Document - Web viewThis will then be entered in to a PASU database, so that longitudinal, as well as cross-sectional, data can be assessed. ... nurses, allied health professionals,

Innovating for improvementFull application form

Deadline for submission of the full application:

5 pm, Monday 24 November 2014.

Important information: Any significant changes to the nature of the project or the partnership in the full application from those stated in the outline application will not be accepted and will lead to rejection.

October 2014

The Health FoundationTel: 020 7257 8000www.health.org.uk

Innovating for improvement – Full application form – Deadline for submission 24/11/2014 1/35

http://www.health.org.uk/

Guidance for completing the full application form

Please ensure that you have read the Call for applications and Frequently asked questions before completing the full application form. The full application requires information related to the selection criteria as described in section 7.1 of the Call for applications.

The full application is a more detailed version of the outline application and you are expected to elaborate on your outline proposal, submitted to us in August 2014.

Some questions build on the information given in the outline application form, while others will ask you to provide the same information with more detail. This is to ensure the external assessors have the relevant information in one document. Assessors will not have reviewed your outline application. You may wish to copy and paste from the outline application and build on this information as appropriate.

Please note that any significant changes to the nature of the project in the full application from those stated in the outline application will not be accepted and will lead to rejection. If you have a question on whether a change would be considered significant please email us at [email protected] .

Guidance on completing the full application form is incorporated into the form and greyed out. This guidance page and all of the grey boxes should be deleted before submitting your application.

Invitation to submit the full application is not a guarantee of success or funding. The full application is accepted on the basis that the Health Foundation can share the content with others.

When completing your application form, you should use lay language and answer each question in a concise manner. Please use 11- sized Arial font and keep to any word limits given. Please specify the actual word count within each question. Any information that exceeds the word limit will not be read. Please use diagrams, charts and tables where you believe they will help the assessor to understand your proposal. References and diagrams or charts are excluded from word limits.

Any attachments received that have not been asked for will not be read. PDF documents will not be accepted. Hard copies will not be accepted. If any sections of the application are removed, omitted or incomplete we will not accept the application.

The full application should be saved as a Word document using the following format:

‘Ref number- Lead organisation name - Lead surname – Innovation full.doc’.

Please use the same naming convention for your Excel spreadsheet.

Please specify the ref. Number and lead organisation in the subject line of the email. Please note that we will not accept duplicate/revised application forms.

Please email your completed full application and budget to [email protected] by 5 pm on Monday 24 November 2014.

We welcome applications earlier than this date. Late applications will not be considered eligible and will therefore not be reviewed.

2Innovating for improvement – Full application form – Deadline for submission 24/11/2014

mailto:[email protected]


http://www.health.org.uk/public/cms/75/76/8760/4911/Innovating%20for%20improvement%20FAQ.pdf?realName=iWp0zH.pdf

http://www.health.org.uk/media_manager/public/75/programme_docs/Innovating%20for%20Improvement%20Call%20for%20applicatons.pdf

Following the assessment process, shortlisted applicants will be invited to attend an interview (please see for available dates in section 10). Applications that are not shortlisted at this stage will be rejected and limited written feedback will be provided. Feedback will be provided to those teams that are selected for interview but are unsuccessful at that stage.

If you have any questions, please contact us at [email protected], in the first instance.



Section 1: The Application

1.1 Project title

Parkinson’s Advanced Symptom Unit (PASU)

The title should be short and descriptive; and should not exceed 20 words.

1.2 Lead organisation

Please note that the lead organisation must be the same as the lead organisation named in your outline application.

Organisation name South Tees Hospitals NHS Trust

Type of organisation NHS Foundation Trust

Registered address The James Cook University Hospital, Marton Road, Middlesbrough, UK, TS4 3BW

Statement (if applicable, please use this space to address any of the bulleted points below)

Not applicable

You should tell us what type of organisation is leading the project. The organisation named here should be the organisation within which the innovation is being tested and must provide or deliver health services free at the point of care in primary, secondary or tertiary care, or across boundaries such as health and social care.

The organisation named here will be responsible for planning and delivering the project. It will be accountable to the Health Foundation for reporting on project progress including project spend. This organisation will receive the funding from the Health Foundation and should be able to manage the budget and distribute it among any partner organisations through local agreements as required.

A lead organisation must be legally constituted. It may be constituted as an NHS body, a ‘not for profit’ organisation (eg a charity or a company limited by guarantee), a social enterprise, a company limited by shares, or a community interest organisation.

The following must be addressed in your statement above, if applicable: If you are a non NHS provider of health services, the organisation must be

commissioned or in an authorised position to provide services (eg registered with Care Quality Commission in England). You should provide a statement that more than 50% of your work is with NHS funded patients (we will require evidence to this effect, if you progress to the full application stage).

If the intervention/s is being delivered to a new group of patients or staff, where a


service does not currently exist, eg virtual care or community based person centred initiatives, the application should be from a lead organisation responsible for establishing and sustaining the new initiative.

If the constitution allows the lead organisation to make a profit, the Health Foundation would have to be convinced that it is not supporting private profit making companies delivering only a small benefit to the NHS.

Where a ‘not for profit’ organisation has another arm that is profit making, the Health Foundation would need to be convinced that our funding is going to the non-profit making arm.

We strongly recommend that NHS service provider organisations (lead organisations) are only involved in a small number of applications from different divisions of the same organisation. We will only accept one application per project lead.

1.3 Primary contact

Full name (and title)

Dr Neil Archibald

Job title Consultant Neurologist

Role on this project

Movement disorder specialist and project lead

Office/contact address

Department of Neurology, James Cook University Hospital, Marton Road, Middlesbrough, UK, TS4 3BW

Email [email protected]

Telephone Phone: 01642 854060 (direct) or 07967 107999Secretary: 01642 835808 (Jane Clayton)

You should name a person from the lead organisation named in 1.2 who will be the project’s primary contact. This should be the person who the Health Foundation can contact if we require further information or clarification throughout the assessment period and preferably the duration of the project. This is the person with whom we will make contact about the progress of the application. S/he should have an in-depth knowledge of the project proposal and we need to know what their role is within this particular project.

1.4 Partner organisations

Please note that if any changes to partner organisations have been made since your outline application, you must explain the reasons for this and demonstrate how it will strengthen your application.

