The SAFER Bundle Supported by #Red2Green Our Journey

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1 University Hospitals of North Midlands (UHNM) Background The SAFER Bundle Supported by #Red2Green Our Journey At UHNM, we started our SAFER implementation journey in November We had previously introduced the SAFER Patient Flow Bundle some years ago and more recently our Exemplar Ward Programme based on the SAFER Bundle. Method As a health system widely understood to be under significant pressure, and with support from ECIST and an investment in PwC manpower and resources we opted for a big bang implementation. The PwC Perform management change system was used, it focused on visual management and supported implementation of SAFER and the red 2 green day tool, simultaneously across 17 inpatient, adult medical wards. Launch Event A launch event was held in November 2016 for the Medical Division. Delegates included, Sisters and Charge Nurses, Discharge Facilitators, Directorate Managers, nursing staff, Senior Pharmacists and therapists. Speakers from the UHNM Executive Team and ECIP described the goals and rationale for implementing SAFER and delegates were encouraged to describe where improvements could be made in their areas. Our Approach All wards were assigned a member of the project team to support their journey. Visual management tools were introduced and in the majority of cases a simple white board was used to record all necessary information. The ECIP Rapid Improvement Guides were used as a benchmark to develop a best practice approach where required. MDT Board Rounds In most areas board rounds were already well established but within the first phase of the roll out key essential board round criteria were agreed and implemented. These included; Attendance by representatives of the MDT A regular 9am start and 20 minute duration Consultant/SPR led EDDs established and reviewed Prioritisation of patients for the ward round (sick, home, other) Board round actions identified, allocated and tracked

2 University Hospitals of North Midlands (UHNM) The SAFER Bundle Supported by #Red2Green Our Journey Visual Management The white boards track all actions and record each patient s red/green day status. The actions are allocated to specific owners providing clarity on who is doing what. This creates a single point of reference for all the ward staff. Early discharges and admissions from emergency portals before 10am are identified and celebrated. All members of the MDT are encouraged to update the boards when actions are completed. Afternoon Huddles and Red2Green Status Afternoon huddles/board rounds give the ward team the opportunity to ensure all of the day s tasks have been completed and delays escalated in accordance with the Trust s internal professional standards. The red/green status of each patient is reviewed and for those cases where the patient's day remains red, the reason for the delay is reported and collated centrally at 3pm.

3 UHNM SAFER & Red to Green Reporting Figure 1 To support effectiveness and sustainability, a simple suite of reports were developed and used to sustain the implementation of the SAFER bundle. Two reports are produced daily and sent to the Divisional Management Team and Operations. Key elements of the bundle, which include the early pull of patients, board round effectiveness and early discharges are reported. Red and green day data is also captured to allow the Trust to target unnecessary delays. The morning data is submitted by ward staff before 10am. Figure 1 shows the data summary which is used to inform the morning bed meetings in medicine. This highlights successes which are acknowledged, and issues with flow and capacity to be addressed. Figure 2 The daily 11:30 bed meetings are central to the success of SAFER red2green in Medicine. The meetings are attended by senior nurses from all medical wards and emergency portals and the risk associated with high demand within the ED is shared across the Division. The daily, afternoon report, shown in Figure 2, gives a summary of the conversion of red to green days, the numbers of internal & external delays and the top 10 reasons for red days. Information on patient delays is no longer hearsay but supported by relevant reported information.

4 UHNM SAFER & Red to Green Reporting Figure 3 Weekly Reporting A weekly report brings together information on Board Round effectiveness (am reporting) and more importantly the aggregated reasons for patient delays (pm reporting). We can see clearly what our biggest causes of internal and external delays are. Determining what these are have led to focus groups and workshops during the initial 12 week project; internal and external service providers have worked closely with Trust staff to work through problems and develop solutions. There is improved understanding by Trust staff as well as external staff and a lot of myth busting has taken place. Communication within departments/wards/staff groups and externally has improved considerably and there is a general feeling of co-operative working and inclusion is reported.

5 UHNM SAFER & Red to Green Successes 12 Hour Trolley Breaches A symptom of the pressure the Trust was experiencing was that UHNM reported a significant number of 12 hour trolley breaches between October 2016 and January Since our SAFER Red2Green initiative this has fallen dramatically to zero 12 hour breaches in February and one in March. Compare and Contrast a Snapshot of Medicine Performance between 2016 & 2017 Site Matron Sit Rep, 09:30, 9 th March 2016 and /03/2016, 09:30 09/03/2017, 09:30 Attendees to now; 100 Attendees to now; 90 Patients in department; 95 Patients in department; 57 Resus capacity; 0 Resus capacity; 4 CDU capacity; 0 CDU capacity; 4 Patients in corridor; 20 Patients in corridor; 0 Medical DTA s; 21 Medical DTA s; 3, plans in place to move Site Matron s Sit Rep Following the end of the support from the PwC team on the 3 rd March 2017, staff were reporting a reduction in the pressures in the ED. To validate this a snap shot of the same date and time comparing the Site Matron s sit rep showed a startling difference in the pressures on the ED. The Medical Division in particular shows real improvement. Pre 10:00 moves; nil, nil planned Pre 10:00 moves; 10 moved by 09:25 Medical Outliers; 15 Medical Outliers; 2 Escalation capacity; open and full AMU; full Triage; full Escalation capacity; closed AMU; full, moving to accommodate DTA s Triage; empty

6 Hearts & Minds at UHNM It s OK to Ask Campaign UHNM Deconditioning Campaign UHNM Deconditioning Campaign Our own geriatrician Dr Arora and his team won an Academy of Fabulous Stuff award in January this year with their deconditioning campaign, which includes end pj paralysis. End PJ Paralysis Campaign On March 31 st, many of our staff (including senior management) wore their pyjamas for the day to raise awareness of the national campaign to encourage patients to get up and get dressed. Dressing into their own clothes helps patients to regain a sense of normality whilst in hospital.

7 Impact & Outcomes Quality Improvements Standardised, MDT Board Rounds Focus on early in the day discharge and pull from assessment units Medical ward rounds prioritised by the board rounds Clinical criteria for discharge form trialled Red and green days implemented for all patients Today s actions completed today A revised morning bed meeting which is now effective, succinct and offers a supportive forum for senior nurses to share their concerns on capacity and staffing Meet the SAFER & R2G Team in the Medical Division In February 2016, the Medical Division introduced the SAFER & R2G Team. All clinicians by background, the Team bring with them skills and knowledge of site management, management of patient flow and community healthcare. Medical Division Staff at the Daily 11:30 Bed Meetings Next Steps Follow us on Twitter NHS Rolling out a bespoke project in Surgical and Specialised Divisions Developing divisional and corporate highlight reports for executive and external reporting Discharge checklist being trialled A revised Ward Information System (WIS) under development to report red2green which will provide live information on effectiveness and delays

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