New pathways based on patient experience are reducing unwanted variation | Dr Chris Streather

Chris Streather, group chief medical officer at the Royal Free London NHS Trust.

Putting orange hats on at-risk babies is just one way that the Royal Free London NHS Trust is improving patient pathways. In the first of two blogs, Dr Chris Streather, group chief medical officer at the Royal Free London NHS Trust, explains how removing variation and working more effectively with partners has enabled them to improve the service patients receive and achieve savings. 
At the Royal Free we set out to reduce the variation in clinical services. Working with Intermountain, a not-for-profit healthcare system in Utah, we learnt how they had used clinicians to co-design services that will reduce unwanted variation. 
We put together multi-disciplinary clinical teams, including patients and carers, to explore the data for different pathways and to develop them around patient need. 
The teams developed process and outcome measures that can be measured in real time to create a cycle of improvement, so that the pathway evolves and improves based on real patient experiences. 
In partnership with the Institute for Healthcare Improvement (IHI), we have trained over 700 of our staff in formal quality improvement methodology and are on course to have trained 2,000 in the next year. 
We have done this in 50 pathways across the Royal Free group of Barnet Hospital, Chase Farm Hospital and the Royal Free Hospital so far, delivering measurable improvements for patients. 
Placing orange hats on at risk babies was one of the new pathways that developed from this. 
The simple act of placing an orange hat on babies who are at risk of needing additional neonatal support alerts the clinicians to their additional needs and provides patients with reassurance that they are being closely monitored.
In the six months since we introduced this the number of babies being transferred to the neonatal unit has reduced by 50 per cent. 
Maternity services have also seen real changes. As part of the Better Births initiative, we have developed a continuity of care pathway, aiming to provide pregnant mothers with a single midwife. 
This has been shown to have better outcomes for the mother, with women reporting a better experience, but also a reduction in miscarriages. 
We are not doing this in isolation though and working with other trusts as part of a group is an important part of developing pathways and learning from others. 
Working with West Hertfordshire Hospitals NHS Trusts we have co-designed new ways of working, where our clinicians can learn from each other and both adopt the same pathway. 
We are also working with North Middlesex University Hospital NHS Trust as a clinical partner. We have a prostate cancer pathway and the design of this was led clinically by one of their urologists. This has incorporated same day MRI reporting into the pathway so that patients are ready for cancer surgery sooner and are spared unnecessary investigations including cystoscopies and trans rectal biopsies.  
This isn’t just improving patient experience but also staff experience. With staff developing the pathways and being able to see how patient outcomes influence the evolution of the pathway, we’re improving staff engagement, and creating a sense that every member of our team has the space and permission to make improvements.
Reducing variation also has a cost benefit with less waste in the service, translating into cost savings. So, everyone wins. 
We are also doing this in our clinical support services, payroll, recruitment, procurement, etc, working with other trusts, community providers and other partners to standardise services. 
There are economies of scale in collaboration, for example through working in partnership in pharmacy services we can exercise our bulk purchasing power. 
In addition, we now run our outpatients pharmacy services via a wholly owned subsidiary, insourcing a previously outsourced entity, restoring value to the public sector. 
We are determined to build efficiencies into the system that deliver real improvements for patients. Working as a group enables us to maximise the benefits and learn from each other for the benefit of patients.
Dr Chris Streather is group chief medical officer at the Royal Free London NHS Trust. Follow him on Twitter @dulwichchris

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