Implementation Clinic: COPD Discharge Care Bundle. Cathy Howe: CLAHRC NWL Jo Cooke: SY CLAHRC

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1 Implementation Clinic: COPD Discharge Care Bundle Cathy Howe: CLAHRC NWL Jo Cooke: SY CLAHRC

2 Why COPD? Chronic Obstructive Pulmonary Disease 5 th Leading cause of death in the UK Leading reason for hospital admission and readmission Large economic burden to the NHS NICE COPD guidelines: 183 recommendations Edward s Story

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4 Distilling the evidence 5 key elements for acute exacerbation of COPD Ideal for development into a Care Bundle

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6 CLAHRC NWL Methods Systematic and scientific approach to implementation using quality improvement tools and techniques

7 Action Effect Diagram - Articulate programme theory - Define measures - Shared aim and vision

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9 Rollout Round 1: Month 1 Month 18 Round 2: Month 12 Round 3: Month 24 Hospital 1 Developed a COPD care bundle Hospital 2, 3 (x2 sites) and 4 (x3 sites) rolling out and adapting bundle Hospital 1 extending use of bundle CLAHRC NWL team facilitates shared learning Month 36: Round 4 Month 37 Hospital 5 rolling out and adapting bundle Hospital 7 & 8 (South Yorkshire) rolling out and adapting bundle

10 Development site Roll-out site

11 Planning Implementation, testing, adapting, iteration 100% 80% 60% 40% % of patients receiving all elements of bundle 20% 0% W1 W3 W5 W7 W9 W11 W13 W15 W17 W19 W21 W23 W25 W27 W29 W31 W33 W35 W37 W39 W41 W43 W45 W47 W49 W51 W53 W55 W57 W59 W61 W63 W65 W67 W69 W71 W73 W75 W77

12 Challenges: Staffing Too busy- not enough not engaged: Solutions and Facilitators Identified 1) Education Education is the key component, understanding what COPD is and how it affects patients, making it more personal so people understand it- makes it more real to them. 2) Bundle Responsibility The responsibility is shared, if one person misses it someone else will capture it. There is responsibility for specific jobs so there is no confusion of who should do what. 3) Changing Perceptions A large part was changing the perception of the bundle, they envisaged it as more time consuming than it actually was, because they are constantly being given more paperwork around various diseases and to them it was just another piece of paper that they thought would be a lot of work. So once the perception was changed and it was part of their everyday role, they didn't see it as an add-on to what they were already doing.

13 Impact on healthcare Quality of Care 1149 patients received all elements of the bundle increased compliance with evidence based care standards Coordination of Care Improved relationship between community and hospital care

14 Impact on outcomes Readmissions and Bed days Multi-site analysis in progress Value Health Economic Impact Patient Experience

15 Impact on policy and practice Bundle design adopted by London Network for COPD NHS London optional CQUIN 2011/2012 Identified as best practice by HIEC Partnership with BTS EOI Collaboration with South Yorkshire Dissemination of learning

16 Conclusion The COPD Discharge Care Bundle has been developed and implemented in North West London and is associated with indications of improvements in healthcare delivery and outcomes. Implementation challenges exist in each new site, and the effort needed to overcome contextual challenges should not be underestimated. Challenges to implementation can be overcome by using tools such as the CLAHRC NWL methodology, though these are not always initially welcomed and further work is underway to ensure they are as accessible as possible.

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18 CLAHRC for South Yorkshire CLAHRC for South Yorkshire Jo Cooke Programme Manager

19 CLAHRC for South Yorkshire Organisational readiness?

20 CLAHRC for South Yorkshire...But it depends on the intervention

21 CLAHRC for South Yorkshire Nature of the intervention: pushing at an open door (Greenhalgh et al 2004 and Damschroder et al 2009) Intervention source Relative advantage/ task relevant/ usefulness Compatibility Complexity Observability Trialability & reinvention Costs NW London CLAHRC! CQINs target & change in care pathways Clear intervention and rings true: want more evidence! Links potentially with other CLAHRC activity (KWILLT, nutritional work); information booklets Agreement given from multiple sources

22 CLAHRC for South Yorkshire..continued Feasibility Stakeholder evaluation and assessment Implementation complexity? Action effect diagram and planning Process mapping

23 CLAHRC for South Yorkshire Initial thoughts Organisational eagerness as compared to readiness- pulling back the reins? Flexibility important but what about implementation fidelity? Spread and innovation: could add valuelinking to other CLAHRC SY projects and provide synergies Contexts and added value: Breathing space; and differences in systems- opportunities for 2 nd loop learning

24 CLAHRC for South Yorkshire "don't just weather the storm; learn to dance in the rain! Vimeo.com:clahrc sy Twitter.com: This presentation presents independent research by the Collaborations for Leadership in Applied Health Research and Care for South Yorkshire (CLAHRC SY). CLAHRC SY acknowledges funding from the National Institute for Health Research (NIHR). The views and opinions expressed are those of the authors, and not necessarily those of the NHS, the NIHR or the Department of Health. CLAHRC SY would also like to acknowledge the participation and resources of our partner organisations. Further details can be found at

25 Discussion Questions How can stakeholders who are not directly involved and want it to happen yesterday (or not at all) be managed effectively? What tools and techniques can support boundary crossing to support the management of complexity? Implementation fidelity : how much change is too much change? And who should decide?