Implementing PEWS Sebastian Yuen Sebastian.yuen@gmail.com Consultant Paediatrician, George Eliot Hospital, Nuneaton Fellow, NHS Institute for Innovation and Improvement (2008-10) With Peter Lachman, Nikki Davey and The NHS Institute

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Overview

PEWS implementation in The Royal Free Hospital

The NHS Change Model

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The NHS Change Model

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PEWS is Recommended By:

CEMACH NCEPOD NHS Institute NHSLA

NICE NPSA RCN RCPCH

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PEWS Project Steps... 1. Strong Leadership

2. Build the team

3. Clarify the aim and vision

4. Implement change: Model for Improvement

5. Design (localise, improve) the PEWS Form

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PEWS Project Steps 6. Train staff in QI and PEWS

7. Measure & display effectiveness of PEWS

8. Communicate & engage all staff

9. Enhance Sustainability

10. Spread to other areas

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1. Leadership Vision Strategy Communication Listen Be authentic Humility Respect Courage

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"Change will not come if we wait for some other person or some other time. We are the ones we've been waiting for. We are the change that we seek”

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2. Build The Team: Who? Executive Sponsor Lead Paediatrician Lead Nurse / Matron Improvement Advisor Clinical Champions Administrator

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2. Build The Team: How? Stakeholder mapping Network Treat followers as equals WIIFM (What’s in it for me)? Expect challenge: know the evidence Walk the talk Focus and Commitment

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"Leaders are visible, have a vision

and share it, often"

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3. Clarify Aim & Vision Create a sense of urgency (drivers for change) Align with strategic objectives SMART aim: Days between crash calls to 365 within 1 year

Develop compelling vision Carefully limit scope Check readiness for implementation

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Vision Build compelling shared vision of outcome This comes from all staff, not top-down What will PEWS look like on a good day? What difference will we feel / hear / see? Describe in present tense Make it something exciting!

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Vision For PEWS Defines the ideal future situation It guides and encourages the organisation What do we want PEWS to look like in the future? “So easy to use - my mother could do it!” “I use it because it works – I trust it “It saves me time and helps me with patient assessment” “It improves situation awareness and reduces harm”

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Sense of Urgency Create a Sense of Urgency Why do we need to do this, now? Respond to:

o Complaints o Incidents o Patient story o Tight deadline

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“It was a question of jump or fry, so we jumped”

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4. Implementing Change

The Model for Improvement o Rapid start o Evolution, not revolution o Builds will and engagement

Driver Diagram: Overview of programme

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What are we trying to accomplish?

How will we know that a change is an improvement?

What changes can we make that will result in the improvements we seek?

Model for improvement

Act Plan

Study Do

Aim: how much, by when? k Measurement Frontline staff suggest innovative ideas to overcome problems

Test ideas before implementing. PDSA Cycles are mini-audits

The Improvement Guide: A practical approach to enhancing organizational performance (2nd Edition 2009) Gerard J. Langley, Kevin M. Nolan, Thomas W. Nolan, Clifford L. Norman, Lloyd P. Provost

Model For Improvement

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Eliminate preventable harm

due to deterioration in

children

Identify early signs of

deterioration

Record physiological observations competently

PEWS Guideline

Recording Observations

Training

Calculate PEWS accurately

PEWS Form

PEWS Training

Use PEWS to improve Situation

Awareness

Ward Whiteboard

PEWS Handover

Respond rapidly to deterioration

Follow PEWS Escalation Plan

reliably Use SBAR

Communication Tool

SBAR Handover

SBAR Training @S3bster

5. Design PEWS Form PEWS forms & literature reviewed Started with Brighton, then Cardiff & GOS Multiple versions Led by users Implement as only observation chart

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The PDSA Cycle

Act • How will we test

what we have learned?

• Start planning the next cycle

Plan • Objective • Questions and predictions (why) • Plan to carry out the cycle (who, what, where, when) • Plan for data collection

Study • Complete the analysis of the data

• Compare data to predictions

• Summarise what was learned

Do • Carry out the plan • Document problems and unexpected observations • Begin analysis of the data

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PDSA Cycle Template

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Testing: Start Small 1 patient 1 nurse 1 doctor 1 day

Testing: 1 3 5 All

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Start Next Tuesday!

Year Quarter Month Week Day Hour

“What tests

can we complete

by next Tuesday?”

