The subsequent Pursuing Perfection Admissions Avoidance and Delayed Discharge Project — skittishly referred to as “P2 A2 D2” — helped avoid 700 unnecessary admissions in 15 months. As part of the project, the team developed software to predict daily, monthly, and yearly discharges, and held daily multidisciplinary meetings to manage the flow of patients through the hospital. By freeing beds as a result, it is now rare for patients to have to spend time on an inappropriate ward or be forced to move — sometimes up to five times — between wards.
"We reduced these 'medical outliers' from the high 60s to zero," says Ms. Pedder. Clinical teams benefit too by being able to concentrate on patients with conditions relevant to their expertise.
Success hinged partly on breaking down organizational boundaries among frontline staff, not just managers. For example, an access team of occupational therapists and social workers is now based in the hospital emergency department. "I'm never too sure who they are employed by," says John Keast, who formerly led the P2 A2 D2 project. In fact it is the Primary Care Trust (PCT), not the hospital.
Allowing staff room to use their initiative has been decisive. "There seems to be a transformation of staff once they become truly empowered," says Mr. Keast. He cites the example of ambulance crews, who are now able to refer patients to social services. "That came about from an off-the-cuff discussion."
Ms. Pedder says, "It was always too easy in the past to blame a problem on someone else. Now everyone is focused on their own bit of the problem and how we work together."
Lambeth and Southwark Health and Social Care Community: Looking After Long-Term Conditions
Almost a fifth of the patients turning up at the emergency department of King's College Hospital in South London three years ago were found to be suffering respiratory problems, and a small number accounted for more than a tenth of all the inpatient activity for such conditions. Average length of stay for those with chronic obstructive pulmonary disease (COPD) was 14 days, and although patients had to endure a three-month wait to be assessed for rehabilitation, only 28 percent ever completed the program. So with help from Pursuing Perfection, the Lambeth and Southwark Health and Social Care Community
— of which the hospital is part — set up a project to redesign the COPD patient's pathway through the system.
Today, length of stay for COPD is 6.6 days and patients can access far more support to keep out of hospital altogether. They need wait only two to three weeks for pulmonary rehabilitation and 70 percent complete the program. The hospital has seen an 11 percent fall in the number of occupied bed days attributed to COPD patients. Lessons from the project are now being applied to a range of other long-term conditions across Lambeth and Southwark, an area of 600,000 ethnically and culturally diverse people, many of them elderly and poor.
Using the Pursuing Perfection approach, the project combined patients' and professionals' expertise with COPD and used all available evidence to identify the components of ideal care. These included rapid and accurate diagnosis, 24-hour support, patient education, care at home, and pulmonary rehabilitation. But Lambeth and Southwark's original rehabilitation program — involving training in self-management skills and structured exercise — was based on a "one size fits all" model. Regardless of the patient's individual needs, preferences, or circumstances, rehab offered seven inflexible weeks of hospital-based group participation, leading inevitably to high non-attendance and drop-out rates.
Seeking ways to offer more choice, the project team "segmented" patients into nine groups according to the severity of their condition and their ability and motivation to manage it themselves. Then the team devised different packages of support for each group. These included written information, support from patient groups, and exercise programs for use at home, in a local leisure centre, or in the hospital. Each package was adapted to suit the patient's needs.
A Pulmonary Rehabilitation Coordinator at Lambeth and Southwark provides exercise training to a COPD patient who has helped design the program as part of the BreathEasy group and Pursuing Perfection
Today, the segmentation technique enables resources to be targeted more effectively, reducing input for more able and better-motivated patients while refocusing it on those who need most help. It has proved so cost-effective that it is now being used in case management for older people, and for patients dealing with diabetes, non-emergency knee surgery, falls, and pediatric occupational therapy. "It's been very important," says Malcolm Lowe-Laurie, Chief Executive of King's College Hospital.
In fact he describes Pursuing Perfection’s effect on Lambeth and Southwark's entire strategy for long-term conditions as "pretty influential." The Health and Social Care Community is now thinking about combining parts of its seven organizations responsible for managing long-term conditions. "Without Pursuing Perfection we wouldn't have got to this point," Lowe-Laurie says. "We would still be on first base."
Central Norfolk Health and Social Care Community: Springboard to Elsewhere
Alone among the NHS's Pursuing Perfection health and social care communities, Central Norfolk has now left the program to pursue its own transformation work. Local circumstances forced the decision. Several of the chief executives leading Pursuing Perfection in nine Norfolk organizations taking part left for other posts, while major financial problems facing the community demanded urgent top management time, making maintaining Pursuing Perfection impossible.
But the new, local transformation program, "Better Care for Norfolk," has inherited a rich legacy from the three other projects and applied them to caring for patients with a fractured neck of femur (broken hip), COPD, or diabetes. "Pursuing Perfection laid the bedrock," says Diana Clarke, Chief Executive of North Norfolk Primary Care Trust. "We haven't discarded anything, and we've got a firm foundation from which to build our new program."
One of Pursuing Perfection’s most significant effects was to bring together Norfolk's health and social care organizations for the first time. "We'd met, of course," says Ms. Clarke, "but we'd never tackled issues collectively. Pursuing Perfection made us focus on common issues and common goals. That was really good."
It also built bridges between managers and medics. "Pursuing Perfection brought managers and clinicians together to talk about things that interested clinicians. Common agendas began to be established. One of the spin-offs was better relations and a willingness to tackle problems rather than ignore them."
Patients benefited too, with the average length of stay for fractured neck of femur falling from 12 days to five. One patient in particular made an impression on Ms. Clarke. "She was home in five days, and then had an hour's physiotherapy. After that she said she was fine, and told the physiotherapist she needn't come back. Before Pursuing Perfection she could potentially have been languishing in bed for another seven days at that point."
Ms. Clarke adds: "That project brought together lots of clinicians — a multidisciplinary team on the ward and in community services, orthopaedic consultants, and medicine-for-the-elderly consultants. They have survived and grown as a group."
But Pursuing Perfection in Norfolk, a mainly rural area about 100 miles northeast of London, was very project-based. The Health and Social Care Community felt it wanted to focus its new transformation program across its entire system rather than concentrate on individual projects.
Still, the Pursuing Perfection vision — no needless death or disease, pain, helplessness, delay, or waste — has had a lasting effect on Norfolk. "It's something that a lot of people here keep in the back of their minds as the real vision," says Ms. Clarke.
Pursuing Perfection in England has been successful on many fronts. In every community, positive changes lead to better results for the patients and the trusts. Not only did each of these communities extend themselves and make dramatic changes, but they were also truly innovative in their pursuit of perfection. They pioneered concepts around customization to patients’ needs, engaged patients in the design of care, and broke down barriers among providers to give the right services at the right time and place. Each of these efforts sparked new approaches among their fellow Pursuing Perfection organizations around the world.