delivering improvements outside the hospital walls

Delivering improvements outside the Hospital Walls

Using Lean Principles

Dr Brian Bradley Bolton Respiratory Team

• Northern industrial town

• Population 270,000

• 12% ethnic minority population

Bolton health survey epidemiology

COPD 2.7%Chronic Bronchitis 7.5%, Chronic Cough 13.5%Wheezing 18.7%

We are here!

About Bolton

About Bolton NHS FT

• Currently 775 beds –Catchment approx 350,000

• Busiest emergency service in the North West

• 2011/12 £260m turnover

• 46,000 non-elective admissions per year

• Respiratory illness is high volume pathway (27%)

Bolton Respiratory Team

Respiratory Team Vision

• Timely, equitable inpatient access to respiratory services

• Best cost-effective outpatient MDT services

• Support primary care to provide equitable good quality respiratory care in community

• Underpinning ethos of ‘Best Possible Care for the Patient’ in the most appropriate setting

Respiratory team: lean journey with BICS

• 2006 Minor changes but sustainability issues

• 2009 Respiratory Inpatient Care

• 2010 Hospital and Community Respiratory Nursing Event

• 2012 Respiratory Outpatient Service

Opening Access and Community Facing

The Bolton Improving Care System

UnderstandingValue Learning

To See

RedesigningCare

DeliveringBenefit

In-patient care - case for Change

Staff Opinions

• All work very hard but don’t always deliver the good care to our patients

• High bed occupancy figure

• Not enough time or staff to change things

• Must be able to do things better!

Targets!

• High Standardised Mortality Ratio 118.9 Jan 2009

• Length of Stay -14,183 Excess bed days

• High mortality for respiratory conditions

• Not implementing pneumonia care bundles as well as we should

What do our patients want from a service?

‘Listen To’

Right Medication @ Right Time

Basic (‘unspoken’)Access

Contact in hours

Straight to Respiratory Ward, Management Plan

Performer

Delighter (‘unspoken’)Contact out of

hoursStraight to Respiratory Ward

Frustrating-‘Having to explain to junior doctors when breathless, ‘history taking’

Kano Model used to identify from patients what do they want from a service

Rapid Improvement Event-April 2009

Core Group of Staff

• Nursing Staff

• Consultants + NCHDs

• Physiotherapy

• Occupational Therapy

• Pharmacy

• Social Workers

• Outsiders !!

4 Day Event!

• Gap Analysis

• Agree new ways of working

• Support this Standard work model

• Devise a model to sustain the changes

Gap Analysis:

Medical issues

• Poor documentation

• Poor discharge planning

• Poor communication with nursing and other staff

• No role in MDT

• Poor follow through on issues

• Juniors – reactive working

• 75% Discharge scripts done on day of discharge !!!!

Nursing

• Not enough staff

• Chasing up doctors to do the tasks / TTOs

• Interruptions –40% of time delivering

• Drugs -i.v. antibiotics

• Handover / prioritise work

• Social work referrals and discharge planning

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Agreed - Needed to Change/ Improve

• Simple evidence based pathways

• Improve Patients journey - ensuring visible status and review this daily

• Monitor: Visible accountability, improved documentation with completion tasks

• Visible proactive discharge planning process – TTOs and Summary

• Strengthen Multidisciplinary Team Working with Clarity of responsibility better Co-ordinating Care

New Ward Day Plan• 7.00 am: Observations• 7.30-9am: Nurse handover and drug round• 9am: Daily consultant ward round with

NCHDs and bay nurse• Daily 11.30 Multidisciplinary Ward Meeting:

Consultant led, bay nurse, NCHDs, therapy staff and social worker

• PM: Ward work procedures, paperwork, teaching & training, relatives

STANDARD WORK FOR WARD ROUNDSRESPIRATORY WARDS

Performed by: Medical & Nursing staff

Stage: Daily throughout patients’ stay

1 Ward round will start at 9am each day.

2

AimsIdentify and document the diagnosis Check appropriate treatment for severity of illness (Drug chart)Check response to treatment - check observations, EWS, fluid balance resultsIdentify new issues / problems (medical, nursing or social)Check VTE prophylaxis assessmentWorking diagnosis / coding (real time) Identify DNAR, ceiling of treatment ( NIV)Patient information / educationUpdate Discharge information & Social Work Log.

