Ward Processes April 2015 Dr Rachel Bradley & Caroline Daley Ward Processes Work Stream

Ward Processes Part of Transforming Care Program To enable all ward staff to improve quality of care Improve patient flow & discharge Right Patient, Right Place, Right Time (R3) Reduced length of stay

Aims of Ward Processes Improved patient experience Improve communication between members of the Multidisciplinary Team, patients & carers Prioritisation of workload to address safety & flow Sick, potential early discharges & new patients Proactive approach towards discharge planning Identify barriers Implement actions & escalation Earlier in the day discharges & use of the Discharge Lounge Increase number of criteria led & weekend discharges Based on LEAN methodology

Benefits Improve patient safety & experience Increase throughput & reduced length of stay Improve Trust 4 hour target performance & trolley waits Reduce outliers Reduce elective surgical cancellations Improved job satisfaction – efficient & effective team working Patient status at a glance at ward, division and trust level Improved resource allocation

Reverse Triage & EDD Ward Processes Goal : To improve earlier in the day discharge to Improve Patient Flow Real-Time Medway Effective Board & Ward Rounds TTA’s & Discharge Summaries Criteria Led Discharges eHandover Weekend Plans Reverse Triage & EDD

Estimated Date of Discharge: Definition Estimated Date of Discharge (EDD) is the expected date a patient recovers from their acute illness and inpatient therapy needs EDD may not represent the actual date of discharge but is the ‘best guess’ if all the discharge processes flow smoothly It should include two working days for social services to complete their assessments It should include time spent at SBCH but NOT other hospitals, interim care homes or rehabilitation settings The term EDD should be used rather than PDD Ward Processes

Estimated Date of Discharge: Guidance A provisional EDD should be considered on admission, then updated and set by the multidisciplinary team (MDT) within 48 hours The EDD must be recorded on: The patient status (‘white’) board on the ward Medway - it will automatically populate the EDD on the e-Handover sheet and the trust operational reports Progress towards achieving EDD should be monitored at the daily board (ward) round reviews This should be done in conjunction with the Reverse Triage Status Any blockages to flow must be escalated to senior staff EDD should be used to engage the patient and relatives in proactive discharge planning Changes to EDD should be minimal Aim to set a realistic achievable date in the first place Where a change is required, (due to new information or a change in the patient’s clinical condition), this must be agreed at the daily board (ward) rounds All changes or reasons for delays must be clearly recorded in the comments box on Medway Ward Processes

Terminology used on Board/Ward Rounds It is important to that the whole MDT communicates using the same terminology when discussing patient status and EDD The statements are relevant to different Reverse Triage Stages Terminology used at Board/Ward Rounds Comments on Reverse Triage Status Medically Fit (or optimised) for discharge patients are no longer Red or Amber Surgically Fit for discharge Therapy Fit for discharge patients are not light green Team Fit – refers the UHB ward team patients may be dark green if still awaiting partner agency support Ward Processes

Reverse Triage & EDD Ward Processes Goal : To improve earlier in the day discharge to Improve Patient Flow Real-Time Medway Effective Board & Ward Rounds TTA’s & Discharge Summaries Criteria Led Discharges eHandover Weekend Plans Reverse Triage & EDD

Reverse Triage Status & EDD Reverse Triage Status must be used to refine a more accurate Estimated date of Discharge ‘Green to Go’ Ward Processes

The Purpose of Reverse Triage Ward Processes

Reverse Triage Ward Processes Work Stream

Reverse Triage Operational Reporting Ward status at a glance visible at Divisional & Trust level Useful for trust bed management - especially in escalation Clinical Site Managers Hospital Discharge Team Discharge lounge Prioritisation of resource Diagnostics & Therapy Social services CDCC

Reverse Triage & EDD Ward Processes Goal : To improve earlier in the day discharge to Improve Patient Flow Real-Time Medway Effective Board & Ward Rounds TTA’s & Discharge Summaries Criteria Led Discharges eHandover Weekend Plans Reverse Triage & EDD

Effective Board & Ward Rounds Achieve better results and improve patient flow Reverse Triage & EDD must be done in combination with an effective Board (and Ward) Round Ward Processes

