Report Out Steve Bradbury Head of Service Improvement 23 April 2014

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

2. Perfect Week • There is no magic bullet; • 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. • Discharge • Continue to drive creating capacity earlier in the day. • Daily board-rounds were effective in the majority of cases. • 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. • 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. • Suggest find space with proper facilities. • Run a pilot for proof of concept.

3. Perfect Week • IT Support and use of Information • Provision of agile iClip training and issue resolution from 0700-2200 proved key success factor – highly recommend continuing this process. • Focus on bed-board & EDD accuracy made for better decision-making. • More work required on producing a hospital view of the bed-board. • Availability of Operational Leaders (eg GMs) • Visible & available to deal with issues in their area (currently variable). • More able to troubleshoot and resolve issues. • Patients in Right Place • Swing beds (Vernon/Keate) moved early to surgery. • 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. • Re-run Perfect Week Quarterly (next 2-9 July 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 • General Management • Clinical Lead – HoN, Consultant • Operations/Site Management • Senior IT Lead • Information/Data Capture • Communications • Mirrored in roaming Team

6. Methodology Escalation Issues • 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 staffing • 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 was a bleep communication pathway set up with a Bat Phone.

7. Issues Escalated SILVER TEAM BRONZE TEAM Key Themes • iClip training. • Theatres. • Notes tracking. • Repatriations. • Discharge Lounge. • Transportation. GOLD TEAM

8. Issues Escalated (Cont..) ISSUES BY DIVISION ISSUES BY DAY ISSUE REPORTED BY CLINICAL v NON CLINICAL

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 emails • 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. Perfect Week: Data Management Priorities • More communication briefings re: Perfect Week and raise awareness • Revise data collection sheets and the language used • Better ICLIP training for staff who need to provide the data • Clearer LO job descriptions for the LO roles • Remove the 12.00 data collection time as this is protected meal time • Allocation of shift and clinical areas before the weeks starts

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?

18. Reasons Why Patients Went to the Discharge Lounge

19. Next Steps • 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 Identify No’s MFFD patients and expected discharges Escalate issues for action to Bronze Team Training session from HSCIC for E referrals

22. Reasons for Delay

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

24. Next Steps • Medical Wards • Band 7’s and DsgCoordinators 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

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

26. Perfect Week Report Out Site Management

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

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 iCLIPvs 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 • Better preparation: - Trial of the data collection tool/process - Engage stakeholders in advance • Keep template simple/avoid scope for variation in the answers • Be clear on the purpose of the questions (link back to measures and metrics) • Go paperless/real time entry if possible • Ask the right questions • Separate issues for escalation • Regular feedback to WLOs

35. Perfect Week Report Out IT

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

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 • Consideration of planned Perfect Week initiatives and their impact on training needs, to provide training ahead of the week. • IT is looking to an extended trial of 7-10pm IT support to cover: • Smart Card Issue. • Locum Training. • Night shift general iCLIP training. • First line IT fixes. • 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. Findings - Performance

43. Findings - Performance 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 resourceWhat to do differently? All-staff emails Posters and leaflets Greater focus on clinical staff

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

50. Perfect Week Report Out Patient Observer Feedback