NHS Lincolnshire

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NHS Lincolnshire Provider Development
Academy Module 5 Creating a high productivity
culture performance analysis, benchmarking and
improvement Lucy Hadfield
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Module objectives

• Support provider performance profiling,
  measurement, monitoring, review and improvement
• Provide a systematic and rigorous framework for
  ongoing performance analysis and improvement
• Dedicate time during class to related project
  team work

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Todays agenda
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Topics covered in todays module are intimately
linked at their core are basic principles of
assessment and improvement
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Irrespective of how you measure it, successfully
managing system productivity is key to the
survival of any organisation
Adapted from Accel-team.com
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Productivity can be measured in three main ways
TOTAL PRODUCTIVITY Incorporates all inputs
required to make product or provide service
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TOTAL FACTOR PRODUCTIVITY Combines labour and
capital, 2 of most important input factors
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PARTIAL PRODUCTIVITY Uses only 1 input
factor, commonly direct labour hours
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Be warned different measures of productivity
result in different perspectives on the same
thing be consistent!
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What are your productivity levers?
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The task for provider units
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In the NHS clinical quality and financial
performance are inseparable
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As an NHS provider unit, a large supporting
framework supports and justifies your
productivity management
Business benefits
Global
Gershon review
UK public sector
Productive time
NHS
Meeting commissioners needs Service
sustainability
Provider units
Note policy context shown on this slide is for
illustrative purposes only and is far from
exhaustive. See www.dh.gov.uk for more information
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All businesses including provider units
benefit from measuring and managing their
productivity
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not least because improving productivity should
have a positive impact on profitability

• Increasing outputs and/or decreasing inputs
  increases the amount of surplus to invest in
  service development because
• This should be a goal of all organisations,
  whether for-profit or social enterprises

Profit revenue (outputs) costs (inputs)
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The whole public sector is targeted with
efficiency savings, around one-third of which
must come from the NHS

• Report by Sir Peter Gershon in July 2004
  Releasing resources to the front line
  independent review of public sector efficiency
• Identified efficiency gains of gt 20bn in 2007/08
  across public sector
• 60 of savings are directly cash releasing
• Set NHS target of 2.7 (6.5bn) in annual
  efficiency gains by 2007/08
• 50 to come from back office functions,
  procurement, transactional services and 50 from
  productive time i.e. increase productivity of
  frontline professionals
• Frees up resources to invest in front line
  services, as increases in NHS investment decline
  after 2007 from current above inflation levels
• Gershon original public sector targets for 2008
  were exceeded by around 4bn
• A new round of Gershon efficiency savings will be
  a key part of the Treasurys measures in future
  years to avoid raising general taxation and to
  contain increased levels of public sector
  borrowing triggered by the banking crisis and
  recession

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And, in turn, half of all NHS efficiency savings
should come from what Gershon calls productive
time initiatives
Adapted from NHS Institute for Innovation and
Improvement (June 2006). Delivering quality and
value. Focus on productivity and efficiency
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The Productive Time Programme identifies nine
areas with greatest potential for productivity
improvement
Source NHS Institute for Innovation and
Improvement (June 2006). Delivering quality and
value. Focus on productivity and efficiency
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Extract from reducing avoidable emergency
admissions
As a whole, the report

• Indicates scale of possible gains
• Suggests areas for benchmarking local performance
  and setting targets for improvement and benefits
  realisation
• Highlights how care quality and value can be
  improved by providers and commissioners
• Provides links to further support and information
  resources

Source NHS Institute for Innovation and
Improvement (June 2006). Delivering quality and
value. Focus on productivity and efficiency
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Commissioners objectives challenge providers to
demonstrate productivity/performance improvements
in multiple ways
Source relevant commissioners objectives
extracted from Department of Health (June 2006).
PCT fitness for purpose programme.
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Improving productivity may also enable you to
overcome downward pricing pressures and upward
cost pressures
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Project team exercise
30mins
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Optimising productivity and performance relies
upon
Fully understanding the system service profiling
Linking performance analysis to the provider
units strategic objectives
Measuring and monitoring the right
performance elements of the system
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Creating a detailed provider/service profile
forces you to question what you really need, and
need to do, to operate successfully
See next slide
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Profiling in a patient-oriented system must
include an understanding of the system from the
customer perspective
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Class discussion
Questions To what extent do your current
provider/service profiles support productivity
and performance improvements? In this context,
what main gaps in your provider/service profiles
need filling?
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Performance analysis
Process
Definition
Goal
An investigation of a systems behaviour using
information gathered as the system operates
To determine which parts of the system need
optimising to improve outputs and meet system
objectives

