to the practice.

Correspondence management

bit.ly/GPcapacitynet4

#GPforwardview

10 High Impact Actions

Innovations from practices throughout around England that release time and improve care. bit.ly/gpcapacityforum

#GPforwardview

10 High Impact Actions

Innovations from practices throughout around England that release time and improve care. bit.ly/gpcapacityforum

#GPforwardview

5 Productive work flows

The idea

• Identify common tasks / processes

and measure them to find priorities for improvement.

• Use tools and techniques from

Improvement science to design and implement improvements (eg 5S, Lean). Implementation tips

• Don't overlook the impact that relatively small improvements to frequent tasks can make.
• Use team techniques that examine everyday processes from a different perspective - you'll
• ften find completely new improvements you could make.

Impact

• A Cheshire practice recently spent a

couple of half days with a Productive General Practice facilitator, focusing on the repeat prescribing process. They freed an estimated 556 hours per year.

• A Yorkshire practice reduced time spent

hunting for prescriptions by 82%, saving 12.5 hour per week.

Efficient processes

bit.ly/GPcapacitynet5

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6 Personal productivity

The idea

• The computer is used in 100% of GP

consultations, the stethoscope in approx 5-15%.

• ‘Hunt and peck’ typing is slower than

touch-typing, with more need to look away from the patient.

• Typical readers read 1/3 as fast as

proficient speed readers. Implementation tips

• Train yourselves in touch typing and speed reading.
• Have a team focus with input from secretaries.
• There are many free & paid apps, books and courses available.

Impact

• In a typical GP day, a proficient touch

typist (65 wpm) saves an average of 10 minutes, with a fast typist (95 wpm) saving 17 minutes.

• Touch typists do not have to look down

at the keyboard, creating fewer interruptions to patient communication.

• Speed reading techniques estimated to

double reading speed for clinical documents (faster for others).

Touch typing & speed reading

bit.ly/GPcapacitynet6

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6 Personal productivity

Australian Medical Association 8 tips:

• Make home a sanctuary
• Value strong relationships
• Have an annual preventive health

assessment

• Control stress not people
• Recognise conflict (and distress / upset) as

an opportunity

• Manage bullying and violence assertively
• Get our medical organisations to work for us
• Create a legacy

Tools & guides

• www.stepsforward.org/modules/improving-physician-resilience
• ‘How Resilient Are You?’ resiliencyquiz.com
• ‘Test Your RQ’ www.testyourrq.com
• ‘Developing resilience’ www.cipd.co.uk/hr-resources/guides/developing-resilience-evidence-

guide.aspx.

Build resilience

bit.ly/GPcapacitynet6

#GPforwardview

10 High Impact Actions

Innovations from practices throughout around England that release time and improve care. bit.ly/gpcapacityforum

#GPforwardview

7 Partnership working

The idea

• Community pharmacies are

conveniently located and often open longer than other primary care providers.

• They can provide additional services

such as minor ailments, emergency repeat medication supply and medicines management input.

• All of these are enhanced by giving

access to the full GP record (with the patient’s consent). Implementation tips

• Engagement of all professionals early on is essential. Ideally pharmacists and project

managers need to meet with practices in person.

• If securing pharmacy commitment is slow, consider launching in phases.

Impact

• Demand for GP appointments is
• reduced. (eg Devon GP Access Fund,

working with 134 pharmacies, saved estimated 7,000 GP appointments + 2,600 OOH consultations + 360 A&E attendances).

• Better collaborative relationships with

local pharmacies improves other aspects of medicines management for practices and patients.

Community pharmacy

bit.ly/GPcapacitynet7

#GPforwardview

10 High Impact Actions

Innovations from practices throughout around England that release time and improve care. bit.ly/gpcapacityforum

#GPforwardview

8 Social prescribing

The idea

• Work with local voluntary and

community groups to recruit and train members of the local community to work at the practice as care navigators. Implementation tips

• Start by building a close working relationship with local voluntary sector groups, and involve

them in shaping the work. and involve them in shaping the work.

• Maintain ongoing close relationships, for staff and volunteers to identify gaps and duplication

in services, as there is usually room for improvement in collaboration in many directions.

• Aim to include plans for using savings (eg from reduced unscheduled care and admissions)

to sustain the scheme.

Impact

• Reduced demand for GP & other

appointments (eg Shropshire, 48% reduction in GP consultations, 33% reduction in A&E attendances and 58% reduction in unscheduled hospital admissions).

• Improved quality of life for patients and

carers.

• Satisfaction and empowerment for

volunteers (many of them former high users of GP practice).

Practice based navigators

bit.ly/GPcapacitynet8

#GPforwardview

10 High Impact Actions

Innovations from practices throughout around England that release time and improve care. bit.ly/gpcapacityforum

#GPforwardview

9 Support self care

The idea

• The GP contract requires practices to

provide access to coded information in records.

• It is also possible to give full access.

Implementation tips

• Play some case study videos in a team meeting: www.england.nhs.uk/ourwork/pe/patient-
• nline/
• Give staff opportunities to raise questions & concerns early on. Compare with experience of

practices already offering full access.

