Our Aspiring to Excellence Journey

Aspiring to Excellence Quality framework- we initially had to describe and rate our service and the current processes that we had in place around 10 statement headings including areas like:

·         recognition and referral

·         diagnosis in specialist care settings

·         information and support that we provide our patients with

·         pharmacological support and non-pharmacological support of axial spondyloarthritis

·         flare management

·         our support for long-term complication

·         how we address mental health and emotional wellbeing of her patients  

This process gave us the opportunity to really look at what we provide as often when we are all very busy, chasing our tails in hectic clinics it is easy to forget and overlook the excellent aspects of care that we provide and sometimes only see the negatives.

Our application was short listed and we were invited to an interview on Monday the 4th November 2019 at 1:00 a.m. lasting 45 minutes at the Royal College of Physicians in London, which in itself seemed a daunting experience.  The lead consultants Dr Lesley Kay and Dr Ben Thompson, Michelle Rutherford, specialist nurse and myself all attended the interview, where we had to present a 10 minute presentation outlining three areas of our service that we would like to improve.

We decided to concentrate on

1.    Reducing referral delay and extending our specialist Axial SpA ‘self-referral, self-management’ programme into the community. Our musculoskeletal services had just been decommissioned and the tender awarded to an NHS organisation called Tyneside Integrated Musculoskeletal Services (TIMS) that were incorporating primary and secondary care physiotherapy work across the Newcastle and Gateshead areas.

2.    Improving overall health for patients with Axial SpA by implementing ‘annual review.’

3.    Making the best use of our department service by reviewing the way we deliver services and investigating innovative ways of working.

Walking into the interview room, we were met with a sea of faces, patient representatives, NASS personnel and AStretch representatives sat round a large table. The interview seemed to pass very quickly, all of us though given the chance to speak and answer questions.

On 16 November at the NASS Voices event in London where it was formally announced which services have been awarded a place on the programme, we learned of our success.  As a department we were so pleased to have been offered a place on this prestigious programme but also appreciated that there would be a lot of hard work involved over the next 3 years.

Tuesday 3^rd December 2019 from 10.00am–4.00pm – we were invited to the first learning event to meet the NHS Transformation Team, Dale Webb CEO of NASS and the other teams on the programme. The programme for the year was out lined and we were to attend as a team for 7 dates throughout 2020.

We came away from the 1st day totally inspired, full of motivation and team spirit of how we could really make a difference to our patients with the help of this programme.  We were also given the opportunity to get some team time away from the pressures of a busy department which was invaluable.  We much appreciated the opportunity to network with other teams and hear about their improvement projects and challenges.  This early face to face team work allowed us to dedicate time to Axial SpA service development, to focus our goals, to leave the hospital environment and network and to learn from other teams.

We decided that we needed more details and data from our current service from initial referral to diagnosis and to map out a number of actual patient journeys, looking for any bottlenecks and areas where there were potential time delays to diagnosis.  Two weeks before we travelled to Manchester I had unfortunately fallen off my bike and sustained a fracture to the greater tubercle in my shoulder.  I was unable to do clinical work but this gave me ample opportunity and time to complete this initial stage of our project.  Ironically, this was pre-COVID where video attend anywhere and telephone calls were virtually unheard of as a means of assessing patients!  We also used this time to make contact with our key stakeholders and management that we would need to work with in order for the project to be successful. We also fully engaged the rest of our Axial SpA team who didn’t attend the interview process- Occupational therapist Gemma O’Callaghan, specialist Nurse Lesley Tiffin, and Consultant Rheumatologist Dr. Rachel Duncan.

Our next A2E day was 12 March 2020 in Manchester- little did we know that 11 days later, the lockdown would start and that would be our last in person day! Hopefully we can all attend the Celebration, end of programme event in June 2022.

We managed to keep working on our projects over the next year, obviously dipping in and out, as many of us were re-deployed to different COVID roles.

From these first 2 sessions we compiled driver diagrams and started PDSA (plan-do-study-act) cycles to effectively implement QI.  The patient journey was mapped, identifying the referral source of patients with suspected Axial SpA. Training of community based physiotherapists in the TIMS organisation was then implemented, including briefing on the importance of identifying Axial SpA and recommended use of screening criteria – specifically, the Assessment of Spondyloarthritis International Society (ASAS) Expert Criteria for Inflammatory Back Pain Assessment.  The quality of referral from TIMS was assessed, exploring use of ASAS expert criteria.  Delays in time from referral to 1st appointment in the Extended Scope Physiotherapist inflammatory back pain screening clinic were assessed. 

In December 2020 we had an online event where we presented our improvements and inevitable challenges over the 1^st year of the programme. The NHS Transformation Team did a fantastic job of keeping us motivated and trying to concentrate on the small gains that we have made despite very challenging circumstances.

On reflection, being part of A2E, I feel gave us the catalyst and enabled us post COVID to kick-start our services and we also had the drive and motivation of the NHS Transformation Team.

At end of year one, around our 2^nd aim, an electronic annual review sheet was developed, (by new consultant rheumatologist Dr Ejaz Pathan), to be included on the electronic record with collated information on co-morbidities and additional health checks.  Innovative ways of working were re-explored, including a hybrid/virtual/in-person model of care and use of the ePROMs – the process much accelerated as an inevitable response to the pandemic.

Our 3^rd aim was around innovative ways of working. We embedded a Web-based programme called Giraffe Health care www.giraffe.com into our Axial SpA management, a platform for the delivery of personalised physiotherapy programmes.

Throughout 2021 we worked on our improvement areas and were kept continually motivated by the NHS Transformation Team- coaching sessions, networking days, and the last session in February 2022 was dedicated to individual teams ,having uninterrupted time to work on their projects.

So what have we gained through A2E? Has it been worthwhile?

We have learnt lots through this process. Driver diagrams in particular have been really helpful to contemplate and write down; they will permeate the way that we work throughout the rest of our careers, and we will use the more formal structure where it is helpful. But also, just to realise that the way to get things done within the NHS is to demonstrate the change, that story that you tell, that you say this is what we tried to do, this is what we measured at the beginning, this is what it was like then, these are the steps that we took, and this is what is different now.

It has been great to see what other teams on A2E have managed to achieve, and also to reassure you that no one’s finding it easy, and no one does it in a simple and straightforward way, which motivates you to carry on striving to make those changes.

Personally, A2E has been a fantastic CPD opportunity, and has greatly improved the service that we offer our patients in Newcastle. We have strong, evidence-based pathways in place now. I would encourage any Rheumatology team to strongly consider applying to join the A2E programme- we have gained so much.  And the programme is still ongoing.

Mo