Spotlight on Visual Management

Using Lean for Continuous Improvement Special points of interest: Ministerial Visit Improvement News Silver Cells BICS Academy Celebrating success Forthcoming events Inside this issue: Ministerial visit 1 Intermediate care ED Rapid initial assessment Safety Express Theatres Pharmacy Clinical Audit Short Stay Surgical Flow Silver Cell Events BICS Academy & Shared HSJ Shortlist Macmillan Coffee Morning 2 3 4 5 6 BICS NEWSLETTER Ministerial Visit On Thursday 21 st July Lord Howe - Parliamentary Under Secretary of State for Quality visited the Trust to see first hand Bolton NHS Foundation Trust s improvement work. Lord Howe specifically requested to visit Bolton as he has heard about departments and clinical areas that have been involved in the Trust s improvement work (BICS), underpinning the Trust s response to the national QIPP (Quality, Innovation, Productivity and Prevention) Initiative. The Minister visited the BICS Department and heard presentations from CAMHS, District N u r s i n g, H e a l t h R e c o r d s a n d Gastroenterology; before taking a tour of C3 ward, meeting staff and patients. ISSUE: JULY 2011 Lord Howe commented The NHS is one of the things that make this country great. Today I saw first hand how staff at the Bolton NHS Foundation Trust have worked to improve their services for patients. Spotlight on Visual Management Visual Management and knowing how we are doing is one of the backbones of a lean organisation. Teams across the Trust in the hospital and the community have been doing great work in increasing the level of visibility of their work, for example, creating better care via safety crosses, responsibly using resources via kanban and other stock control visual systems and respecting each other and our patients by ensuring good visual communications about our care. At an organisational level, one of the ways of doing this is via the lean approach of Policy (Strategy) Deployment ( hoshin kanri ) and the quarterly review process for teams and departments. Some fantastic examples of this are in Blood Sciences and Radiology and you may have heard of L1s L2s and L3s for your own area priorities. This year we are looking for further ways to strengthen this work, and spread this best practice further across the integrated organisation by increasing the visual management for the organisation and the new divisions. We hope you can help us with your ideas on how to do Visual Management of Policy Deployment in Lab Medicine this better. For more information please Joy Furnival c o n t a c t j o y. f u r n i v a l @ b o l t o n f t. n h s. u k o r Head of Lean Debbie.carr@boltonft.nhs.uk Transformation

Improvement News Page 2 Intermediate Care Rapid Improvement Event Following on from the Urgent Care Event in March 2011, work concerning Intermediate Care resources was identified. Intermediate Care comprises 80 beds over 4 units and a domiciliary service (Intermediate care at home). A multi-disciplinary, multi-agency team came together to identify areas for improvements. During the week the team members visited different locations of Intermediate care and associated services. They mapped the patients journey and talked to staff and patients. This allowed the team to identify the waste and the frustrations the staff often feel with the current state. As a team they designed a future state that will offer a more equitable and responsive service called The Perfect Match A series of rapid experiments are planned over the next few months along with events to facilitate a staged implementation. This new future state provides opportunity to reduce waste and defects in the system by up to 45%. Key features of the future state include: Single point of access Early decision making about appropriate patient for IMC, within hours not days Flow and Pull One key question to be asked is Why not community? Improved equity of service, (age and referral source). Concept of safe to transfer care to continue in community once clinically fit Overall the team worked hard, formed new relationships and created a future vision supported by a robust action plan. If you would like to know more about this event please contact LesleyAnn.Fraser@boltonft.nhs.uk ED rapid initial assessment ~ Experiment A Rapid Initial Experiment was chosen to improve the quality of Percentage time RIA Open treatment in the Emergency Department. The main issues with the Emergency Department was with the inconsistency of opening hours for the Rapid Initial Assessment team, with RIA only being open until 9pm and therefore not matching demand. There is a constant struggle to provide a consistent ambulance handover time, consequently the department June July August is not meeting all its quality indicators. As a result of the event, measures are being put into place in an attempt to address the issues. A dedicated rapid assessment team will be formed, and a redesign off the staff rota and shift patterns for the whole of majors will be implemented so that the workforce reflects demand. Work was done with ambulance staff to improve data and standards for handovers. Standard work for the team will be developed to raise staff awareness. The event was a success and preliminary findings show that the measures which have been implemented have made the department more efficient, for example the rapid initial assessment area is now open until 11pm. The staff rota was redesigned using the same workforce and as a result more patients are receiving a full assessment. Further work is being done to implement a contingency plan in times of staff sickness and major incidents. For more information please contact Susan.Beswick@boltonft.nhs.uk, Matron in Emergency Department.

