Reducing Internal Waits Nottingham University Hospitals

1. Reducing Internal WaitsNottingham University Hospitals Liz Williamson- Deputy Programme Director Scott Purser- Project Lead

2. What we plan to cover today • The NUH improvement programme • Why this was important • Getting started • Discovery • Toolkit • Rollout • How we captured the benefits • Developing the toolkit • What the Future holds • Reflections

3. Our hospitals QMC: our emergency site (Emergency Department & trauma centre); Children’s Hospital City Hospital: largely elective & chronic care centre (including cancer)

4. Our vital statistics • Turnover £755 million • Circa 1,700 beds and 87 wards • Over 13,000 staff & 1,200 volunteers • 180,000 A&E attendances and 96,000 admissions • 66,000 day cases and 24,000 elective operations

5. Our whole hospital improvement programme is called “Better for You” Started in 2009/10, Better for You is our most comprehensive improvement programme It is a quality driven programme, which releases financial savings Currently, 250+projects across the organisation, directly involving 2000+ staff Change, which is caring, safe and thoughtful The key feature is staff and patient engagement

6. We developed the Better for You 5 Step Process – where staff engagement is key Set Up and Plan Engage with stakeholders & establish scope – Identify potential benefits - Set up Team & Hub Discovery Identifying the issues and problems to be solved from every perspective – staff views, patient views, ‘business data’ Design & Trial Testing Future state in a real environment – Agree Plan Do Study Act – Assess whether trials deliver benefits Implementation Controlled implementation &/or roll out of future state and realisation of benefits identified Embed Ensure changes are sustainable – full handover into operational environment – Knowing How We Are Doing

7. Why did we need to reduce patient waits? • Good quality care is helped by good patient flow • Improvements to the Emergency Pathway relies on consistent ‘pull’ from the specialties • To meet some of our formidable challenges (activity, £££) • We needed to shrink our in-patient capacity (“more with less”?) • We respect patient’s time and do not want to keep healthy people in hospital • We want patients to have a positive experience • Some staff have learnt to accept/not challenge internal waits • Research says hospital stays can create safety issues • In-patient/hospital care is a scarce and expensive resource

8. Aim and Scope of the project • Identify where and why waits occurred • Identify opportunities to work differently and/or smarter • Support directorate CIP plans • Reducing LOS • Reducing in-patient beds • Reduce the number of waits by 50-80% • All adult wards Point us in the direction of where the opportunities for improvement might be

9. Discovery started with a 4 week data collection of internal waits The size of the problem The opportunities for improvement What patients were waiting for, where and for how long Extensive analysis of data Identified a group of staff to undertake data collection as part of their existing role

10. From this data, we found that ‘internal’ waits made up 40% of all waiting time • We found that every day, we had on average: • 117 patients waiting for internally provided services • Average wait for internal services = 4 days • 87 patients waiting for externally provided services • Average wait for external services = eight days Internal External Internal (average 117 patients per day) Internal (average 117 patients per day) Internal (476 bed days) Internal External External (average 87 patients per day)

11. Top eight waits accounted for 50% of bed occupied by patients ‘waiting’

12. Data analysis proved to be very complex! The data was analysed by specialty, wait and opportunity We calculated baseline and stretch targets for bed reductions Clinical judgement was used to determine the ‘% of time waiting’ that could be ‘released’ If every wait on every day is included Also includes estimations for wards not included (NB assessment wards, maternity)

13. We needed a message which created shared drive for (the need for) change • Patient safety is paramount • Financial imperative to reduce costs An in-patient wait is a wasted resource and exposes patients to unnecessary risk

14. We took the decision early on that we needed to ‘do something’ across the trust and at pace • Set up a Steering Group – initially chaired by the Deputy CEO/DoN • Key involvement – Medical Director, senior nurses • Early involvement with other improvement projects (imaging, heart services)

15. We created a ‘toolkit’ of actions which would help us reduce internal waits • The toolkit included: • key principles of each of the 4 components • ‘how to’ section • glossary of terms

16. Daily Board Round is at the heart of the process How to set up.......................and lead a daily boardround

17. Statusat a Glance At the time we had a mix of electronic and manual white boards - we had to standardise the layout Who is ready for discharge? What are patients waiting for? Who is medically stable?

18. Problem Solving • Identifying waits at board round • encouraged the MDT/ward staff to be pro-active in resolving waits themselves, at an earlier stage • gathered on-going data on the top waits • enabled us to focus improvement efforts in the right areas Examples of some of the waits identified at board round

19. Escalation Process for wards Aimed to get the right people involved at the right time – not too early, but not too late! Key role for matrons Wait occurs Resolved by ward staff Wait occurs frequently Resolved by ward staff Ward staff inform matron of theme Matron informs Clinical Lead during daily meeting Issue taken to internal waits steering group for investigation Wait occurs Ward staff unable to resolve Ward staff inform matron of theme Matron resolves Wait occurs Ward staff unable to resolve Ward staff inform matron of theme Matron unable to resolve Matron informs clinical lead during daily meeting Clinical lead resolves or takes to internal waits steering group Feedback loop at all stages of the process

20. We planned a comprehensive rollout across 60 wards – took a team of 8 people 4 months to complete Training Team – from Better for you and Productive Ward Mostly senior nurses – plus an OT! 1-2 hours per day

