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Delivering improvements Using Lean Principles Dr Brian Bradley, Michaela Bowden Bolton Respiratory Team Cindy Walton Bolton Improving Care System.

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Presentation on theme: "Delivering improvements Using Lean Principles Dr Brian Bradley, Michaela Bowden Bolton Respiratory Team Cindy Walton Bolton Improving Care System."— Presentation transcript:

1 Delivering improvements Using Lean Principles Dr Brian Bradley, Michaela Bowden Bolton Respiratory Team Cindy Walton Bolton Improving Care System

2 Northern industrial town Population 270,000 12% ethnic minority population Bolton health survey epidemiology COPD 2.7% Chronic Bronchitis 7.5%, Chronic Cough 13.5% Wheezing18.7% We are here! About Bolton

3 About Bolton NHS FT Currently 775 beds – Catchment approx 350,000 Busiest emergency service in the North West 2011/12 £260m turnover 46,000 non-elective admissions per year Respiratory illness is high volume pathway (27%)

4 The Bolton Improving Care System Understanding Value Learning To See Redesigning Care Delivering Benefit

5 Why Change? Difficult Winter Care unsafe 98% not being achieved Stressed Staff We needed to change

6 Concept of Flow Applying concept of flow Value adding steps How could it we apply to ward activities Batch –common way One piece flow would not be possible on ward One decision flow

7 One Decision Flow Right People present to make decisions flow Ward Rounds – Daily Consultant Lead Board Rounds Daily Decisions being made on a daily basis by the right people Not Traditional

8 Bolton Respiratory Team

9 In-patient care - case for Change Staff Opinions All work very hard but dont always deliver the good care to our patients High bed occupancy figure Not enough time or staff to change things Must be able to do things better! Targets! High Standardised Mortality Ratio Jan 2009 Length of Stay -14,183 Excess bed days High mortality for respiratory conditions Not implementing pneumonia care bundles as well as we should

10 Respiratory Team Vision Timely, equitable inpatient access to respiratory services Best cost-effective outpatient multi disciplinary team (MDT) services Support primary care to provide equitable good quality respiratory care in community Underpinning ethos of Best Possible Care for the Patient in the most appropriate setting

11 Respiratory team: lean journey with BICS 2006 Minor changes but sustainability issues 2009 Respiratory Inpatient Care 2010 Hospital and Community Respiratory Nursing Event 2012 Respiratory Outpatient Service Opening Access and Community Facing

12 What do our patients want from a service? Listen To Right Right Time Basic (unspoken) Access Contact in hours Straight to Respiratory Ward, Management Plan Performer Delighter (unspoken ) Contact out of hours Straight to Respiratory Ward Frustrating- Having to explain to junior doctors when breathless, history taking Kano Model used to identify from patients what do they want from a service

13 Rapid Improvement Event- April 2009 Core Group of Staff Nursing Staff Consultants + non consultant hospital doctors (NCHDs) Physiotherapy Occupational Therapy Pharmacy Social Workers External (to the process) 4 Day Event! Gap Analysis Agree new ways of working Support this Standard work model Devise a model to sustain the changes

14 Gap Analysis: As reported by staff Medical issues Poor documentation Poor discharge planning Poor communication with nursing and other staff No role in MDT Poor follow through on issues Juniors – reactive working 75% Discharge scripts done on day of discharge Nursing Not enough staff Chasing up doctors to do the tasks / To take out drugs for patients on discharge from hospital (TTOs) Interruptions –40% of time delivering Drugs -i.v. antibiotics Handover / prioritise work Social work referrals and discharge planning

15 Agreed - Needed to Change/ Improve Simple evidence based pathways Improve Patients journey - ensuring visible status and review this daily Monitor: Visible accountability, improved documentation with completion tasks Visible proactive discharge planning process – TTOs and Summary Strengthen Multidisciplinary Team Working with Clarity of responsibility better Co-ordinating Care

16 New Ward Day Plan 7.00 am: Observations am: Nurse handover and drug round 9am: Daily consultant ward round with NCHDs and bay nurse Daily Multidisciplinary Ward Meeting: Consultant led, bay nurse, NCHDs, therapy staff and social worker PM: Ward work procedures, paperwork, teaching & training, relatives

17 STANDARD WORK FOR WARD ROUNDS RESPIRATORY WARDS Performed by: Medical & Nursing staff Stage: Daily throughout patients stay 1Ward round will start at 9am each day. 2 Aims Identify and document the diagnosis Check appropriate treatment for severity of illness (Drug chart) Check response to treatment - check observations, EWS, fluid balance results Identify new issues / problems (medical, nursing or social) Check VTE prophylaxis assessment Working diagnosis / coding (real time) Identify DNAR, ceiling of treatment ( NIV) Patient information / education Update Discharge information & Social Work Log. 3Complete all documentations in clinical notes including a clear management plan 4 Review Drug prescription sheet with particular emphasis on: antibiotic prescription -consider transfer to oral antibiotic treatment on a daily basis. Please sign wardex to indicate review of i.v. antibiotics. Check Oxygen is prescribed and administered appropriately Review the need fluid balance, completing IV Fluid prescription if required 5Decide any actions or investigations required 6 Allocate tasks Nursing Junior medical staff – Investigations, results, re-write drug wardex 7Identify any issues for the board round, including notifying Social Worker to attend MDT for complex issues around identified patient. 8 Identify patients for Discharge Process TTOs for next day discharges should be completed between 12 noon and 2 pm Same day discharge TTOs to be completed on the ward round – if possible Discharge letter to be completed before patient leaves the ward 9INR to be completed at 6am on the day of discharge. 10 Weekend planning when appropriate IV antibiotics / Nebs / O2 / Warfarin / Drug charts Clarify NIV arrangements Fluids Request weekend bloods /Investigations and arrange results reviews Re-write wardex Discharges and TTOs when appropriate 11Complete Sustainment Graph Daily

