reducing internal waits nottingham university hospitals
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Reducing Internal Waits Nottingham University Hospitals. Liz Williamson- Deputy Programme Director Scott Purser- Project Lead. What we plan to cover today. The NUH improvement programme Why this was important Getting started Discovery Toolkit Rollout - PowerPoint PPT PresentationTRANSCRIPT
Reducing Internal
WaitsNottingham University Hospitals
Liz Williamson- Deputy Programme Director
Scott Purser- Project Lead
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
Our hospitals
City Hospital: largely elective & chronic care centre
(including cancer)
QMC: our emergency site (Emergency Department & trauma centre); Children’s
Hospital
• 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
Our vital statistics
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
We developed the Better for You 5 Step Process – where staff engagement is key
Set Up and PlanEngage with stakeholders & establish scope – Identify potential benefits - Set up Team & Hub
Discovery
Design & Trial
Implementation
Embed
Identifying the issues and problems to be solved from every perspective – staff views, patient views, ‘business data’
Testing Future state in a real environment – Agree Plan Do Study Act – Assess whether trials deliver benefits
Controlled implementation &/or roll out of future state and realisation of benefits identified
Ensure changes are sustainable – full handover into operational environment – Knowing How We Are Doing
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
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
Discovery started with a 4 week data collection of internal waits
The size of the problemThe opportunities for improvementWhat patients were waiting for, where and for how longExtensive analysis of data
Identified a group of staff to undertake data collection as part of their existing role
From this data, we found that ‘internal’ waits made up 40% of all waiting time
Internal (average 117 patients per day) Internal (476 bed
days)
Internal (average 117 patients per day)
External (average 87 patients per day)
City
QMC
10 30 50 70 90 110City QMC
Internal 50 40
External 34 72
Average number of beds occupied per day by 'waiters'
External
External
Internal
Internal
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
Top eight waits accounted for 50% of bed occupied by patients ‘waiting’
Imag
ingEch
oAngio
Speci
alty b
ed
Psychiat
ric bed
(e.g.
B50, A23)
Speci
alty r
eview
Thera
pies
Family
decisio
n0.0
2.0
4.0
6.0
8.0
10.0
12.0
0.0
10.0
20.0
30.0
40.0
50.0
60.0
BedsCumulativeBe
ds
Beds
(cum
ulati
ve)
Clinical judgement was used to
determine the ‘% of time waiting’ that could be ‘released’
If every wait on every day is
includedAlso includes estimations
for wards not included (NB assessment wards,
maternity)
Base target for internal
waits
95 beds
Base target for external
waits
118 beds
Stretch target for all waits
279!!
Internal = 149
External = 130
Data analysis proved to be very complex!
The data was analysed by specialty, wait and opportunityWe calculated baseline and stretch targets for bed reductions
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
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)
14
We created a ‘toolkit’ of actions which would help us reduce internal waits
Status at a
glance
Escalation process
Daily boardround
Problem solving and
resolving waits
The toolkit included: • key principles of each of
the 4 components• ‘how to’ section• glossary of terms
How to set up.......................and lead a daily boardround
Identify a time for board round (eg 8am, 9am etc)
Identify essential MDT members who need to attend daily board rounds
Inform essential MDT members of their roles and responsibilities when participating
Set a date to commence board rounds and invite essential MDT members
The identified lead for board round begins discussions by asking for each patient:
What is the patient waiting for today to progress their care?
Has the referral been made?
When do we anticipate the patient will be medically stable?
What is the predicted discharge date?
Identify patients who are:
Sick
Being discharged
Waiting for tests and diagnostics
Daily Board Round is at the heart of the process
Status at a Glance
Is the patient medically stable/fit (y/n) i.e. do they need an acute medical bed
Expected date the patient will no longer require an acute hospital bed. This should be reviewed daily by medical teams and should not incorporate any delays/waits
Date patient is expected to actually be discharged. For most patients this should be the same as the medically fit date but for some e.g. patients waiting Lings Bar, it may be different
This should be since admission to hospital
Please list all the things that the patient is waiting for and the date referred. Codes/suitable abbreviations should be used if your board is in a public area
Optional column headings
Bed Name Consultant Nurse Medically stable y/n
Predicted medically stable date
Predicted Discharge Date
LOS (since admission)
Destination Waiting for (incl date/time of ref) TTO Social worker Occ Therap Physio Updated by (date, time, initials)
R1 Ann Other AA1 Jenny X05-Jan 06-Jan 3 H 24 hour tape (4.1.10 9am) TTO Needed Needed Needed Jenny31/12/08 0815
R2 Jean Smith AA1 Jenny y 02-Jan 1 H Ultrasound (4.1.10) TTO Complete Complete Jenny31/12/08 0815
R3 And so on…. BB2 Jenny y01-Jan 2 NH OT assessment (referred 5.1.10) TTO Jenny31/12/08 0815
R4 CC3 Jenny y03-Jan 3 H Social services assessment (4.1.10) TTO Referred Complete Jenny31/12/08 0815
R5 AA1 Jenny y02-Jan 4 CITY Internediate Care (2.1.10) TTO Jenny31/12/08 0815
R6 CC3 Jenny n03-Jan 1 H TTO Referred Jenny31/12/08 0815
B1 AA1 Jane n
02-Jan H TTO Complete Complete Jane 31/12/08 0830
B2 AA1 Jane y
09-Jan 1 H Jane 31/12/08 0830
B3 CC3 Jane n
01-Jan 3 H TTO Complete CompleteJane 31/12/08 0830
B4 CC3 Jane y
03-Jan 3 H TTO Needed Jane 31/12/08 0830
B5 BB2 Jane n
03-Jan 4 NH TTO Jane 31/12/08 0830
B6 AA1 Jane n
02-Jan 3 H TTO Complete Jane 31/12/08 0830
G1 BB2 Sarah y04-Jan 2 H TTO Referred Needed Needed Sarah 31/12/08 0830
G2 BB2 Sarah y02-Jan 1 H TTO Complete Sarah 31/12/08 0830
G3 CC3 Sarah n01-Jan 3 CITY TTO Complete Complete Sarah 31/12/08 0830
G4 AA1 Sarah y03-Jan 3 H TTO Sarah 31/12/08 0830
SR1 CC3 Jenny n10-Jan 2 H Complete Jenny31/12/08 0815
SR2 BB2 Jane y
06-Jan 1 H Jane 31/12/08 0830
At the time we had a mix of electronic and manual white boards - we had to standardise the layout
Who is medically
stable?