Name of partner organisation Organisation type Role within the projectParkinson’s UK – North of Charity Patient and carer involvement


England Publicity of serviceProvision of Information Support Worker

Integrated Occupational Therapy Service (IOTS)

NHS Coordination of allied therapies sector with Middlesbrough & Redcar and Cleveland Social Care Department

Tees, Esk and Wear Valley Mental Health Trust

NHS Provision of psychiatric liaison and CPN support

Applicants will need to show that they have the skills and understand the processes required for successful innovation. Where an applicant organisation does not possess the range of experiences and skills needed, it is expected to link up with other organisations such as universities, consultancies and innovation intermediaries in order to secure the right skill mix within the team. Ideally they should involve an organisation/s that represents the interests of the patient, service user or carer. The size of the project team may vary depending on the expertise of the individuals involved.


Section 2: About your proposed project

2.1 Please provide an overview of your proposed project. (400 words)

Parkinson’s disease (PD) affects 1 in 100 people over the age of 65 years and, in an ageing society, this number is anticipated to rise. PD is commonly characterized as a “movement disorder” although it is better defined as a progressive multi-system disorder. Motor fluctuations, postural instability, gait freezing and falls, in addition to mood disturbance, psychosis and dementia, are key determinants of disability, quality of life and mortality.

Our proposal will demonstrate that, with increasing emphasis on community care, comes a pressing need to provide an outpatient service that can meet the needs of PD patients with advanced disease. The “Parkinson’s Advanced Symptom Unit” (PASU) will address this unmet need.

PASU will offer flexible scheduling of patient slots, dependent upon clinical need. Problems will be “red-flagged” in a standard clinic environment, and patients fast-tracked to PASU for pre-planned assessments. For many patients, PASU will function as a “one stop shop” to address a specific clinical need. Others may attend for a number of weeks, until their condition has stabilized. A small minority will need weekly review for a number of months. This set-up will also allow for closer monitoring of higher risk groups, to ensure that treatment complications are minimised.

The proposed clinic will run every week. The day hospital setup allows prolonged assessment from members of the multi-disciplinary team, without the time pressures of a normal clinic environment. Having a bedded area facilitates the outpatient initiation of drugs, such as apomorphine, currently commenced on an inpatient setting; thus saving money, without compromising patient safety.

The clinic service will be available to referrals from patients and carers, primary care providers, and community-based teams, and will function as a centre of excellence. Whilst specialist PD services exist in other regions of the UK, none are designed to offer rapid access to a specialist, multi-disciplinary, inter-agency team. Furthermore, the range to treatments on offer is not available from within any other single unit, and we will therefore be uniquely placed to assess the efficacy of our interventions.

The overall aim will be to document the subsequent impact of such a service on validated Parkinson’s outcome measures, as well as other key metrics, such as hospital admission/re-admission rates. In addition, we will offer training to doctors, nurses and allied health professionals who work with PD patients in the region.

Actual word count: 387Please provide a summary of your project in lay language clearly explaining the aims, objectives (outputs and outcomes) and innovative approach/intervention. Applicants should include a brief summary of the problem, explain how their project is innovative, describe the setting/s in which the intervention will take place (eg home, community setting, clinic, organisations, wards, departments, etc) and in what locality/localities. You should also describe the specific and tangible improvements in quality that you seek to achieve and the key measures you will use to evidence your improvements. This is only a summary: you will be asked to provide more detail on key aspects of your project in subsequent sections.


Applicants should ensure that they have read section 5.1 which details the types of projects we will not fund.

Please refer to sections 3, 5.1 and 7.1 of the Call for applications.


2.2 Total amount of funding requested

If the funding requested has changed since the outline application, please explain why.

£ 74,895

Changes: re-costing of job plans, including greater detail of banding; increase in cost offset by larger contribution to project from Trust Parkinson’s fund.

2.3 Length of project in months

If the length of project has changed since the outline application, please explain why.

Months: 15 months

Changes: none

2.4 Please state the level of innovation to which your project corresponds (tick one box only). Please be realistic about the level of innovation you believe your project corresponds to.

Level 1: Innovations with no previous history in any context – they are genuinely

new or novel.

Level 2: Innovations transferred into health care from another sector such as

another public service body, another industry or non-health related field.

Level 3: Innovations transferred into the UK health care sector from overseas

health care systems.

Level 4: Innovations transferred or adapted from one health care setting to

another: for example, adult care to paediatrics, social care to health care.


2.5 Tell us why you have chosen the stated level of innovation. If you have chosen level two, three or four please tell us about the setting where it has been used or tested. (200 words)

The PASU project will be the first of its kind in the country.

We are aware of other specialist PD services, delivering conventional outpatient models of care, from hospital or community settings. Sub-speciality services, offering advanced therapies, such as deep brain stimulation and intestinal levodopa gel infusions, also exist elsewhere in the country, but tend to be tertiary centre services, seeing small numbers of patients from a wide regional referral base.

Whilst all of these services are multi-disciplinary, they rarely allow team members to perform side-by-side assessment of both “motor” and “non-motor” issues. This is particularly true for neuropsychiatric complications, such as depression, psychosis and dementia, which are key determinants of quality of life and early, costly institutionalisation.

The PASU will be staffed and resourced to meet this challenge, providing seamless care for our most complex patients, cutting across existing boundaries and barriers.

The PASU hub, being based in a primary care setting, provides unique linkage between hospital and community services, and between neurological, psychiatric and allied health professionals. Data generated by the project will inform best practice in Parkinson’s disease, as well as providing guidance for commissioners on the most cost-effective service configuration for the region.

Actual word count: 197You should explain what your decision process was in choosing the stated innovation level.

In our review of outline applications, we found that a number of applicants selected level 1 or level 2 innovations but did not back this up with very strong evidence. It is important that your selection is realistic and that you can demonstrate the justification for your chosen innovation through evidence.

If you have chosen level two, three or four you should provide some information of the current setting, including the organisation, the scope of the work and any key people who are leading the work.

2.6 Tell us what is innovative about your intervention/approach and how it is innovative. (250 words)

To date, Parkinson’s services are delivered in the hospital setting, either by neurologists, geriatricians or PD nurse specialists. There is little link-up between primary and secondary care, and almost no joint working between allied health professionals. This model is therefore outdated and inefficient.

Psychotic symptoms in PD are common, but collaboration between psychiatric and movement disorder services are the exception, rather than the rule. This leads to poor care, higher rates of admission to nursing homes, high costs and, perhaps most


importantly, a huge decline in quality of life.

