Implementing patient gateways to improve emergency

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Transcript Implementing patient gateways to improve emergency

Delivering improvements

Using Lean Principles

Dr Brian Bradley , Michaela Bowden

Bolton Respiratory Team

Cindy Walton

Bolton Improving Care System

About Bolton

• Northern industrial town • Population 270,000 • 12% ethnic minority population

Bolton health survey epidemiology

COPD Chronic Bronchitis Chronic Cough 13.5% Wheezing 2.7% 7.5%, 18.7% We are here!

About Bolton NHS FT

• Currently 775 beds – Catchment approx 350,000 • Busiest emergency service in the North West • 2011/12 £260m turnover • 46,000 non-elective admissions per year • Respiratory illness is high volume pathway (27%)

The Bolton Improving Care System

Understanding Value Learning To See Delivering Benefit Redesigning Care

Why Change?

• Difficult Winter • Care unsafe • 98% not being achieved • Stressed Staff • We needed to change

Concept of Flow

• Applying concept of flow • Value adding steps • How could it we apply to ward activities • Batch –common way • One piece flow would not be possible on ward • One decision flow

One Decision Flow

• Right People present to make decisions flow • Ward Rounds – Daily Consultant Lead • Board Rounds Daily • Decisions being made on a daily basis by the right people • Not Traditional

Bolton Respiratory Team

In-patient care - case for Change

Staff Opinions

• All work very hard but don’t always deliver the good care to our patients • High bed occupancy figure • Not enough time or staff to change things • Must be able to do things better!


• High Standardised Mortality Ratio 118.9 Jan 2009 • Length of Stay -14,183 Excess bed days • High mortality for respiratory conditions • Not implementing pneumonia care bundles as well as we should

Respiratory Team Vision

• Timely, equitable inpatient access to respiratory services • Best cost-effective outpatient multi disciplinary team (MDT) services • Support primary care to provide equitable good quality respiratory care in community • Underpinning ethos of ‘Best Possible Care for the Patient’ in the most appropriate setting

Respiratory team: lean journey with BICS

• 2006 Minor changes but sustainability issues • 2009 Respiratory Inpatient Care • 2010 Hospital and Community Respiratory Nursing Event • 2012 Respiratory Outpatient Service

Opening Access and Community Facing

What do our patients want from a service?

Kano Model used to identify from patients what do they want from a service Contact out of hours Straight to Respiratory Ward

Contact in hours

Delighter (‘unspoken ’) Performer

Straight to Respiratory Ward, Management Plan

Frustrating ‘Having to explain to junior doctors when breathless, ‘history taking’ Access ‘ Listen To’ Basic (‘unspoken’) Right Medication @ Right Time

Rapid Improvement Event April 2009

Core Group of Staff

• Nursing Staff • Consultants + non consultant hospital doctors (NCHDs) • Physiotherapy • Occupational Therapy • Pharmacy • Social Workers • External (to the process)

4 Day Event!

• Gap Analysis • Agree new ways of working • Support this Standard work model • Devise a model to sustain the changes

Gap Analysis: As reported by staff

Medical issues

• Poor documentation • Poor discharge planning • Poor communication with nursing and other staff • No role in MDT • Poor follow through on issues • Juniors – reactive working • 75% Discharge scripts done on day of discharge


• Not enough staff • Chasing up doctors to do the tasks / To take out drugs for patients on discharge from hospital (TTOs) • Interruptions –40% of time delivering • Drugs -i.v. antibiotics • Handover / prioritise work • Social work referrals and discharge planning

Agreed - Needed to Change/

• Simple


evidence based pathways • Improve Patients journey - ensuring visible status and review this daily • Monitor: Visible accountability, improved documentation with completion tasks • Visible proactive discharge planning process – TTOs and Summary • Strengthen Multidisciplinary Team Working with Clarity of responsibility better Co-ordinating Care

New Ward Day Plan

• 7.00 am: Observations • 7.30-9am: Nurse handover and drug round • 9am: Daily consultant ward round with NCHDs and bay nurse • Daily 11.30 Multidisciplinary Ward Meeting staff and social worker • PM: Ward work procedures, paperwork, teaching & training, relatives : Consultant led, bay nurse, NCHDs, therapy


Medical & Nursing staff 1 2 3 4 5 6 7 8 9 10 11 Stage: Daily throughout patients’ stay Ward round will start at 9am each day.


