The CHANGE room story Dr Jennifer Hill Clinical Director of Respiratory Medicine NIHR CLAHRC for Yorkshire & Humber
What is the Respiratory service in Sheffield? National - Pulmonary hypertension Regional - CF, ILD, interventional bronchoscopy, asthma, ventilation, OLD Local - Acute respiratory work, TB, bronchiectasis, COPD, lung cancer, PE, pleural disease
Who are our staff? 17 consultants 31 trainee Drs 15.72 wte Specialist nurses 181.92 wte ward nurses 14.58 wte physiologists 30.78 wte admin and clerical staff
What is our foot-print? Pulmonary vascular disease unit RHH Brearley 1-4 NGH Cystic fibrosis ward NGH Brearley outpatients department NGH incorporating Respiratory Physiology
HOW DID THE JOURNEY START?
Rita s story A Doctor told me last week she thought I d be home by the end of the week. I said I hope so! But I m still here a week later. Nothing really happened over the weekend I ve been in here quite a few times but I wish they knew about your medical history. It always surprises me that nobody knows about you, what tablets you are on, so you get asked the same questions over and over On MAU they did tests, blood tests and that, and I had a chest x-ray. Then I had the same tests again here, more blood tests. I was asked the same set of questions in A&E, MAU and then here, over and over. It s what happens when you come in here same questions, same tests over and over.
Visit to Bolton..
Ownership (Dec 2011)
Quality Improvement - The structure SDSA Standardise PDSA Change Ideas Assessment - 5Ps Define Themes
5Ps Identifying themes 250 Data Discharges By Day Analysis Of The Week (01/11/10 - of 06/11/11) the system - 120 Discharges By Hour of the Day (01/11/10-06/11/11) 100 200 80 150 100 Brearley 1 Brearley 2 Brearley 3 Brearley 4 60 40 Brearley 1 Brearley 2 Brearley 3 Brearley 4 20 50 0 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 0 Mon Tue Wed Thu Fri Sat Sun Brearley 1 - On the scale below please indicate what you would change to improve the experience for patients and staff. 100% 80% 60% 40% 20% 0% Clinical Outcomes Patient Care and Dignity Patient Safety Hospital environment - layout Hospital environment - cleanliness Ward Organisation and routines Ward Rounds Handovers and continuity of care Communication Protected meal times for patients Information available for patients and relatives Medicines management Staff working patterns/hours Statutory meal breaks for staff 4 - Large change required 3 2 1 0 - No change required Available equipment Interface with allied health professionals I ve been in here quite a few times but I wish they knew about your medical history. It always surprises me that nobody knows about you, what tablets you are on, so you get asked the same questions over and over
5Ps - Learning lots of variation in ward round, ward and MDT processes across the Wards communication highlighted as an issue by all the staff discharges peaked late in the day delaying flow drug rounds were regularly interrupted TTO process caused delays
CHANGE Themes Ward rounds and MDT processes Q Coding Medicines Management
Change Ideas Assessment to PDSA Global Aim Improvement Themes
Global aim We aim to improve the daily multidisciplinary delivery of care from admission to discharge in the four Respiratory wards It is important to work on this now because we are not as good as we could be. We care, and we want to be the best!
Brearley Ward Process map
Quality Improvement - The structure SDSA Standardise PDSA Change Ideas Assessment - 5Ps Define Themes
First PDSA BOARD ROUNDS Specific aim - to achieve daily 9am MDT face to face communication and problem solving across all 4 Brearley Wards 100% of the time for the successive 2 weeks
First PDSA Board Rounds Initial test for 2 weeks w/c 16 th July 2012 Measures attendance time taken time of referral to OT or PT qualitative survey monkey after test
4 Step Board Round Structure Diagnosis Medically fit? Sick needing immediate review? Social issues? Y/N Y/N Y/N NB. Please prioritise sick patients and those who are medically fit with no social issues for review first on WR - and do TTOs immediately
Do you think the daily board rounds should continue? 25 20 15 10 5 yes no don't know 0
STANDARDISATION ON WARDS
WHAT HAVE WE DONE SO FAR? Issue PDSA Data collected Standardised Ongoing work Board rounds Yes Yes Yes Yes Pharmacy run Yes Yes Yes Virtual checking station Yes Yes Labelling notes trolleys Yes Bed Wizard Yes Yes White boards Yes Stock Yes Near INR patient testing Yes Yes Drug omissions Yes Yes Baseward summary Drs sheet Yes Ward round check list Yes Yes Medicines reconciliation Yes Stalled Drug rounds Yes Yes Nurse handover Yes Yes Paperwork filing Yes On-line anticoag appointments Yes Yes Yes Open visiting Yes Yes Red social folder Yes Parked
Stock take in early 2014 (1) Successes - board rounds - drug rounds - standardising paperwork - bay and trolley labelling - open visiting
Stock take in early 2014 (2) Ongoing work - stock storage/ordering - nursing handover - ward round checklists -bed wizard
Stock take in early 2014 (3) Lessons learnt - INR testing
WHAT DO THE STAFF THINK?
Do you think that the CHANGE room should continue? 100 80 60 yes 40 no 20 0
What resources could help improve your working day? PJ's, Nighties, Gowns Linen, Blankets, Bedding, Laundry Basic/decent food for patients Portable PC with PACS More PCs Equipment - Chairs, stools, hoists Coffee machine TTOs Drug Trolleys Pharmacy Technician Slipper Socks Medical Cover on Wards Redesigned Paperwork Upgraded Fax Pillows Pens Shampoo Caps Warmer for wipes 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Responses
WHAT HAS THE CHANGE ROOM CHANGED?
Rita s story A Doctor told me last week she thought I d be home by the end of the week. I said I hope so! But I m still here a week later. Nothing really happened over the weekend I ve been in here quite a few times but I wish they knew about your medical history. It always surprises me that nobody knows about you, what tablets you are on, so you get asked the same questions over and over On MAU they did tests, blood tests and that, and I had a chest x-ray. Then I had the same tests again here, more blood tests. I was asked the same set of questions in A&E, MAU and then here, over and over. It s what happens when you come in here same questions, same tests over and over.
Hospital Standardised Mortality Ratio (HSMR) Patients discharged from Respiratory Medicine Respiratory CHANGE commenced (Jan 2012) First PDSA - Board Rounds (Aug 2012) Source: Dr Foster
Strengths and limitations of the process +ve - Engaging staff - Measured improvements -ve - mesosystem - traditionalists - Lifestyle change
ANY QUESTIONS?