PASU would be the first of its kind in the country. Whilst other multi-disciplinary clinics exist, they do not offer rapid access to comprehensive assessment, do not encourage self-referral and do not offer advanced therapies, all on the same site. We are aware of one service, in Sheffield, offering clozapine to PD patients, although this service does not provide joint input from allied health professionals, such as physiotherapists, speech and language therapists and occupational therapists, all of whom may also be required. Other units use their clinics to signpost users to other services; in contrast, we will be in a position to provide on-site therapies, due to our inter-agency approach.

Drawing together all key team members in one locality will facilitate the development of a service of excellence, in a more cost-effective fashion. PASU also allows clear measurement of health and quality metrics, which will help inform future service developments, both in Teesside and in the country as a whole.

Actual word count: 249You should explain what is innovative about your intervention/your particular approach and how it is innovative. You must be able to demonstrate that your intervention is innovative and explain what sets it apart from other approaches. You should refer to the Health Foundation’s criteria for innovation in section 5.2 of the Call for applications.

This programme will not support any potential solutions to problems in health care delivery or quality that have already been tested in the same health care setting. We will give preference to the most innovative proposals during the selection process.

Please refer to sections 2, 5.1, 5.2 and 7.1 of the Call for applications.

2.7 What evidence do you have that your intervention is genuinely innovative? How do you know your intervention is innovative? Tell us about the evidence you are drawing on and search strategies used. (250 words)

No other regions have configured PD services in such an innovative and responsive fashion. Nowhere else are specialist PD services available, offering advanced motor and non-motor symptom management, in a community setting.

The ParkNet project has proven that a well-trained, well-resourced, multi-disciplinary PD service is cost-effective. In the Dutch setting, such services actually delivered better outcomes for patients, in a cost-neutral fashion. The project also showed that, by offering training and support to non-specialists in the wider community, there was a ripple effect, as better care spread throughout the surrounding regions (http://parkinsonnet.info/).

Whilst there is little direct evidence from the UK, a “Parkinson’s Excellence Network”, using a similar approach, is envisaged by Parkinson’s UK over the next 5 years (http://www.parkinsons.org.uk/content/uk-parkinsons-excellence-network).

Our project takes this one step further, offering support not just for patients with motor complications, but also for those with dementia and psychosis. If anything, it is this latter group who currently receive the least input, yet whose quality of life is worst affected, and whose care is most costly.


http://www.parkinsons.org.uk/content/uk-parkinsons-excellence-network

http://parkinsonnet.info/

Improving access to timely, specialist medical advice and assessment is one of the few interventions proven to reduce hospital admissions (http://www.kingsfund.org.uk/sites/files/kf/Avoiding-Hospital-Admissions-Sarah-Purdy-December2010.pdf)

A lack of options for PD patients with advanced symptoms, coupled with a lack of expertise in primary care, leads to a “default” pathway of unscheduled admission to acute services. A service tailored to the complex needs of PD patients is envisaged to reduce unplanned admissions – something we will look to provide evidence for during the project itself.

Actual word count: 250Tell us about the evidence you are drawing on to demonstrate that your approach/intervention is genuinely innovative and fits with one of the descriptors above. You should explain clearly the link between existing evidence and your intervention.

You should refer to relevant national and international published and grey literature as well as contact and discussions with experts and appropriate national and international networks. You should describe your search strategy – for example, the terms you used for your literature review – and any discussions with stakeholders or experts.

The application will be strengthened if you can show that national/leading experts in the field are aware of this proposal and endorse it.

In our review of outline applications, it was felt that this answer could be strengthened in a number of applications. We need to be convinced that your approach is genuinely innovative. If the intervention proposed is already in regular use in the same or a very similar setting in other localities in the UK, we do not consider it to be innovative.

Please refer to sections 2, 5.1, 5.2 and 7.1 of the Call for applications.


http://www.kingsfund.org.uk/sites/files/kf/Avoiding-Hospital-Admissions-Sarah-Purdy-December2010.pdf

http://www.kingsfund.org.uk/sites/files/kf/Avoiding-Hospital-Admissions-Sarah-Purdy-December2010.pdf

Section 3: Identifying the problem and solution

3.1 Please describe the nature and severity of the problem your project seeks to address. (200 words)

PD is common, complex and costly.

Our service cares for 800 PD patients; 300 have complex needs, such as motor fluctuations, falls, psychosis and dementia. The latter are particularly devastating, leading to expensive, and potentially unnecessary, institutionalisation (Aarsland et al. J Am Geriatr Soc 2000).

Complex patients are difficult to assess in a busy clinical service; most PD clinics operate 15-20 minute appointments, leaving little room for comprehensive, advanced symptom management.

People with PD are more likely to be hospitalized than the non-PD population. Admissions are costly – over 2012/13, there were 700 PD patients admitted to South Tees NHS Trust, accounting for 7000 bed days, at a cost of £1.5 M.

Key drivers of hospital admission are falls, motor fluctuations, psychosis and dementia (Gerlach et al. Mov Dis 2011). Once in hospital, care of patients is challenging, prolonged and often sub-optimal. This is particularly true for those patients with PD dementia (Fletcher et al. Mov Dis 2011).

Improving mental health is a key component of our PD Integrated Care Pathway. PASU will allow us to offer treatments that are denied to most PD patients, reducing health inequality, and providing a model of care for other areas in the country.

Actual word count: 199You should give a clear description of the nature of the problem clearly explaining the problem, the cause, nature and severity, as well as its impact on patients.

Applicants should demonstrate that it is a significant quality issue, widely relevant to UK health care, and potential improvements will be generalisable and widely applicable. You may refer to the significance of the health issue, condition or disease for patients; the impact on mortality; impact of symptoms; and the impact on quality of life locally or nationally. You may want to draw on information such as population prevalence and incidence, cost to health services and to wider society, and alignment of priorities with key stakeholder organisations.

Please refer to sections 3, 5.1 and 7.1 of the Call for applications.


3.2 What is the intervention/solution you are proposing and how will it address the identified problem? Please describe your chosen intervention including location and scale. (400 words)

PASU will run in parallel to the existing PD clinics, allowing care to be stepped up in the short- to medium-term. The unit will be based at Redcar Primary Care Hospital, which has all the facilities required, with the added benefit of being based in the community, rather than in a traditional secondary care setting.

A variety of complications can be managed in this setting.