 Identify and document the diagnosis  Check appropriate treatment for severity of illness (Drug chart)  Check response to treatment - check observations, EWS, fluid balance results  Identify new issues / problems (medical, nursing or social)  Check VTE prophylaxis assessment  Working diagnosis / coding (real time)  Identify DNAR, ceiling of treatment ( NIV)  Patient information / education  Update Discharge information & Social Work Log.

Complete all documentations in clinical notes including a clear management plan

Review Drug prescription sheet with particular emphasis on:

   

antibiotic prescription -consider transfer to oral antibiotic treatment on a daily basis.

Please sign wardex to indicate review of i.v. antibiotics.

Check Oxygen is prescribed and administered appropriately Review the need fluid balance, completing IV Fluid prescription if required Decide any actions or investigations required Allocate tasks  Nursing  Junior medical staff – Investigations, results, re-write drug wardex Identify any issues for the board round, including notifying Social Worker to attend MDT for complex issues around identified patient.

Identify patients for Discharge Process  TTOs for next day discharges should be completed between 12 noon and 2 pm  Same day discharge TTOs to be completed on the ward round – if possible  Discharge letter to be completed before patient leaves the ward INR to be completed at 6am on the day of discharge.

Weekend planning when appropriate  IV antibiotics / Nebs / O2 / Warfarin / Drug charts  Clarify NIV arrangements  Fluids  Request weekend bloods /Investigations and arrange results reviews  Re-write wardex Discharges and TTOs when appropriate Complete Sustainment Graph Daily

Visual Management – ExtraMed

Daily Update

• Admission date • Original predicted discharge date • Current predicted discharge date • Status: on target/at risk/overdue/exempt • Comment field – social issues section 2/5 awaiting

Room Patient Name

Actions from Rapid Improvement Event (RIE)

Implementation Time Table New Consultant Job Plans

• May 2009 Board Round / MDT commence • June - Respiratory Consultant daily ward round on 1 ward and MDT • Review of process August 2009 September 2009 – Respiratory Consultant on both wards, new outpatients (OPD) system • Consultant on each ward weeks slots. Males or females on AMRU/HDU/ICU /consults • 3 Consultants off wards increased number of clinics, bronchoscopy lists Student teaching • Continue medical on call rota, Respiratory NIV rota. Holidays / study leave when in OPD

a Confirmed State Improved Health Bed Occupancy b Go No Go Best Possible Care Delays c Value for Money Planned vs Actual d Joy and Pride Start / Finish on time 30, 60, 90 day Measures - underpinned by our 4 True Norths

Discharges from D3 & D4

250 200 150 100 50 0 A pr il 08 M ay 08 Ju ne 0 8 Ju ly 08 A ug ust S 0 8 ep te m be r 0 8 Oct ob er 0 N 8 ove m be r 0 D 8 ece m be r 0 8 Ja nu ar y 09 Fe br ua ry 09 M ar ch 0 9


A pr il 09 M ay 09 Ju ne 0 9 Ju ly 09 A ug ust S 0 ep 9 te m be r 0 9 Oct ob er 0 N 9 ove m be r 0 D 9 ece m be r 0 9

Number of Transfers to ICU/HDU Number of Patient Transferred from D3/D4 to ICU/HDU

15 10 25 20 5 0 April 08 June 08 August 08 October 08 December 08 Total February 09


April 09 Mea June 09 August 09 UCL October 09 December 09 10

Proportion of All Patients Readmitted

10.50% 10.00% 9.50% 9.00% 8.50%


8.00% 7.50% 7.00% Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09


Source: Dr Foster 2/2/2010

100% 80% 60%

Time to specialist wards

140 random patients reviewed March 2010 24 hrs 50 random Patients September 2012 Non electiveDirect admissions 24 hrs 25-50 hrs 24 hrs 24 hrs 40% 24 hrs 51-+ hrs 20% 25-50 hrs 25-50 hrs 25-50 hrs 25-50 hrs 25-50 hrs 0% 30 days60 days90 days Mar-10 Sep-12 Elective direct

Respiratory Nursing Team – 2009/10

Why change ?

