Transcript Summit - Leeds Beckett University

Transforming
community services:
the Productive series
Helen Bevan
The Productives: “Releasing Time”
series
• Powerful, common sense
knowledge on how to improve
key units of care
• How to achieve great results
for patients and staff using the
latest evidence based
approaches
• Mobilising front line staff
• The practical application of
the most effective change
methods such as Lean or Six
Sigma but framed in a
different way
• The Productive
Ward
• The Productive
Mental Health Ward
• The Productive
Community Hospital
• The Productive
Leader
• The Productive
Operating Theatre
• Productive
Community Services
What we are learning from
Releasing time to care
How much energy can be
unleashed by encouraging front
line teams to question how they
work and providing simple tools
and skills to do this
Releasing time to care: The Productive Ward
‘The paperwork is
easy to understand
I am not interrupted
by
and quick to
people requesting
complete’
information or looking
for things
Role Time (e.g. nurse)
“Everything I need to
do my job is
conveniently
located”
Total
Time
Motion
Admin
Discussion Handovers
‘We
‘It is clear
to have the
information
everyone
who is we need
solve
our own
responsibletofor
what”
problems, and find out
are
if ‘’Handovers
we were successful”
concise, timely and
provide all the
information I need”
Opportunity to increase
safety and reliability of
care
Roles
Information Direct
Care
Time
The Productive Ward: the evidence
NHS Institute impact assessment
March 2009
Nottingham University Hospitals:
• sickness rate fell from 8% to 5%
• nurse direct care time increased from 38% to 45%
Manchester University Hospitals Foundation Trust:
• increase in direct care time of 8%
• reduction in short term sickness
Portsmouth City Hospital:
• 10 months of no pressure ulceration on flagship ward
• 30% drop in falls rate
The Productive Ward: the evidence
Research study from NHS London
•
•
Releasing Time to Care has been a significant catalyst for change
It has resulted in measurable, positive impacts.
– 13 percentage points increase in median Direct Care Time
– 7 percentage points increase in median Patient Satisfaction Scores
– 23 percentage points increase in median Patient Observations
•
Benefits will continue to accrue so long as there is continued support
•
There are 6 key factors which have driven success
1. Leadership engagement
2. Strategic alignment
3. Governance
4. Measurement
5. Capability and learning
6. Resourcing - people
Source: NHS London 2009
The Productive Ward: the evidence
Research study from National Nursing Research Unit
•
•
•
•
The Productive Ward
programme has huge perceived
value and it is easy to identify
local evidence of impact
Has been framed and
communicated in ways that
connect with staff’s need and
will for change
Thrives where local
communication and leadership
are strong
Huge potential for on-going
spread
Source: King’s College London, June 2009
Type of impact reported
by respondents
% responses
ranked “high”
Teamworking
86.3
Staff experience
82.2
Efficiency
80.4
Patient experience
76
Safety
75.2
Clinical
effectiveness
62.4
Improvement opportunities within Releasing Time to Care:
Productive Community Services
Observed issue
Preparing
for the
visit
Visiting
the patient
Following
up the
visit
Overall
1 Time to look for and complete missing information on referrals
8 hours/week
2 Discharge procedures create additional work for staff and affect continuity of
2 hours/week
care for patients
3 Limited communication and interactions between Community staff and other
13 hours/week
professionals
4 Organising and collecting prescriptions is a non-essential task
4 hours/week
5 Unnecessary trips are made to collect forgotten equipment or get urgent stock
10 hours/week
6 Driving takes longer than necessary due to routes not being fully optimised
15 hours/week
and difficulties finding specific addresses
7 Time is spent waiting to access patients’ houses
6 hours/week
8 Patients are not always at home when staff visit, or DNA at clinics
15 hours/week
9 Staff have to wait for other carers if they are already in a patients’ house
2 hours/week
10 Some of time staff spend with patients does not directly address care needs
7 hours/week
11 The care may be refused as being unnecessary or unwanted
2 hours/week
12 Staff record the same information 2, 3 or 4 times in many different areas
20 hours/week
13 Technology is often inappropriate for a mobile workforce
30 hours/week
14 Staff skills are not fully utilised
15 The best levels of care are not always provided due to low levels of skill for
the treatments required
16 Community staff are unclear on how they are doing against objective criteria
17 Delays in providing clinical care at home
Staff Productivity
Receiving
a referral
Primary benefit
Improved quality of care
Utilising staff skills;
Improved management
process, support changes
