in Acute Care Collaborative Evaluation Older People in Acute Care Collaborative Evaluation Pat O’Connor, Clinical Director R&D, NHS Tayside

Scotland’s Pop. 5.1 million 14 health Boards 150,000 staff Orkney Shetland Western Isles And 7 Special Boards NHS24 NHS Education Scotland NHS Health Scotland NHS Healthcare Improvement Scotland Scottish Ambulance Service State Hospital National Waiting Times Unit Highland Grampian Tayside Fife Greater Glasgow Clyde Forth Valley Lothian Lanarkshire Borders Dumfries & Galloway Ayrshire & Arran

Challenges Increase in the elderly population NHS Tayside 60-70% of inpatients are over 65 Acute hospital care not set up or designed specifically for the elderly Poor experience data older people and their carers of hospital care Patient population: 60-70% over 65 years 50% over 75 years 15-20% over 85 years

Aim To improve the experience of older people in acute care through the delivery of a person centred approach by November 2013 Goals: 95% of patient satisfaction scores are excellent 300 days between formal complaints 95% of appropriate patients receive a standardised screening

Public Mrs V died aged 80 in hospital on December 2008. Following her death an independent doctor (psychiatrist) raised concerns regarding aspects of Mrs V's care with the Mental Welfare Commission, in particular, her lack of nutrition during a sustained period.

Government Level Improving the assessment of people who might have dementia who are admitted to hospital; Improving patient information systems Patient centred -about the person, including their likes, dislikes and routines; Reducing unnecessary admissions of people with dementia; facilitating timely discharge; Better assessment, treatment and management in hospital of frail elderly people Improving access to telecare, intermediate care services and re-ablement.

IHI Breakthrough Series Participants (14 Teams) Select Topic (Develop Mission) Prework P S A D P S A D P S A D Develop Framework & Changes Expert Meeting LS 1 June 2012 LS 2 January 2013 LS 3 May 2013 LS4 December 2013 Holding the Gains Planning Group Photo 1 – master class for opac planning group with improvement methodology LS1 – Mr potatoe head –stracathro LS2 – pitoddrie – top and bottom – snow, had visitor from oz, who skyped in LS3 – westpark doing the chinese whispers and bottom LS4 – how do we hold the gains and keep doing the great work we have been doing. Fireworks here to celebrate AP1 AP2 AP3 4 4 4

NHS Tayside/NHS Grampian Older People In Acute Care Collaborative Aim Screening tool Reliable comprehensive assessment: Medical health (e.g. medicine reconciliation) Functioning Psychological Social function Risk identification Person centred assessment & plan of care by the multidisciplinary team To improve the experience of older people in acute care through the delivery of a person centred approach by November 2013 Goals: 1. 95% of patient satisfaction scores are > 4 2. 300 days between formal Complaints 3. 95%patients receive a standardised screening Increase family and carer involvement in care Review revise environment of care Optimise use of volunteer services Delivery of patient family centred care Promote open communication among MDT, patients, carers and families Optimise efficiency in handoffs and discharge process Promote use of patient, family, carer feedback to improve care Equip staff with the appropriate knowledge and skills to care for patients with dementia Collaborative multidisciplinary team and person centred Culture Develop infrastructure to support teams QI work Provide oversight of collaborative align position collaborative with wider organisational agenda Develop infrastructure to work in partnership with teams across NHS Tayside and NHSGrampian Leadership framework to support improvement progress

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Collaborative Model Leadership group Medical Director Nurse Director CEO Senior Manager Ward Team lead Patient and carer Medical Nursing Pharmacy Support services Porters Volunteers Dedicated locally developed change package of interventions

Evaluation Aim To critically evaluate the of the implementation of the older peoples collaborative in NHS Tayside Mixed methods case study Analysis of design and implementation plans and arrangements -: local structure, minutes, actions and, reflective diaries Participation and observation in learning sets Focus group and semi structured interviews with Tayside attendees of learning sets (n= 70) Analysis of measurement data recorded by frontline staff

Research Questions Is the programme or intervention in place reaching the people as intended? What are the challenges to implementing the programme? What appears to be working so far? How satisfied are people with the delivery of the intervention services? What do they like most, and what are they concerned about? Cost and value considerations? Leaders and mainstream managers views of OPAC?

