UHCW NHS Trust’s Orthoptic Department has been providing a school vision screening service for 4 to 5 year olds since 2002/03, in line with national screening guidelines. The service is provided to all primary schools in Coventry, Rugby and North Warwickshire over a 33-week academic year. Screening was provided to 8,130 pupils across 173 schools in 2017-18. Its success is predicated on the relationship and processes in place with school nurses, parents and education providers.
The efficiency and effectiveness of this service was undermined by outdated paper-based workflows that were no longer fit for purpose and teams stretched to meet increasing demands for the service, generated by both increasing needs and booming population growth. As well as a data protection risk, the system was time consuming and inaccuracies were being created by manual inputting and not using staff skills to best effect.
To combat this, the Orthoptic Department and the Trust’s System Development Team collaborated to develop more automated processed including a bespoke webpage that could be used safely and effectively with external organisations. Close links were established with local authority colleagues in Child Health for the availability of pupil data and the IT department to ensure the website could be used offsite in rural areas. Successes have been numerous, with cost and efficiency savings realised and stronger clinical governance now in place. It is believed that this pioneering solution is the only one of its kind developed across the country.
A comprehensive range of activity has been developed to deliver improvements to the service. This has included:
- Reviewing what we knew - 2 years data was scrutinised to help us understand the pattern, issues and provide a full picture for encouraging changes in the clinical practice involved in school screening. The data also helped provide a compelling view of the need to change the method of service delivery that could be shown and discussed with schools to help introduce changes effectively with maximum support for moving to a new digital solutions (see attached presentation June 2017).
- A training package was developed for the team and pilot of new school vision screening service including the new processes to ensure changes were supported and sustainable.
- Changes were communicated to all those involved with opportunities for feedback into the new way of working.
- Reviewed practice in other areas and benchmarked ourselves against other areas in UK providing vision screening and also adhering to latest PHE guidelines
- Undertook an internal service evaluation of special school provision, especially the highlighted inequality in provision within areas served that was of concern. (see attached presentation –special school)
According to a comprehensive audit undertaken, more than 1,000 hours of manpower was required to update the paper based system per year. The majority was carried out by Band 6 and Band 7 employees, meaning their hard earned time and expertise was being engulfed by administration. This inevitably proved costly, with staffing costs to support admin duties amounting to £23,847 per year.
- To provide the best service which is evidence-based, financially and workforce efficient
- Threat of community service being withdrawn/lost to an alternative provider
- Other areas of community screening required investment eg special schools
- Managing expectations of all involved in change process (see attached testimonial from orthoptists and technicians)
Our key aim was to create a paperless pathway to ensure availability for clinical duties increased (see Process Flow One). Cost savings were also targeted to ensure vital funds could be reinvested into the service. This links back to the Trust’s strategic objective of putting patients and people at the forefront of day to day operations. Other aspirations included improving the audit process, being able to share information securely with all stakeholders and developing a cost-effective solution that hadn’t been achieved elsewhere in any other vision screening programmes nationally.
Most importantly we wished to ensure that our workforce model was fit for purpose, supporting our staff and ensuring maximum time released for adding clinical value. We sought to deliver within our budgets but actually increased the service for less money (shown in evidence pack attached).
We liaised closely with our governing body, the British and Irish Orthoptic Society, on the validity of the changes. Barriers identified ranged from timetable constraints to winning the hearts and minds of staff resistant to change. Employees were given an open forum for their concerns and we worked with them every step of the way to ensure their expertise was stamped on the final solution.
The Orthoptic service was able to create a new sustainable model for delivery of a better service that could reach even more children, particularly those arguably more vulnerable, in a consistent and timely way. By changing the model for delivery, the service, using fewer resources, was able to reach new audiences such as the local special needs schools, with an increasing demand, who had previously not been consistently serviced before.
Using digital technology, web-enabled screening data, the new processes were not only quicker but had a single view of information, with reduced margin for manual error. For schools, once the process was tested and agreed, this meant more timely information and improved ability to co-design reports for all involved. For children, the more efficient process, means that more schools and those children ‘at risk’ for are reached earlier, helping them reach their educational potential and attainment.
And for staff, the outcomes have included: reduced pressure on individuals and the team, a feeling of being supported with better information and digitally-enabled so they can do a good job but increased time for the things that add value, giving advice to schools and screening children. The service now meets Public Health England guidelines 2018. The additional resources that have been released from the new service model, has enabled 198 sessions from orthoptics technicians to be freed up and is now diverted into the development and provision of other community service areas.
