Transforming community services: the Productive series

Helen Bevan

The Productives: “Releasing Time” series

• The Productive Ward

• The Productive Mental Health Ward

• The Productive Community Hospital

• The Productive Leader

• The Productive Operating Theatre

• Productive Community Services

• 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

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

Direct Care Time

Motion Admin Discussion Handovers InformationRoles

Opportunity to increase safety and reliability of

care

Rol

e T

ime

(e.g

. n

urse

)

Total Time

“Everything I need to do my job is

conveniently located”

‘The paperwork is easy to understand

and quick to complete’

I am not interrupted by people requesting

information or looking for things ‘’Handovers are

concise, timely and provide all the

information I need”

‘It is clear to everyone who is

responsible for what”

‘We have the information we need

to solve our own problems, and find out if we were successful”

Releasing time to care: The Productive Ward

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 engagement2. Strategic alignment3. Governance4. Measurement5. Capability and learning6. Resourcing - people

Source: NHS London 2009

The Productive Ward: the evidence

• 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

Teamworking 86.3

Staff experience 82.2

Efficiency 80.4

Patient experience 76

Safety 75.2

Clinical effectiveness

62.4

Research study from National Nursing Research Unit

Type of impact reported by respondents

% responsesranked “high”

Improvement opportunities within Releasing Time to Care: Productive Community Services

Receiving a referral

Preparing for the visit

Time to look for and complete missing information on referrals1

Limited communication and interactions between Community staff and other professionals

3

Discharge procedures create additional work for staff and affect continuity of care for patients

2

Driving takes longer than necessary due to routes not being fully optimised and difficulties finding specific addresses

6

Unnecessary trips are made to collect forgotten equipment or get urgent stock5

Organising and collecting prescriptions is a non-essential task4

Time is spent waiting to access patients’ houses7

Patients are not always at home when staff visit, or DNA at clinics8

Some of time staff spend with patients does not directly address care needs10

Staff have to wait for other carers if they are already in a patients’ house9

The care may be refused as being unnecessary or unwanted11

Overall

Observed issue Primary benefit

Delays in providing clinical care at home17 Shorter waiting times for patients

The best levels of care are not always provided due to low levels of skill for the treatments required

15Improved quality of care

Community staff are unclear on how they are doing against objective criteria16Improved management process, support changes

Staff record the same information 2, 3 or 4 times in many different areas12

Visiting the patient

Following up the visit

8 hours/week

13 hours/week

2 hours/week

15 hours/week

10 hours/week

4 hours/week

6 hours/week

15 hours/week

7 hours/week

2 hours/week

Staff skills are not fully utilised14

Utilising staff skills;

20 hours/week

2 hours/week

Sta

ff P

rodu

ctiv

ity

Technology is often inappropriate for a mobile workforce13 30 hours/week

Source: Workshop issue identification 4th November 2008

Gen

eric

Sp

ecia

list

Wound Continence

78%

22%

Stroke

GP and other professionals expect District Nurse to give

patient pads to deal with continence

Care plans need to be clear

80% of the issues identified were generic to all conditions

C

The generic nature of the issues suggested the “house” modules should be generic to all conditions and not pathway specific

1 week wait1 week wait1hr/week x manager + 9hr/wk1hr/week x manager + 9hr/wk

10hr/week for East Somer-set (~30hr/wk for E+W Somerset, bath/Wiltshire)

Continence specialists

• Referrals normally come to us by patients asking for pads

2 or 3 days wait

Continence referral• Self referral• GP

75–80%• Consul-tant• MS nurse• Chemists

• Divide up patients between

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

Scheduling of clinics• Appointment

with clinic • Assessment

form to patient to bring to clinic

Reschedule Clinic visit by patient x 3 or 4 followups

Handwrite letter

When time avai-lable during week

Letter <_> draft form phone call, email 1~2%

New referral form by fax

• GPs refer patients to continence specialists and consultants at the same time (1 month)

• Nursing home staff need more training. Their assessment forms are completed ‘incorrectly’

On going issue due to their staff turnover

• Idiot proof the assessment form – it exists

• Change from paper to electronic fool proof form – like on line banking

• Taunton area clinic visits passed to Taunton

• Specialist staff spend 1.5 days, ~2 days per week on administration

• 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

FTEs Actual Gap

37.5 37.5 0

37.5 25.0 12.5

37.5 20.0 17.5

Total gap hr per wk

30.0

Over 6 months

• 1/3 of clinics are typed

• 2/3 of clinics –no admin help (8–18 months)

• Call patients to arrange home visits and try to schedule a few together if nearby

Phone 1hr per day calling and recalling to arrange • Di and Catherine are

the only 2 full time team members. Others part time.– Catherine <___>– Di x <_____>– Band 5 x 3 –

<____>

• 1st visit assess

• Physical examinations or visual bladder scans on all patients

• 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 <____>

• Refer to another service

• E.g., Physio• Bowl clinic• Gynae-

cologist

1hr/week x manager + 9hr/wk1hr/week x manager + 9hr/wk

10hr/week for East Somer-set (~30hr/wk for E+W Somerset, bath/Wiltshire)

10hr/week for East Somer-set (~30hr/wk for E+W Somerset, bath/Wiltshire)

3–4 week wait3–4 week wait

3–4 week3–4 week

• 1/2hr/patient initial • 1/4hr/patient followup

x 9 appointments per clinic

1/2 day per week

1/2 day per week

East Somerset – 1 person

• DNAs – 1 per clinic

20 referral/week

East West

1

2

3

• 1hr/visit• 2 or 3 visit/patient• 7 visit/wk East Somerset• Travel time

– 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

Somerset continence specialist team, pathway work shop

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.