Evaluation Being present, and seeing staff in action Conducting the interviews with the teams Listening to contributions that people were able and willing to make in terms of their work and responsibilities Hearing the openness with which people spoke about their work and the Older People and thier families in their care Learning about some of the examples/innovations developed in response to OPAC

Staff Interviews “Something about this method(PDSA and collaboration for learning) that works” “Better communication” “Improved environment” Large clocks coloured doors picture signs toilet etc “Improved handover” “Faster and more complete patient assessments for our most vulnerable patients” “We’re making it better form the inside out”

Enhancing Care Cutting meal distribution down from 1½ hours to 12 minutes Weighing Older Persons on admission then settling them into bed rather than vice versa Domestic and Auxiliary Staffs’ role in risk assesment and safety briefing assisting Older Persons’ hydration and in pre-meal hand washing Increased use of “This is Me” and Butterfly Scheme

The Butterfly Scheme reaching out to people with dementia

Planned Date of Discharge (PDD) Safety / patient info boards

OPACC – Ward Information Board

AMU Percentage of patients screened using a standardised screening tool Poster highlighting importance of screening for patients > 75 years of age on wall. Education for nursing staff by by Senior Charge Nurse and Nurse Consultant New nursing staff.

Arbroath-% of patients who have received an initial screening for a SAM assessment Embedded in clerk in document Results shared with nursing staff so more on board review of form Testing 1-3-5 patients introduced screening form for self admin of medications Team joins OPAC and starts testing

MDT-Staff Involvement in Safety Briefs Taped handover introduced including safety brief Domestic support symbols introduced for safety brief Whiteboard-symbols introduced Weekly This illustrates the involvement of a variety of staff groups within the safety briefings also captured each week since July 2013. At the commencement the team were hoping all staff would be involved in safety briefs but there were difficulties with everyone being available at the same time, For example the AHPs –OTs and physiotherapists did not participate as this was difficult due to the geographical areas they cover across Angus. The ward tested and implemented a taped handover with safety brief at the start which can be listened to by the physios and Ots. Nursing staff also listen to this at the handover. It was also recognised that information on the white boards did not always relate to safety issues and the list not always updated. The introduction of magnetic symbols on the whiteboards has made it much quicker and easier for MDT members to understand information on the board. The domestic staff also the safety board and have devised symbols transferring the symbols onto the board in the domestic support room to ensure support staff are also aware of safety issues within the ward. This is held twice a day.

5 Wards are more than 300 days since their last complaint, one achieving > 500. All show improvement.

Staff Feedback “it’s brought back some of the personal elements” “[it allows us] to take action rather than create action plans” “it provides an opportunity for deep reflection” “support has been phenomenal” “enjoying patient interaction” “the [Ward] is relentlessly busy and…it’s difficult to step back and consider BUT the collaborative has provided a structure for reflection on quality” “[we have] more sense of worth [as] part of the team” “[we’re] seeing barriers breaking down” “we can incorporate each other’s ideas” “it’s infectious!”

How much did it cost? Staff member Cost Consultant £410.92 Pharmacist £195.88 Senior Charge Nurse £164.17 Physiotherapist £137.08 Staff Nurse £109.37 Nursing Assistant £71.60 Porter Domestic £65.95 Local collaborative accommodation for learning sets Staff time out cost per day Additional funding for local environment and signage improvements £35K Evaluation £10K

Conclusions Some evidence of improvement in all participating wards High level of patient experience scores in participating ward areas Sense of purpose and team vitality for participating staff groups Action oriented programme of work Real ‘can do’ attitude for change and improvement

Conclusions cont. Understanding of the programme and collaborative goals not widely understood senior leadership. Sustained change not yet evident in all areas for the goals set Some Middle and Senior managers often felt left out of the main stream collaborative work

The work continues Older peoples implementation groups operational changes at scale integrated health and social care More cohesive and inclusive approach Team vitality been maintained (pic) Quality award

Contact Dr Anne Fearfull a.fearfull@dundee.ac.uk Dr Pat O’Connor p.oconnor@dundee.ac.uk

Table Exercise Find at your tables large post-it notes – some yellow, some blue – and take some of each color Using the post-it notes, answer the following questions: On the yellow post-it notes: What am I doing that is like this? On the blue post-it notes: What would we like to do that incorporates this idea and moves it forward? At the break, place your post-it notes the driver diagram so people can walk around and read them