Extremely impressed by all involved in first Rapid Process Improvement Week

March/April 2016 Putting Patients First Focusing on clinical quality and improvement in The Shrewsbury and Telford Hospital NHS Trust Sensei Melissa (right) draws reflections of the week from the team. Extremely impressed by all involved in first Rapid Process Improvement Week Last month I was privileged to witness, and to be part of, the very first Rapid Process Improvement Workshop (RPIW) report out held within our Trust. A RPIW is a five-day workshop which focuses on a particular process in which our staff who do the work are empowered to eliminate waste, improve the patient experience, improve their own experience and make changes that they feel are right and will be sustainable. A RPIW is designed around the Plan, Do, Study, Act cycle. In the planning phase we observe what really happens to our patients as they go through our services and we plan how we may improve those services. In the do stage, we give it a go. We try changes and we are able to study the results and try something different if the results aren t those that we want, and then in our act stage, we are making those changes that have been shown to give the results that we desire. This also produces a change in thinking, an awareness that we can make successful, sustainable changes when we work together as a team. Simon Wright Chief Executive The RPIW comes after six weeks of planning, and in that planning stage we identify the area to be our test area, our Genba. We will have identified team members, both those that will come away from their clinical areas, department areas, and work on the Plan, Do, Study, Act cycle, and those home team members who will continue their day-to-day work but working with the away team, testing those changes and providing feedback and advice on the impact of those suggested changes. We identify a Workshop Lead and a Team Lead from the Kaizen Promotion Office (KPO) who help to maintain the methodology and the philosophy of the Virginia Mason Production System that we know works. This is a methodology that has been used for over 13 years in the Virginia Mason Hospital with significant successes. These Plan, Do, Study, Act cycles and Rapid Process Improvement Workshops are significant events in a year-long targeted improvement plan in identified areas, and in this case the Respiratory Discharge pathway. The process involves identifying advisory members who are available during the RPIW week to advise on how changes can be implemented in a rapid way. It is important that we identify the process boundaries as this type of Kaizen event is aimed at being a mile deep and inch wide so we really get to understand what our staff and our patients are experiencing on a day-to-day basis: collect the data, declare the targets, communicate as much as we possibly can with the team members and wider organisation, and look to the support of the VMI 1 sensei to guide us through the process. The role of the Sponsor Lead is to remove barriers, motivates the teams and reminds everyone of the significant reasons and urgency of the work that is being undertaken. Respiratory patients make up 40% of our emergency admissions to the hospital. They require on average a seven-day length of stay and so experience our services at one of the most vulnerable times of their lives when they are acutely unwell with often shortness of breath and illness which makes them extremely reliant on our services. This is a worrying time for them and for their families and we need to ensure our staff are set up with the right environment and tools to provide the service that our patients and families deserve. It was very clear to me that the RPIW event relies on strong teams and I was extremely impressed with the performance of all the teams involved the home time, the away team, the advisory team and the KPO team who supported and led the events. Kaizen events (the simple definition of Kaizen is improvement for the better ) rely on strong teams but the whole event strengthens relationships. Continued on page 2

Improving experiences for patients and staff Continued from front Individuals who may only work loosely together come together to undertake an intensive piece of work with real emotive reasons for making improvements in just five days. In order for this to happen, as it did during the March event, silos need to come down, hierarchical walls need to be breached as people get to understand one another s work. They get to walk in each other s shoes, measuring in detail activity such as number of steps, the movement of equipment, following laboratory specimens through their journey, watching how a patient goes through their X-ray process. These are opportunities that do not present themselves every day to us and were wholeheartedly embraced by the Respiratory RPIW teams. The Virginia Mason Production System which is the basis for our Transforming Care work, is totally team-based. It relies on staff members trusting each other, and creating the gold which is in the work of the team rather than individual stars. My take away message from the week was that impressive improvements can be made by small teams in a short period of time when they share a collective and clear goal. The small team consisted of many disciplines including HCA, Consultant, Ward Clerk, Staff Nurse, who up until this week had not worked together and some did not even know each other. I can only look forward to the future RPIW s with great excitement as we realise that together SaTH is very rapidly going to improve the existing experiences for our patients and our staff. The Away Team discussed ideas to improve flow. The data wall is a really important source of information. Standard operations tools are used to describe the current state. Workplace reorganisation to reduce waste in the reception area. The Away Team is pictured testing ideas with staff on duty. Comments from Sponsor Debbie Kadum, Chief Operating Officer. It was a case of standing room only during the Midweek Report Out, which featured great discussion, challenging questions and valuable feedback. The RPIW Report Out gathered a huge amount of interest from staff across the Trust. Page 2 2 Chief Executive Simon Wright took to the stage during the RPIW Report Out. He said: An incredible amount of work has been achieved in a week.