Impact

• If 30% of patients accessed their full record
• nline twice a year, a 10,000 patient practice

would save 4,747 appointments and 8,020 telephone calls per year.

• This takes account of additional time spent

giving explanations to a minority of patients.

• 76% of patients feel feeling more involved in

their care, 62% have improved understanding

• f consultations, 77% understood & manage

their condition better

• Medication compliance increases 42%, 64%

are more likely to follow lifestyle advice better.

Patient online

bit.ly/GPcapacitynet9

#GPforwardview

10 High Impact Actions

Innovations from practices throughout around England that release time and improve care. bit.ly/gpcapacityforum

#GPforwardview

10 High Impact Actions

Innovations from practices throughout around England that release time and improve care. bit.ly/gpcapacityforum

bit.ly/gpcapacityforum

#GPforwardview

#GPforwardview

Preparation

Aligning plans, federation development, local champions

Launch event

Development Advisor Support

Learn from innovators

General Practice Improvement Leaders Programme

Your Time for Care programme

Showcase event

Productive General Practice

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Opportunity Spotting

• 1. How can you create/continue to create the

environment for continuous learning, collaboration and sharing?

• 2. What great stuff do you already have that you can

share ‘and’ what can you learn from elsewhere?

• 3. What can you do individually ‘and’ what would be

best done collectively?

• 4. What can you do now in practice ‘versus’ what needs

to be considered in the longer term?

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• Consider your top 2 priority areas:
• Review the case studies
• Clarify what you mean by ….?
• Share local experiences – what’s already happening
• What ideas do you have?

Write one idea per post it in CAPITALS Post on the flip chart Group like topics

Activity Two

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We know that…

• Every system is perfectly designed to get the

results it gets

• If we want different results, we must change

(transform) the system

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Edward de Bono’s Mental Valleys Model for Thinking Streams of thinking Valleys

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Purposeful channel Random jump

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70

Synopsis Since others will have different ways of thinking and approaching challenges, we might be able to make a novel connection by using “Fresh Eyes” and thinking like another person, or making links to another industry. New ideas come from differences.

Nicholas Negroponte

Tool: Fresh Eyes

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Prioritisation Matrix

HIGH IMPACT LIKELY LOW IMPACT LIKELY HARD TO IMPLEMENT EASY TO IMPLEMENT Start with these Longer term projects Not worth the effort For spare capacity

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Activity 3

• On tables : consider each project on the impact v do-

ability matrix

• Colleagues to provide helpful challenge:
• WHAT – do you need to do to make this happen?
• WHO – needs to be involved (impacted &

influence, experience)

• HOW – availability of resources
• WHEN – a small test of change

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Making changes locally: working with the Model for Improvement

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What are we trying to accomplish? How will we know that change is an improvement? What change can we make that will result in improvement?

The Model for Improvement

Developed by Associates in Process Improvement’ Langley, G., Nolan, K., and Nolan, T., 1994. The Foundation of Improvement, Quality Progress, June 1994

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Measurement video

• https://m.youtube.com/watch?v=Za1o77jAnbw

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Set AIMS that are measurable, time-specific, and apply to a defined population

What are we trying to accomplish? How will we know that change is an improvement? What change can we make that will result in improvement?

The Model for Improvement

Developed by Associates in Process Improvement’ Langley, G., Nolan, K., and Nolan, T., 1994. The Foundation of Improvement, Quality Progress, June 1994

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The Aim Statement

Helps you focus on what your project needs to accomplish. It provides a specific, measurable statement of intent. The aim should be:

• A clear and unambiguous end deliverable

S - Specific

• Observable outcomes of performance

Quantity, Quality, Cost, Time

M - Measurable

• Realistic within the capabilities and contraints

A – Achieveable

• Address a significant need

R - Relevant

• You have a target date for completion
• Now is an opportune time to undertake the project

T – Timebound

• Project will stimulate all concerned to action

E – Engaging

• Written down for clarity, communication and

review

R - Recorded

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An example of an aim we often see… We will implement active signposting by receptionists in our practice by the end of June in order to reduce demand for inappropriate appointments

Inspired by Dr Robert Lloyd, IHI

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An example of an aim we often see… We will implement active signposting by receptionists in our practice by the end of June in order to reduce demand for inappropriate appointments

How good? By when?

Hope is not a plan…

Inspired by Dr Robert Lloyd, IHI

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Activity 4 : Creating your aim statement

Aim Statement: (What’s the specific issue we want to address?)…

• 1. Use the worksheet to build

the ingredients of a good aim

• 2. Create a statement that

brings them all together

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I hope that has whetted your appetite!

• Making measurement simple,

quick and meaningful

• Driver diagrams
• Process mapping
• Defining the right measures
• Measurement over time :run and

control charts

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Actions and next steps

Home work to share at the next session on 30th Feb 2017 :

• Engage your practices in the work to date and

consider your project proposals

• Firm up aims
• Consider measures

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Key dates and plans

Learning sessions

• Session 2 : 30th March
• Session 3 : April – to be determined
• Session 4 : 25th May
• Session 5 : 29th June

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Rachel Duffy Rachel.duffy@nhs.net Carolyn Robertson carolynrobertson@nhs.net

Contact details