• First steps in setting up a performance analysis
  framework
• Identify measures to reflect the organisations
  strategic goals
• Profile each measure in the measures record
  sheet
• Work out how you will turn performance
  measurement into performance improvement

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Connecting an organisations strategy to its
performance metrics ensures that both achieve
what they are supposed to do
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Profile each performance metric in a measures
record sheet
Source adapted from Warwick Business School, cf.
NHS Institute for Innovation and Improvement, CSI
learning programme
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Knowing how you are performing is not enough
this knowledge must be used to drive performance
improvement
Internal expectations Influenced by strategic
goals
Current performance level
Required or desired performance level
Bridge the gap
The market Benchmarking, competition, customers,
stakeholders
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But temper the desire to take immediate action
with the benefits of careful consideration
Performance improvement model
Source adapted from NHS Institute for Innovation
and Improvement, CSI learning programme
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Balanced scorecard

• Move away from purely financial outcomes to a
  more balanced portfolio of multiple financial and
  non financial measures closely linked to
  strategic objectives
• Comprised of performance measures that are
• Focused
• Appropriate
• Balanced
• Robust
• Integrated
• Cost effective

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The balanced scorecard quadrants
A Practitioners Guide to the Balanced Scorecard
CIMA (Allan Mackay) 2004 Kaplan Norton (1996a)
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Example quadrant objectives
Suggested measures Kaplan and Norton (1996a)
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Example quadrant objectives
Suggested measures Kaplan and Norton (1996a)
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PCT Provider ServicesPerformance Scorecard
2008/2009
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Top 10 most popular performance measures
A Practitioners Guide to the Balanced Scorecard
CIMA (Allan Mackay) 2004
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Typical key performance measures (HAZ diabetes)
A Practitioners Guide to the Balanced Scorecard
CIMA (Allan Mackay) 2004
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Developing process measures for the recuperation
and rehabilitation of the elderly after
hospitalisation
A Practitioners Guide to the Balanced Scorecard
CIMA (Allan Mackay) 2004
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Networking tea/coffee break
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Project team exercise
45 mins
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Benchmarking supports ongoing improvement through
comparisons with best practice
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Why do it?
?
WHICH ENABLE US TO
TO ANSWER 3 KEY QUESTIONS

• Where are we now?
• Where do we want to get to?
• How do we get there?

Learn from best practices Share experiences
Make a strong case for change Continuously
improve Understand market position Gain a
competitive edge
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Why do it?
AND MAKE STEP CHANGES IN PERFORMANCE
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To justify investment in benchmarking, the
subject of the exercise must be business critical
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Once the subject has been identified, the type of
benchmarking done depends on the objectives of
the exercise and the partner network
Performance/ competitive
Strategic
Process
International
Functional/ generic
External
Internal
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Irrespective of the benchmarking subject, network
or purpose, the same underlying process is used
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Productivity across services
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District nursing skill mix against benchmark
X

• XXX PCT has a total of 84 of FTE of a grade 5 or
  above, this compares with 81 for PCT 1 87 for
  PCT 2, 88 for PCT 3 and 76 for PCT 4

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District nursing cost per contact against
benchmark

• The cost per contact for XXX PCT is the highest
  of the group.