Annual time spent looking for cupboard items (hours)

31.2

91.0

Before After

66%

Labeled

Eye-level

Free space

Items most commonly searched for were placed in well-labelled eye level shelves

Well Organised Working Environment…

Patient Status at a glance ...

…enables multi-professional and multi-location 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..

…saves time

20

4556%

Before After

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

Handover meeting duration

minutes

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

Size of gap More visits than staff capacity Less visits than staff capacity

+/- XXXCheck next day’s workload and create shortlist of pull forward patients from tomorrow

Check next day’s workloadShortlist push back from today

+/- XXX

Absent staff member: Move visits to another dayAbsent staff member: Drop non-critical visitAbsent staff member: Reallocate visits to another team member (including across internal teams)

Additional visits for high priority patientsAllocate/complete outstanding non-routine work

+/- XXX

Team Leader drop downReallocate to external teamCancel trainingCreate waiting list

Pull referrals from other teams

DAILY CAPACITY CALCULATOR

Week Beginning

Band 3Band 5

Band 6/7

Staff Type (Band)

Staff availability

(Hours)Staff capacity

(Hours)Planned patient

work (Hours)Gap

(Hours)

Staff availability

(Hours)Actual staff

capacity (Hours)

Unplanned patient work completed

(Hours)

Planned patient work completed

(Hours) Comments

MONDAY 3 → - = →

5 → - = →

6/7 → - = →

TOTAL QUALIFIED

→ - = →

TUESDAY 3 → - = →

5 → - = →

6/7 → - = →

TOTAL QUALIFIED

→ - = →

WEDNESDAY 3 → - = →

5 → - = →

6/7 → - = →

TOTAL QUALIFIED

→ - = →

THURSDAY 3 → - = →

5 → - = →

6/7 → - = →

TOTAL QUALIFIED → - = →

FRIDAY 3 → - = →

5 → - = →

6/7 → - = →

TOTAL QUALIFIED → - = →

SATURDAY 3 → - = →

5 → - = →

6/7 → - = →

TOTAL QUALIFIED

→ - = →

SUNDAY 3 → - = →

5 → - = →

6/7 → - = →

TOTAL QUALIFIED

→ - = →

What is our expectation for patient facing time:

COMPLETE AT START OF DAY: COMPLETE AT END OF DAY:

Four tools to support our demand and capacity planning process…

Monthly Time Out Planner

Monthly/Weekly Trend Tracker

Daily Capacity Calculator

Managing Caseload and Staffing…

Daily/Monthly Decision TablesWEEKLY CAPACITY TRACKER

Hours20

19

18

17

16

15

14

13

12

11

10

9

8

7

6

5

4

3

2

1

1 2 3 4 5 6 7 8 9 10 11 12 13

Sta

ff P

FT

Pla

nned

Unp

lann

ed

Sta

ff P

FT

Pla

nned

Unp

lann

ed

Sta

ff P

FT

Pla

nned

Unp

lann

ed

Sta

ff P

FT

Pla

nned

Unp

lann

ed

Sta

ff P

FT

Pla

nned

Unp

lann

ed

Sta

ff P

FT

Pla

nned

Unp

lann

ed

Sta

ff P

FT

Pla

nned

Unp

lann

ed

Sta

ff P

FT

Pla

nned

Unp

lann

ed

Sta

ff P

FT

Pla

nned

Unp

lann

ed

Sta

ff P

FT

Pla

nned

Unp

lann

ed

Sta

ff P

FT

Pla

nned

Unp

lann

ed

Sta

ff P

FT

Pla

nned

Unp

lann

ed

Sta

ff P

FT

Pla

nned

Unp

lann

ed

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

TOTAL

Hours

Team: Year:

WEEKLY CAPACITY TRACKER

Hours20

19

18

17

16

15

14

13

12

11

10

9

8

7

6

5

4

3

2

1

1 2 3 4 5 6 7 8 9 10 11 12 13

Sta

ff P

FT

Pla

nned

Unp

lann

ed

Sta

ff P

FT

Pla

nned

Unp

lann

ed

Sta

ff P

FT

Pla

nned

Unp

lann

ed

Sta

ff P

FT

Pla

nned

Unp

lann

ed

Sta

ff P

FT

Pla

nned

Unp

lann

ed

Sta

ff P

FT

Pla

nned

Unp

lann

ed

Sta

ff P

FT

Pla

nned

Unp

lann

ed

Sta

ff P

FT

Pla

nned

Unp

lann

ed

Sta

ff P

FT

Pla

nned

Unp

lann

ed

Sta

ff P

FT

Pla

nned

Unp

lann

ed

Sta

ff P

FT

Pla

nned

Unp

lann

ed

Sta

ff P

FT

Pla

nned

Unp

lann

ed

Sta

ff P

FT

Pla

nned

Unp

lann

ed

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

TOTAL

Hours

Team: Year:

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