Key outcomes from the Trust s first Rapid Process Improvement Week (RPIW) Our teams showed belief all week and have clearly shown just what can be achieved I am the very proud sponsor of the first Rapid Process Improvement Week (RPIW), which took place as part of our exciting partnership with the Virginia Mason Institute in Seattle. The week used the methodology we have learnt from Virginia Mason to look at ways to improve Respiratory Discharge which is our first Value Stream as part of the partnership. A Value Stream looks at a pathway of care that our patients experience, and makes sure that at every stage we are focusing on activities that add value for patients and put patients first. The RPIW was the culmination of many weeks of planning and preparation work, from identifying the current state of the Respiratory Discharge Pathway through to the use of a Value Stream Map, identifying the care we would want to provide for our patients in the future. The aims of the week were to significantly improve the privacy and dignity of patients attending Walking Distance ACP/Junior Doctor Nurse Health Care Assistant Patient Parts Travel Distance Debbie Kadum Chief Operating Officer the Ambulatory Care Unit at the Royal Shrewsbury Hospital and reduce the time it takes for a patient to be assessed in the unit by 50%. My role as sponsor was to remove any barriers that the team came up against and to provide challenge to ensure we got the right output for patients at the end of the week. Why is this work important for us at SATH? Because what drives us is that we want to ensure that we provide the best outcome for our patients and, when we are at our busiest, this 3 can be an incredible burden on you, our staff. The RPIW looked at ways to improve the process for Respiratory Discharge to benefit patients and also to bring improvements for you. The work done during RPIW has been incredible. The journey was amazing. The challenges we set ourselves on the first day were to absolutely put the patient first at all times, give the care we want to give, to improve privacy and dignity; remove the waste, ensure equipment is always available, reduce the amount of walking, and find the opportunities for improvement. We also wanted to challenge ourselves to celebrate what we do well and set the standard for the rest of the Trust. It is evident that all these challenges were achieved during the week. During the RPIW we learned that small changes can have big impacts. We also learned that we can improve patient care by working together and asking those who know best how to improve it. That gives us hope that at SATH we can break out of the fire fighting that we do Putting Patients First Prior to RPIW Final Day of RPIW % Change 462 steps 420 steps 246 steps 92 steps 10 steps 161 steps 38 steps 20 steps every day. 98% Reduction 62% Reduction 85% Reduction 78% Reduction ECG Machine 102 steps 14 steps 85% Reduction Observation Machine 32 steps 0 steps 100% Reduction Quality (Defects) X-ray request forms 75% 6.6% 91% Reduction Missing stock items 80% 17% 79% Reduction Privacy and Dignity 80% 0% 100% Reduction Lead Time Time measurement of the process being studied. 3 hours and 24 minutes 2 hours 3 minutes 40% I want to thank everyone who played a role in our first RPIW for their commitment, hard work and belief. There is a saying that to accomplish great things we must not only act but also dream, not only plan but also believe. Our teams showed belief all week and have clearly shown just what can be achieved. At the start of the week I said I wanted a patient who attended the Ambulatory Care Unit not to be more breathless at the end of their assessment process than they were when they arrived by reducing the time for an assessment and the steps taken this will now be a rare occurrence. However, this is only the start. The challenge now is to ensure that we embed these improvements and I, alongside Sarah Kirk (Matron at PRH and Process Owner for the Value Stream), Clare Walsgrove Matron at RSH), and Lesley Stokes (AMU Ward Manager at RSH) will ensure that this happens. Page 3

Medical Director DR EDWIN BORMAN explains how our hospitals are taking the lead in the fight against a condition which claims more lives every year than breast cancer, bowel cancer and colon cancer combined Campaign launched to raise awareness of Sepsis and try to reduce number of deaths Our hospitals are taking the lead in the fight against a condition which claims more lives every year than breast cancer, bowel cancer and colon cancer combined. There are around 150,000 cases of Sepsis in the UK every year with, sadly, 44,000 people dying. Sepsis arises when the body s response to an infection injures its own tissues and organs. It leads to shock, multiple organ failure and death, especially if not recognised early and treated promptly. The Shrewsbury and Telford Hospital NHS Trust (SATH) has launched a campaign to raise awareness of the condition and try to reduce the number of deaths. Page 4 Although Sepsis is relatively uncommon, it can prove fatal and patients who develop the condition can deteriorate very, very quickly. Sadly, in our hospitals, around four patients a month die from Sepsis, along with other cases where the patient does not reach us in time. We want to reduce that number and believe that we can do so by increasing awareness of the condition and improving treatment. A couple of weeks ago, 110 members of staff at SATH attended an event highlighting what is known as the Sepsis Six a series of measures which should be delivered within one hour of a diagnosis of Sepsis. These measures include delivering oxygen and administering antibiotics. Anyone with early signs of a serious infection, together with one of the symptoms of sepsis should seek medical advice immediately. If a person has two or more of a very high - or very low - temperature, a racing heartbeat, rapid shallow breathing or confusion, then they may have sepsis and should seek medical advice immediately. If you are coming into our hospitals and are concerned, ask a Doctor or Nurse if this could be Sepsis. It could make all the difference. 