PD dementia (n=200 per year)

Patients with evolving cognitive and behavioural symptoms will attend for a two-hour assessment, encompassing patient and carer interviews, investigations and cognitive assessment. A second appointment, one week later, will be used to discuss the diagnosis of dementia, commence treatment, arrange a plan for monitoring and make onward referrals to social services. This meets best practice requirements of the National Dementia Strategy (2009).

PD psychosis (n=20-30 per year)

Patients with psychosis will attend, with their care giver/family, and undergo a workup to ensure no reversible cause can be easily identified. A psychiatric assessment will be undertaken, and community support put in place. Treatment with a drug such as clozapine would be offered. Careful monitoring is required, with the patient attending pre-existing clozapine clinics for assessment and blood tests. This may prevent crisis admissions to hospitals, reduce morbidity and carer stress, and reduce the need for expensive, long-term institutionalization.

Advanced motor fluctuations (n=30)

These patients require joint neurological, nursing, physiotherapy and occupational therapy assessment. Currently, this involves multiple visits for the patient, introducing inefficiency, due to delays in communication. PASU allows all team members to work in parallel, improving patient experience and outcomes. We will also be able to work patients up for more advanced drug management - such as apomorphine, intestinal levodopa gel infusion or even deep brain stimulation. Currently, much of this work is done by admitting patients to a neurology ward. The clinic would provide a more cost-effective way of delivering the service.

As you can see from the description above, the PASU will not require funding for additional expensive investigations. The key to improving outcomes in this context is by providing the setting by which individuals involved in care of PD patients can communicate quickly and efficiently, making prompt management decisions and providing intervention in a timely fashion.

Actual word count: 370You should describe what the intervention is and where it will take place (eg patient services, departments, wards, etc) and in what locality/localities. You should provide an explanation of the rationale and how the proposed innovative intervention/s will address the problem and thus result in improvements.


You should describe which clinicians, service users, patients, carers, etc in the project will be involved in testing and carrying out the intervention. You should tell us why this intervention will work in your setting and how it will work in the context of your project (ie how it aligns with your organisational approach). You should also explain how your proposed intervention differs from the current provision/service if it already exists (this only applies to projects applying under innovation level 4.

You should demonstrate that the innovation/intervention is well designed, with detail about the resources that will be used.

Please refer to sections 2, 3, 5.1 and 7.1 of the Call for applications.


Section 4: Making improvements and measuring impact

4.1 Tell us about the improvement approaches/change methodology you propose to use to implement the project? (300 words)

The approach is evidence-based, using audit and evaluation to prove the concept and tailor the service to maximise benefit.

We have undertaken a baseline analysis of our Parkinson’s service, gathering data on patient numbers, projected complications, and regional Hospital Episode Statistics. We have mapped our service delivery, both in terms of response time and quality, and surveyed user experience. This proposal is born out this detailed local knowledge.

Our Integrated Care Pathway (ICP), unique to the field, gives guidance on management in primary and secondary care, as well as linking health and social services with patient support and charities sectors.

The ICP process has allowed us to engage key stakeholders, ensuring we have a well-defined, shared purpose. It not only provides clear aims for project delivery, but means that we know the metrics against which our service innovation can be measured.

Examples include:

High-level performance indicators

• Hospital admission/re-admission rates )• Hospital re-admission rates ) quantifiable financial impact• Bed days ) A&E attendances )

Validated PD-specific assessment tools

• Unified Parkinson’s Disease Rating Scale • Non-motor symptom scale• PDQ-39 Brief psychiatric rating scale Montreal cognitive assessment

Caregiver assessments

• Carer quality of life/stress measures

Allied health professional data

• Nationally agreed metrics for physiotherapy and occupational therapy

Audit & service evaluation tools

• Parkinson’s disease national audit tool

These measurement tools will provide the data to show how the PASU model drives up quality, whilst reducing costs, both to Clinical Commissioning Groups and local NHS Trusts. Transparent, clinically relevant data is key to the spread of innovation within the health service. With this at our disposal, we will be able to provide the leadership required to deliver real improvements for patients across the region, and the country.


Actual word count: 293Please clearly detail what you are going to do in your innovation trial and how you will set about doing it. Tell us what you will test, what changes you will introduce, what improvements you plan and how you will implement these. You should include how the trial will be implemented in your organisation and the other sites involved, the clinical and patient/service user involvement, any form of testing and specific change methodologies you will use.

Please refer to sections 5.4, 5.5, 5.6 and 7.1 of the Call for applications.

4.2 What is the expected impact on patients/carers/service users and what are the anticipated outputs and outcomes of your proposed intervention? (300 words)

At present, care of complex PD is delivered in a reactive, rather than proactive fashion. Pressure on outpatient services means that accommodating the needs of our most challenging patients, is often impossible to achieve.

The organisational barriers that exist between primary and secondary care, and mental health services, mean a holistic assessment is difficult to offer, without requiring repeated visits to hospital and clinics.

The PASU will address this unfavourable situation.

The ability of the PASU to offer neurological, psychological, psychiatric and allied health professional support, all under one roof, will reduce outpatient appointments for patients, and reduce delay in commencing best-evidence treatments. This will be reflected in improvements in service user satisfaction – data we regularly collect.

The right care, at the right time, and in the right place will improve motor and non-motor aspects of PD. This will have a positive impact on quality of life for our patients, and reduce care-giver stress. We will seek to demonstrate this using validated tools (section 4.1).

Providing better access to physiotherapy, occupational therapy and speech and language therapy is a central component of the Parkinson’s UK national care audit. Over the course of the intervention, we expect a rise in referral rates and assessments.

Part of our service strategy is to promote self-referral, both to the PASU itself, and to our allied health professionals. Encouraging self-management will demonstrate to our patients, and their carers, the benefits of taking some control over their symptoms.

We will use our data to help commissioners to better understand the cost of PD in terms of hospital admissions, bed days, outpatient referrals, morbidity and mortality. This will help the region develop a longer-term, more proactive strategy for care, with PASU at its core.

Actual word count: 287This programme is specifically concerned with projects that equip people to manage their own


conditions and health care more effectively, or equip health care providers to improve the quality of care provided to their patients on a daily basis. Please use this answer to clearly explain to us how your intervention will improve care, either directly or indirectly, with the life of the award (so by July 2016). Please specify the outcomes you are anticipating.

Please refer to sections 5.1 of the Call for applications.

