A Perfect Week in Worcestershire

An initial presentation & discussion 29 April 2014

Our patients are not receiving the best urgent care provision in Worcestershire
We know this because we see the following symptoms: Patients wait longer than needed Patients wait in the wrong locations EMS level 3 seen as normal Daily fire fighting Tired & exasperated workforce We dont meet national indicators for urgent care

Our care is not the best

Impacts of ED crowding

Impacts of ED crowding

Beds are where patients wait for the next thing to happen the aim should always be to minimise the waiting patients experience Capacity in hospitals..is skilled permanent staff, diagnostics

Do you agree with this view? Is it time to press the reset button in Worcestershire?

We need to change the service we provide to our patients

We cannot do this through one big system change, we can only do it through individual changes. We all need to.

Learn

Change

Test

Deliver

Perfect Week as a solution?

The Perfect Week is an approach used across the NHS to deliver improved urgent care for a week and change the way we all think and operate. The perfect week seeks to provide a really excellent high quality week of urgent care provision. The lessons learnt are then used in future weeks. The Perfect Week involves every member of staff in every organisation.

The delivery of a perfect week

Involves every member of staff, this includes support services A useful focus is the SAFER bundle

Patient Flow Bundle SAFER

The Patient Flow Bundle - SAFER

S - Senior Review, all patients will have a Consultant Review before 11am A - All patients will have a Estimated Discharge Date (that patients are made
aware of) based on the medically suitable for discharge status agreed by the clinical teams

F - Flow of patients will commence at the earlier opportunity (by 10am) from
assessment units (LAMU, ACU & SAU) to inpatient wards

E Early discharge, 50% of our patients will be discharged from base

inpatient wards before midday. TTOs for planned discharges should be prescribed and with pharmacy by 3pm the day prior to discharge

R Review, a weekly systematic review of patients with extended lengths of

stay ( > 14 days) to identify the issues and actions required to facilitate discharge. This will be led by senior leaders within the Trust

Why a bundle?
Bundles work people find them easy to understand Things we have seen work An explicit tool with a small set of interventions and clear parameters that, when delivered together, as part of a multidisciplinary approach, help to deliver the best possible care It helps standardises behaviours which results in safer care for patients

Does Daily Senior Review Work?

Twice weekly consultant ward rounds compared with twice daily ward rounds
Impact: Over study period, no change in length of stay on control wards Average length of stay on study wards fell from 10.4 5.3 The impact of twice-daily consultant ward rounds on the length of stay in two general medical wards No deterioration in other indicators (readmissions, mortality, bed occupancy)
The impact of twice-daily consultant ward rounds on the length of stay in two general medical wards Aftab Ahmad, Tejpal S Purewal, Dushyant Sharma and Philip J Weston (2011) Clinical Medicine . Vol 11, No 6: 5248

Senior Review
The Board Round introduces structure to the day to day running of the ward and helps the ward team to manage the patients safely and effectively Consider sick and unstable patients first is the patient deteriorating? What actions are required?

Board Rounds Initial 8am Review

Have new patients been given a EDD that the MDT agree on? Are there any patients to be discharged today/tomorrow? What needs to be done to ensure they go Home 4 Lunch? Are there any delays that need to be expedited?

Senior Review
The ward round should promote a consistent organised and disciplined approach to ensure an efficient use of time and resources , ensuring care is coordinated appropriately The ward round should follow the board round in the morning each day Patients should be seen in a specific order: Sick unstable patients MDT Potential discharges one-stop The remaining patients A record of the round, with clear management Ward plans, should be written in the patients notes Rounds TTOs should be prescribed and diagnostics ordered in real time Identify patients for discharge early discharge tomorrow

ALL Patient have EDD

Expected Date of Discharge (EDD) helps the Hospital to plan and understand its available capacity at all times it must be up to date Has the patients EDD been set within 24 hours of admission?

Estimated Date of Discharge (EDD)

Is the EDD realistic and does it reflect the actual date and time the patient is expected to go home?

Has the EDD been reviewed and, if necessary, updated each day?
Is the patient aware of the date and time they are expected to go home?