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Core Metrics
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How Key Metrics are Derived
Cost per contact
Service costs / volume of activity
Patient contacts per WTE
Volume of activity / WTE in PCT, team
WTE per 10,000 pop
WTE / (overall pop /10,000)
Spend per 1,000 pop
Service costs / (overall population/1000)
of time spent with patients
(time spent with patient / minutes available in
audit period) x 100
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Selecting an appropriate peer group
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Competitive benchmarking will only yield
meaningful results if it is populated with
meaningful information from competitor analysis
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Turn information into intelligence creating a
competitor array (1 of 2)
Key steps (a) to (e) are illustrated in next
slide
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Step 5 A competitor array
Hypothetical example from the market for PCT
provider services
b
a
c
d
e
a
Key relate to steps to be followed
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Making the shift key success factors

• OHOCOS
• Five components of the secondary care pathway
  that could shift
• Simple diagnostic tests
• Outpatient appointments
• Day case surgery
• Step down care
• Outpatient follow up

NHS Institute for Innovation Improvement and
the University of Birmingham found good evidence
to support the use of strategies grouped around
seven themes (July 2006)
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Enabling strategies
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Re-engineer business processes

• Fundamental review of the key processes that make
  up the business
• Strong, fact-based analysis, focussed on factors
  critical to the success of the business
• Does require investment of time effort
• But can dramatically improve productivity
• Sends out a strong, positive message
• Few negative side-effects
• Can often reduce unit costs by 10-30
• Often seen as very positive
• Lean and Six Sigma approaches popular in the NHS

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Service redesign
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Example 1 cycle time is the key measure.
Compared to the 62 day target, XXXs mean cycle
time is 147 days

• Overall cycle time
• Mean - 147 days
• Shortest - 62 days

Discharge
Discharge
Referral received at hospital
First seen in hospital
Scanned
Date diagnosis given
Treatment
Hysteroscopy

• Referral to 1st seen
• Mean - 32 days
• Shortest - 7 days
• Longest - 115 days

• Scanned to hysteroscopy
• Mean - 36 days
• Shortest - 0 days
• Longest - 158 days
• UPL - 186 days

• Hysteroscopy to diagnosis given
• Mean - 16 days
• Shortest - 9 days
• Longest - 28 days
• UPL - 32 days

• Diagnosis to treatment
• Mean - 36 days
• Shortest - 5 days
• Longest - 96 days
• UPL - 99 days

• 1st seen to scanned
• Mean - 19 days
• Shortest - 0 days
• Longest - 94 days

Cycle time analysis based on patients referred
from 2001-04 UPL upper process limit
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Even without a major redesign the current cycle
time could be reduced to 62 days
Nothing seen advice discharge
Advice discharge
GP refers all PMB via TWW
Bloods, ECG, anaesthetic assessment
Hysteroscopy

• PMB clinic visit 1 scan exam
• If scan gt5mm hysteroscopy assessment
• Decide whether I/P or O/P

Results see consultant, plan further treatment,
refer to xxx, etc
First definitive treatment
Referral received at DGH
Pathology
PMB clinic visit 2 full hysteroscopy list
Scan lt5mm advice discharge
Nothing seen advice discharge
Advice discharge
Wk 1
Wk 5/6
Wk 3/4
Wk 2
Wk 7/8
out-patient
in-patient
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and with further improvements could
theoretically be as short as 21 days
Theoretical cycle time 21 days
Referral received at hospital
First seen in hospital
Scanned
Date diagnosis given
Treatment
Hysteroscopy
Referral to 1st seen Shortest - 7 days when
going via OPD but increases overall cycle time
Scanned to hysteroscopy Shortest - 0 days when
done in PMB clinic
Hysteroscopy to diagnosis given Shortest - 9
days when done as inpatient or in PMB clinic
Diagnosis to treatment Shortest - 5 days when
hysteroscopy done as inpatient and patient
treated at Barnsley
1st seen to scanned Shortest - 0 days when both
done in PMB clinic
Cycle time will be extended if inappropriate to
perform hysteroscopy at first visit
Having revised and standardised the pathway, it
needs to be communicated widely
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Newchurch methodology consists of four key steps
1
2
3
4
Simplify the process
Identify, control and eliminate variation in the
process
Set up feedback systems to measure and control
the process
Manage and refine the process
Successful trusts started to address the task of
reducing waiting times in a systematic way and
persevered with the task Sustaining reductions
in waiting times Kings Fund, January 2005
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IT solutions can address many of the common
resourcing and scheduling issues
A lot of time and effort is expended in making
the system workwhen the system should actually
enable staff to work more effectively
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Module 5 follow-up prioritising productivity
improvements
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Module 5 follow-up prioritising productivity
improvements
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Thank you
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Appendix 1
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Sources of further information
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Appendix 2 Service redesign case study
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Endometrial cancer care pathway review -
objectives
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Key messages and findings
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Over three months, Newchurch and the XXX team
worked together to identify, diagnose and resolve
pathway problems
Our methodology