4.3 Tell us how the improvements in the quality of care you seek to achieve will be measured. Tell us about your measurement framework including key metrics and existing baseline data. (400 words)

Baseline benchmarking measurements are in place (section 4.1). These include comparison of our current service against national audit standards, Parkinson’s-specific HES data, and referral response times, both for new and existing patients.

Improvement will be demonstrated by:

• outcome measures – PD-specific disease severity measures; activities of daily living measures; carer quality of life/stress assessments; patient satisfaction surveys

• process measures - hospital admission/re-admission rates; nursing home admission rates; “avoidable” admissions; A&E attendances; home care costs

• balancing measures – health resource utilisation rates (social services referrals, psychiatry/neurology appointments, pharmacy costs)

financial measures – cost of acute, community and social care resources used; cost of service provided

Data on admission rates, re-admission rates and bed occupancy will be generated by South Tees NHS Trust. We are working with our hospital coding unit to ensure that the data generated is as accurate as possible. In addition, we have developed an alert system, which notifies our hospital team when a patient known to our service is admitted. We will continue to assess HES data, to provide higher-level data.

At present, we are collating data on admission rates to, and cost of, nursing care for PD, as well as assessing reasons for admission. We will use this information to assess impact on one of the key goals of the PASU i.e. a reduction in avoidable admissions to long-term nursing care.

Our team is well acquainted with the PASU outcome measures; no additional training will be required. Data will be collected prospectively, and presented at the MDT meeting each week. This will then be entered in to a PASU database, so that longitudinal, as well as cross-sectional, data can be assessed. Interim analysis will be undertaken at months 3, 6 and 9, enabling us to make necessary adjustments, and provide real-time reporting to the Health Foundation.

Dr Neil Archibald, the project lead, will have ultimate responsibility for the data, which will be keep on secure trust servers, under existing information governance arrangements.

Our outcome measures will provide evidence that the PASU model results in better standards of care, improvements in patient quality of life and reductions in care-giver distress. Our process and financial measures will show that, by having a proactive service, key healthcare costs can be reduced or, at worst, kept at a cost-neutral level. Our balancing measures will give commissioners the confidence to support the PASU model beyond the lifetime of the grant.

Actual word count: 399Applicants should explain how they will measure the planned improvements. Your


measures should be able to tell you whether the changes are actually leading to the improvements you planned. You should explain your measurement protocol, specifying the indicators and measures you will use, how data will be collected and presented, how often, and who within the project team will be responsible for this. You should describe your outcome measures (how the changes impact on patients and other stakeholders), process measures (whether the changes in the system are performing as planned and if you are on track in efforts to improve the system) and balancing measures (whether changes designed to improve one part of the system are causing new problems in other parts of the system). Please also explain the data collection method.

The expected benefits should be clearly stated, and their measurement clearly explained. The link between the measurement and outcomes should be clear.

Please refer to sections 5.5 and 7.1 of the Call for applications.

4.4 Explain the potential contextual challenges and barriers to the successful delivery of improvements. How do you plan to address them? (400 words)

There are a number of challenges to the successful delivery of our improvements. Broadly speaking, these can be categorised as follows:

Service user engagement Workforce planning Production of evidence Unexpected costs Commissioning barriers

Service user engagement

Setting up a new service could result in a low referral rate. Initially, referrals to the PASU will be identified by members of the PD MDT, so a prolonged lag time from clinic set-up to service delivery is unlikely. As we are not looking to increase our patient numbers, merely target interventions to those most in need, over-subscription should not be problematic. Parkinson’s UK will publicise the PASU, so that self-referral becomes a realistic prospect over the course of the project.

Workforce planning

Whilst we have agreement to release staff from current roles, and have costed this activity, work-force pressures, and staff absence, are unpredictable. For many of the roles in the team, we have alternate personnel to whom we can turn. This is not the case for all team members, however. South Tees NHS Trust and Tees Esk and Wear Valley Mental Health Trusts have pledged their support in this matter.

Production of evidence

The project is ambitious, particularly when it comes to “process” measures. Providing evidence of a reduction in cost of healthcare is difficult, particularly over a relatively short time frame (15 months). Hospital admission rates are a known quantity but, at the time of writing, data on nursing home admission rates are not available. This is a key driver of cost of care, and, if rates are low, we may struggle to provide proof of an impact in this regard. We believe that we have sufficient metrics to overcome this potential issue.

Unexpected costs

We have carefully constructed our business case with respect to staff costs, and do not anticipated overspend in this regard. Given the challenging financial position of the NHS at present, it remains possible that unexpected costs may occur during the lifetime of the project. This should not adversely affect the core aims of the PASU project.


Commissioning barriers

The purpose of the PASU project will be to provide proof that a change is needed in the way services are designed for complex PD. We are in negotiations with local CCGs to ensure that, should the project achieve its primary goals, the longer-term future of the PASU will be secure.

Actual word count: 398You need to explain in more detail the challenges to the successful delivery of your innovation trial and your strategies to overcome them. You should demonstrate that you have a good understanding and awareness of what the barriers and risks are. You should show that you clearly thought through how you will deliver the project, the obstacles you will face, and how you will overcome these. We expect you to refer to how executive sponsors will support you in addressing these challenges. You should also tell us about any unintended consequences you foresee and how these will be addressed.

4.5 Describe how you will capture learning on making improvements in health care (300 words)

Because the PASU concept is novel, we have a responsibility both to our patients, and also to those funding the innovation, to ensure that all learning opportunities, positive and negative, are recorded.

Enshrined in our service is a monthly team meeting, dedicated to reflecting upon the challenges we are facing in delivering the service. This will include maintaining a contemporaneous “lessons learned log”, to which all team members will contribute. We will use the NHS learning handbook template (http://media.nhsiq.nhs.uk/learninghandbook), allowing us to record the “type” of lesson (start - a suggestion for improvement, stop - something that should not be continued in the future, and continue - something that went well and should be continued), binding this with an action plan, where necessary. For unexpected outcomes, positive or negative, an “after action review” will take place, detailing differences between intended and actual outcomes.

We will produce project reports at months 3, 6, 9 and 12, incorporating information from the monthly team meetings into “lesson reports”. A final report, complete with executive and lay summaries, will be created from this rolling data.

We plan a regular journal club, led by Dr Neil Archibald, helping us to build up a best evidence resource, which will link with the Teesside ICP, our key, regional knowledge asset. This will then sit alongside the outcome and process data, ensuring that unit practice is based on best available evidence.

