Research
Care Pathway Simulator
Winner of the HITEA Award for Best Use of IT in the Health Service 2005
HITEA Award April 2005 BJHC&IM June 2005
Background
The principle of continuous quality improvement (CQI) in healthcare is that health care delivery must be constantly reviewed, assessed and improved. Widely used "suck it and see" methods such as PDSA (plan-study-do-act) are insufficient to cope with the pace of change and designing complex systems: more robust techniques are needed. Process design is a well understood subject and modern computer-based process simulation and design tools have revolutionised manufacturing industry. However these tools are not designed for use in patient-centred care processes and to-date have had very little impact in healthcare. A new tool has recently been developed specifically for use in healthcare (Care Pathway Simulator, SAASoft Ltd UK) and has been used to assist the redesign of the Vascular Surgery One Stop Clinic at Good Hope Hospital. Specifically CPS was used to test proposed clinic booking schedules that were designed to minimise patient waiting, reduce the number of clinic overruns and maximise clinic capacity. The final solution was implemented as a simple paper-based booking schedule that increases maximum capacity by 40% - this new schedule has been in use for over 9 months and has performed as predicted by the computer simulation. In effect we have achieved a win-win-win outcome: a better service for patients, reduced stress for staff, and increased capacity to provide resilience to cope with unpredictable changes in demand.
For further information:
Leg Ulcer Telemedicine System
Winner of NHS Innovation Award for Service Delivery 2004
Background
Leg ulcers affect around 0.2% of the population, most of who are elderly, with direct treatment costs in the region of £500 M per year in the UK alone. The high cost of leg ulcers is mainly due to repeated dressing by community nurses over extended periods of time, often many years. Any means to accelerate healing time and reduce ulcer recurrence will therefore result in quality of life improvement for the patients and their carers and major cost savings for the NHS. Over 80% of leg ulcers are due to vascular disease and treatment should be based on an accurate diagnosis that requires expert assessment in a specialist unit with direct access to duplex ultrasound. Treatment in the community by specially trained nurses is more acceptable to patients and reduces the burden on busy hospital outpatient departments. Thus, optimum management requires close cooperation between the hospital and community-based specialists.
Following an initial audit of the Good Hope Hospital vascular outpatient clinic, two changes in the existing care process were implemented:
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Firstly, the conventional multiple visit clinic was
re-organised as a One Stop Clinic (OSC) with availability of a consultant
vascular surgeon, vascular nurse specialist and vascular technologist in the
outpatient clinic. |
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Secondly, an image-based electronic patient record (EPR) system was designed to link the OSC with the community nurses via NHS net. Further audit cycles were completed after each change to measure the effect of these process modifications. |
Following the implementation of the OSC, the time from referral to a definitive management plan was reduced from 24 weeks to 4 weeks and the average number of repeat hospital visits was reduced from six to five.
Following the addition of the EPR system, the time from referral to definitive treatment plan was reduced to 2 weeks and the average number of repeat hospital visits reduced from five to two.
Despite the initial reservations, we found that the EPR system was enthusiastically adopted by the community nursing teams once they had direct experience of real benefits for their patients.
The Hurdles
The problems with the implementation an EPR were a lack of appropriate software that met the essential functional and non-functional requirements, and the resistance to change of both hospital and community staff. These hurdles were overcome by development of a dedicated client-server software application and the provision of extensive familiarisation, training and hands on experience of the system for the community and hospital teams. The community nurse teams were encouraged to visit the OSC and experience first-hand how the whole care process works before using the EPR system in the community. A randomised controlled trial (RCT) is now underway to compare the conventional paper-based care process with the EPR system and we are also running a number of advanced study days for the local community nurses to provide an introduction to these new models of care.
The Benefits
The OSC/EPR shared care model for leg ulcers has provided a number of benefits.
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There is a complete problem-specific care record that includes colour digital images that can be accessed 24 hours a day by both community and hospital teams.
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The rate of healing can be measured from the digital images using the EPR software and displayed graphically. We have found that these graphs give a simple method of assessing the effectiveness of treatment, predicting the time to complete healing and identifying problems quickly. We have also found that visible evidence of progress is a great psychological boost for patients and their carers and aids in compliance with treatment.
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The community team can refer patients very quickly for a complete assessment, access the results and expert interpretation as soon as they are available and then treat the patient in the community without further hospital visits.
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The community team can request advice and usually receive a response within 24 hours.
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The specialist hospital OSC can focus its finite resources on initial detailed assessment and providing expert support and yet still get information on the outcome of the treatment provided without the patient having to re-attend the hospital.
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Both community and hospital teams develop a cumulative experience of cases which is valuable as a training resource for students and new staff.
The Lessons
Our experience in the successful design and implementation of this OSC/EPR system has taught us a number of valuable lessons:
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That the development of any EPR solution must follow
from a detailed analysis of the whole care process and simple organisational
changes are synergistic with complex technological solutions. | ||||||||
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If an EPR solution is adopted it must be tailored to
address the specific clinical problem and allow best-known care to be
delivered more efficiently and effectively. | ||||||||
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The EPR solution should be designed with the users and
evolved to meet their changing needs and expectations. | ||||||||
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The EPR solution must be
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The EPR system must deliver immediate, tangible and
measurable benefits for staff and patients. | ||||||||
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The EPR system should provide beneficial "spin
offs" such as improved audit, training and opportunities for research. | ||||||||
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The EPR system must be secure and must be compatible with future EPR systems as they evolve either to act as a feeder system or to allow transfer of the data to a future system. |
Publications
Samad A, Hayes S, Dodds S. Telemedicine: an innovative way of managing patients with leg ulcers. Br J Nursing 2002 (Suppl): Vol 11 (6); S38-S52.
Samad A, Hayes S, French L, Dodds SR. A comparative study of computerised digital image tracing versus contact tracing for objective measurement of leg ulcers. J Wound Care 2002; 11: 137-140.
Hayes S. Dodds S. Telemedicine: a new model of care. Nurs Times 2003; 99: 48-49.
Dodds SR. Shared community-hospital care of leg ulcers
using an electronic record and telemedicine. Int J Lower Limb Wounds
2002; 1: 260-270.
Prince S, Dodds SR. Use of ulcer size and initial responses to treatment to
predict the healing time of leg ulcers. J Wound Care 2006; 15 (7):
299-303.
Further Information
e: simon.dodds@goodhope.nhs.uk
© S.R.Dodds 2006