3 Complete all documentations in clinical notes including a clear management plan

4

Review Drug prescription sheet with particular emphasis on:antibiotic prescription -consider transfer to oral antibiotic treatment on a daily basis.Please sign wardex to indicate review of i.v. antibiotics.Check Oxygen is prescribed and administered appropriatelyReview the need fluid balance, completing IV Fluid prescription if required

5 Decide any actions or investigations required

6Allocate tasks

NursingJunior medical staff – Investigations, results, re-write drug wardex

7 Identify any issues for the board round, including notifying Social Worker to attend MDT for complex issues around identified patient.

8

Identify patients for Discharge ProcessTTOs for next day discharges should be completed between 12 noon and 2 pmSame day discharge TTOs to be completed on the ward round – if possibleDischarge letter to be completed before patient leaves the ward

9 INR to be completed at 6am on the day of discharge.

10

Weekend planning when appropriateIV antibiotics / Nebs / O2 / Warfarin / Drug charts Clarify NIV arrangementsFluidsRequest weekend bloods /Investigations and arrange results reviewsRe-write wardex Discharges and TTOs when appropriate

11 Complete Sustainment Graph Daily

Visual Management –ExtraMed

Daily Update

• Admission date

• Original predicted discharge date

• Current predicted discharge date

• Status: on target/at risk/overdue/exempt

• Comment field – social issues section 2/5 awaiting

Actions from RIE

Implementation Time Table

• May 2009 Board Round / MDT commence

• June - Respiratory Consultant daily ward round on 1 ward and MDT

• Review of process August 2009September 2009 – Respiratory Consultant on both wards, new OPD system

New Consultant Job Plans

• Consultant on each ward -weeks slots. Males or females on AMRU/HDU/ICU /consults

• 3 Consultants off wards -increased number of clinics , bronchoscopy lists Student teaching

• Continue medical on call rota, Respiratory NIV rota. Holidays / study leave when in OPD

Confirmed State

30, 60, 90 day Measures - underpinned by our 4 True Norths

No GoGo

Improved HealthBed Occupancy

Best Possible Care Delays

Joy and PrideStart / Finish on time

Value for Money Planned vs Actual

a b

c d

Discharges from D3 & D4

0

50

100

150

200

250

April 0

8

May 08

June

08

July

08

Augus

t 08

Septem

ber 0

8

Octobe

r 08

Novem

ber 0

8

Decem

ber 0

8

Janu

ary 09

Februa

ry 09

March 0

9

April 0

9

May 09

June

09

July

09

Augus

t 09

Septem

ber 0

9

Octobe

r 09

Novem

ber 0

9

Decem

ber 0

9

Month

Num

ber o

f Dis

char

ges

Number of Patient Transferred from D3/D4 to ICU/HDU

0

5

10

15

20

25

April 08 June 08 August 08 October 08

December 08

February 09

April 09 June 09 August 09 October 09

December 09 February 10

Month

Number of Transfers to ICU/HDU

Total Mea UCL

Proportion of All Patients Readmitted

7.00%

7.50%

8.00%

8.50%

9.00%

9.50%

10.00%

10.50%

Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09

Month

Trend

Source: Dr Foster 2/2/2010

140 random patients reviewed March 2010

Respiratory Nursing Team – 2009/10

• High input into respiratory ward no longer necessary

• Focusing non respiratory areas supporting implementation of best practice

• Inequity among the patient groups

• Focusing input earlier in the patient’s journey

• Non-patient contact time handovers/travel

Why change ?