Dissemination of learning will rely on formal feedback to sponsors, as above, and oral presentations on both a regional and national level. Dr Archibald, as chair of the Northern Parkinson’s Excellence Network, due to launch in February 2015, will be in an excellent position to promote the learning captured, and service improvements made, from the PASU innovation.

Actual word count: 290

The Health Foundation is interested in learning about how to make improvements in health care i.e. the factors that contribute to successes, the challenges that are tackled and the factors that contribute to failures in improvement.You should tell us how you will capture this learning, who within the key project team will be responsible for doing this and the skills they bring in. We expect the project team to capture and share this level of learning in a structured and timely manner. You should demonstrate this in your project plans. You should tell us how and when you will reflect on this learning, how you will capture issues that would be useful to others who are carrying out improvement work, and how you will capture the challenges to making improvements. You should have robust plans in place to capture knowledge that involves taking a step back from the day to day activity and reflecting on the ‘why did that happen’ questions.


http://media.nhsiq.nhs.uk/learninghandbook


4.6 Please tell us about the current costs of financial provision and how you expect this to change following your intervention. (400 words)

Our service cares for 800 PD patients; 300 have complex needs, such as motor fluctuations, falls, psychosis and dementia. At present, we seek to review all patients on a six-monthly cycle. In practice, some are seen more frequently, and some less frequently, depending on need.

The current new patient tariff is £263, whilst that for a review patient is £156. This cost is met by specialist commissioners (NHS England). We envisage the PASU to be cost neutral, both for South Tees NHS Trust and commissioners. Whilst the need to see some complex patients more frequently will increase the cost of outpatient activity to commissioners, this will be compensated for reductions in routine clinic appointments elsewhere in the system, and the predicted positive impact on unscheduled care (A&E, acute admissions) and care home placement.

In general, the cost of admission to an acute bed is £1,248 per admission, across elective and non-elective admissions, at an approximate cost per bed day of £200. The cost of A&E attendance is £100-£200, depending on the treatment given.

Whilst it is difficult to describe an ‘average’ admission, avoiding and saving the cost of a single ‘average’ admission would offset the costs of up to 8 outpatient review appointments in the PASU. In addition, the saving would accrue against cost of A&E attendances, ambulance transport, and nursing care in the community.

People with PD are more likely to be hospitalized than the non-PD population. Admissions are costly – over 2012/13, there were 700 PD patients admitted to South Tees NHS Trust, accounting for 7000 bed days, at a cost of £1.5 M. Stopping just 35 admissions, 5% of the this total, would save the £75,000 required to resource PASU for this trial phase.

Actual word count: 286

You should tell us the financial cost of current service provision, as well as the financial cost of implementing your intervention.

You should then tell us about the costs of running the service after implementation and provide an estimate of the financial benefits that will be accrued as a result of the intervention. You should tell us which department/organisation(s) will accrue the financial benefit, and explain the impact of this new improved service. You must ensure that you account for any cost transferred elsewhere, in the system and in the wider community. We need to see evidence that costs have not just been transferred into another area of the health service or a different sector. You should tell us if some organisations be financially worse off if this proposal is successful and how this will be approached. Where the costs of running the service after implementation are higher, we expect applicants to make a very strong case that the increase in quality achieved is an acceptable trade-off.


Section 5: Managing the project

5.1 Tell us about the experience, expertise and responsibilities of the core project team, ie those who will be closely involved in the project on a day-to-day basis.

Name Current role Role in project

Relevant expertise and connections to relevant expert/specialist networks or community of practice

Time allocated to the project (WTE)

Dr Neil Archibald

Consultant Neurologist

Project Clinical Lead

Consultant Neurologist with sub-speciality interest in PD and related conditions; PhD in cognitive and psychiatric complications Parkinson’s; experience of clinical trials and database management; project lead on Teesside Integrated Care Pathway; Chair of Northern Parkinson’s Excellence Network; member of working group developing national care pathways for advanced symptom management in PD; Parkinson’s Academy Masterclass faculty member

0.2

Sr Zenita Cowen

PD nurse specialist

Senior specialist nurse

Experienced PD nurse; expertise in the use of advanced symptom treatments such as apomorphine, tolcapone, deep brain stimulation; working on Masters project examining advanced care planning in Parkinsonian disorders; involvement in clinical trials at James Cook University Hospital; Parkinson’s disease dementia diagnostic service development expertise

0.2

Dr Matt Rowett

Consultant Psychiatrist

Liaison psychiatry lead

Neuro-psychiatrist with interest in liaison psychiatry and psychosis in Parkinson’s disease; project lead in development of liaison service at Tees, Esk and Wear Valley Mental Health Trust; expertise in use of anti-psychotic drugs in PD

0.25

Rosie Warnett

Neuro Physiotherapy

Physiotherapy lead

Senior neuro-physiotherapist; therapy lead for neuro-rehabilitation at The James Cook University Hospital; sub-

0.4


speciality expertise in PD; Angela Birleson

Occupational therapy

Occupational therapy lead and project oversight

Clinical lead for OT; PhD in Movement Disorders; member of NICE appraisal group for OT; Database coordinator for IOTS; leadership and management expertise

0.02

Applicants will need to show that they have strong clinical leadership (this includes doctors, nurses, allied health professionals, etc) and should also involve people who work in the operational environment/s where the innovation will be tested. The latter may be clinical or non-clinical, depending on the nature of the innovation. Project teams should have experience in change and project management, measurement and evaluation.

Please refer to section 6 of the Call for applications.

5.2 Please provide a detailed project plan which includes key deliverables, milestones and timelines (300 words)

Key to the success of the PASU is the specialist staff involved. These individuals have already been identified and have the necessary expertise to deliver the service.The majority of the funding will be used to realign current job plans, ensuring regular attendance at the clinic for all core staff.

We already work within the Redcar Primary Care Hospital, with one of our PD clinics operating from the site. The facility at Redcar is state of the art and is well-equipped. We envisage minimal spend on materials.

Initially, we will filter small numbers through the service, collecting a variety of metrics as part of the assessments. We will enshrine a multi-disciplinary team meeting in to each session. We will then open up the clinic to both GP and patient self-referrals.