4 Sepsis has been chosen as one of the areas SaTH will look at in the first year of its partnership with the Virginia Mason Institute in Seattle. This is a subject that, eventually, all clinicians will be involved in and will result in us being able to save many patients lives. The Virginia Mason system involves looking carefully at every step of the way we care for our patients and encourages us to think of ways we can do this better. We will also be working with our partners throughout the local healthcare system to improve awareness around this condition and to make a real difference to our patients.

In December, NHS sharedplanning guidance set out a new approach to help ensure that health and care services are planned by place - rather than solely around individual institutions - and over a period of five years, rather than just a single year. Central to this guidance is the design and delivery of Sustainability and Transformation Plans (STPs). Last month, details were published of 44 footprint areas that will bring local health and care leaders, organisations and communities together to develop STPs - local blueprints for improved health, care and finances over the next five years. One of these STPs will cover Shropshire and Telford & Wrekin, and I am honoured to have been named the lead officer for our health system. It will be my responsibility to work with partners to develop and co-ordinate work on the STP for our area to help transform health and care over the next five years. The STP will help drive a genuine and sustainable transformation in health and care outcomes, and help build and strengthen local relationships, enabling a shared understanding of where we are now, where we want to be in 2021 and the concrete steps that need to be taken in order to get us there. We keep saying that this winter, our health and social care services have been under greater pressure than ever, and that s because it is true. Our hospitals, community units and GP practices have been extremely busy for a long period, which causes delays for our patients. The increase in complexity has presented real challenges for social services and, as a system, we need to work together to build sustainable solutions for our aging population. We are very concerned about this and are working hard with system partners and commissioners to manage demand in more suitable locations than A&E, to support the timely discharge of frail elderly patients once their acute care is over, and to treat more patients through an ambulatory pathway enabling them to avoid a hospital admission. The headlines always seem to focus on A&E, so it would be easy to assume that the problem is just with our Emergency Departments. This just isn t the case. It is about the whole 5 system of urgent and emergency care in our county. Putting Patients First Garden of Tranquility for patients, staff and visitors A new peaceful garden was unveiled at the Princess Royal Hospital last week to benefit patients, staff and visitors as part of events to mark NHS Sustainability Day. The Boningale Garden of Tranquillity, near the Macmillan Unit and Haematology Clinic, is the third garden to be opened at PRH following the creation of the Memory Garden and Garden of Reflection last year. Each of the three gardens has transformed one of the courtyards at PRH to bring them into use for the benefit of patients, staff and members of the public. As a Trust we feel we have a major role to play in looking after our environment and take our sustainability efforts seriously. NHS Sustainability Day was marked with a range of events to provide information about our sustainability programme for patients, visitors and staff. People had the opportunity to find out how we recycle our domestic waste, talk to the Wildlife Trust about how we re using our grounds for conservation, and get a stamp on their bike by British Transport Police. But the centrepiece of the events was the opening of the Boningale Garden of Tranquillity. The garden has been completely redeveloped, at no cost to the Trust, thanks to the generosity of Boningale Garden Creations and other businesses, as well as the fantastic support of volunteers who planted the area. Thank you to everyone who has helped to make the garden a reality. A special thanks to the following organisations for their generous donations of time and resources: Border Harwood Ltd Breedon Aggregates Brewin Dolphin David Wilson Homes all pump solutions LLP Simon Wright Chief Executive Staff, volunteers and representatives from organisations