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Delivering improvements

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Presentation on theme: "Delivering improvements"— Presentation transcript:

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

2 About Bolton Northern industrial town Population 270,000
12% ethnic minority population Bolton health survey epidemiology COPD % Chronic Bronchitis %, Chronic Cough % Wheezing 18.7% We are here!

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 Delivering Benefit Redesigning Care

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 Targets! All work very hard but don’t 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! 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
Minor changes but sustainability issues Respiratory Inpatient Care Hospital and Community Respiratory Nursing Event Respiratory Outpatient Service Opening Access and Community Facing

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

13 Rapid Improvement Event- April 2009
Core Group of Staff 4 Day Event! Nursing Staff Consultants + non consultant hospital doctors (NCHDs) Physiotherapy Occupational Therapy Pharmacy Social Workers External (to the process) 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 Nursing 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 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
7.30-9am: 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

RESPIRATORY WARDS Performed by: Medical & Nursing staff Stage: Daily throughout patients’ stay 1 Ward 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. 3 Complete 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 5 Decide any actions or investigations required 6 Allocate tasks Nursing Junior medical staff – Investigations, results, re-write drug wardex 7 Identify 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 9 INR 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 11 Complete 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)
New Consultant Job Plans 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 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 No Go Go a b Improved Health Bed Occupancy
Best Possible Care Delays Value for Money Planned vs Actual Joy and Pride Start / Finish on time c d 30, 60, 90 day Measures - underpinned by our 4 True Norths 21






27 140 random patients reviewed March 2010
50 random Patients September 2012

28 Respiratory Nursing Team – 2009/10
Why change ? 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 patient’s journey Non-patient contact time handovers/travel

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 RNS Ward / Base Cell Pull 6S Visual Management 1 Piece Flow
How visits are organised Agreed best way of working 1 Piece Flow Standard work Clear standard work, for pulling specialist skills/ also pulling patients to the right ward Pre- 6S Score 12.5% Post Score 93 – 100% Pull 6S How are we doing at a glance? Where are staff located Visual Management (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



34 Pneumonia mortality

35 Pneumonia RAMI- April 11- June 12

36 Patients seen by RNS (new way)

37 Respiratory team: lean journey with BICS
Minor changes but sustainability issues Respiratory Inpatient Care Hospital and Community Respiratory Nursing Event 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
Urgent investigations Diagnosis Treatment Same day correspondence 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 Outcome Discharge with treatment plan Discharge with H.A.H Services Admit Specialty Multi-disciplinary Team Follow-up Clinic

40 Better Community Working
, Better Community Working Instant Access – October 2012 Current Community Working Disease Management Team 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 days for primary care Impact: Better Care less A/E patients per day Paid Tariff between that of OPD and A/E rate Agreement in principle with Commissioners

41 9.5% 8.5% 8.2% Readmissions ICU Escalation 101pts 64pts 57 pts
Measure 2009/10 2010/11 2011/12 LoS* Dr Foster CHKS 8.9 days 6.4 days 6.9 days 5.7 days 7.8 days 5.8 days Mortality (HSMR) 119 91 79 RAMI Readmissions 9.5% 8.5% 8.2% ICU Escalation 101pts 64pts 57 pts Home Visits (per month) 38 58 92 Aug, 146 per month RNS Time to Care (patient facing time) 26.25 Hrs/wk 52.5

42 Respiratory Team Vision
Timely equitable inpatient access to Respiratory Services Best cost-effective outpatient 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

43 This would not have been possible without the hard work of all the staff supported by the tireless energy of Cindy Walton and the rest of the BICS team. Thank you

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