RCP Effective Board Rounds Ward Processes

Effective Board Rounds Location Ideally in front of White Board. Why? MDT focus all in one place Patient status at a glance Allows real-time update of information on white board Top Tip: Open eHandover on computer and allocate someone to update this real-time during the board round Key members/representatives of the ward multidisciplinary team should be present This should include a senior doctor & nursing staff, therapists, member of Hospital Discharge Team and Social Worker Timings Always Start on time – don’t wait for late comers Duration <1.5 min per patient Approximately 15-30mins for 18 patients Information Nursing and medical staff must know their patients Use eHandover as a means of joint MDT communication & update regularly Discuss each patients key issues: Current main medical or surgical problems Social background Current functional ability on the ward Rehabilitation potential and agreed goals Potential care needs EDD Barriers to discharge/flow Actions to address these Ward Processes

Effective Board Rounds Documentation Key issues and clear action plans for each patient should be documented This can be done in the medical records (gold standard) and/or on ehandover Update Reverse Triage status and EDD on ehandover asap as this is used for operational reporting Mini Board Rounds These can occur later in the day, noon & 3-4pm Usually <15mins Ward doctor and nursing staff minimum Useful to update and clarify decisions from ward rounds, identify potential transfers off the ward or prepare discharges for the next morning Leadership The best Board Rounds occur with good clear leadership A designated leader should: Ensure that the BR keeps to time and the key issues covered Highlight barriers to discharge Agree action plans to tackle these Identifies patients for transfer off ward or NOT to transfer and remain on speciality ward It is useful to summarise the priority tasks at the end Ward round to review sick patients 1st , then potential early discharges and new patients Examples of tasks; urgent TTOs, escalation of an outstanding investigation, complete section 2 or CM7, priority physio review Note: Board Rounds ensure better communication, patient safety and flow Board rounds also provide an opportunity for a Safety Brief, update on key ward issues etc. One size may not fit all across the trust Ward Processes

Reverse Triage & EDD Ward Processes Goal : To improve earlier in the day discharge to Improve Patient Flow Real-Time Medway Effective Board & Ward Rounds TTA’s & Discharge Summaries Criteria Led Discharges eHandover Weekend Plans Reverse Triage & EDD

Timely TTOS & Discharge Summaries Reverse Triage & EDD should predict which patients require TTOs & D/Cs Effective Board/Ward Rounds ensure that a proactive decision are made to prepare TTOs & D/Cs in advance of the EDD These must be completed before patients are able to transfer to the Discharge Lounge Dossette Boxes require 24hours notice ALL Medically/Surgically Fit patients, Light/Dark GREEN or ?HOME<24hrs Reverse Triage Status should have completed TTOs and D/Cs Minor adjustments can be made nearer the EDD Update D/Cs & TTO status on eHandover

Reverse Triage & EDD Ward Processes Goal : To improve earlier in the day discharge to Improve Patient Flow Real-Time Medway Effective Board & Ward Rounds TTA’s & Discharge Summaries Criteria Led Discharges eHandover Weekend Plans Reverse Triage & EDD

Criteria Led Discharge CLD & Weekend Plans Some patients may be suitable for Criteria Led Discharge Examples include if post transfusion Hb >8, after Echo, if manages stairs practice with physio Use the © magnet on the patient status at a glance ‘white’ board Update CLD status on eHandover Weekend Management Plan Sticker placed in Medical Notes Friday afternoon Useful summary of key issues Escalation plans Highlights potential Weekend & CLD patients

Ward Processes Project Work 2013-2014 Criteria Led Discharge CLD CLD under utilised at weekends Should include Nurse Led Discharges & DC to Care Homes (supported by Brisdoc GP weekend reviews) Medicine Division Little scope to improve CLD Mon-Friday on wards in new model of care Applied to some Day Cases such as Endoscopy Surgical Division Some application already exists in Enhanced Recovery Pathways Further potential in Day Cases & Elective Admissions Specialised Services Lots of potential in cardiology Particularly in ACS, STEMI, NSTEMI pathways

GP Weekend Reviews r Would your patient benefit from a GP weekend review to support their discharge at the weekend?