• High input into respiratory ward no longer necessary • Focusing non respiratory areas supporting implementation of best practice • Inequity among the patient groups • Focusing input earlier in the patient’s journey • Non-patient contact time handovers/travel

Rapid Experiment – resources same

• Respiratory nurse specialist on wards 7 days • Board round aiming for early respiratory review • Fast track to most appropriate area • Support non-respiratory areas • Liaise with other specialist nurses • Re-organisation of community working

RNS Ward / Base Cell

How visits are organised

1 Piece Flow Standard work

Agreed best way of working Pre- 6S Score 12.5% Post Score 93 – 100%

6S Pull

Clear standard work, for pulling specialist skills/ also pulling patients to the right ward How are we doing at a glance? Where are staff located

Visual Management

(c) 2011 Royal Bolton Hospital NHS Foundation Trust. All rights reserved. This document may be copied for use in the NHS only on the condition that Royal Bolton Hospital NHS Foundation Trust is acknowledged as the copyright holder and originator of the work.

Home Visits

90 80 40 30 20 10 0 70 60 50 jul aug sep

34.5% increase in


Pre Event 800 miles / month Post improvement 624 miles / month 22% reduction per month on average

nov dec Jan Feb Mar Apr May Jun Jul Average 2009 2010 /11 Average 38

900 800 700 300 200 100 0 600 500 400 янв.12

Specialist Nurses Respiratory Team mileage January to September 12 Average 459 / month








250 200 150

Respiratory nurse visits January to August 12 Average 147 / month

100 50 0 янв.12








250 200 150 100 50 0

Pneumonia mortality

HSMR Линейная (HSMR)

New Ways of working RNS May 2010

Pneumonia RAMI- April 11- June 12

80% 70% 60% 50% 40% 30% 20% 10% 0%

Patients seen by RNS (new way)

COPD Pneumonia Asthma Bronchiectasis ILD

Respiratory team: lean journey with BICS

• 2006 Minor changes but sustainability issues • 2009 Respiratory Inpatient Care • 2010 Hospital and Community Respiratory Nursing Event • 2012 Respiratory Outpatient Service

How can we provide the best cost effective MDT outpatient services?

• Outpatient Services – short waiting time (best). 100% 2 week rule target, 1:2 New to Follow up ratio • Need full MDT Specialist clinics for some Chronic Diseases • Eliminate waits - Redesign current clinics • Introduce MDT specialty clinics for complex patients • Comprehensive range of Clinics / Services. But some provided elsewhere – Sleep • Care closer to home – income generation such as sleep services • Demand & need for alternatives to admission and GP advice services • Single point of contact for advice and/or slot in admission avoidance clinic

Respiratory Assessment Clinics

Assessment Referral Source Booking Outcome

Discharge with treatment plan 1.Community Team (Med/Nursing) Choose & Book Clinic slots 2. Hospital Team (Bleep 2000) Respiratory Triage •Advice •Same day clinic Respiratory Assessment Clinic Urgent investigations Diagnosis Treatment Same day correspondence Discharge with H.A.H Services Admit 3. Self Referral (Agreed list) Specialty Multi disciplinary Team Follow-up Clinic

Better Community Working

Current Community Working Disease Management Team General Practitioner with Special Interest in Respiratory Disease

Respiratory Clinics Supports Community Team Consultant liason

Instant Access – October 2012

Shorten Clinic waiting times:

Routine referral 24-48hrs Exacerbations – same day review •

Immediate telephone advice

7 days for primary care •

Nursing Team:

Community Matrons, Active Case Managers, District Nurses, Respiratory Nurses •

Impact: Better Care

2-3 less A/E patients per day •

Pulmonary Rehabilitation

Poor community uptake – need to broaden access •

Paid Tariff

between that of OPD and A/E rate •

Education Events

on End of Life Care Gold Standard Framework • Agreement in principle with Commissioners

Measure LoS* Dr Foster CHKS Mortality (HSMR) 2009/10 8.9 days 6.4 days 119 Readmissions 9.5% ICU Escalation Home Visits (per month) RNS Time to Care (patient facing time ) 101pts 38 26.25

Hrs/wk 2010/11 6.9 days 5.7 days 91 8.5% 64pts 58 52.5

2011/12 7.8 days 5.8 days 79 RAMI 8.2% 57 pts 92 Aug, 146 per month 52.5

Respiratory Team Vision

1. Timely equitable inpatient access to Respiratory Services 2. Best cost-effective outpatient MDT services 3. Support primary care to provide equitable good quality respiratory care in community 4.

Underpinning ethos of ‘Best Possible Care for the Patient’ in the most appropriate setting

Thank you