Transcript From Zero to FLS: Implementation & Beyond
From Zero to FLS: Implementation & Beyond
National Osteoporosis Society FLS Education Programme October 2010
Size Matters!
Determinants of the scale of your service
-
The FLS’ target population which fracture groups?
what age group?
Previous fracture New Fracture Non-vertebral & Vertebral Non-vertebral & Vertebral
Size Matters!
Determinants of the scale of your service ~650 new non-vertebral fractures & ~120 new vertebral fractures age 50+ per 100K, per year Previous fracture New Fracture Non-vertebral & Vertebral Non-vertebral & Vertebral
NEW FRACTURE PRESENTING TO A&E / ORTHO / TRAUMA NEW RADIOLOGY REPORT OF FRACTURE PREVIOUS FRACTURE FALLS RISK ASSESSMENT
McLellan et al. Osteporos Int 2003;14:1028 –1034
EXERCISE CLASSES Rx FOR FRACTURE 2 Y PREVENTION PRESCRIPTION ISSUED BY GP EDUCATION PROGRAMME
From Zero to FLS: Implementation & Beyond
Project Management
From Zero to FLS: Implementation & Beyond The first steps
• Appointment of project management team & Chair
Membership of FLS implementation project team
x1 x1 x1 x1 x1 x1 x1 Number x2 x1 x3-4 x1-3 x2 Post Local champion / lead clinician Chair GG&CHB Osteoporosis Subgroup (clinician) Other HB lead clinician & secondary care clinicians from involved sites CHP GP lead Osteoporosis Nurse Specialists General Manager – Medical Services GG&C osteoporosis exercise service lead physio Superintendent Radiographer Assistant General Manager, Radiology Consultant radiologist (DXA) – local imaging lead Estates manager NOS patient representative
From Zero to FLS: Implementation & Beyond The first steps
• Appointment of project management team & Chair • Redefine & agree with providers of funding remit of group & scope of service
Remit of group & scope of planned service
1. To roll out an FLS, to provide systematic post-fracture assessment to all men & women age 50+ with new fracture presentations or with new report of vertebral fracture or with previous fracture age 50+ 2. To ensure equitable access of all relevant patients in the region 3. To implement these services within the constraints of the proposed funding 4. Case-finding for new fracture presentations & for new reports of vertebral fracture – by the FLS ONS
Remit of group & scope of planned service
5. Case-finding for previous fractures – by primary care 6. Post-fracture, risk assessment based on one-stop consultation with FLS-ONS incorporating DXA, where appropriate 7. All episodes of FLS-patient care recorded in database 8. To provide this for population of x over y sites and covering fracture patients from z hospitals
From Zero to FLS: Implementation & Beyond The first steps
• Appointment of project management team & Chair • Redefine & agree with providers of funding remit of group & scope of service • Work breakdown
From Zero to FLS: Implementation & Beyond
Project Management
Work Breakdown
DXA Personnel Logistics
From Zero to FLS: Implementation & Beyond
Project Management
Work Breakdown
DXA Personnel Logistics
From Zero to FLS: Implementation & Beyond The first steps
• Appointment of project management team & chair • Redefine & agree with providers of funding remit of group & scope of service • Work breakdown • Schedule work & establish timeline for delivery of service
ID Task Name Start Finish
1 2 Scope & Remit – Group Membership WB – Personnel Appointments 05/12/2007 05/12/2007 3 WB – DXA procurement to delivery 05/12/2007 09/01/2008 15/04/2008 14/03/2008
Dec 2007 Jan 2008 Feb 2008 Mar 2008 Apr 2008 May 2008 Jun 2008 Jul 2008 Duration 2/12 9/12 16/12 23/12 30/12 6/1 13/1 20/1 27/1 3/2 10/2 17/2 24/2 2/3 9/3 16/3 23/3 30/3 6/4 13/4 20/4 27/4 4/5 11/5 18/5 25/5 1/6 8/6 15/6 22/6 29/6 6/7 13/7 20/7 27/7
5.2w
19w 14.6w
4 WB - Exercise class infrastructure 05/12/2007 07/05/2008 22.2w
22.2w
5 WB - protocols 6 WB – Induction – training 05/12/2007 07/05/2008 05/12/2007 04/06/2008 7 WB – Communications incl website 27/02/2008 30/05/2008 8 Service launch 05/12/2007 01/08/2008 26.2w
13.6w
34.6w
From Zero to FLS: Implementation & Beyond
Project Management
Work Breakdown
DXA Personnel Logistics
What do you need to provide a DXA for a FLS service ?
• Space for DXA (may require building works!) • DXA scanner/s – DXA (VFA) site visit to inform choice – DXA procurement • Radiographer/s • ONS clinic space - near DXA • Database - reporting system • Patient transport issues
From Zero to FLS: Implementation & Beyond
Project Management
Work Breakdown
DXA Personnel Logistics
Personnel
• Overview – Banding & Grades of Staff – Job descriptions – Appointments processes - job descriptions - adverts – interviews – Consultant Sessions • How are Consultant sessions best deployed?
• Osteoporosis Nurse Specialist/s – Band 6/7 Osteoporosis Nurse Specialist – ONS line management – ONS where & how will they work?
Personnel
• Administration & Clerical Staff – Band 3 A&C • Physiotherapist/s for exercise services – Band 6 Physiotherapist • Radiographer/s – Band 6 Radiographers
From Zero to FLS: Implementation & Beyond
Project Management
Work Breakdown
DXA Personnel Logistics
Logistics
• Pathways of care – New fracture presentations in which hospitals & FLS in which centres – New reports of vertebral fractures in which hospitals & FLS in which centres – Past fractures from across region referred to which centres • Protocol development • Access to Mineral Metabolism clinic for those who don’t fit with management protocols • Liaison re exercise classes • Liaison with falls service
Logistics
• Communication within secondary care & with GPs • Standardisation of forms • Website development to facilitate communication • Patient education materials • Patient education classes • ? Nurse telephone follow up (? Telephone BPR tariff) • Training & induction • Launch meeting
What do you need to provide exercise classes?
• Access to health service physio gym – Identify exercise class locations • Access to leisure centre gyms – Identify exercise class locations • Patient transport issues
If at first you don’t succeed…
If at first you don’t succeed…
you’ve failed!
Pathway to success… & it will be incremental!
What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make to effect improvement?
Pathway to success… & it will be incremental!
Plan Do Act Study
PDSA & the Evolution of the Glasgow FLS for new fractures
Objective 1
Cycle 1
Case-finding all new fx F&M age 50+ by GP Objective 2 Fracture risk assessment by ONS at one-stop clinic with DXA Outcomes audit Essential change Only 5% wrist fx & 11% hip fx identified / referred for assessment Case-finding must be by ONS in secondary care
PDSA & the Evolution of the Glasgow FLS for new fractures
Objective 1
Cycle 1
Case-finding all new fx F&M age 50+ by GP
Cycle 2
Case-finding all new fx F&M age 50+ by ONS in secondary care Objective 2 Outcomes audit Essential change Fracture risk assessment by ONS at one-stop clinic with DXA Only 5% wrist fx & 11% hip fx identified / referred for assessment Case-finding must be by ONS in secondary care ~all fx patients identified & assessed – but only 4% of fx were vertebral Need for new approach to identify vertebral fx
PDSA & the Evolution of the Glasgow FLS for new fractures
Objective 1 Objective 2
Cycle 1 Cycle 2 Cycle 3
Case-finding all new fx F&M age 50+ by GP Case-finding all new fx F&M age 50+ by ONS in secondary care Case-finding all new fx F&M age 50+ by ONS in secondary care & all new radiology reports of vertebral fx Fracture risk assessment by ONS at one-stop clinic with DXA Outcomes audit Essential change Only 5% wrist fx & 11% hip fx identified / referred for assessment Case-finding must be by ONS in secondary care ~all fx patients identified & assessed – but only 4% of fx were vertebral Need for new approach to identify vertebral fx ~all fx patients identified & assessed – now 12% of fx are new vertebral fx