The Power of a Fly by Heather Currie

Acceptably, an unusual title! The reason will be become clear but essentially, the message is that something very small can make a huge difference.

Following on from Ross McGarva’s blog last week on reducing waste and CRES, let’s look at how we as clinicians can make a difference. A recent report from the Academy of Medical Royal Colleges, “Protecting resources, promoting value: a doctor’s guide to cutting waste in clinical care” was published with the aim of supporting doctors and other clinicians to ensure that the resources of the NHS are used in the most effective way possible to provide the best possible quality and quantity of care for patients—one doctor’s waste is a patient’s delay or lack of treatment. (The report can be read by clicking here) The following is a summary of the key messages of the report with my observations on relevance to ourselves in Dumfries and Galloway.

It is becoming increasingly clear that use of NHS resources in the current form is unsustainable and without major changes the safety and quality of patient care will decline. Therefore waste must be reduced. Most waste within the NHS lies within clinical practice and models of care. Estimates suggest that around 20% of mainstream clinical practice brings no benefit to the patient as there is widespread overuse of tests, interventions, prescribing, hospital beds, clinics and theatres. According to a report in 2010, the cost of prescribed medicines wasted is estimated to be around £300 million each year. Influences that affect how a doctor uses clinical resources include:

• Individual practices
• Defensive practices
• Time pressures
• Responding to senior or patient pressures
• Inefficient pathways

Before we explore some of the specific examples as discussed in the report, let’s have a think about our own experiences of the above non-exhaustive list.

Are you completely sure that you are following best practice, is it different from your colleagues, if so why? Could one of us be wrong?!

Have you ever arranged tests or started treatment “just to make sure” when, with full clinical assessment the likelihood of the test or treatment being helpful is very small? How often does a seemingly simple “routine” test lead to even further unhelpful tests?

We are all affected by time pressures and it may be a short term fix to ask the patient to come back another day to complete assessment/treatment when a little more time could prevent another visit.

Am I simply doing repeat tests to prevent being caught out on the ward round, even though it may not be clinically indicated? A recent spot check in our own hospital revealed that of over 25 blood form requests, very few contained any clinical details—what thought had gone into making these requests?

Are we making the best use of clinics, hospital beds, and theatres? Do we bring patients back to clinics inappropriately when we could write to them, phone them, or let them contact us directly if they have a problem? Do our clinics start on time and do we book the full clinic session? Are patients coming to the hospital more than once because of an inefficient pathway? Have you examined the pathway of your patients recently? Do we cancel clinics or theatres at short notice because of lack of forward planning? Every clinic which is cancelled with less than 6 weeks’ notice leads to at least 2 hours of time for Patient Focussed Booking staff to contact patients and rearrange appointments, let alone the inconvenience and reorganisation required by patients.

Do we ever ask patients to attend their GP to have blood tests, collect prescription, get results of tests that we have carried out or requested or to be referred to another hospital specialist? All of these can be done or arranged by ourselves in secondary care saving precious time for both patients and our GP colleagues.

With waiting time guarantees extreme pressure and scrutiny of pathways is constantly applied, especially to patients referred with suspected cancer. While this is to be applauded, time and effort is often wasted by leaving out the clinicians in the process; we know our services best and are able to adapt to accommodate urgent patients as required, talk to us not about us!

At all times, with every patient encounter, we should ask ourselves “Are there points of delay and waste in any stage of the process due to duplication, lack of resources or availability of information, or inefficient use of clinical and patient time. Could we do better?”

Specific areas of waste discussed in the report include prescribing, inappropriate investigations, staff and patient movement, maximising capacity in theatre, and reducing inappropriate interventions.

Reducing prescribing costs

GPs are well aware of need for generic prescribing, and use of low cost options, but are we as aware in secondary care? With increasing provision of prescriptions from clinics for reduced inconvenience to patient and GP, we in secondary care also need to be aware of cost and generic formulations. Why not develop a list of commonly prescribed medicines in generic form to have available in clinic?