Rapid Experiment – same resources

• Respiratory nurse specialist on wards 7 days

• Board round aiming for early respiratory review

• Fast track to most appropriate area

• Support non-respiratory areas

• Liaise with other specialist nurses

• Re-organisation of community working

Visual Management

RNS Ward / Base Cell

6S

1 Piece Flow

Standard work

PullPre- 6S Score

12.5%

Post Score

93 – 100%

Agreed best way

of working

How visits are

organised

How are we doing at a glance?

Where are staff located

Clear standard work, for pulling specialist skills/

also pulling patients to the

right ward

(c) 2011 Royal Bolton Hospital NHS Foundation Trust. All rights reserved. This document may be copied for use in the NHS only on

the condition that Royal Bolton Hospital NHS Foundation Trust is acknowledged as the copyright holder and originator of the work.

0

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90

jul aug sep oct nov dec Jan Feb Mar Apr May Jun Jul

Nu

mb

er

of

ho

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its

2009

2010 /11

34.5%

Average

Average Pre Event 800 miles / month

Post improvement 624 miles / month

Home Visits

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9

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v-10

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HSMR

Linear (HSMR)

New Ways of working RNS May 2010

Pneumonia mortality

0%

10%

20%

30%

40%

50%

60%

70%

80%

COPD

Pneumonia

Asthma

Bronchiectasis

ILD

Patients seen by RNS (new way)

How can we provide the best cost effective MDT outpatient services?

• Outpatient Services – short waiting time (best). 100% 2 week rule target, 1:2 New to Follow up ratio

• Eliminate waits - Redesign current clinics

• Need full MDT Specialist clinics for some Chronic Diseases

• Introduce MDT specialty clinics for complex patients

• Comprehensive range of Clinics / Services. But some provided elsewhere – Sleep

• Care closer to home – income generation such as sleep services

• Demand & need for alternatives to admission and GP advice services

• Single point of contact for advice and/or slot in admission avoidance clinic

Outpatient Service: 2600 New, 5000 Review

Traditional Working

• Consultant – 3 clinic per week ( now 4-5 )new and review patients

• Standard clinic :5 new and 12 reviews

• “Routine” except cancer and tuberculosis

• Nurse led clinics in Asthma,

COPD, TB, Cancer, Oxygen, Rehabilitation

Problems

• Waiting times 6 weeks

• Review: new ratio variable 2.5 to 0.8

• Inflexible:Chronic Conditions Urgent – GP callsNot accessible/easy to contactNot proper MDT Working

• Some services provided in Manchester

Rapid Improvement Event

Respiratory Assessment Clinics

1.Community Team(Med/Nursing)

2. Hospital Team (Bleep 2000)

3. Self Referral(Agreed list)

Referral Source Booking

Choose & BookClinic slots

Respiratory Triage•Advice•Same day clinic

Assessment

Respiratory Assessment Clinic

Urgent investigations

Diagnosis

Treatment

Same day correspondence

Outcome

Discharge with treatment plan

Discharge with H.A.H Services

Admit

Specialty Multi-disciplinary Team Follow-up Clinic

New Clinic Patterns ( February 2012)

• 6 Months of Disease Coding of clinic patients

• Re-designed Clinic Templates with New and MDT Review Clinics starting on February 6th

• Assigned Medical and Nurse Lead for Each Speciality Clinic

• Staggered introduction of News – Rapid Access on Hold until review volumes diminish