21. We designed a daily manual checklist to capture data on process steps and waits • Recorded daily and submitted at the end of each week - one form for each ward • Process measures • Board round undertaken • Senior decision maker present • LOS graph plotted • Waits escalated • Cause of waits review undertaken • + details of waits • Hugely time consuming to collect and analyse (but crucial) • After 6 months, these forms were individualised for each ward, based on their top waits

22. Every week we reported the total number of internal waits (in patient-days) and the average number of pt-days per form/ward Bed reduction programme commenced 96 beds

23. We created a dashboard for every ward ward, which updates automatically

24. What was achieved during Phase 1 Implement Toolkit on all medical and surgical adult wards All adult wards (n=56) implemented the toolkit • Other benefits: • Reduction in • number of • inappropriate • cardiology • Investigations • (24 hour tapes • for in-pts) • Enhanced patient • experience through • fewer unnecessary • waits Reduce the number of internal wait Patient days by 50% (min); 80% (max) Internal waits reduced from 750 (July 2010) to 260 (October 2011) = 66% reduction Reduce LOS to support closure of 95 beds 96 beds closed were during March/April 2011 across both campuses Reduce outliers to zero Reduced from a high of 120 during February 2011 to around 15-20 in October 2011

25. Impact on top 4 waits... Ward processes Imaging Imaging Reduced from a baseline of 128 in March to an average of around 25 Dropped from baseline of 172 in March to an average of around 90 Dropped from baseline of 172 in March to an average of around 90 Cardiology Cardiology Specialty Bed Reduced from a baseline of 112 in March to an average of around 40 Reduced from a baseline of 112 in March to an average of around 40 Reduced from a baseline of 100 in March to an average of around 35 There were Better for you projects running concurrently in Imaging and Cardiology – this was crucial in being able to affect changes in these complex areas

26. Successes from the Services Imaging: % of in-patient ultrasound scans completed within 24hrs of request Cardiology: % of in-patient ECHOs completed within 24hrs of request

27. How staff felt about the project... I can now tell my patients what’s going to happen next and when we’re planning for them to go home You have won me over! I didn’t think it would make a difference but it has! We have tried to improve our communication as a team for a while now - a daily board round has given us the ability to progress this Being able to see how long patients have been in hospital is a real eye opener

28. Reducing Internal Waits The Future

29. At the end of Phase 2 (18 months on) • We had evidence that reported waits had reduced by a further 20% (NB using a more robust SPC approach now!) • Evidence that the culture of accepting waits as unavoidable was no longer the ‘norm’ • Most wards had a board round, but.. • Not all had a senior decision-maker • Role of matrons had become less visible • We weren’t identifying enough of the remaining waits • We really wanted a better KHWD approach

30. A new Data Analyst brought a new set of skills to our analysis, expanding use of SPC charts We needed to be able to more accurately detect ‘process change’ and not react to normal variation

31. Moving into Phase 3, our aim was • Eradicate unnecessary waits to: • improve patient experience and safety • ensure our patients have the smoothest journey possible through our hospitals and services • improve capacity/flow • Some of the main changes in the third phase include • Waits of < 1 day (including TTOs) • Increase service responsibility for ‘pull’ • Re-focus board rounds

32. During spring 2012, we realised we had ‘plateaued’ – so we re-design the toolkit and re-launched it

33. We have refocused the board round on Safety & Flow

34. The toolkit was re-developed using an approach developed by lead cardiologist and his ward team Do our patients have a plan of care which is known to all key individuals? All other patients Patient needs to be seen by a senior decision-maker now – deteriorating, overnight/ un-reviewed admission Today’s discharges PLAN Other pts HOME pts SICK pts Safety Is everyone aware of what actions are required to deliver each plan of care? Is all the information about each patients correct, including the consultant? On Friday is there a plan for the weekend including nurse facilitated discharge? & “How do we know we have runa successful Safety and Flow Board Round?” flow Have waits been identified? Who is responsible to for resolving them? Weekend Plans Could any outstanding investigations/tests be done as an outpatient? Incoming patients and outliers from our ward

35. We have improved and expanded data analysis By Directorate By Ward By Service

36. Imaging and cardiology waits have (more than) halved - but are still the biggest cause of waits

37. Our Current Challenges! • Reduce the number of internal waits by a further 20% in six months • Harness the opportunities of our new electronic bed management system • Waits measured in hours not days • Escalation plans for the top 5 services • Electronic data collection • Integrate Internal Waits ‘processes’ to daily capacity/flow meetings

38. Some reflections(or “what we would do differently if we could”!)

39. It was (and is) tough To get started...... To create the drive for change..... To get enough of the ‘right’ people involved and actually helping..... Getting the cultural change from the bottom up.....

40. But it has made a huge difference • It’s part of ‘our’ language now • Board rounds are an accepted part of everyday life (doesn’t mean they always happen though!) • Some wards have taken to the concept well and easily, others......... • Most of our services have responded very positively and pro-actively to reducing waiting times

41. What would we do differently? • Get matrons much more actively involved from the start • Including training & rollout • Get better and quicker feedback for wards regarding their performance • More medical staff involvement throughout • Integrate into everyday systems more quickly • Manage poor performers more robustly • Early involvement from services – creating the pull

42. Questions?Thoughts?Comments? Liz Williamson: liz.williamson@nuh.nhs.uk Scott Purser: scott.purser@nuh.nhs.uk 7