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PEWS Cycles 1-9

A P S D

A P

S D

A P S D

A P

S D

Cycle 1: First draft of modified Brighton PEWS – 1 nurse, 1 child, 1 shift

Cycle 2-4: Design of PEWS form improved. Tests similar to Cycle 1

Cycle 5: PEWS form now incorporated into observation form

Cycle 6-8: Design of PEWS form improved. Tests similar to Cycle 1

Cycle 9: PEWS design simplified Tests increase from 1-3-5-all

Result: Increased buy-in from stakeholders

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Format of PEWS

Usability Testing

Addition of section to audit action & added

to safety briefing

Link to SBAR & handover

Change Concepts

Multiple PEWS Cycles @S3bster

PDSA PEWS Forms @S3bster

PDSA PEWS Forms @S3bster

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Observation Charts Transformed

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6. Train staff in QI and PEWS Model for Improvement & PDSA Cycles Measurement for Improvement PEWS SBAR (RFH & NHSI DVD) How to measure vital signs Recognition of the sick child Remember new, night & temporary staff!

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"Some is not a number.

Soon

is not a time."

IHI 100,000 Lives Campaign

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7. Measurement Process Measures Outcome Measures

Crash Calls Transfers to PICU

Balancing Measures Review missed cases, deaths, incidents

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PEWS Process Bundle

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Measurement @S3bster

Measurement: Process @S3bster

Measurement: Outcome Interval between Crash Calls on The Royal Free Paediatric Ward

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8. Communicate Frequently – every opportunity! Match your message to this audience Tell patient stories Ask questions with genuine curiosity Listen! Posters announcing: PEWS is coming! Explain why (rational / evidence / emotional) Celebrate success!

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Capture Learning PDSA Forms Diaries Cameras

Share Learning with… Staff Families Executive sponsor Network

Spread Learning: Measures, Posters, Stories

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Engagement

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Engagement The team must want to implement PEWS They cannot be forced to do it Listening, trusting and empowering are key Communication in different ways is crucial Important to continue to engage the team It must make their lives better It must be easy to try and easy to do

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Sustainability @S3bster

9. Enhance Sustainability Handover SBAR Safety Briefing Resuscitation scenarios Audits The Productive Ward

Ward whiteboard Mandatory training Induction Involve parents Quality dashboard

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PEWS-SBAR Handover Sheet

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Patient Status At A Glance

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PEWS-SBAR Card 1

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PEWS-SBAR Card 2

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Spread of Innovation

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10. Spread Emergency Department Paediatric Neurological PEWS Form Neonatal PEWS Form Spread in UK Spread via Partners in Paediatrics Spread via the NHS Institute Spread to Slovenia and Uganda

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Rigorous Delivery Week 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

2

Team

M

eetin

gs

Mea

sure

s Co

mm

s

Review Meeting

Plan Next Steps

Review Meeting

Core Team Setup Meeting

1

Pre-measures

PDSA

PE

WS

Form

PDSA 4 3 PDSA 5

Project Team

Trai

ning

All Staff New / Temporary Staff

Project summary to team

PDSA summary after each

cycle

Launch email to all staff

PEWSletter 1: Why PEWS?

PEWSletter 2: What is PDSA?

PEWSletter 3: Why Measure?

PEWSletter 4: Progress

PEWSletter 5: Next Steps

Laun

ch

PEW

S

Week 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

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All truth passes through 3 stages:

1st it is ridiculed.

2nd it is violently opposed.

3rd it is accepted as being self-evident.

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#SocialEra #SoMe #RCPCHEPA13

@hesham_abdalla

@Nadeem_Moghal

@PeterLachman

@RCPCH_President

@KathEvans2

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@Damian_Roland

@ingridjohanna66

@CheungRonny

@Runnacles_J

@Qualityknitting

LinkedIn: The Running Horse Group

@PIPSQC

Paediatric QI Resources 1. www.pipsqc.org 2. RCPCH Quality Improvement and Patient Safety series:

http://ow.ly/lyX15 3. The Running Horse Group on LinkedIn:

http://ow.ly/lyXgA 4. Institute for Healthcare Improvement 5. Patient Safety First Campaign 6. The Health Foundation @S3bster

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Learning Points Implementation more important than the tool Align with priorities & other projects Co-produce from the beginning Executive leadership support essential MfI enables rapid start & builds will PDSA Cycles maximise learning Measurement helpful, but must lead to action Engage all team-members, often

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