ALL Patient have EDD

ALL Patient have EDD

Criteria Led Discharge facilitates a smoother discharge by non-medical members of the MDT for patients that are deemed fit, provided certain defined criteria are met Consider a simple and timely discharge undertaken by nursing staff using agreed criteria Clinical criteria must be set by the medical team with functional and social criteria discussed by the MDT, and recorded in the patients notes The patients TTOs and discharge letter will be completed by the medical team

Criteria Led Discharge

Flow early from LAMU, ACU & SAU

Wards that routinely have patients transferred to them from assessment units on a daily basis will receive a patient before 10am every day to create the required capacity for incoming patients or will need to go to the assessment unit to find one Inpatient wards that routinely have patients transferred to them from the assessment units need to pull the first patient to their wards before 10am everyday By creating assessment unit capacity earlier in the day, unnecessary waiting for patients awaiting admission will be significantly reduced

Flow early from assessment units to IP wards

Earlier discharge
Target of 35-40% for non assessment units by midday Patients pre-prepared on admission for early discharge and use of Discharge Lounge Non use of Discharge lounge by exception Potential to write up and issue TTAs even though patient has already gone to Discharge Lounge

Earlier discharge

Review long length of stay patients

We need to proactively respond to the identified delays through appropriate action planning Do all patients have clear management plans for their medical care within the medical record?

Length of Stay Reviews

Is the patient waiting for any procedures or tests? Do these need chasing? Have you considered whether the care of the patient can be provided in an alternative setting rather than an acute hospital

Benefits
Patients will benefit from improved care coordination ensuring they receive their care in a timely manner in the right environment Patients will benefit from a well planned, timely discharge Staff will benefit from being able to provide patients with the specialist care for their needs Staff will have all the information they need to ensure care is delivered appropriately Staff will be able to deliver real time, accurate information to the Site Management Team and ensure the Ward Information System is up to date The Trust will benefit from improved patient flow throughout the organisation The Trust will benefit from having meaningful information to enable capacity and demand to be managed

Background to the Perfect Week

Social Movement Theory starts with.
Planning and preparation this is crucial to reduce the number of predictable problems during the week Creation of a compelling story why do we need to do this? Creation of a commitment is the board & everyone else fully committed to this? Staff engagement is everyone on board? How do you know? Creation of a structure (gold, silver, bronze) Sustainability the week is a start

Communication start now

One page simple brief from Exec team sent to all (first test for the team how quickly can you get this info to the majority of people face to face beats emails) Social movement tipping point Dont exclude anyone

If we randomly ask 10 people a week before will they know what this perfect week thing is about?

Some proposed commitments

Cancel all non urgent meetings and reduce e mail traffic To improve patient experience, safety, quality and

flow throughout the trust and beyond Consultants stand down non clinical SPAs to enable To urgently recalibrate the system 2 x daily senior review To reduce overall bed occupancy, how many empty beds at 8am? Increased visibility of senior staff To accelerate and improve the discharge processes To use the week to accelerate embed Liaison Officers to wards to resolve and problems known corporate services can help provide these, ask them good practice To engage staff and improve the working Move to a go and see model environment To reduce high escalation levels We will not tolerate unnecessary waiting for To improve performance patients, if I were the patient. Reduce patients waiting for things to happen

How will it work ?

The economy will be run as a controlled critical incident for 1 week Gold and silver command in place from day 1 in both hospitals to resolve problems with speed Ward liaison officers or equivalent in place in all urgent care locations Measure success daily Run daily wash up meetings to gather intelligence Listen, learn and share our experiences Thank staff daily for their input

The structure for the perfect week

Improved Care for Patients, delivered by all front line staff in the NHS and Social Care across Worcestershire

Supported by: Ward Liaison Officers

Bronze level - operational management Silver level - site management and the economy HUB

Ward Liaison Officers are support staff (e.g. HR and Finance who can provide additional support to wards for one week)

Gold level Executive staff with an active presence across sites

There is a guide to planning for the perfect week

There are seven key priorities: Planning and preparation this is crucial to avoid potential problems cropping up. Creation of a compelling story so we know why we are doing it. Creation of a commitment - so everyone shares a commitment to making it work. Staff engagement to involve everyone. Creation of a structure so its clear how things will be done. Creation of a series of measured actions to measure success and spot drawbacks. Sustainability to make the good things stick. Lets agree our next steps & timescales .