This approach gave staff ownership – and the results have been transformative. With admin time reduced to 375 hours per year (down from 1,000), clinical hours can be repatriated to other parts of the Orthoptic service to meet high demand. In terms of the service, 45 children were previously seen in the morning and 30 in the afternoon. With admin time reduced to 375 hours per year (down from 1,000), 105 children can now be examined a day. The net result is that ALL children that need to, will be able to access free eye care per year, helping to ensure any problems are detected from an early age. This achieves our prevention ambition for children in Warwickshire. Staffing costs have reduced from £23,847 to £6,237 (a saving of £17,610) – a welcome boost to the service during the age of austerity.
The website has been rolled out to local Orthoptic screening provisions, including pre-school screening and special school areas. As part of our Trust improvement methodology, in partnership with Virginia Mason Institute in Seattle, we have been using lean techniques to identify any step improvements in our processes, both into and out of the department, as well as within our own service. This has been very much about frontline staff being empowered and trained with tools (lean methods) and getting the whole team behind the changes that are needed to remove any waste in processes and resources.
For examples of this continuous improvement approach has been:
- Ongoing improvement to processes by the orthoptic technicians and all staff driving improvements
e.g. Pass/fail label sheet, updates to school packs, training new team members on laptop and auto refractor
- Continuous updates through team emails for developments/procedure changes
- Child health and school nurse teams kept informed of changes to the workforce
- Audit is presented every year to the Ophthalmology department
Jackie Cornock, Service Lead for Child Health at the South Warwickshire NHS Foundation Trust, said: “Data transfers between our departments have become more secure and up to date. The information is complete, accurate and timely. This has led to an extremely efficient solution for uploading and recording the screening results into the Child Health System.” Emily Lind, Orthoptic Lead at St Cross Hospital, Rugby, added: “The introduction of the school and preschool websites have improved collection of screening data, which was previously collected on paper forms increasing security, saving time, and allowing easier auditing of the service.”
Plans are also in place to share the bespoke webpage at professional committee meetings and other NHS Trusts across the country. The experience has also led to improved communication with Child Health and the information provided for health records. The new system will help to identify child protection issues at an earlier stage as well as compliance with attendance and treatment.
We have delivered a new service delivery model that costs less money but enables staff to operate at the right level for their skills and expertise. The team has seen a substantial reduction on burden of administration by using automated online processes through the web-screening tool, saving time to add value – advising schools and seeing more children for screening.
The value of the new service model not only delivers a better and more expanded geographical service (more schools and new types of schools (special needs), but it does this with a different complement of staff, supported to use their expertise in the best way possible.
At the outset, the team were hoping to streamline the service, reach new audiences in special schools and help achieve compliance with new 2018 PHE guidance. The value from staff redesigning the model themselves has been – strong ownership from all team members for ideas and implementing the changes, new roles emerging within the team, more timely and accurate ways of managing information and more time for advising and reaching those who need the service.
- Improved collaboration and morale in the team
- SEND screening development plan
- Reducing time for admin duties
- Staff cost savings by skill mixing (>10K) (see attached sheet)
The bespoke webpage has had a positive knock on impact for all elements of the screening service and its beneficiaries. The welfare of young people has been greatly enhanced. More extensive records are helping to set out detailed pathway journeys for children in Coventry and Warwickshire. Collated data is being used to reduce numbers being referred to hospital and send patients into a community setting (helping the Clinical Commissioning Group to save money).
Sensitive information is now received via secure email, meaning it can easily be transported between sites and the need for paper is eradicated. As well as the administration savings for the service outlined, service users (schools) have repeatedly informed us that the process is slicker and more easily managed. Overall administration work has decreased by 625 hours over the course of the year, while staffing cost savings amount to £17,610. And the bottom line is that more additional children will be able to access free eye care per year, helping to ensure any problems are detected from an early age.
The University Hospitals Coventry and Warwickshire NHS Trust’s mission statement is to care, achieve and innovate. These words have been put into action during the creation of the bespoke webpage and supportive processes for delivering iits improved school vision screening service. The Orthoptic and Optometry departments joined forces with the Systems Development Team to create a bespoke solution – the only one of its kind in the country. Intrinsic to this have been the staff who know the service so well and have been engaged in two-way conversations throughout a process which has continuously evolved.
Solutions have been found to all problems as the result of joined up working and a thinking outside of the box mentality. The Orthoptic team appraised the website before it went live and a pilot was done to gauge user feedback before screening started. Other agencies have also been pivotal, with Child Health involved in providing secure data transfer and schools consulted to ensure value has been added for them.
The full review of two years data analysis together with audit evidence was used to discuss potential improvements with those in orthoptics. The new way of working was developed, by talking with those who are involved in the process and taking any feedback into the developing screening tool. Stakeholder such as CCG were kept informed of the changes and clinical governance colleagues for GDPR changes and DBS checks. And our work is not yet done. We will now be approaching other NHS Trusts to see how they can benefit from this unique invention.