• Statistical process control
• PMB clinic outcomes
• Demand data

Populate model
Data analysis
Create data model
Process mapping
Questionnaire development
Problem definition
Questionnaire completion
Analyse process maps
Synthesis interpretation

• Face to face interviews with staff

• Cancer mgmt peer review
• Client validation

PMB post-menopausal bleeding
Client activity
Newchurch activity
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endometrial cancer pathway referral to initial
booking
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endometrial cancer pathway scanning to decision
to treat
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Analysis highlights four main and interrelated
areas of the pathway where problems exist
1 Cycle time
Discharge
Discharge
2 Routes into and through the pathway
Referral received at hospital
First seen in hospital
Scanned
Date diagnosis given
Treatment
Hysteroscopy
3 Resource optimisation
4 PMB clinic
These problems are substantiated by anecdotal
and/or quantitative analysis
PMB post-menopausal bleeding
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Problem 1 cycle time is the key measure.
Compared to the 62 day target, XXXs mean cycle
time is 147 days
Cycle time analysis based on patients referred
from 2001-04 UPL upper process limit
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Problem 2 a patients route into the pathway and
where they are first seen affects the time to
first appointment
Average times from GP referral to first
appointment
Where 1st seen
Grading
25 days
2 week wait
PMB clinic
27 days
GP referral
80 days
Urgent
Routine
24 days
8 days
Soon
102 days
GOPD
No grading
GOPD Gynaecology Out-Patient Clinic
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Problems 3 4 scheduling without reference to
patient notes can result in poor scanning
utilisation
PMB clinic outcomes
48 of patients attending PMB clinic had already
been scanned, potentially resulting in 122 lost
scanning slots
24 of patients attending PMB clinic discharged
30 of patients attending PMB clinic referred to
GOPD for follow-up
WL waiting list appt appointment
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First, we suggest that XXX simplifies its
referral process and routes into and through the
pathway

• Use existing process maps to remove
  non-value-added steps
• Adopt single point of access using two week wait
  route
• Eliminate route via GOPD
• Helps to meet two week wait targets but is
  detrimental to overall cycle time
• Resolve capacity issues and route via PMB clinic
• Update GP referral protocol accordingly

46 of all patients were referred via TWW yet 90
of these referrals were first seen in GOPD
24 of patients first seen in PMB clinic but 50
had no referral grading, 20 were routine, 10
urgent and 10 TWW
TWW two week wait
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Then SPC analysis can be used to explain shorter
cycle times
Total cycle time from receipt of referral to
treatment
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Even without a major redesign the current cycle
time could be reduced to 62 days
Nothing seen advice discharge
Advice discharge
GP refers all PMB via TWW
Bloods, ECG, anaesthetic assessment
Hysteroscopy

• PMB clinic visit 1 scan exam
• If scan gt5mm hysteroscopy assessment
• Decide whether I/P or O/P

Results see consultant, plan further treatment,
refer to xxx, etc
First definitive treatment
Referral received at DGH
Pathology
PMB clinic visit 2 full hysteroscopy list
Scan lt5mm advice discharge
Nothing seen advice discharge
Advice discharge
Wk 1
Wk 5/6
Wk 3/4
Wk 2
Wk 7/8
out-patient
in-patient
81
and with further improvements could
theoretically be as short as 21 days
Theoretical cycle time 21 days
Referral received at hospital
First seen in hospital
Scanned
Date diagnosis given
Treatment
Hysteroscopy
Referral to 1st seen Shortest - 7 days when
going via OPD but increases overall cycle time
Scanned to hysteroscopy Shortest - 0 days when
done in PMB clinic
Hysteroscopy to diagnosis given Shortest - 9
days when done as inpatient or in PMB clinic
Diagnosis to treatment Shortest - 5 days when
hysteroscopy done as inpatient and patient
treated at Barnsley
1st seen to scanned Shortest - 0 days when both
done in PMB clinic
Cycle time will be extended if inappropriate to
perform hysteroscopy at first visit
Having revised and standardised the pathway, it
needs to be communicated widely