which supported the opening of the garden are pictured in the Boningale Garden of Tranquillity. Julia Clarke, Director of Corporate Governance Working together to improve health care Too many people are attending hospital for urgent care, too many are being admitted and too many are spending too long in our hospitals as they face delays that are beyond their control before they can move back home or into more appropriate care closer to home. We need to work with our population to remove social isolation, develop and support our communities and neighbourhoods and create social capital with a focus on wellbeing not illness. In my role as Chief Executive of this Trust, and as the local STP lead, I am just a part of the wider jigsaw. Many other pieces need to be put into place if we are to genuinely tackle the problems we face and create sustainable services. I don t underestimate the task at hand, but I am looking forward to facing this challenge with my colleagues from across the health system so that we can deliver the care we want for our patients, families and carers. Page 5

Event generates additional discharges Ceri Adamson Head of Capacity at RSH Staff on six hospital wards took part in a Multidisciplinary Accelerated Discharge Event (MADE) to help patients who no longer need to be cared for at our hospitals be discharged earlier. The purpose of the campaign was to deliver a unified whole-system approach where patients who no longer require an acute level of care can be safely discharged. These events, which took place on Ward 25G, 28 and 32 at the Royal Shrewsbury Hospital and on Wards 4, 6 and 16 at the Princess Royal Hospital generated a number of additional discharges earlier than anticipated. The events also resulted in staff feeling empowered to get medically fit patients safely and appropriately out of hospital and back home. With senior executive encouragement during these events, staff felt supported to change how they work, identify process improvements that are sustainable, and morale improved as staff saw patient flow improve. Early, safe and appropriate discharge can lead to better patient experience, empty cubicles in the Emergency Department, and cost savings for local authorities as these patients require less on going care. National patient experience lead praises cancer services at SATH We were delighted earlier this month to welcome one of the leading figures in Patient Experience at NHS England to the Trust to look at Cancer Services at RSH. Catherine Thompson is the Experience of Care Lead in the Patient Experience Team and her visit to SATH was her first to specifically look at a dedicated Cancer Service. We invited Catherine to attend our Lung Support Programme, which is a collaboration between the Lung Clinical Nurse Specialists and the Macmillan Integrated Therapy Services team, providing information and support to the new Lung Cancer Patients. This is quite an innovative approach and has been in progress since September 2015. We also talked about the challenges of patient engagement in the development of new services, as well as the practical issues of delivering world-class cancer care in such a rural location with a diverse population. Improving patient experience is key to driving our services forward. Julia McAdam Operational Manager for Oncology and Haematology During Catherine s visit, we showed her the Lingen Davies Centre and met with Ben Jenkinson, the Centre s Admin Manager, as well as Dr Sheena Khanduri, Lead Clinician for Cancer Services. We also undertook a tour of the Radiotherapy department and Chemotherapy Day Centre. Catherine was very complimentary about our work and told us she enjoyed her visit. She said it was lovely to be able to come here and see how things are done. She said that one of the things that really struck her was the efforts to make it not feel like a hospital. She liked that the services are designed to make it feel, as far as is possible, less clinical. It was helpful to know that now we have built up our relationship, Catherine is very happy for us to contact her, and has offered advice and support. She also usefully said, we don't need to always formally obtain patient feedback, we need to remember to just ask. It was wonderful that Catherine chose to make us her first visit to a cancer facility, highlighting her interest in our work as well as in her understanding of our catchment areas and local population needs. The aim is to rapidly reduce the number of inpatients in our hospitals that are ready to be discharged or transferred and waiting for the next step to be taken. The next step is to pilot the SAFER patient flow bundle commencing in April on four wards across the Trust. It is a combined set of simple rules for adult inpatient wards to improve patient flow and prevent unnecessary waiting for patients. If we routinely undertake all the elements of the SAFER patient flow bundle we will improve the journey our patients experience when they are admitted to our hospital. Page 6 Catherine Thompson is shown one of the Linear Accelerators at RSH. 6 Catherine Thompson (centre) with (from left) Lorraine Eades, Head of Dietetics and Care Closer to Home Centre Manager; Julia McAdam, Operational Manager for Oncology andhaematology; Jessica Hancox, Lead Cancer Nurse and Sonia Rogers-Dodson, Therapy Co-ordinator.