We have drawn up the following timeline to ensure the PASU meets its objectives:

Set-up phase

• May ‘15 – Identification of key members of the MDT; job planning sessions to take place well in advance of clinic opening• Jun ‘15 – Updating of Teesside Parkinson’s Integrated Care Pathway, to ensure best practice for the clinic itself; agreement on outcome measures and evidence base documents• May - Jul ‘15 – Site visits to Redcar PCH; key equipment to be procured/identified; joint working documents to be signed; collation of benchmarks/metrics from 2013/14, to serve as baseline

Implementation & measurement phase

• Aug ’15 – Initial patient groups to be assessed in PASU; initial throughput low volume to ensure efficient joint working and assess early outcome measures; patient and carer feedback collected via Parkinson’s UK• Aug ’15 – Jul ’16 – PASU to “open”; filtering of high risk patients in to clinic set-up; rolling collection of outcome data; report to Health Foundation; secure ongoing funding from CCG and Specialist commissioning for ongoing work


Actual word count: 298You should set out your project plan here. The project plan could be a Gantt chart, a table or a written explanation of how you will plan and deliver your project over the funding period. You should consider deliverables and high level milestones which include the set-up phase (recommended) followed by implementation including measurement. Do not insert your project plan as a separate document.

All projects are expected to start with the recommended set-up phase from May 2015. If your project is likely to need ethical/R&D approval you should include this step as one of your milestones, ensuring you have enough time to make the necessary enquiries that will enable you to have final approval and be ready to start your work by 1 August 2015.

Your project plan should make reference to all milestones in the project (including those described in answer 4.1) and demonstrate when the project will impact on patients/service users (as described in answer 4.2).

Please refer to sections 5.4, 5.5, 5.6 and 7.1 of the Call for applications.

5.3 How will the project be managed on a day to day basis? (200 words)

Oversight of the project direction, and ultimate responsibility for resolving issues, will fall to Dr Archibald. This role will be supported, and informed, by weekly team “business” meetings, and monthly learning and governance meetings.

Project governance will centre on staff and patient needs, quality improvements and leadership development. Our team has a track record of collaborative working, delivering excellence and clinical leadership. Our patient and carer feedback, regularly surveyed, is excellent.

The involvement of Parkinson’s UK will further ensure that patients and carers have a voice. It also allows us to utilise the huge amount of experience that Parkinson’s UK has in promoting service development and self-management.

We already work closely with mental health services in the region. Tees, Esk and Wear Valley NHS Trust is highly regarded for its standards of mental health care, and Dr Matt Rowett will lead on delivery of psychiatric care and interventions.

The Integrated Occupational Therapy Service (IOTS) will be central to linking community services to the PASU. The database system in place will ensure that resources are accessed in a timely and appropriate fashion. Angela Birleson, clinical lead for OT, will oversee this aspect of the project.

Actual word count:194You should explain how the direction and implementation of the project will be arranged, the reporting mechanisms that will be in place and who will be responsible for making decisions about the direction of the project, including resolving issues as they arise. You should tell us about the governance structures of the project and how these fit within existing organisational structures, how partners are involved and the role of executive sponsors and external stakeholders.


Section 6: Embedding and spread

6.1 Tell us how you will sustain the improvements you achieve in this project beyond the life of the award. (200 words)

The success of the PASU project is dependent on recurring funding from CCGs/specialised services commissioners. The only way to ensure this is to provide convincing “proof of concept” evidence by the end of the 15-month funding period.

CCGs are increasingly focussed on moving care from hospital settings into the community. This is seen as a more viable long-term model. The PASU is aligned with this aspiration and, if we are successful in reducing the need for unscheduled hospital care, and preventing untimely admission to nursing care, then ongoing funding from CCGs is more likely.

Through out work with the Teesside ICP, we have developed good working relationships with a number of the CCGs, and will seek support for the PASU initiative from them as the project develops.

We already have the support of South Tees and Tees, Esk and Wear Valley NHS Trusts for our initiative. The PASU project matches the trusts’ commitment towards service excellence and cost-effective care.

With respect to specialist commissioning, one of the keys to providing excellence is to build a critical mass of both patient need and service expertise. The PASU will allow us to concentrate our efforts, enhancing the care we deliver.

Actual word count: 198Please explain how you will sustain your planned improvements beyond the life of this award. You need to demonstrate that you have clear and achievable strategies in place. You should show us that you have considered who the decision makers are and what your influencing strategy is. You should tell us how you will utilise your networks, partners and other stakeholders to sustain your work. In particular, you should highlight how your partner organisations and executive sponsors will provide support in achieving this, and any links you will make with new partners, networks or commissioners.

6.2 Tell us how and when you will disseminate, communicate and spread the improvements you achieve in this project beyond the participating sites. (200 words)

Sustaining the improvements will only be possible if all those involved with, or affected by, the PASU project can see, and understand, the benefits, as they evolve. Disseminating this information is therefore a key component of our project plan.

We intend to use the expertise and “reach” of Parkinson’s UK to help promote the service locally. In addition, we can utilise Parkinson’s UK to help us spread our evidence to other regions, and other potential funders. Three-monthly project reports will be made available to Parkinson’s UK, much as they will to the Health Foundation.

Dr Archibald is chair of the Northern Parkinson’s Excellence Network (PEN), a new national initiative designed to promote best care in PD. Not only will this provide a unique platform to showcase innovation, but will also allow potential benefits to be offered to, and adopted by, other regions in the country.

The PEN launches in February 2015, although the Northern Network will begin work in January 2015.


Contributors to the network include representatives from NHS England, CCGs and the Strategic Clinical Network, ensuring that outcomes from the PASU are high up the agenda regionally and nationally.

Actual word count:190You should tell us how and when you will disseminate, communicate and spread your improvements beyond your participating sites. You need to demonstrate that you have clear strategies in place to embed best practice including a timescale for doing this. You should show us that you have considered who the decision makers are and what your influencing strategy is. You should tell us how you will utilise your communities, networks and partners to spread your work. In particular, you should highlight how your partner organisations and executive sponsors will provide support in achieving this, and any links you will make with new partners or networks.

If you have any external stakeholders endorsing, supporting or advising on your work (such as leading experts or national organisations) please include the details of this in your answer.

6.3 Provide an example of how you and/or your team have encouraged others to adopt new ways of working in previous initiatives. (300 words)

The South Tees Movement Disorder service is constantly seeking to improve the care of patients with Parkinson’s disease in the region.

Over the last 18 months, we have developed a comprehensive integrated care pathway (ICP) for Parkinson’s disease (http://southtees.nhs.uk/services/neurology/parkinsons-disease-service/pathway).