Improvement News Page 3 Safety express - Catheter Documentation ~ Experiment Section A: Please fill in on catheter insertion Ward:.. Verbal consent obtained Patient given a Urethral Catheters information leaflet Urinalysis taken Results NB CSU sample to be sent to lab only if Patient has clinical symptoms of urinary infection. Section B: Ongoing Section catheter A care Decontaminate hands before manipulating the catheter in any way Wash and dry tubing daily with soap and water and dry the tube Empty catheter bag every 4 hours Check urine volume 4 hourly Ensure catheter tubing remains lower than bladder Catheter bag dated on insertion and changed every 7 days Use catheter stand, hooks and straps avoid floor contact Use leg bag on ambulant patients to promote privacy and dignity Ensure Coloplast catheter discharge pack given to patient on discharge. Section C: Patient observed for sign of infection PREVENT INSERTION- PREVENT INFECTION Catheterisation Record Date.. Time... Allergies to Latex Use Silicone Catheter. Indication for Catheterisation.. Urinary Retention - Painful/Painless/Clot Retention ANTT Yes/No Easy Procedure Yes/No Volume Water H2O in balloon mls Catheter Identification Label Signature Residual Volume mls Urine colour.. Foreskin repositioned if applicable Expected Date of Removal.. District Nurse Referral. Referral to Charter Del Service Print The Trust is presently working on the Safety Express initiative as part of the QIPP programme in order to reduce harm. The Catheter Team have been working to reduce urinary tract infections. As part of an improvement cycle an updated catheter care plan (pictured) is presently being piloted in theatres and several ward areas. Evaluation of practise appears to be promising at the moment. Pathology are presently recording the number of CSU tests which are being requested at the moment to identify if there is a reduction in unnecessary tests. The catheter team have also looked to improve the discharge documentation to form a catheter passport to facilitate good communication for patients with long-term catheters as they revisit the organisation. Results from this work will be included in future team briefs If you would like to know more please contact N a s h a. E l l a h i @ b o l t o n f t. n h s. u k o r Carol.Bernstein@boltonft.nhs.uk Theatre Pharmacy Rapid Improvement Event An event was held to effectively and efficiently organise the drug storage areas in Theatre, in order to eliminate wasteful processes and risks. A central store cupboard was created to hold stock for all theatres, to significantly reduce the time wasted stocking individual cupboards, especially lots of pharmacy waiting time when the anaesthetic rooms are inaccessible. Standard work was created ensuring Anaesthetic Practitioners re-stock the anaesthetic room cupboards on a daily basis. With the new layout drugs will be visible and more quickly accessible and Pharmacy re-stocking time will be reduced from 3 hours twice per week to 30 mins 3 times per week. For more information please contact David.Haworth@boltonft.nhs.uk Clinical Audit Using BICS in Every Day Improvement Activity Bolton Improving Care System is not just about the BICS team, it s a system for creating a culture of continuous improvement to be adopted by all teams within the hospital. Clinical Audit have been putting their skills into practice with a recent initiative. Qpulse is a shared electronic system which allows the team to log and monitor the Trust s Clinical Audit Activity. The team planned a half day event to review and identify any areas which needed to be adapted after its first year in situ. In preparation team members visited MRI to learn from their experiences. They examined their current and target state, used various techniques including process mapping to identify problems and waste before agreeing solutions. Some examples of immediate changes included: Ensuring reporting update is accurate on weekly basis to ensure all colleagues have accurate data in staff absences Destroy and delete all patients lists upon completion of the audit Long term changes involve removing the reliance on other electronic systems to avoid duplication and visual changes to the Q-Pulse system so they can monitor audits more efficiently. The Team are all Green and/or Bronze trained, and used these skills in order to devise their final checklist for standard work. If you would like to know more please contact Michelle Warner or Chedia Hoolickin on ext 5815.

Improvement News Page 4 Short stay Surgical Flow Team - 90 Day Results A well done to the Short Stay Surgical flow RIE team who increased the % of short stay patients going home within 23 hours by 60% and reduced the number of patients placed on standby by 30% by the introduction of standard work for nurse led discharge on F6, F4 & G3. This means that patients have a better experience as they are not having to wait to see if a bed becomes available to be admitted and they able to be admitted to their ward prior to surgery rather than waiting in the admissions unit. For more information please contact Vicky.Welsby@boltonft.nhs.uk Silver Cell Improvement Events In addition to classroom learning, staff embarking on the Silver training participate in setting up a lean cell. A cell is the name for an area of work with a specifically defined purpose and processes. Learning by doing is one of the key principles of BICS and teams always remark on how much this consolidates and embeds the classroom learning. For further information on Silver Cell events or to apply for Silver level training please contact Emma.Broda@boltonft.nhs.uk Blood Sciences (Immunology) ~ Silver Cell Immunology recently participated in a BICS silver cell implementation event. Change was required because of an increase in volume of immunology work from Manchester and Salford. The new service and cell was set up based on BICS principles, enabling it to be more efficient. They also aimed to reduce the turn-around time by 50%, reduce the costs of delivering repatriated tests by and increase staff satisfaction a baseline of zero. During the event the team reviewed the current process in detail and removed numerous unnecessary steps and wasteful processes. A suitable work area was created using 6S and standard work was developed and tested. The results of the event so far show that for the first two tests the turn around time has reduced from up to 12 days to 24 hours while the work environment is much safer. Costs have been reduced by up to 15,000 per year. Initial staff feedback has been excellent and electronic results are available to the customer, ensuring they are timely and delivered to the right place. If you would like to know more about this event please contact Barry.Gallagher@boltonft.nhs.uk General Surgery Outpatients ~ Silver Cell A number of issues had been identified with patient flow and the NHS Direct telephone assessment contract has not been fully utilised. They also wanted 90% of patients to be seen 2 to 6 weeks prior to surgery and increase the number of telephone assessments by 50% reducing the burden in face to face clinics. During the event the team managed to identify issues and came up with solutions that could be implemented without major IT development. The improvements include access to the Trust patient administration system for NHS Direct to ensure more accurate contact details are recorded, telephone assessment clinics to be trialled in August, operation booking/appointment form and telephone assessment forms combined and a clinic suite within General Outpatients was set up to support the flow of staff and patients using 6S tool. Over the next few months these improvements will be reviewed ant it is expected that they will see the number of patients seen within a week of surgery reduced to 10%. The number of attempts to contact a patient will reduce from 6 or 7 to 1 or 2 and the overbooking of face to face appointments will reduce by 50% and concurrently telephone assessments will increase by 50%. If you would like to know more about this event please contact Stephanie.Leonard@boltonft.nhs.uk