To improve earlier in the day discharge to Improve Patient Flow Ward Processes Goal : To improve earlier in the day discharge to Improve Patient Flow Real-Time Medway Effective Board & Ward Rounds TTA’s & Discharge Summaries Criteria Led Discharges eHandover Weekend Plans Reverse Triage & EDD

Real Time Medway Target to update <15mins on admission & discharge from Wards Supports eHandover, bed management & reports Reduces ED trolley waits as identifies availability of beds for admissions Ensures correct patient location and consultant is recorded real time More efficient Ward Rounds Assist in better outlier management by site managers and clinical teams Improves patient safety

Real Time Medway

To improve earlier in the day discharge to Improve Patient Flow Ward Processes Goal : To improve earlier in the day discharge to Improve Patient Flow Real-Time Medway Effective Board & Ward Rounds TTA’s & Discharge Summaries Criteria Led Discharges eHandover Weekend Plans Reverse Triage & EDD

E-Handover What is it? Why should we use it? How do I access it? Electronic handover system used by ward multidisciplinary team Separate Nursing & Medical print versions available This should replace separate patient lists Why should we use it? Improves communication at ward level between all members of the multidisciplinary team Improves efficiency - avoids duplication as auto populates patient details Links to eLogger used for Complex Discharges - Used by ward staff, Hospital DC Team, CDCC & Social Services Links to Reverse Triage Operational Report How do I access it? ‘Top 10’ list on the right hand side of the trust homepage Avon Portal account username and password Patient information needs to be updated electronically by all members of ward team

Ward Processes Make a Difference ? Does Embedding Ward Processes Make a Difference ?

Background Reverse Triage Ward Processes One of seven Trust wide Patient Flow Projects (phase 1) February -September 2013 Ward Processes A phase 2 Patient Flow project building on RT phase 1 and broadening the remit to include several key ward processes October 2013 – June 2014 Breaking The Cycle Together (BTCT) Ward processes underpins many components of the Breaking The Cycle Together Project and SAFER Bundles May 2014

Patient Flow Project Projects in programme – Phase II An additional 7 projects have been prioritised for phase II of the patient flow programme. The project teams are in the process of mobilising the individual projects. Each project will be run in line with the project methodology and will be overseen by the R3 : Patient Flow Project Steering Group. Whilst a number of these projects focus on internal improvements in our patient flow, there is a higher proportion of projects that focus on improvements with partner organisations in the second phase. Project Objectives 1. Ambulatory care Maximise the use of ambulatory care pathways for ambulatory care conditions to reduce emergency admissions 2.Ward Processes – Including Reverse Triage, eHandover Criteria Led discharge, TTA’s & Discharge Summaries Proactive approach to discharge planning Increase in number of patients discharged before midday Increase TTAs and discharge summaries prepared day before discharge Increase number of discharges at weekend 3. ITU - pathways Reduced the number of patients transferred to wards out of hours Reduce the number of Elective operation cancellations due to ITU availability Tertiary referrals are repatriated to referring location within agreed timeframes 4. Care homes 7 day transfers to care homes Improved timeliness from referral to transfer to care homes (including assessment 5. Improved work with partners Improve information sharing and joint working to smooth pathways for patients across partner organisations Reduce the amount of time patients are delayed in an acute hospital setting 6. Out of hospital care Better utilisation of community beds available for rehabilitation Clarify the care needs of beds to support patients discharged from hospital into community beds 7. MAU Ensure specialty ownership of management of patients within MAU Early supported discharge from MAU either via outpatients or Ambulatory Care.