Reducing inappropriate laboratory investigations

Blood tests

CRP testing has risen dramatically in recent years with many patients now being subjected to daily measurements even if levels remain low. National benchmarking showed a 31% increase in CRP requests over 1 year in one region. Disease related protocols were agreed and requests reduced by 85%. Minimum re-testing interval for CRP of 3 days, with exceptional requesting still possible and overseen by a senior clinician, was introduced in Borders leading to reduction in testing of 30 to 40%.

Minimum re-testing interval for Vitamin D of 1 year led to reduction of 50%.

Minimum re-testing interval for HbA1C of 3 months led to levelling off of rising trend.

Local experience–Patients presenting with infertility have frequently had blood tests taken for renal, liver, and thyroid function along with hormone profile, androgen screen and prolactin despite the woman having regular menstrual cycle. With a regular, 21 to 35 day cycle in a clinically well woman, significant renal, liver, thyroid, hormone, androgen or prolactin problem is extremely unlikely. Provision of information to primary care colleagues and publication of infertility assessment guideline to easily accessible Guidelines area on HIPPO should reduce unnecessary tests.

Does your specialty have similar examples of inappropriate tests being taken before referral for which guidance could be made available?

Imaging

Some radiological investigations contribute little to clinical management, particularly lumbar spine and knee radiographs. Guidance notes provided alongside the report of every relevant radiograph reduced referrals for knee and lumbar spine radiographs by 20%. If applied nationally this could save £221 million per year (presumably in England). While we are working towards improved MSK pathways in Scotland, are all imaging requests absolutely required? In gynaecology we often find that a scan for an uncertain reason leads to further scans due to the finding of a probable insignificant feature.

Staff and Patient Movement

Separate sites for outpatient clinics increases travel time and reduce numbers of patients that can be seen. While recommendations encourage clinical care to be closer to home, rethink of use of peripheral clinics would be reasonable. Review of reasons for clinic appointment, especially return appointment and increasing use of telehealth clinics (telehealth incudes option of telephone follow up) and video-conferencing is already taking place in D & G.

Maximising capacity in theatre

Each week around 15 to 18 hours of theatre time is wasted due to late starts. Many late starts are significant and recurring. While the majority of patients are now admitted on the day of theatre instead of the day before as in the past, do we plan appropriate time and do we use space efficiently so that patients can be seen before theatre early enough and theatre starts on time? Occasionally cases are cancelled on the theatre day because the operation was not needed—have we ensured that the patient was fully assessed before theatre by a senior doctor?

Reducing inappropriate interventions

Many interventions may be unnecessary or harmful. NICE “do not do’s” identifies clinical practices that should be either discontinued completely or not used routinely. Are we sure that we have studied areas relevant to our speciality? To read the NICE document click here.

To conclude, while at times it feels like we are all working harder and under greater pressure than ever before, there are small changes that we can all make. Much of this article refers to the practices and actions of doctors, but hopefully there is something of relevance to everyone. Just take a few moments to think about our practices, tests, pathways, processes, and most of all, what is best for each patient.

To finish on a light-hearted, but pertinent point and to explain the significance of the title, the urinal shown above was developed at Schiphol airport to include a fly in the basin. This simple act reduced urinal spillage requiring frequent floor washing by 80%, proving beyond doubt that simple changes can indeed make a huge difference.

Heather Currie is an Associate Specialist in Obstetrics and Gynaecology and is Clinical Director for Women and Children at NHS Dumfries and Galloway

 

CRES and Our Collective Responsibility for Waste by Ross McGarva

As an accountant and a Scotsman I’m well aware of the stereotypes around being tight fisted and penny pinching. In fact, I’m quite proud to admit I fit in with that particular stereotype, although ‘proud’ is not the word my better half would use to describe me! However, in recent years it has become more socially acceptable to be frugal or thrifty. The economic situation over the last few years and an increase in environmental awareness around our own carbon footprint has increased the need to reduce waste and live within our means. This is evident with the rise in popularity of budget supermarkets, Martin Lewis, extreme couponing and the ‘bag for life’, to name but a few.

So what’s this got to do with the health board? I wanted to talk about waste and CRES or Cash Releasing Efficiency Savings and how the responsibility sits with everyone employed by the board and how it’s not really a million miles away from what we do every day at home. 