What are patients waiting
for?
Who is ready for
discharge?
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
A CT scan requested yesterday at 10am and not done by
10am today
Waiting for a decision to progress the patient’s journey
from a senior decision maker
An investigation that is only undertaken on a
Wednesday and today is Friday
Waiting more than 24 hours for a review
from another specialty after referral
Waiting more than 24 hours to move to
another ward/specialty
Waiting for TTO’s to be prescribed
Therapy assessment more than 24 hours
after referral
Referrals made on Friday but not done until Monday (due to
a 5 day service)
Problem Solving
Aimed to get the right people involved at the right time – not too early, but not too late!
Wait occursResolved 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 occursWard staff unable to resolve
Ward staff inform matron
of theme
Matron resolves
Wait occursWard 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
Escalation Process for wards
Key role for matrons
1 week preparation with B4Y project lead, Matrons, Clinical Lead and Head of Service for
each directorate
2 weeks intensive support per ward within directorate
from B4Y team member (supported by B4Y project
lead)
2 weeks light touch to all wards within the directorate from B4Y project lead. B4Y
team members move to next directorate
B4Y project lead remains named contact for
directorate until end of rollout
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
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
Bed reduction programme
commenced 96 beds
Every week we reported the total number of internal waits (in patient-days) and the average number of pt-days per form/ward
We created a dashboard for every ward ward, which updates automatically
What was achieved during Phase 1Implement
Toolkiton all medical and surgical adult wards
All adult wards (n=56) implemented the toolkit
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
Other benefits:
• Reduction in number of
inappropriatecardiology
Investigations(24 hour tapes
for in-pts)
• Enhanced patient experience through fewer unnecessary
waits
Impact on top 4 waits...
Imaging
CardiologySpecialty Bed
Ward processesDropped from baseline of 172
in March to an average of around 90
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
Reduced from a baseline of 128 in March to an
average of around 25
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
Imaging
Cardiology
Dropped from baseline of 172 in March to an
average of around 90
Reduced from a baseline of 112 in March to an average of
around 40
Successes from the Services
Cardiology: % of in-patient ECHOs completed within 24hrs of request
Before: 60% After:
98.8%
Imaging: % of in-patient ultrasound scans completed within 24hrs of request
Before: 58% After: 98%
How staff felt about the project...
You have won me over!
I didn’t think it would make a difference but
it has!
I can now tell my patients what’s going to happen next and when we’re
planning for them to go home
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
Reducing Internal Waits
The Future
• 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
At the end of Phase 2 (18 months on)
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
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
Status at a glance
Escalation process
Safety & flow
round
Problem solving and
resolving waits
During spring 2012, we realised we had ‘plateaued’ – so we re-design the toolkit and re-launched it
Board Round
Therapy team• Identify patients who require input• Identify and report any delays to assessment/input
• Identify which patients need to be seen first
Nurse in charge•Facilitate board round and update Horizon
•Ensure unexpectedly poorly & un-reviewed are discussed first
•Agree who is responsible for actions•Ensure identified waits are escalated/resolved
Nurse•Overnight events•EWS & pain control•Outstanding investigations or delays•Falls assessment /Braden and grade
Senior Decision Maker•Delegate Dr to review unexpectedly poorly /unreviewed patients
•Review all requested investigations• Is patient progressing as planned?•Review PDD & MS•Ensure correct consultant is allocated to patient
Doctors•Check investigations on Notis• Identify which patients require E-TTO’s commencing
•VTE assessment required
We have refocused the board round on
Safety & Flow
Patient needs to be seen by a senior decision-maker now – deteriorating, overnight/ un-reviewed admission
Today’s discharges
All other patients
Incoming patients and outliers from
our ward
Weekend Plans
SICK pts HOME pts Other pts PLAN
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?
Could any outstanding investigations/tests be done as an
outpatient?
Is everyone aware of what actions are required to deliver each plan of care?
Have waits been identified?Who is responsible to for resolving
them?
On Friday is there a plan for the weekend including nurse facilitated
discharge?
Is all the information about each patients correct, including the
consultant?
Safety
&
flow
“How do we know we have run a successful
Safety and Flow Board Round?”
We have improved and expanded data analysis
By Directorate
By Ward
By Service
Imaging and cardiology waits have (more than) halved - but are still the biggest
cause of waits
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
Some reflections
(or “what we would do differently if we could”!)
It was (and is) toughTo 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.....
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
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