Ward 10 promoting April Falls to highlight falling is not an inevitable part of getting older Stephanie Kane Falls Prevention Practitioner Sian Silgram, Ward Manager, and the staff on Ward 10 at the Princess Royal Hospital in Telford, are promoting April Falls by looking at how they can reduce the number of patient falls. Falls are the most commonly reported type of patient safety incident in healthcare and represent the most frequent and serious type of accidents in people aged 65 and over. A fall is classed as an unexpected event in which a person comes to the ground or lower level with or without consciousness. This is a broad definition which includes all types of Incidents such as slips, trips, falls and faints The impact of falls has psychological factors, such as loss of independence and a prolonged stay in hospital. Tackling the problem of inpatient falls is challenging for staff but research has shown multiple interventions performed by multidisciplinary teams, combined with risk assessments can help to address risk factors and reduce falls. From this we are then able to put in place support to help the patients. Falls prevention is everyone s business and on Ward 10 we want to help prevent further falls that could cause harm and require further treatment. We also want to minimise any fall that occurs in hospital. To aid this we have produced a poster (see below) which provides visual cues to assist staff, patients and visitors. Falling is not part of ageing. With the right knowledge and support the older people can stay active and falls can be prevented. Our April Falls focus topic is falls prevention helping to ensure that patients at risk of falls are: Nursed in the bay or side room nearest the nurses station. All patients in these beds are provided with and wear antislip socks. A member of staff is present at all times in the bay. Advice sheets to be above each bed advising on how to reduce falls. Checklists to be produced and in all patients nursing notes to 7 Helen Williams, Trauma Specialist Nurse. ensure if a fall occurs that correct procedures are followed. Champions to assist the ward in minimising falls. Teaching sessions to promote falls awareness and knowledge for all staff. Ensuring patients are nursed on the correct bed and have crash mats as required. Visual aid on patient s board and PSAG to highlight those at risk. Patient and visitors information board highlighting falls prevention. Reflective practise sessions for staff to help improve our practise. With these measures in place Ward 10 aims to reduce our falls and become an example of good practise in the prevention of falls and harm. Throughout June and October there will be a Link Worker course for falls. Anyone interested in attending should book a place on the course by using the online Training Diary on the intranet. Page 7

Every month Putting Patients First goes behind the scenes at a department within the Trust. This time we meet Clinical Coding Manager, Angela Coles. While patients and their families come first and foremost at SATH, the Trust still needs to make money to survive. Most of that income is generated by the team in Clinical Coding. For each and every patient who comes into our hospitals, our Clinical Coders translate the medical terminology that describes a patient's complaint, problem, diagnosis, treatment or other reason for seeking medical attention into codes that can then be easily tabulated, aggregated and sorted for statistical analysis. It is quite technical stuff. The codes are used to generate what are known as HRGs Health Resource Groups. These are standard groupings of clinically similar treatments which use common levels of healthcare resource. These HRGs are used as a means of determining fair and equitable reimbursement for care services we deliver. Their use as consistent 'units of currency' supports standardised healthcare commissioning across the service. Clinical Coders are the health informatics professionals, they are required to have a strong understanding of anatomy and physiology, they may not physically treat our patients, but their depth of understanding and knowledge is on a par with any new Junior Doctor. Clinical Coders Liaise regularly with clinical staff throughout the Trust. We are fortunate to have strong links with our clinical staff who are happy to answer questions and provide input when we ask. The demand on the team is quite intensive. We have a team of 27 people across the two sites, and we code around 150,000 episodes a year and that is just inpatient episodes. I am immensely proud of my colleagues. We work as a team and are all fully supportive of each other. The team keeps on delivering month after month after month and it is a privilege to be a part of it. 8 Angela Coles, Clinical Coding Manager The Clinical Coding Teams at PRH (top) and RSH (above) For the second year in succession the Clinical Coding Department has achieved a Level 3 in their Information Governance Clinical Coding Audit, with a primary diagnosis accuracy of 97.50% and primary procedure accuracy of 96.77%, for inpatient activity. The results are well above the recommended 95% accuracy for primary diagnosis and primary procedures. This is a huge achievement and something to be celebrated. The team is audited on a monthly basis with 300 sets of case notes being examined each time to test the quality of the data that is being collected. Angela said: Our team of Clinical Coders here at SATH are a team of conscientious, dedicated people who empower the Trust Values, even when the odds are stacked against them. Life in the Coding Department can often be very challenging, but they never let me or the Trust down. They always go above and beyond what is expected of them, I am extremely proud to manager such a hardworking, dedicated group of people. Page 8