Embedding Ward Processes Ward Processes Pilot work in 2013 Medical wards – more embedded especially EAU & care of the elderly Upper GI Surgery – variable results T&O wards – ongoing focussed work becoming embedded Cardiology – excellent results in pilot but not sustained Children Hospital – successful RT pilot in admissions Lots of Communications to all staff members Change happens gradually and often over several steps Divisional & Trust support Operational plans Link to SAFER bundles & breaking the Cycle together

Embedding Ward Processes Ward Processes have been embedded into the EAU/OPAU models of care MDT working as standard Gold standard Board Rounds Prioritisation on Ward Rounds – sick, potential discharges then new patients New OPAU opened Nov 2014 Average length of stay in Care of the Elderly has fallen from 10 in 2013 to <4 days in 2015 Positive feedback from ward staff Ward Processes Pilot work in Children’s Hospital Admission Unit 2013 Increased number of discharges seen Increased number of discharges earlier in the day Positive staff feedback Ward Processes becoming embedded in new T&O Wards 2014 New Ward 602 & 604 opened Sept 2014 Increased bed base & direct admissions Full MDT Board Rounds since November 2014

Ward Processes Project Work 2013 Focussed Ward Processes work on Elderly Admissions Unit (EAU) & Care of the Elderly (COE) wards Cardiology wards 51&53 Ward Process work on EAU & COE wards Focused Ward Process work on wards 51 & 53 New Discharge Lounge Opened New Discharge Lounge Opened

BCH Reverse Triage Pilot Oct 2013 Discharges Before Midday

Staff Feedback Regarding Reverse Triage, White Board Pilot on Paediatric Admission Unit Jan 2014 Q How would you rate Reverse Triage as a tool to assist with discharge planning ? 0 Excellent 11 Good 8 Fair 0 Poor Reasons stated below:

Trauma & Orthopaedic Length of Stay Full daily MDT Board Rounds part of new T&O ward model of care 30 bedded ward 14 now 2 wards 602 & 604 Small expansion in bed base permitting more direct admissions New T&O Wards 602 & 604 opened Full MDT Daily Board Rounds

Ward Processes, S.A.F.E.R. and Breaking The Cycle Together Ward Processes underpins the S.A.F.E.R. quality standards The S.A.F.E.R. bundles formed part of the 2014 Breaking the Cycle Together Exercise

FLOW at UHB Problems with FLOW was identified as the number one issue for UHB to address following the 2014 CQC inspection Feb 2015 Poster Campaign

Use of the Discharge Lounge Open Monday to Friday 08:30 – 20:00 8 reclining chairs 24 Chairs – some pressure relieving chairs Hot food available end of April Pharmacist on site

Voluntary Services – Home from Hospital Support Home From Hospital Service Launched on 1st April 2015 Collaboration between RVS and RedCross & UHB Identify patients at Board/Ward Round who would benefit from this support – Integrated Discharge Hub (IDH) team member will make referral

Medicine: 2013 to Current Performance Data % of Total DCs <12pm Ward Process work on EAU & COE wards Matrons Pilot ‘3 at 3’ embedding Ward Processes New MAU & OPAU models of Care New Discharge Lounge Opened

Surgery 2013 to Current Performance Data New Surgical wards & model of care New Discharge Lounge Opened

Cardiology & Cardiac Surgery BHI 2013 to Current Performance Data Focussed work on promoting DC Lounge Focused Ward Process work on wards 51 & 53 New Discharge Lounge Opened

BRI & BHI 2013 to Current Performance Data

Change Management Some initiatives can show improvements in the short term However, in order to provide quality improvements that lasts improvement processes must be: Embedded at ward level Supported at Divisional & Executive levels Important to audit performance and feedback outcome measures to all staff Particularly positive feedback

Ward Performance Book Total Discharges before 10 Total Discharges to the Discharge Lounge before 10:00 Total Discharges to the Discharge Lounge before 12:00

Medicine Ward KPI’s

Summary

Aims of Ward Processes Improved patient experience Improve communication between members of the Multidisciplinary Team, patients & carers Prioritisation of workload to address safety & flow Sick, potential early discharges & new patients Proactive approach towards discharge planning Identify barriers Implement actions & escalation Earlier in the day discharges & use of the Discharge Lounge Increase number of criteria led & weekend discharges Based on LEAN methodology

Conclusion There is no single component that improves Flow A combination of different improvement processes can increase efficiency and effectiveness Different wards have different strengths and weaknesses It is important for the ward team to identify the key challenges in need of improvement A toolkit of Ward Processes available Key outcome measures

Any Questions? Any Questions?

For further info email: Rachel.Bradley@UHBristol.nhs.uk