Shorter waiting times for
patients
C
80% of the issues identified were generic to all
conditions
Continence
Stroke
Generic
Wound
Specialist
78%
22%
GP and other professionals
expect District Nurse to give
patient pads to deal with
continence
Source: Workshop issue identification 4th November 2008
Care plans need to be clear
The generic nature of the issues suggested the
“house” modules should be generic to all conditions
and not pathway specific
Somerset continence specialist
team, pathway work shop
Continence specialists
New referral form by fax
x 9 appointments per clinic
1hr/week x
manager + 9hr/wk
20 referral/week
Continence
referral
• Self referral
• GP
75–80%
• Consul-tant
• MS nurse
• Chemists
• Referrals
normally come
to us by patients
asking for pads
• GPs refer
patients to
continence
specialists and
consultants at
the same time
(1 month)
Letter <_>
draft form
phone call,
email
1~2%
• Divide up
patients
between
East
West
2 or 3
days wait
Read or assess
form from GP. If
 assigned in
clinic based
may be
reassigned to
house call ~70%
most referrals
are clinic as can
see of patients
in clinic
When
time
available
during
week
• Taunton area
clinic visits
passed to
Taunton
• Specialist staff
spend 1.5 days,
~2 days per
week on
administration
1hr/week x
manager + 9hr/wk
• Nursing home
staff need more
training. Their
assessment
forms are
completed
‘incorrectly’
10hr/week for East Somerset (~30hr/wk for E+W
Somerset, bath/Wiltshire)
• Idiot proof the
assessment
On
form – it exists
going
• Change from
issue
paper to
due to
electronic fool
their
proof form – like
staff
on line banking
turnover
3–4 week wait
Scheduling of
clinics
• Appointment
with clinic
• Assessment
form to
patient to
bring to clinic
FTEs
Actual
Gap
1
37.5
37.5
0
2
37.5
25.0
12.5
3
37.5
20.0
17.5
Phone 1hr
per day
calling and
recalling to
arrange
• 1/2hr/patient initial
• 1/4hr/patient followup
Clinic visit by
patient x 3 or 4
followups
1/2 day per week
Handwrite
letter
• 1/3 of clinics
are typed
• 2/3 of clinics –
no admin help
(8–18
months)
Over 6 months
Total gap
hr per wk
10hr/week for East Somerset (~30hr/wk for E+W
Somerset, bath/Wiltshire)
Reschedule
3–4 week
30.0
• Hours are lost as PT
nurses <_> lost hours
are not reallocated to
an extra staff <____>
– 30hr/wk
• “We have very limited
admin. support. I run
my own clinic diaries,
send appointment
letter, etc.” – Di
• Call patients
to arrange
home visits
and try to
schedule a
few together
if nearby
• Di and Catherine are
the only 2 full time
team members.
Others part time.
– Catherine <___>
– Di x <_____>
– Band 5 x 3 –
<____>
• Refer to
another
service
• E.g., Physio
• Bowl clinic
• Gynaecologist
1 week wait
• 1hr/visit
• 2 or 3 visit/patient
• 7 visit/wk East Somerset
• Travel time
• 1st visit
assess
• Physical
examination
s or visual
bladder
scans on all
patients
1/2 day
East Somerset – 1
per week person
• Plan or refer
no exact
number of
visits
• Cure
treatment
• Managed
treatment
• Refer on to
another
service
• 9 out of 10
handwrite
letter
• <__> up
and <__>
then sent to
<___> and
lip <____>
• DNAs – 1
per clinic
– The issues highlighted in the condition
specific workshops were the same as
those identified during the ‘ride-alongs’
with district nurses and other specialists
– Issues were generic and not linked to a
specific single condition pathway
Development so far
Focussed on field work services
Concentrated on the ‘how to’
Developed tools to help staff
Built and tested by staff in the community
Productive Community Services will…
Increase patient-facing contact time,
Reduce inefficient work practices,
Improve the quality and safety of care.
Re-vitalise the workforce
Put staff at the forefront of redesigning their own
services
Our plans for launch…
Autumn 2009 – Foundation Modules
Spring 2010 – Planning and Delivery Modules
Well Organised Working Environment ...
…helps
front line teams to analyse their
current activities and to develop and test
more effective working systems.
Well Organised Working Environment…
Annual time spent looking for cupboard
items (hours)
91.0
Free space
66%
31.2
Labeled
Eye-level
Before
After
Items most commonly searched for
were placed in well-labelled eye level
shelves
Patient Status at a glance ...
…enables
multi-professional and multilocation teams to understand the status of
every patient, using the most up-to-date
“visual management” techniques.
Patient Status at a Glance..
…is a good idea! I have more awareness of
what’s going on.
…acts as a guide to discuss patients while
prompting us to follow things up.
…breaks down a problem and has given us
purpose and power.
..say District Nurses
Patient Status at a Glance..
Handover meeting duration
minutes
45
56%
20
Before
For a nurse team of six with
daily handover meetings, this
saves over 60 work days p.a.
As meetings shortened and
time effectiveness increased,
team contributions
strengthened
After
…saves time
Patient Status at a Glance..
