Sustainability the seventh dimension of quality

The Committee on the Quality of Healthcare in America report focussed on how the healthcare delivery system can be designed to innovate and improve care. It defines 6 aims for improvement of healthcare quality:

1. safe – avoiding injury to patients from the care that is intended to help them
2. effective – providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding under use and over use)
3. patient centred – providing care that is respectful of and responsive to individual patients’ preferences, needs and values and ensures that patients’ values guide all clinical decisions
4. timely – reducing weights and sometimes harmful delays for both those who receive and those who give care
5. efficient – avoiding waste, in particular waste of equipment, supplies, ideas and energy
6. equitable – providing care that does not vary in quality because of personal characteristics because of gender, ethnicity, geographic local and socio-economic status.

To these 6 we can now add sustainability. Any quality aims that cannot be maintained with the resources available to us are set up to fail. It is important to realise that working to improve sustainability will seldom be in conflict with the other dimensions of quality; in particular, low carbon healthcare is likely to improve cost efficiency and patient empowerment.

Kidney care has this year become the first clinical specialty to address environmental impact, with the creation of a green nephrology programme. The aim of the programme is to support the transformation to sustainable kidney care whilst improving quality and efficiency. It is delivered through a partnership between the Renal Association, the British Renal Society, NHS Kidney Care, the NHS Sustainable Development Unit, the National Kidney Federation, the Association of Renal Industries and Baxter Healthcare, led and supported by the Campaign for Greener Healthcare.

In September 2009, renal trainee Dr Andy Connor joined the team as the first “Green Nephrology Fellow” funded by NHS Kidney Care. At the BRS/RA meeting last week we heard what has been achieved:

• Green network – 79% of kidney units in the UK now have a green nephrology local representative. Kidney Patient Associations have been invited to put forward a green representative too – find out if your unit is going green.
• Sustainability survey – 87% of represented units completed this survey covering topics from staff travel to procurement of dialysis products. Slide presentations on the survey results have been sent to your local representatives for discussion in your unit.
• Case studies and how to guides giving best practice in: conserving water in haemodialysis
  Retrofit of heat exchangers to dialysis machines; telephone clinics for follow up for renal transplant recipients; reduce, re-use, recycle in the dialysis unit
• Webinars – held on water conservation and on waste management in haemodialysis
  10:10 renal checklist – 10 actions for renal units to support the 10:10 campaign: cutting carbon by 10% in 2010
• Articles on sustainability – accepted in medical journals, indexed once published
• Commissioning – sustainability clauses included in the national peritoneal dialysis pathway
• Carbon footprinting – the first carbon footprint of a clinical specialty is soon to be published!

At the Green Nephrology reception during the conference some of these projects were showcased. We heard from Libby Critchley that the Countess of Chester Hospital had stopped sending paper copies of all blood test results as they are already in the IT system. Saving £20000 per year. Patient care plans have been reduced from 14 to 6 pages. The patients love the change. John Stoves from Bradford described electronic consultation as an alternative to hospital referral for patients with chronic kidney disease. In participating practices half the referrals are now through the e-consult service. The NHS sustainability development unit estimates that an outpatient visit generates a carbon footprint of approximately 40 Kgs CO2e (carbon dioxide equivalent). Rachel Westecott from the University Hospitals of Leicester told us that by adding an extra bin into the procedures room to allow black sacks and orange sacks to be used simultaneously the amount of incinerated waste fell dramatically to a third of the previous levels. The average cost of disposing of incinerated waste (orange sacks) is in the region of £400 per tonne compared with £80 per tonne to dispose of waste to landfill sites (black sacks). Rachel did comment that a lot of the waste in black sacks is actually recyclable and I think has her eyes set on establishing systems for recycling of paper, carbon, plastic. The renal unit of the Royal Cornwall Hospitals was one of the first to adopt a “green action plan”. Simeon Edwards described the use of a whole system approach. The team quickly identified carbon reduction opportunities, prioritised them and moved into action. By the end of the first year they have achieved

• An improved workplace with more nurse patient time
• A reduction in healthcare acquired infections
• “Cost avoidances” running at £32,000 per year
• Carbon reductions running at approximately 33 tonnes CO2 eq per year
• Clear improvements in the patient experience with reduced waiting times, fewer aborted journeys and more patient self-care.

We heard that the Bradford unit are preserving water by copying the Kent water treatment approach: Bristol have adopted the Coventry telephone transplant clinic and Fife are retro fitting heat exchangers as described in one of Andy Connor’s first published case studies.

Andy summed up the progress as cycles of experiments creating a revolution rather than merely next steps. You can see all the posters at NHS Kidney Care and learn more at the Greener Healthcare website.