The development of the ICP involved service user engagement, and identification of multiple stakeholders, and we received support from Parkinson’s UK and Neurological Commissioning Support to help us achieve this. The Tees ICP is the first such initiative to be fully launched in the UK, and runs alongside our departmental audit and service improvement strategy. This coordinated approach has allowed us to identify key points of service deficiency - inpatient prescribing, referral of PD patients to allied health service input, diagnosis of psychosis and dementia - and we are now using the ICP to improve outcomes.

Launching the ICP has involved organising training sessions for GPs, hospital teams and pharmacists, and the feedback from these sessions has been positive. We continue to provide this training, to ensure consistency of service delivery.

At present, we are collaborating with Teesside University, to turn the pathway in to an interactive website and tablet app. This will ensure that the most up to date information on PD care is available to all those interacting with our patients. We hope to be able to make this information available nationally, in due course.

We feel the ICP is not just a success story for our service, but is also delivering real improvement in patient care, whilst utilising existing resources to do so.

Actual word count:255You should describe how you or your team (if you have worked together before) have encouraged others to adopt new and improved ways of working. You should provide us with one example explaining your/or your team’s role in doing this, what the challenges were, how they were addressed and overcome, and what the outcome was.


http://southtees.nhs.uk/services/neurology/parkinsons-disease-service/pathway

http://southtees.nhs.uk/services/neurology/parkinsons-disease-service/pathway

Section 7: Project budget

7.1 How much funding are you requesting from the Health Foundation?

Total cost of project: £ £ 82,895

Total amount requested from the Health Foundation: £ £ 74,895

7.2 Is there any funding from other sources (include in-kind and/or cash)?

Source Amount In-kind/cash

South Tees Hospital NHS Trust Parkinson’s fund

£8000 cash

Add more rows as necessaryEach project will receive up to £75,000 of funding to support the implementation of the work. This funding can be supplemented by applicant organisations if appropriate. Whilst co-funding is not a requirement, we do need to know if there are any other confirmed funding sources.

7.3 Please provide a breakdown of your proposed budget – how will you use the funding on a separate Excel spreadsheet. Please submit it in the same email as the application.

You do not need to write anything here, it is a reminder for you to complete and submit the budget template.

Please use this template to provide an overview of the budget. Do not attach any appendices as they will not be taken into consideration. Your budget should contain detailed costs that are your best estimate and, where appropriate, based on written quotations. Please round the total to the nearest whole £.

Our award must only be used to cover costs that are directly attributable to carrying out the project. The Health Foundation will not fund capital expenditure such as:

vehicles or buildings large items of equipment (over £2,000) including scanners, printers, IT hardware,

etc organisational overheads such as costs of premises, management and HR the procurement of day-to-day consumables or of ‘business-as-usual’ equipment


additional clinical posts linked to the specific intervention, unless there is a very convincing case for how these posts will be sustained beyond the funding period

Please add more rows and headings as and where necessary giving as much detail as possible. Include subheadings in your breakdown and ensure that totals are correct.

Please refer to section 5.7 of the Call for applications.


Section 8: Organisational Support

8.1 Tell us about the executive sponsors for this project and how they will support the project.

Name Organisation name & job title/role

Statement of active support for the duration of the project

Signature

Parkinson’s UK – North of England

Charity Provision of the following, for the duration of the project:

Patient and carer involvement

Publicity of service Provision of Information

Support Worker

Tees, Esk and Wear Valley Mental Health Trust

NHS Provision of the following, for the duration of the project:

psychiatric liaison CPN support


Section 9: Declaration and Signatures

To comply with the Data Protection Act, we require your consent to the Health Foundation using personal data supplied by you in the processing and review of this application and in any other legitimate activity of the Foundation; this includes transfer to and use by such individuals and organisations as the Foundation deems appropriate. The Health Foundation requires your further assurance that personal data about any other individual is supplied to the Foundation with their consent.

The applicant also accepts the Health Foundation’s requirements relating to the Data Protection Act (see above). The signatory below will provide this consent and assurance. The signatory below also confirms that the information provided in the application form is accurate.

Electronic signatures are required as the application form is to be returned by email.

9

9.1 Primary contact (named in 1.3)

Applicant name Dr Neil Archibald............................................................................................

Signature ....................................................................................................................................

Date 20/11/2014...............................................................................................................

9.2 A senior leader (chief executive, senior deputy or senior clinical lead) from the lead organisation (named in 1.2) must fully support this application signing the declaration below:

‘I confirm that I have read and fully support this application. The organisation accepts The Health Foundation’s requirements relating to the Data Protection Act (see above). The signature below provides this consent and assurance.’

Name Prof Rob Wilson, Medical Director

Signature

Organisation South Tees Hospitals NHS Trust

Date 20/11/2014

9.3 The Head of Finance Department or Director of Finance or equivalent of the organisation financially accountable to the Health Foundation (the lead organisation named in 1.2) if an award is made should sign the declaration below.

‘I confirm I have read and fully support this application and, if an award is made, the Organisation will administer it. The organisation also accepts The Health Foundation’s


requirements relating to the Data Protection Act (see above). The signature below provides this consent and assurance.’

Name Chris Newton, Director of Finance

Signature

Organisation South Tees Hospitals NHS Trust

Date 20/11/2014

9.4 A senior leader from each partner organisation (chief executive, senior deputy or senior clinical lead) from the lead organisation (named in 1.4) must fully support this application signing the declaration below:

Partner organisation 1:


Name Ebbie Hulland

Signature

Organisation Parkinson’s UK (North East)

Date 20/11/2014



Name Angela Birleson

Signature

Organisation Integrated Occupational Therapy Service

Date 20/11/2014





Name Angus Bell, Consultant Psychiatrist, Senior Clinical Director Adult Mental HealthSignature

Organisation Tees, Esk and Wear Valley Mental Health Trust

Date 20/11/2014

Please add/delete as many boxes as required.


Section 10: Telephone interviews

Telephone interviews with shortlisted applicants will be held in March 2015. You should confirm the lead applicant and key members of the team’s availability to attend.

Please tick at least 3 preferences for interview dates and times.

Date Morning Afternoon9 March 2015 10 March 201511 March 2015 12 March 2015 16 March 2015 17 March 201518 March 201519 March 2015

We will make every effort to schedule an interview at your preferred time but we cannot guarantee this.


Documents

Document - Web viewThis will then be entered in to a PASU database, so that longitudinal, as well as cross-sectional, data can be assessed. ... nurses, allied health professionals,