Keeping mothers and their babies together in those first few days offers lifelong benefits, promoting breastfeeding and enabling confident parenting and a strong emotional bond between parent and child.

When the infant needs care in the neonatal unit though, what should have been a happy time can quickly become a period of worry and distress for the whole family.

Thanks to innovative work at the Royal Free London NHS Foundation Trust (RFL), neonatal unit (NNU) admissions have significantly dropped over the past few months.

During this year’s European Collaboration Forum in London, the Trust presented some of the benefits seen only a few months after the implementation of an innovative approach to reduce unwarranted variation and improve care quality and efficiency.  

Clinical transformation led by clinical experts

Back in 2016, the RFL started a clinical reorganisation process to group their organisation in what they have called Clinical Practice Groups (CPGs) – CPGs are permanent multi-professional teams that oversee clinical strategy in their specialty. This organisational structure aims to drive evidence-based redesign of care processes, including the development of standardised care pathways for implementation across the Trust.

One of the early results from this approach is their new Keeping Mothers and Babies Together pathway, which is safely reducing unnecessary admissions to the NNU for babies born at or after 34 weeks from 13 per cent to six per cent.

The pathway has been designed to identify babies at risk, meaning they can be assessed, monitored and treated appropriately in time without being taken away from their families. This is just one example where clinical pathways are reducing unwarranted variations in care and providing a better experience for patients, moving the RFL closer to their ambition of becoming one of the highest performing hospital groups in Europe.

Standardised clinical pathways covering over 40 conditions and workflows have been designed and road-tested. To date, 13 of these have been digitised and are already in use across Chase Farm and Barnet hospitals, with a further seven pathways under development and expected to be live in the EHR by the end of 2019.

Enabling standardised care

“The goal of this ambitious programme is to ensure every patient can get the same high-quality treatment in any of the Trust’s three hospitals” explains Dr John Connolly, medical director for the Royal Free Hospital and the group’s director for clinical pathways.

“Another aim is to create value for the entire healthcare system in the locality – not just our hospitals, but also primary care and public health services in an area that has high levels of deprivation."

Once the pathways and their supporting systems are in place, staff can also enjoy a better working experience and are able to use cutting edge technology to provide the best possible care for their patients, he adds.

The Trust, covering a population of 2.5 million people, employs more than 10,000 staff. With at least 400 clinicians involved in the development of new pathways so far, clinician engagement has played a key role in the success seen by the project so far. Their involvement at every stage ensures that new ways of working are sensible, effective and followed through.

Dr Connolly is quick to add that standards are meant to guide, not restrict. “Clinical teams should use their expertise and judgement to treat the patient in the best way they and the patient have decided,” he says.

How it works

a. Identifying key areas for improvement

The Trust established four CPGs that cover broad areas of care:

• Women and children
• Transplant and specialist services
• Surgery and associated services
• Medical and urgent care

A four-quadrant analysis was then used to prioritise pathways within each group based on activity levels, quality, and outcome metrics.

b. Securing engagement

Through a series of collaborative workshops, members of each group review existing evidence, while patients advise on their needs, gaps in the current set-up, and possible improvements.

c. Leveraging partnerships and collaboration

Learning from partner organisations is vital, as well. The Trust has been exchanging ideas and knowledge with colleagues from Intermountain Health, a U.S. hospital group renowned for the outstanding results of the quality improvement work they have done over the past 30 years through a similar approach that involved the development of care process models (CPMs).

Embedded in the team, experts from Cerner are also involved from the very beginning of the project – or “brown paper” stage, as performance improvement manager Billy Short likes to call it – all the way through go-live and beyond.

d. Setting clear parameters

Billy explains that the gateway document, a comprehensive guide from the group that sets out parameters for the pathway, is of utmost importance in developing the digital solutions.

Equipped with this document, the team then holds a series of four stakeholder workshops where the process is established, and then prototypes are presented, discussed and refined until they are an accurate representation of the standardised pathway.

Digitising the pathways

By ensuring all the pathways across each CPG are digitised and embedded in the Trust’s electronic health records (EHR) system, Cerner Millennium®, RFL can ensure that every stage of the care redesign process is underpinned by reliable, accessible information. Along with the real-time impact on patient safety, it also ensures that information is recorded for future encounters, creating an instant positive impact in the patient experience.

Results from this initiative are already evident across many departments. For example, the Trust has one of the lowest NNU admission rates in the country. Meanwhile, in the Outpatients department, more pre-operative assessments are being done by phone instead of face-to-face, which is convenient for patients and releases time for nurses and other members of staff to help more people.

Potential for the future

Clinical quality will always be the primary driver for change, but costs also matter, and the pathways are freeing up resources. For conditions covered by the existing pathways, clinical delivery accounts for between 50% and 60% of the Trust’s operating costs.

“We will be looking at 44 pathways in the first three years and we think that we will deliver savings of approximately half a million pounds on each through actually improving the patient experience and removing waste. That’s £20m that we can spend on our patients.“

Dr Chris Streather, chief medical director, Royal Free London group

Well designed and implemented clinical pathways allow staff to excel in their professional roles too. Consider a nurse specialist who, if qualified to carry out a particular aspect of care, could free up a doctor to devote time and attention to a more complex problem.

Good use of data, with regular reporting for staff, also allows continuous improvement. Once a pathway is in operation, collecting and applying the right data can reveal trends and patterns, flag problems that need attention, and create opportunities to further refine the system.

The RFL is also in an excellent position to share what’s been learned, as one of NHS England’s Global Digital Exemplars – one more way that the Trust is reaching far beyond its own borders to improve healthcare for millions of people.

Explore some of the early successes of Royal Free London's CPG project in our latest client achievement story.