 

Financially managing a health board is similar in some respects to financially managing your household. We all have to manage our household bills and outgoings to live within our income budget. If your outgoings are more than your income then you have a problem, one of the solutions being to reduce your expenditure.

In terms of the health board, in the current financial year we received a 2.7% uplift in our annual budget allocation, the equivalent to about £7 million. At the same time our expenditure has increased by £14 million (made up of incremental uplifts, pay awards, 7% drugs inflation, general inflation, etc). In order to balance the books we need to save £7 million which we look to achieve through CRES. Although the responsibility for formulating the CRES plans sits primarily with the General Managers, everyone, as an employee of the NHS, has the responsibility to use resources efficiently and to avoid waste.

There are a number of concepts and theories around waste and lean working, the majority of which originate from the Toyota Production System and relate mostly to manufacturing. However one of these concepts can be applied to the healthcare environment and even your own household. This concept is known in Japan as muda (無駄) which is a term for anything that is wasteful and doesn’t add value and if you’ve ever heard Jason Leitch (Clinical Director of The Quality Unit, Scottish Government) talk about finance then you may be familiar with the notion.

Jason does however warn that once you’re aware of the 6 concepts of muda you will start seeing waste everywhere. This may lead to you become as annoying around the house as I am. The 6 categories of muda are: 

1. Delay – idle time spent waiting for something such as appointments, test results, reviews, spare beds, late starts to theatre or clinics or even meetings that go on longer than they should. Under utilisation of clinic spaces so delaying time for appointments. How often do you wait around picking your kids up from their various after school clubs and hobbies? 
2. Re-work – performing the same task a second time, re-sending, re-scheduling, late cancellation of clinics or theatres, repeating questions, multiple bed moves, performing multiple diagnostic tests. Re-laundering clean towels or linen. Or cleaning the kitchen floor at home only for the dog to run through with muddy paws 
3. Over-production or Over-service – manufacturing of products or information that is not needed, such as precautionary “defensive” medical tests, “routine” blood tests taken without considering clinical value, inappropriate imaging which then leads to findings of clinically insignificant features, leading to further imaging… surplus medications, excessive levels of paperwork. For example, at home – your subscription TV package, how many channels do you actually watch?
4. Movement – the unnecessary transport of people, products or information, such as requiring patients to see a primary care provider before seeing a specialist who is clearly needed. Asking patients to attend their GP for investigations, results, prescriptions when these can be arranged while the patient is in secondary care. The unnecessary movement of patients between wards. Requesting patients to attend a hospital clinic when a phone call or letter would provide the same information. At home – driving the kids to school after they’ve miss the bus.
5. Defects – design of goods that do not meet customer needs such as medication errors, wrong side surgery, laboratory labelling errors and clinical errors.
6. Waste of Talent, Spirit and Skill – failure to address the many hassles in everyday life, hunting and gathering, re-calling, the same things every day. Making decisions without the involvement of the whole front-line team so missing valuable contributions. People disengaging due to lack of feeling valued and appreciated. I’m sure we can all relate to this at some point.

As you can see, waste is everywhere. The real challenge is highlighting it and coming up with a solution to tackle it. One of the most prominent messages I’ve came across as a regular reader of the blog is ‘the standard you walk past is the standard you accept’. This is an incredibly powerful comment particularly in context with patient safety and quality but the same also applies to waste and protecting the valuable resources we are so privileged to have access to.

The CRES challenge is huge but if we can all remove some of the waste from our day it can soon add up to a realisable tangible benefit. For example, it only costs the board £0.43 to launder an item such as a towel or a pillow case but we launder nearly 2 million items per year at a total cost of nearly £800,000. Even something as small as segregating waste properly has an impact. The disposal of clinical waste costs £400 per tonne compared to £100-£200 per tonne for normal waste – last year it cost £216,000. It is estimated that around 50% of waste is subject to incorrect segregation. Assuming we could divert even 20% of our clinical waste into black bag stream domestic waste, we would save around £30,000 per year.

So as the old thrift saying goes, look after the pennies and the pounds will look after themselves. On that note I’m off home to turn down the thermostat.

Ross McGarva is a Management Accountant at NHS Dumfries and Galloway