… helped us to reduce interruptions to staff by 50%
allowing us to do an extra 27 visits to patients each
week Says Occupational Therapist
Keycode to
colours, symbols
and colours
clearly posted
next to the board
Daily meetings are
held where next steps
are agreed and
recorded for Amber or
Red patients
Managing Caseload and Staffing ...
…gets
the most out of the people and avoids
bottlenecks by managing caseloads better
and planning staff activity more effectively.
Managing Caseload and Staffing…
We’re surprised by how much time is spent on travel/admin/meetings.
Only 35% spent with patients.
Our current understanding of demand and capacity is inadequate to
manage our service well.
Evidence-based decision making is possible with the tools from this
module.
The key to balancing demand and capacity is to smooth out staff
availability and/or demand for the service.
say frontline staff
… increases patient-facing time
Managing Caseload and Staffing…
Four tools to support our demand and
capacity planning process…
Monthly Time Out Planner
Daily Capacity Calculator
DAILY CAPACITY CALCULATOR
Week Beginning
What is our expectation for patient facing time:
Band 3
Band 5
Band 6/7
COMPLETE AT START OF DAY:
Staff Type
(Band)
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
3
Staff
availability
(Hours)
Staff capacity
(Hours)
→
COMPLETE AT END OF DAY:
Planned patient
work (Hours)
-
Gap
(Hours)
Staff
availability
(Hours)
=
Actual staff
capacity (Hours)
Unplanned
patient work
completed
(Hours)
Planned patient
work completed
(Hours)
Comments
→
5
→
-
=
→
6/7
→
-
=
→
TOTAL
QUALIFIED
→
-
=
→
3
→
-
=
→
5
→
-
=
→
6/7
→
-
=
→
TOTAL
QUALIFIED
→
-
=
→
3
→
-
=
→
5
→
-
=
→
6/7
→
-
=
→
TOTAL
QUALIFIED
→
-
=
→
3
→
-
=
→
5
→
-
=
→
6/7
→
-
=
→
TOTAL
QUALIFIED
→
-
=
→
3
→
-
=
→
5
→
-
=
→
6/7
→
-
=
→
TOTAL
QUALIFIED
→
-
=
→
3
→
-
=
→
5
→
-
=
→
6/7
→
-
=
→
TOTAL
QUALIFIED
→
-
=
→
3
→
-
=
→
5
→
-
=
→
6/7
→
-
=
→
TOTAL
QUALIFIED
→
-
=
→
WEEKLY CAPACITY TRACKER
Team:
Year:
Hours
Daily/Monthly Decision Tables
Hours
20
19
18
17
Size of gap
16
More visits than staff capacity
Less visits than staff capacity
15
14
13
+/- XXX
Check next day’s workload and create shortlist of pull Check next day’s workload
forward patients from tomorrow
Shortlist push back from today
+/- XXX
Absent staff member: Move visits to another day
Absent staff member: Drop non-critical visit
Absent staff member: Reallocate visits to another
team member (including across internal teams)
Additional visits for high priority patients
Allocate/complete outstanding non-routine work
+/- XXX
Team Leader drop down
Reallocate to external team
Cancel training
Create waiting list
Pull referrals from other teams
12
11
10
9
8
7
6
5
4
3
2
1
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
TOTAL
Unplanned
Staff PFT
Planned
Unplanned
13
Planned
Staff PFT
Unplanned
12
Planned
Staff PFT
Unplanned
Staff PFT
11
Planned
Unplanned
10
Planned
Staff PFT
Unplanned
Staff PFT
9
Planned
Unplanned
8
Planned
Staff PFT
Unplanned
7
Planned
Staff PFT
Unplanned
Staff PFT
6
Planned
Unplanned
5
Planned
Staff PFT
Unplanned
4
Planned
Staff PFT
Unplanned
Staff PFT
3
Planned
Unplanned
2
Planned
Staff PFT
1
Monthly/Weekly Trend
Tracker
Knowing How We are Doing...
…enables
local teams to understand team
performance and set team improvement
goals in areas such as safety, quality,
productivity, patient experience and staff
experience.
Knowing How We are Doing...
…has
helped us to move us from a
disjointed, demoralised, self doubting team,
to one which is excited/motivated by the
goals and opportunities we have to impact
change within our PCT
… says Nurse Team Leader
Our testing and development to date
suggests that PCS could fundamentally
change the way you deliver healthcare
• Fits strategy with service design and reshapes the channels for
delivering care
• Aligns teams in traditional silos on a single agenda like never
before
• Potentially doubles the amount of patient care time delivered by
the same staff
• Increases management skills such as planning and performance
management
• Lifts the confidence and morale of the workforce
• Transforms the culture to fact-based and data driven, able to take
improvement actions
• Explores the possibility of real time data tracking for staff
• Provides an opportunity to explore electronic medial records that
allow better access and mobility
For more information
http://www.institute.nhs.uk