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Report Out Steve Bradbury Head of Service Improvement 23 April 2014.

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Presentation on theme: "Report Out Steve Bradbury Head of Service Improvement 23 April 2014."— Presentation transcript:

1 Report Out Steve Bradbury Head of Service Improvement 23 April 2014

2 Perfect Week There is no magic bullet;There is no magic bullet; capacity and flow achieved through attention to dealing with low-level operational issues, hour-by-hour.capacity and flow achieved through attention to dealing with low-level operational issues, hour-by-hour. scrutiny of processes and appropriate decision-making drove changes.scrutiny of processes and appropriate decision-making drove changes. DischargeDischarge Continue to drive creating capacity earlier in the day.Continue to drive creating capacity earlier in the day. Daily board-rounds were effective in the majority of cases.Daily board-rounds were effective in the majority of cases. Criteria/Nurse-led discharge has limited support.Criteria/Nurse-led discharge has limited support. Need to drive discipline of completing Merlin and TTOs day before identified patient due discharge to reduce delays.Need to drive discipline of completing Merlin and TTOs day before identified patient due discharge to reduce delays. Capacity created earlier if pts moved from AMU when ward beds available and not in batches.Capacity created earlier if pts moved from AMU when ward beds available and not in batches. Ambulatory model of discharge lounge is not what’s needed.Ambulatory model of discharge lounge is not what’s needed. Suggest find space with proper facilities.Suggest find space with proper facilities. Run a pilot for proof of concept.Run a pilot for proof of concept.

3 Perfect Week IT Support and use of InformationIT Support and use of Information Provision of agile iClip training and issue resolution from proved key success factor – highly recommend continuing this process.Provision of agile iClip training and issue resolution from proved key success factor – highly recommend continuing this process. Focus on bed-board & EDD accuracy made for better decision-making.Focus on bed-board & EDD accuracy made for better decision-making. More work required on producing a hospital view of the bed-board.More work required on producing a hospital view of the bed-board. Availability of Operational Leaders (eg GMs)Availability of Operational Leaders (eg GMs) Visible & available to deal with issues in their area (currently variable).Visible & available to deal with issues in their area (currently variable). More able to troubleshoot and resolve issues.More able to troubleshoot and resolve issues. Patients in Right PlacePatients in Right Place Swing beds (Vernon/Keate) moved early to surgery.Swing beds (Vernon/Keate) moved early to surgery. No of outliers reduced from 46 to 19.No of outliers reduced from 46 to 19. Escalation areas closed, with the exception of Amyand Annexe for cohorting of renal pts – need to review renal capacity/flow/pathway.Escalation areas closed, with the exception of Amyand Annexe for cohorting of renal pts – need to review renal capacity/flow/pathway. Re-run Perfect Week Quarterly (next 2-9 July 14).Re-run Perfect Week Quarterly (next 2-9 July 14). Also run ad hoc special issue weeks (Notes tracking – 1 May 14)Also run ad hoc special issue weeks (Notes tracking – 1 May 14)

4 Perfect Week Report Out Team Structure and Issues

5 Team Structure Bronze Team Team Leader - Service Improvement Team Leader - Service Improvement General Management General Management Clinical Lead – HoN, Consultant Clinical Lead – HoN, Consultant Operations/Site Management Operations/Site Management Senior IT Lead Senior IT Lead Information/Data Capture Information/Data Capture Communications Communications Mirrored in roaming Team

6 Methodology Escalation Issues The time frames for escalation were agreed to be :The time frames for escalation were agreed to be : –2 hrs. for Bronze Team –1 hr. for Silver –1 hr. for Gold All issues were accepted- except staffingAll issues were accepted- except staffing Every shift, there was a Team Leader for the bronze who would coordinate the escalation of issues.Every shift, there was a Team Leader for the bronze who would coordinate the escalation of issues. There were agreed meetings each day with updates and communication updates.There were agreed meetings each day with updates and communication updates. There was a bleep communication pathway set up with a Bat Phone.There was a bleep communication pathway set up with a Bat Phone.

7 Gold Clinical2 delayed discharge1 medic review1 repatriation3 Theatres1 Grand Total8 Silver repatriation11 capacity7 Theatres2 (blank)2 non-clinical2 Clinical1 diagnostics1 social servcies1 delayed discharge1 transport1 other1 Diagnostic1 Notes1 Grand Total32 CategoryBronze ICLiP68 Theatres37 Facilities32 transport23 medic review19 capacity14 non-clinical14 staffing14 IT11 diagnostics11 IT Hardware11 Clinical10 IT Software9 TTOs8 Diagnostic6 Social Services6 Notes6 GOLD TEAM SILVER TEAM BRONZE TEAM Issues Escalated Total IssuesClosedOpenPendingblank Grand Total Gold3148 Silver Bronze Roaming66 (blank)246 Grand Total Key Themes iClip training. Theatres. Notes tracking. Repatriations. Discharge Lounge. Transportation.

8 Date entered on LogTotal 26/03/ /03/ /03/ /03/ /03/ /03/ /04/ /04/ Grand Total389 Reported byRole Manager Medical StaffNursingOtherWLO(blank)Grand Total Total ISSUES BY DAY ISSUE REPORTED BY DivisionGrand Total Med Card104 Surgery83 IT60 transport12 (blank)8 Neuro8 CSW7 estates7 Support services6 ISSUES BY DIVISION ClinicalNon Clinical(blank)Grand Total Total CLINICAL v NON CLINICAL Issues Escalated (Cont..)

9 Perfect Week Report Out Liaison Officers

10 Perfect Week: Data Management What went well? Overall, nursing staff were approachable and easy to talk to LO’s were treated with kindness and clinical staff were willing to help LO’s were treated positively even though some staff said they were “too busy” Working in Theatres was fun as LO’s were treated as part of the team and got to dress up in scrubs Data collection sheets were easy to use Briefings and information packs were useful Working in the same area allowed LO’s to form a relationship with the staff which made fulfilling the role easier

11 Perfect Week: Data Management What to do differently? Deliver the message that LO’s are helpers Earn the trust of clinical staff from the outset Allocate areas beforehand and introduce LO’s to Ward Managers before their shift Early communication and engagement of the Perfect Week for clinical manager/staff Allow more time for LO’s to spend time on the same wards Provide more notice for students and note that they do not read s Involve St George’s University staff

12 Perfect Week: Data Management Recommendations for next time Briefing sessions (07.30/15.00) should focus on a handover of issues between the AM and PM LO’s Revise the data collections sheets LO’s should spend the entire shift in one area Champion how the LO roles work and what the staff get from their input/contribution Engage managers and clinical staff before the actual week Capitalise on Bio-medical students as a resource Provide scenarios and examples of when to escalate issues to the Bronze team

13 1.More communication briefings re: Perfect Week and raise awareness 2.Revise data collection sheets and the language used 3.Better ICLIP training for staff who need to provide the data 4.Clearer LO job descriptions for the LO roles 5.Remove the data collection time as this is protected meal time 6.Allocation of shift and clinical areas before the weeks starts Perfect Week: Data Management Priorities

14 Perfect Week Report Out Discharge Lounge

15 The Discharge Lounge The Discharge Lounge opened as a ‘pilot’ during perfect week. The aims of the Discharge Lounge were to: Enhance the quality of the patient journey Free up inpatient beds as early as possible Assist the Trust in meeting key performance targets: – 25% of discharges by 10am – 50% of discharges by 12noon – 75% of discharges by 2pm – 100% of discharges by 4pm Which patients could use the Discharge Lounge? The Discharge Lounge could take any ambulatory adult patient from any part of the hospital. Which patients couldn’t use the Discharge Lounge?  Patients that need to be in a bed  Patients who require on-going nursing prior to discharge  Patients who are incontinent

16 Number of Patients Seen in the Discharge Lounge

17 Which Wards Transferred to the Discharge Lounge? WardTotal Transfers to D/c Lounge Richmond7 Gray5 Gunning5 Caesar Hawkins4 Amyand3 Belgrave2 Keate2 Kent2 Marnham2 Vernon2 Cavell1 Clinical Decisions Unit1 CSU1 Florence1 Holsworth1 McKissock1 Neuro ITU1 Grand Total41

18 Reasons Why Patients Went to the Discharge Lounge

19 Next Steps Agreement to develop discharge lounge facility: Agreement to develop discharge lounge facility: – Need to finalise the model, we want to open access up to other groups of patients, e.g. stretcher patients – Looking at identifying suitable space within the hospital – Develop a permanent team and consider how to embed in the running of the hospital- driving earlier planned discharges Timescales tbc

20 Perfect Week Report Out Discharge Process

21 Support, Confirm and Challenge Sessions Senior Health & Medical Wards Senior Health & Medical Wards Identify No’s MFFD patients and expected discharges Identify No’s MFFD patients and expected discharges Escalate issues for action to Bronze Team Escalate issues for action to Bronze Team Training session from HSCIC for E referrals Training session from HSCIC for E referrals

22 Reasons for Delay

23 Observations EDD is not used consistently EDD is not used consistently Dalby & Heberden reported consistently Dalby & Heberden reported consistently Nurses on wards not currently managing discharge process Nurses on wards not currently managing discharge process No central phone directory for numbers/inforamtion on discharge No central phone directory for numbers/inforamtion on discharge Noticeable lack of coordination if Discharge Coordinator absent from the ward Noticeable lack of coordination if Discharge Coordinator absent from the ward

24 Next Steps Medical Wards Medical Wards – Band 7’s and Dsg Coordinators tasked with training all nurses in simple discharge (by end of May) – 1 nurse on each ward to be trained by Dsg Coordinator in complex discharges (target is to have worked on 5 complex discharges within 3 months May-August) Senior Health exploring model of having more than 1 Dsg Coordinator on the wards Senior Health exploring model of having more than 1 Dsg Coordinator on the wards

25 Next Steps Update Intranet Page Update Intranet Page – Discharge Paperwork (HNA/DST) – Borough specific inforamtion – Telephone directory Daily Walk around/Escalation by AGM and Service Manager Daily Walk around/Escalation by AGM and Service Manager

26 Perfect Week Report Out Site Management

27 Observations from Perfect week The Bronze team picked up many of the issues that would have been escalated to the site team Useful for the team to have overview of the live data from ED Good response from divisions when additional medical support was required in ED Repatriations highlighted as a problem Bed board on iclip not reliable Discharge lounge did not release many beds earlier in the day Even though we showed having empty beds these were often not available when they were required (ie too late in the day) Discharges on the whole occurred after 2pm Access to designated managers in the Bronze team was very effective

28 What could we do differently? A Light version of the Bronze team as BAU Cross divisional senior patient flow coordinator in ED between 4pm and 10 pm Clinician to challenge discharge times creating more capacity earlier in the day Discharge lounge that is more suitable to a wider range of patients Rapid response process for specialty Drs to attend ED when volumes high Web based repatriation list to increase visibility between hospitals Regular patient census to cleanse iclip bed board Ensure all wards identify at least 1 patient to be discharged at 10 am Identify medical and nursing staff to take part in next perfect week within the next week Review the data to be collected by the WLOs to ensure this is consistent and meaningful Introduce as many initiatives as possible before the next perfect week

29 Perfect Week Report Out Information and data

30  Pulse check – how accurate and up-to-date is our existing data?  Compare iClip data to ‘real time’ activity from the WLOs Perfect Week: Data Management Outcomes and Success Measures

31 Dashboard Data Capture Data collected from iClip and TheatreMan 130 Ward/Theatre Liaison Officers employed 2 Shifts Gathering data and escalating issues Information Department developed dashboard:

32 Perfect Week: Data Management iCLIP vs WLOs example

33 Perfect Week: Data Management What went well?  Lots of data collection forms were completed.  Excel templates worked well with people keying the data adapting well – hardly any breakages to fix.  Collection into the Central store worked well – one repository for each type of questionnaire.  Heat maps on Tableau were very visual and clear.