Monday Tuesday Wednesday Thursday Friday

Morning COPD New Lung Cancer

New Lung Cancer

Rapid AccessNew patients


Rapid AccessNew Patients


Oncology General Respiratory

Tuberculosis Nurse / Medical

Oxygen Nurse

Afternoon Rapid AccessNew Patients

Asthmapm/ evening

Bronchiectasis Interstitial Lung Disease

Thoracic Surgical

Lung Cancer Review

Chronic Disease Management

Palliative Care


Positives

• Routine waits already down to 5 days

• Lung cancer < 1 week

• Proper MDT clinics inILD, Asthma, COPD, Bronchiectasis, Cancer

• Peer review

• Nursing staff increasing Skills

Challenges

• Patients not all in the most appropriate clinic

• Continuity of care

• Standard work for each MDT clinic

• Summary Treatment Sheetfor each patient

• Nurse training – schedule

• Need to discharge more reviews to open access fully

5 Year Sleep Service Projections

• British Thoracic Society figures

• 1% of adult men have severe OSAOnly 1 in 4 patients identified

• Projections for Bolton (300,000)300 referrals per year200 new cases of severe OSA900 patients cumulative long term follow up

• Costings: SurplusYear 1 = £86,000Year 5 = £139,743

• Agreed with Commissioners and now being repatriated

• Income & expenditure

-400000

-300000

-200000

-100000

0

100000

200000

300000

400000

500000

Year 1 Year 2 Year 3 Year 4 Year 5

Income

Expenditure

Surplus

Funded Elsewhere


Bolton One – Town Centre Move in on June 11th 2012

• General Practitioners and Secondary Care Services

• Pulmonary rehabilitation

• Sleep Service from July 2012

• Patient Support Group

• Lung Function / Smoking Cessation

• October - open up to Rapid Access Clinics

Current Community Working Disease Management Team

Instant Access – October 2012

Better Community Working

• General Practitioner with SpecialInterest in Respiratory DiseaseRespiratory ClinicsSupports Community TeamConsultant liason

• Nursing Team: Community Matrons, Active Case Managers,District Nurses, Respiratory Nurses

• Pulmonary Rehabilitation Poor community uptake – need tobroaden access

• Education Events on End of Life CareGold Standard Framework

• Shorten Clinic waiting times:Routine referral 24-48hrsExacerbations – same day review

• Immediate telephone advice7 days for primary care

• Impact: Better Care2-3 less A/E patients per day

• Paid Tariff between that of OPD and A/E rate

• Agreement in principle withComissioners

How can we best support primary care to provide equitable good quality Respiratory care?

• Hospital admissions are not diminishing despite proactive management of long term conditions

• Replicate , COPD model, and extend it with Pathway development from Smoking prevention to end of life care

• Small numbers of patients in each practice on GSF – little proactive planning or co-ordination of care

• Have a virtual Ward of these patients in primary care with regular review and updates of status

• Small numbers of patients in each practice on GSF – little proactive planning or co-ordination of care

• Have a virtual Ward of these patients in primary care with regular review and updates of status

• Roles of wider team not defined or uniform

• Define the roles & responsibilities of respiratory team – Specialist Nurses, DN, ACM, PN, GPs, GPWSI and Consultants

• Break down barriers furthers between Primary and Secondary Care

• Allocate named Consultant / specialist Nurse to practice groups to support care delivery and training

Measure 2009/10 2010/11 2011/12

LoS*Dr FosterCHKS

8.9 days6.4 days

6.9 days5.7 days

7.8 days5.8 days

Mortality (HSMR) 119 9179 RAMI

Readmissions 9.5% 8.5% 8.2%

ICU Escalation 101pts 64pts 57 pts

Home Visits(per month)

38 58 92

RNS Time to Care (patient facing

time)26.25Hrs/wk

52.5 52.5

Respiratory Team Vision

1. Timely equitable inpatient access to Respiratory Services

2. Best cost-effective outpatient MDT services 3. Support primary care to provide equitable

good quality respiratory care in community4. Underpinning ethos of ‘Best Possible Care

for the Patient’ in the most appropriate setting

Lean Thinking

Not sure what to expect

Good for you and your patients

Feeling of Satisfaction

Taste for more

Thank you

delivering improvements outside the hospital walls

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