18 Visual Management – ExtraMed Daily Update Admission date Original predicted discharge date Current predicted discharge date Status: on target/at risk/overdue/exempt Comment field – social issues section 2/5 awaiting

19 Room Patient Name

20 Actions from Rapid Improvement Event (RIE) Implementation Time Table May 2009 Board Round / MDT commence June - Respiratory Consultant daily ward round on 1 ward and MDT Review of process August 2009 September 2009 – Respiratory Consultant on both wards, new outpatients (OPD) system New Consultant Job Plans Consultant on each ward - weeks slots. Males or females on AMRU/HDU/ICU /consults 3 Consultants off wards - increased number of clinics, bronchoscopy lists Student teaching Continue medical on call rota, Respiratory NIV rota. Holidays / study leave when in OPD

21 Confirmed State 30, 60, 90 day Measures - underpinned by our 4 True Norths No Go Go Improved Health Bed Occupancy Best Possible Care Delays Joy and Pride Start / Finish on time Value for Money Planned vs Actual ab c d

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27 140 random patients reviewed March random Patients September 2012

28 Respiratory Nursing Team – 2009/10 High input into respiratory ward no longer necessary Focusing non respiratory areas supporting implementation of best practice Inequity among the patient groups Focusing input earlier in the patients journey Non-patient contact time handovers/travel Why change ?

29 Rapid Experiment – same resources Respiratory nurse specialist on wards 7 days Board round aiming for early respiratory review Fast track to most appropriate area Support non-respiratory areas Liaise with other specialist nurses Re-organisation of community working

30 Visual Management RNS Ward / Base Cell 6S 1 Piece Flow Standard work Pull Pre- 6S Score 12.5% Post Score 93 – 100% Agreed best way of working How visits are organised How are we doing at a glance? Where are staff located Clear standard work, for pulling specialist skills/ also pulling patients to the right ward (c) 2011 Royal Bolton Hospital NHS Foundation Trust. All rights reserved. This document may be copied for use in the NHS only on the condition that Royal Bolton Hospital NHS Foundation Trust is acknowledged as the copyright holder and originator of the work.

31 Home Visits

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34 Pneumonia mortality

35 Pneumonia RAMI- April 11- June 12

36 Patients seen by RNS (new way)

37 Respiratory team: lean journey with BICS 2006 Minor changes but sustainability issues 2009 Respiratory Inpatient Care 2010 Hospital and Community Respiratory Nursing Event 2012 Respiratory Outpatient Service

38 How can we provide the best cost effective MDT outpatient services? Outpatient Services – short waiting time (best). 100% 2 week rule target, 1:2 New to Follow up ratio Eliminate waits - Redesign current clinics Need full MDT Specialist clinics for some Chronic Diseases Introduce MDT specialty clinics for complex patients Comprehensive range of Clinics / Services. But some provided elsewhere – Sleep Care closer to home – income generation such as sleep services Demand & need for alternatives to admission and GP advice services Single point of contact for advice and/or slot in admission avoidance clinic

39 Respiratory Assessment Clinics 1.Community Team (Med/Nursing) 2. Hospital Team (Bleep 2000) 3. Self Referral (Agreed list) Referral Source Booking Choose & Book Clinic slots Respiratory Triage Advice Same day clinic Assessment Respiratory Assessment Clinic Urgent investigations Diagnosis Treatment Same day correspondence Outcome Discharge with treatment plan Discharge with H.A.H Services Admit Specialty Multi- disciplinary Team Follow-up Clinic

40 Current Community Working Disease Management Team Instant Access – October 2012 Better Community Working General Practitioner with Special Interest in Respiratory Disease Respiratory Clinics Supports Community Team Consultant liason Nursing Team: Community Matrons, Active Case Managers, District Nurses, Respiratory Nurses Pulmonary Rehabilitation Poor community uptake – need to broaden access Education Events on End of Life Care Gold Standard Framework Shorten Clinic waiting times: Routine referral 24-48hrs Exacerbations – same day review Immediate telephone advice 7 days for primary care Impact: Better Care 2-3 less A/E patients per day Paid Tariff between that of OPD and A/E rate Agreement in principle with Commissioners

41 Measure2009/102010/112011/12 LoS* Dr Foster CHKS 8.9 days 6.4 days 6.9 days 5.7 days 7.8 days 5.8 days Mortality (HSMR) RAMI Readmissions 9.5%8.5%8.2% ICU Escalation101pts64pts57 pts Home Visits (per month) Aug, 146 per month RNS Time to Care (patient facing time ) Hrs/wk 52.5

42 Respiratory Team Vision 1.Timely equitable inpatient access to Respiratory Services 2.Best cost-effective outpatient MDT services 3.Support primary care to provide equitable good quality respiratory care in community 4.Underpinning ethos of Best Possible Care for the Patient in the most appropriate setting

43 Thank you


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