BICS Academy Page 5 Bronze Training Bronze Level Accreditation is the second level of the BICS Learning and Development Academy. The course focuses on enhancing your leadership and BICS skills either to lead improvements or to be a more confident team member. It covers using tools such as A3 thinking, mapping and problem solving. It will help you to see waste and prepare for how your staff may react to change. The course provides theory, supported by practical application and examples, reflection, group discussion and sharing experiences. Should you wish to apply, please ensure you fulfil the pre-course criteria of attending Green Level Awareness and participating in at least one BICS event. Dates available: 6th-8th September (now fully booked) 3rd-5th October 28th-30th November To apply or for further information see our Academy page on our intranet site, contact BICS@boltonft.nhs.uk or 01204 390482 (ext 5382) There are a number of WebEx seminars available via AQuA for those wishing to further enhance their knowledge and skills around improvement and leadership. The following 2 WebEx seminars are offered by Dr Dafydd Williams who is an A&E Consultant, Astronaut and Aquanaut: Understanding Leadership, Followership and Team Performance 15th August at 15:45 to 17:00 Performing at Your Personal Best 14th September 15:45 to 17:00 These sessions require pre-registration at https://aqua.webex.com Sharing the Learning Across the hospital and community services 100 s of good ideas are being implemented everyday to overcome problems. Many of these are never shared with other wards and departments. The aim of the SHARED LEARNING web pages is to provide a place to be able to share this good practice and to offer inspiration when you are looking for ideas to address an issue The site supported by the Exemplar Programme, the BICS Team and sponsored by the North West Leadership Academy will allow you to search through hundreds of ideas already being used. It also gives you contact names so that you can find out more details and visit areas to see it for yourself. If you have an idea to share or to find out more email the BICS Team at BICS@boltonft.nhs.uk

Celebrating Success & Other News Page 6 Congratulations to teams short-listed for Health Service Journal Efficiency Awards Take a look at our case study page on our intranet site for more information on these events. Forthcoming Events There is no official event week in August, however the following activities will be taking place.: 6S event for the new Children s Unit 6S event with the PALS Team Musculoskeletal Team 2P Event Ongoing Productive Community Services Work Several teams within the Trust have fought stiff competition to be shortlisted for the prestigious HSJ Efficiency Awards: Creation of a Centralised Booking Service for District Nurses lead by Lynn Price Streamlining of Outpatients Admin & Clerical Services lead by Lisa Galligan-Dawson and under the category of Communicating Efficiency the Trust has been short-listed for supporting a number of clinical leaders with their recent strategic reviews. The number of teams short-listed reflects the personal dedication of all staff within the teams and the Trust s commitment to continuous improvement. All teams have demonstrated not only tremendous efficiencies but significant qualitative improvements too by keeping patients at the heart of everything they do. BICS Team Coffee morning 30th September 11am to 1:00pm Next event week begins on the 19th September 2011 Watch this space for more information Next BICS Outbrief 23rd September in the Lecture Theatre 11.30am Everyone welcome! For more information about any of our events or about BICS in general, please refer to our intranet site Bolton Improving Care System Contact details: BICS@boltonft.nhs.uk ext: 5482 Would you like to help raise money for Macmillan Cancer Support? We are holding a coffee morning in support of the Macmillan World s Biggest Coffee Morning initiative. Please come and join us, enjoy delicious refreshments which will be brought in by the team and enjoy a chance to catch up with your colleagues in other departments. (A very small donation of 2 is requested to attend). We look forward to seeing you. Everyone welcome!! Website: