Quality, safety and value at the frontline

The small changes, big differences campaign has been developed to help drive savings and promote patient safety – with product quality and patient care being key factors. The aim is to harness the knowledge and expertise that exists in the NHS and to provide simple, interactive tools that can help to drive long lasting change and share best practice.
Janet Davies, RCN Director of Nursing & Service Delivery, says in the foreword to the ‘Small Changes, Big Differences’ guide: “Say the word ‘procurement’ to a lot of nurses, and they’ll probably start to glaze over. But talk to them about making sure they provide safe care to their patients, and you really have their attention. What they may not realise is how closely the two are linked – making the right choices about which equipment and supplies the NHS buys can make a huge difference to patient safety.”

Procurement value
Nursing staff are on the frontline of patient care, using clinical products and equipment on a daily basis. They have the potential to add real value to procurement processes by highlighting other crucial aspects of product suitability besides simply cost, such as usability, safety, quality and patient comfort. NHS procurement processes vary across the devolved health systems of the UK. There are many opportunities to learn from the experience of devolved systems and to share experiences, successes and challenges.
When nursing and midwifery staff are involved in procurement activities, all too often this occurs at a late stage in the process when the impact of nursing experience and knowledge is least effective. Creating an inclusive relationship between clinical and procurement staff is a crucial first step to ensuring both financial and clinical benefits are considered from the outset.
Waste has always been an unpalatable word but in today’s austerity-era NHS it is fast becoming a taboo. Nonetheless, getting the best value out of procurement remains a challenge for many trusts. 

The reasons are complex, but one of the most common is a lack of true clinical involvement. Often, the entire process of selecting and purchasing items has been managed by procurement departments alone. This approach tends to mean that the financial perspective is the main one considered when products are chosen – product usability and clinical suitability becomes a secondary consideration. This in turn means staff are asked to use products they may find inefficient or ineffective. The launch of clinical commissioning groups, alongside other changes introduced by the Health and Social Care Act, may prove an unprecedented opportunity to address this problem.
The boundaries between hospital procurement and health care commissioning are being dismantled, leading to increasing opportunities for clinical input into the procurement process. Evidence shows that nursing involvement can be particularly valuable. Their position on the frontline of patient care, using a vast range of clinical products on a daily basis, leaves them uniquely qualified to offer detailed insight on what items do and do not work.

Empowering senior nurses
The implementation of the EU directive on the prevention of sharps injuries within health care settings, from May 2013, is a case in point. Individual trusts were required to identify the existing sharps products used and to identify, where appropriate, replacements which comply with the requirements of the directives.
Nursing staff were responsible for defining the technical specifications of the products – a central part of the procurement process, and one in which their clinical expertise was crucial. At Heart of England Foundation Trust, a similar model has been implemented.
Traditionally, large numbers of stakeholders were involved in identifying technical specifications for products being procured. Consensus was difficult to achieve, and the process extremely lengthy. On occasion, several products were procured which served the same purpose. Now senior nurses are the decision makers on the products generally used by nursing staff. Discussions take place at the trust nursing and midwifery board, to which procurement colleagues are invited on a quarterly basis. This drives collaboration, allows any barriers to be identified and addressed, and for new savings opportunities to be identified. 
Empowering senior nurses to make procurement decisions has also helped to drive product standardisation across clinical areas.

Rather than placing several small orders for several similar products, one larger order for one product can now be placed. This makes it possible to capitalise on economies of scale, leading to significant cost savings.

Agreeing a standard item during a recent contract renewal for curtains and glide sheets secured savings of £106,000. On a potential contract covering body warming and continence products, potential savings of around £187,000 have been identified. Standardising examination gloves will deliver another £100,000 back to the trust. 
On top of the financial savings are the quality and patient safety improvements. Using the same product across the organisation reduces the potential for clinical errors, particularly when it comes to medical devices. The need to train staff on new products should they move wards is also eliminated – another time and cost saving. If more organisations are to realise such benefits, senior clinical managers will need to drive collaborative involvement in procurement.
Nursing directors should be highlighting that every £30,000 saved on products equates to one Band 5 nurse. They should also be encouraging nurses to take ownership of procurement. The benefits – and the necessity – are now beyond debate.

The Traffic Light Support System
With £4.5 billion spent by the NHS each year on clinical supplies, and with constant pressure on budgets, NHS Supply Chain were keen to develop a process by which staff at all levels could be involved in better, more informed decisions around which products to use.

Helping to raise awareness around how clinical supplies could be used more efficiently is not a new concept. One popular approach already used by some trusts, the unit-cost labelling of supplies in stock rooms, has helped to increase awareness of costs but feedback has confirmed some tweaks were necessary. The approach was seen to be too time-intensive to manage, and staff were at risk of becoming blind to a sea of stickers. A simpler, quicker and more visual solution was developed, using fewer, more visible stickers with a longer shelf life to be used as part of a flexible process which could be tailored to each site. 
NHS Supply Chain’s Clinical Nurse Advisor Karen Hudson and Shelley Scothorne from their communications team devised the Traffic Light Support System – a simple red (think), amber (consider) and green (go) sticker system to label clinical supplies in the stock room.

The purpose was to help raise awareness of the cost of clinical supplies, identify where relevant alternatives are available, and to encourage staff to think before using the most expensive items.
Pennine Acute Hospitals NHS Trust (PAT) agreed to support a three-month pilot of the system. Working with NHS Supply Chain, scoping of the project started in May 2014.

PAT’s project team led the pilot which included the Head of Procurement, Chief Nurse, Assistant Operations Manager and Senior Supplies Assistant from Materials Management. Aware that the system needed to work across different types and sizes of stockrooms and storage areas, they identified 11 suitable sites and wards for the pilot.

Piloting the supplies
When selecting the clinical supplies to be targeted for the pilot, the team focused on small, consumable, easy-to-use and frequently used items. As supplies are often selected from trollies in wards, the system needed to work in static storage areas as well as mobile ones. Eye-catching, wipeable stickers, a user guide and posters were included in the toolkit.

The pilot ran from July to November 2014. It was reviewed on implementation, after six weeks, and at the end. Relevant teams were provided with regular updates throughout the pilot to ensure engagement.
At the beginning of the pilot, a survey of participants revealed a disengagement around effective purchasing, highlighting the importance of the project to put procurement back in to the spotlight in a simple but impactful way. A survey of the nursing teams involved at the conclusion of the pilot identified that the Traffic Light Support System had raised awareness of the cost of clinical supplies, with over half of the teams stating that a red sticker on a product drawer would highlight that there may be a cost effective alternative and that they would think twice before using that product. The results also showed that the system had great potential to help with standardisation, and that the majority of teams were not always aware of the cost of clinical supplies, as they were not directly involved in purchasing decisions. This pilot gave them the opportunity make savings and improve patient safety, with cost awareness in mind.
Additionally, good practice was shared across the trust with the potential for significant impact with minimal time and effort required, as well as achieving its primary goal, in every area the Traffic Light Support System was piloted, other new and innovative ways to drive efficiencies and savings were discussed.
Spring 2015 will see the implementation of the Traffic Light Support System at Colchester Hospital University NHS Foundation Trust and Rotherham Doncaster and South Humber NHS Foundation Trust.

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