From Zero to FLS:Implementation & Beyond

National Osteoporosis Society FLS Education Programme

October 2010

Previous fracture

Non-vertebral & Vertebral

Size Matters!Determinants of the scale of your service

The FLS’ target population- which fracture groups?- what age group?

New Fracture

Non-vertebral& Vertebral

Previous fracture

Non-vertebral & Vertebral

New Fracture

Non-vertebral& Vertebral

Size Matters!Determinants of the scale of your service

~650 new non-vertebral fractures &~120 new vertebral fractures age 50+ per 100K, per year

~70 previous non-vertebral & Vertebral fractures age 50+ per 100K, per year

NEW FRACTUREPRESENTING TO

A&E / ORTHO / TRAUMA

EDUCATIONPROGRAMME

EXERCISECLASSES

FALLS RISKASSESSMENT

NEW RADIOLOGY REPORT OF FRACTURE

PRESCRIPTION ISSUED BY GP

Rx FOR FRACTURE 2Y PREVENTION

McLellan et al. Osteporos Int 2003;14:1028–1034

PREVIOUS FRACTURE

From Zero to FLS: Implementation & Beyond

From Zero to FLS: Implementation & BeyondThe first steps

• Appointment of project management team & Chair

Membership of FLS implementation project team

Number Post

x2 Local champion / lead clinician

x1 Chair GG&CHB Osteoporosis Subgroup (clinician)

x3-4 Other HB lead clinician & secondary care clinicians from involved sites

x1-3 CHP GP lead

x2 Osteoporosis Nurse Specialists

x1 General Manager – Medical Services

x1 GG&C osteoporosis exercise service lead physio

x1 Superintendent Radiographer

x1 Assistant General Manager, Radiology

x1 Consultant radiologist (DXA) – local imaging lead

x1 Estates manager

x1 NOS patient representative

From Zero to FLS: Implementation & BeyondThe first steps

• Appointment of project management team & Chair • Redefine & agree with providers of funding remit of group &

scope of service

1. To roll out an FLS, to provide systematic post-fracture assessment to all men & women age 50+ with new fracture presentations or with new report of vertebral fracture or with previous fracture age 50+

2. To ensure equitable access of all relevant patients in the region

3. To implement these services within the constraints of the proposed funding

4. Case-finding for new fracture presentations & for new reports of vertebral fracture – by the FLS ONS

Remit of group & scope of planned service

5. Case-finding for previous fractures – by primary care

6. Post-fracture, risk assessment based on one-stop consultation with FLS-ONS incorporating DXA, where appropriate

7. All episodes of FLS-patient care recorded in database

8. To provide this for population of x over y sites and covering fracture patients from z hospitals

Remit of group & scope of planned service

From Zero to FLS: Implementation & BeyondThe first steps

• Appointment of project management team & Chair • Redefine & agree with providers of funding remit of group &

scope of service

• Work breakdown

From Zero to FLS: Implementation & Beyond

From Zero to FLS: Implementation & Beyond

From Zero to FLS: Implementation & BeyondThe first steps

• Appointment of project management team & chair • Redefine & agree with providers of funding remit of group & scope

of service

• Work breakdown

• Schedule work & establish timeline for delivery of service

ID Task Name Start Finish DurationDec 2007 Jan 2008 Feb 2008 Mar 2008 Apr 2008 May 2008 Jun 2008 Jul 2008

2/12 9/12 16/12 23/12 30/12 6/1 13/1 20/1 27/1 3/2 10/2 17/2 24/2 2/3 9/3 16/3 23/3 30/3 6/4 13/4 20/4 27/4 4/5 11/5 18/5 25/5 1/6 8/6 15/6 22/6 29/6 6/7 13/7 20/7 27/7

1 5.2w09/01/200805/12/2007Scope & Remit – Group Membership

2 19w15/04/200805/12/2007WB – Personnel Appointments

3 14.6w14/03/200805/12/2007WB – DXA procurement to delivery

4 22.2w07/05/200805/12/2007WB - Exercise class infrastructure

5 22.2w07/05/200805/12/2007WB - protocols

6 26.2w04/06/200805/12/2007WB – Induction – training

7 13.6w30/05/200827/02/2008WB – Communications incl website

8 34.6w01/08/200805/12/2007Service launch

From Zero to FLS: Implementation & Beyond

What do you need to provide a DXA for a FLS service ?