34 Perfect Week: Data Management Recommendations for next time 1.Better preparation: - Trial of the data collection tool/process - Engage stakeholders in advance 2.Keep template simple/avoid scope for variation in the answers 3.Be clear on the purpose of the questions (link back to measures and metrics) 4.Go paperless/real time entry if possible 5.Ask the right questions 6.Separate issues for escalation 7.Regular feedback to WLOs

35 Perfect Week Report Out IT

36  Staff should maintain the iCLIP Estimated Date of Discharge in real time Perfect Week: IT Outcomes and Success Measures

37 Perfect Week: IT What went well?  The availability of iCLIP trainers to provide ‘on the job’ training for iCLIP users.  The availability of IT support staff 8-10 to resolve urgent technical issues.  The availability of a senior IT manager to man the Bronze team command centre

38 Perfect Week: IT Recommendations for next time 1.Consideration of planned Perfect Week initiatives and their impact on training needs, to provide training ahead of the week. 2.IT is looking to an extended trial of 7-10pm IT support to cover: 1.Smart Card Issue. 2.Locum Training. 3.Night shift general iCLIP training. 4.First line IT fixes. 3.Continued presence of Senior IT management

39 Perfect Week Report Out Theatres

40 Objectives Understand barriers to productivity Reduce late starts Reduce turnaround time Reduce bottleneck in recovery

41 Findings - Performance

42

43 Modest increase in utilisation – not significant Modest reduction in late starts Significant increase in turnaround time Significant reduction in early finishes - unexpected

44 Findings - Performance Anomalies with Theatreman data – sessions missing Does not match observed results (but incomplete) Does not match anecdotal feedback Further analysis required Review at knowledge transfer session

45 Findings - Issues Ward capacity Note availability Communication Live entry of data Availability of staff Mixed adults & paeds lists

46 Next Steps Knowledge transfer session – Review data capture issues Continuous Improvement Workstream – Robust processes to: Identify & quantify issues Resolve or escalate to appropriate management level Note Tracking Workstream Prepare for Perfect Week 2

47 Perfect Week Report Out Communications

48 Communications: Looking back What went well? Strong, recognisable brand identity Daily updates during the Perfect Week Intranet resource What to do differently? All-staff s Posters and leaflets Greater focus on clinical staff

49 Communications: Looking forward Solutions 3 months rather than 3 weeks 3 months rather than 3 weeks Planned campaign rather than ‘spray and pray’ approach Planned campaign rather than ‘spray and pray’ approach Ward Walking Ward WalkingPriorities Get buy-in from clinical staff Get buy-in from clinical staff Liaison Officer recruitment Liaison Officer recruitment

50 Perfect Week Report Out Patient Observer Feedback

51 WHAT WORKED WELL saw how staff communicate, work as a team and interact with other departments. gained a clearer idea of how the management and hospital systems work - or, sometimes, don't. are better informed for their departmental and committee roles. could contribute comments from a patient viewpoint. were invited to handover and escalation sessions. were asked to contribute to 'wash up' reporting meetings. Patient Representative Observers (Pt reps)

52 WHAT COULD BE IMPROVED more defined time requirements. Perhaps manageable slots could be listed so Pt reps could choose what suited them best. clearer role outlines. Responsibilities and contributions need more definition. it is important to realise that 'the devil is in the detail' so the richness of the data should be 'captured'. Sometimes feedback in our opinion seemed to lack this. CONCLUSION Pt reps were delighted to be involved in such an ambitious project as The Perfect Week and we believe it is essential that Pt reps on behalf of patients in the Trust, continue to be included in the project as it evolves. Leslie Robertson Patient Ambassador TIP; Charlotte Ennis and Jasmine Taylor Patient Representatives. April 2014 Patient Representative Observers (Pt reps)

53 Perfect Week Report Out Next Steps

54 Turn the lessons learned into improvement programme projects or action plans. We are running a Notes Tracking week, and notes amnesty. Agreed the next Perfect Week dates for the 2 nd – 9 th July Continue to implement the Discharge Processes. TTOs & Merlins to be completed day before discharge. Set up a permanent Discharge Lounge. Continue with an IT Support roaming team to operate between 7am-10pm. Implement a scaled-down ‘Bronze Command’ for BAU. Create a ward-based set of escalation processes. ED are implementing a Senior Patient Flow Co-ordinator function. Continue data capture and development of operationally focussed dashboard. Reduce the number of meetings and s for clinical staff/GMs.


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