• Space for DXA (may require building works!)

• DXA scanner/s – DXA (VFA) site visit to inform choice

– DXA procurement

• Radiographer/s

• ONS clinic space - near DXA

• Database - reporting system

• Patient transport issues

From Zero to FLS: Implementation & Beyond

Personnel

• Overview– Banding & Grades of Staff– Job descriptions– Appointments processes - job descriptions - adverts – interviews– Consultant Sessions

• How are Consultant sessions best deployed?

• Osteoporosis Nurse Specialist/s– Band 6/7 Osteoporosis Nurse Specialist– ONS line management– ONS where & how will they work?

Personnel

• Administration & Clerical Staff– Band 3 A&C

• Physiotherapist/s for exercise services – Band 6 Physiotherapist

• Radiographer/s – Band 6 Radiographers

From Zero to FLS: Implementation & Beyond

Logistics

• Pathways of care– New fracture presentations in which hospitals & FLS in which centres– New reports of vertebral fractures in which hospitals & FLS in which

centres– Past fractures from across region referred to which centres

• Protocol development

• Access to Mineral Metabolism clinic for those who don’t fit with management protocols

• Liaison re exercise classes

• Liaison with falls service

Logistics

• Communication within secondary care & with GPs

• Standardisation of forms

• Website development to facilitate communication

• Patient education materials

• Patient education classes

• ? Nurse telephone follow up (? Telephone BPR tariff)

• Training & induction

• Launch meeting

What do you need to provide exercise classes?

• Access to health service physio gym– Identify exercise class locations

• Access to leisure centre gyms– Identify exercise class locations

• Patient transport issues

If at first you don’t succeed…

If at first you don’t succeed…you’ve failed!

Pathway to success…& it will be incremental!

What are we trying to accomplish?

How will we know that a change is an improvement?

What changes can we make to effect improvement?

Pathway to success…& it will be incremental!

Cycle 1 Objective 1 Case-finding all new

fx F&M age 50+ by GP

Objective 2 Fracture risk assessment by ONS at one-stop clinic with DXA

Outcomes audit

Only 5% wrist fx & 11% hip fx identified / referred for assessment

Essential change

Case-finding must be by ONS in secondary care

PDSA & the Evolution of the Glasgow FLSfor new fractures

Cycle 1 Cycle 2 Objective 1 Case-finding all new

fx F&M age 50+ by GP

Case-finding all new fx F&M age 50+ by ONS in secondary care

Objective 2 Fracture risk assessment by ONS at one-stop clinic with DXA

Outcomes audit

Only 5% wrist fx & 11% hip fx identified / referred for assessment

~all fx patients identified & assessed – but only 4% of fx were vertebral

Essential change

Case-finding must be by ONS in secondary care

Need for new approach to identify vertebral fx

PDSA & the Evolution of the Glasgow FLSfor new fractures

Cycle 1 Cycle 2 Cycle 3Objective 1 Case-finding all new

fx F&M age 50+ by GP

Case-finding all new fx F&M age 50+ by ONS in secondary care

Case-finding all new fx F&M age 50+ by ONS in secondary care

& all new radiology reports of vertebral fx

Objective 2 Fracture risk assessment by ONS at one-stop clinic with DXA

Outcomes audit

Only 5% wrist fx & 11% hip fx identified / referred for assessment

~all fx patients identified & assessed – but only 4% of fx were vertebral

~all fx patients identified & assessed – now 12% of fx are new vertebral fx

Essential change

Case-finding must be by ONS in secondary care

Need for new approach to identify vertebral fx

PDSA & the Evolution of the Glasgow FLSfor new fractures

‘The only place success comes before work is in a dictionary!’