project brief - st george's hospital€¦ · project brief introduction a recent visit by the...

Version 1.1 dated 16 March 2014

PROJECT BRIEF INTRODUCTION A recent visit by the Emergency Care Intensive Support Team (ECIST) suggested that St Georges needs to do something significantly different to move out of black escalation and regain control of patient flow. Following conversations with a number of senior members of staff, ECIST and the Executive team have agreed a programme of action to re-balance capacity and operations across the Trust in an initiative called „The Perfect Week‟. Our Perfect Week will begin at 12.00pm Wednesday 26th March and end at midday the following Wednesday. It will be live 24 hours a day and will involve all staff members from board to ward. The week will be managed in a similar format as a serious clinical incident e.g. with a command centre and operational performance managed throughout the day.

BACKGROUND The Trust is currently facing significant operational difficulties, caused by a significant increase in the demand for acute care. These challenging times have left us with high occupancy rates, high and sustained escalation, patients in the „wrong‟ beds not best placed to deal with their health issues, crowding in assessment units, elderly care increases, longer length and cancellations for elective surgery and outpatient appointments. All of these issues are detrimental to the excellent care and safety that we strive to provide for our patients; they also add further pressure on our staff, which if not contained will have a lasting and damaging effect on morale. Many other hospitals have successfully used the Perfect Week (see an example here) to make long-lasting improvements to their services. This initiative aims to generate energy for change by doing things differently to support patient flow and consequently improve patient experience, safety and staff morale. The underlining principle is that if the patient needs to be admitted then it‟s: „Right Bed, Right Patient, First Time’. AIMS Why are we doing this? • Patients are able to get to the next step in their journey more quickly. • Patients are more likely to be admitted to the appropriate ward.

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• Delays in transferring to an in-patient bed will be reduced. • Non-clinical inter-ward transfers will be reduced. • Systems will be less frustrating and confusing for patients, relatives and carers. • Less time in hospital means less risk of harm. • Extended senior medical review will be provided. Why is improving patient flow important for staff? • We will strive to lower bed occupancy. • We hope to have no (or significantly less) outliers (patients in the wrong specialty wards). • Patients should benefit from improved care received in a timely manner in the right

environment. • Patients should 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. • The Trust will benefit from meaningful information enabling capacity to be effectively

managed. The main aims of the week are to: • Allow clinical staff more time to focus on clinical duties. • Enable support services to provide a rapid response to clinical departments. • Recalibrate (or reset) the system. • Benefit from improved patient flow throughout the organisation. • Free up capacity earlier in the day (to prevent bottlenecks).

MEASURES Progress of the project will be measured through a series of high level outcomes and metrics, which are detailed at Appendix 1. Each outcome will be measured throughout the day and displayed as run charts in Bronze command. This will form the „performance dashboard‟ for the week. Stretch targets and trajectories will be set from the outset for each metric where possible and annotations will be included to demonstrate the reasons for improvement or deterioration in performance at a project level. The metric baselines will be established prior to the beginning of the week and a sustainable method of capturing the information beyond the perfect week will be developed. In addition to the metrics detailed above, the following outcomes are planned to be achieved during the Perfect Week: • Implement SAFER Care Bundle (see below for details). • Deploy a discharge lounge (ambulatory only). • Use SBAR „verbal‟ referral tool across wards into Community Services as appropriate. • Implement 24/7 IT Helpdesk Support • Review theatre lists daily to fill gaps (CEPOD only). • Reduce late Theatre starts. • Reduce Theatre overruns. • Reduce Theatre turnaround time.


SAFER Care Bundle The SAFER (Senior review, Assessment, Flow of patients, Early discharge, Review) Care Bundle is 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. Each ward and department will develop a SAFER scorecard similar to the example provided at Appendix 2. The scorecard not only provides standard operating procedures but a set of measurable outcomes that is ward/department specific that also align to the Trust metrics. GOVERNANCE The Perfect Week is a trust-wide initiative which is being led by the executive directors, with the full support of divisional chairs, divisional directors of operations, divisional directors of nursing and the service improvement team. During the Perfect Week, the Trust will be operating a command and control structure on a similar footing to a major incident. The difference to a major incident is that the clinical operations, elective surgery and outpatients activities will carry on as normal, but with additional focussed support from management and support services. For that reason, there will be dedicated time from key staff, both clinical and managerial, during the week. What this means for individuals will be confirmed by divisional leadership teams by Wednesday 12 March; however, where possible, non-essential meetings and e-mail traffic should be reduced significantly. Command and control The command and control structure during the Perfect Week is detailed below:


There will be approximately 130 ward liaison officers that will be deployed to all wards, theatres and ITUs within St Georges and Queen Mary‟s Hospital sites over 2 shifts. In addition to data capture, they will provide support to the ward managers and escalate issues that cannot be resolved within 1 hour to the Bronze team. The Bronze team will be located in the Ingredients Seminar Room, 1st Floor Lanesborough Wing, behind Costa Coffee and will operate from 0730 to 2200. The roles and responsibilities of the teams and key personnel are detailed below and rota templates are at Appendix 3 and 4.

ROLES AND RESPONSIBILITIES

Ward Liaison Officers

Primary focus is to be ward based and ensure the ward is supported to allow the safe and timely discharge of patients. Follow existing protocol for requesting needs of the ward. WLOs will not circumnavigate existing process, for example, if there is a need to log a call with IT, estates, transport, diagnostic tests, the usual process will be followed. If the need of the ward isn‟t met within 1 hour then the ward has the right to escalate the need to bronze control.

Role Responsibility

Ward LO

Capture data as detailed in the responsibilities detailed at Appendix 5. Be the wards voice and escalate to the Bronze Team if you see/hear/feel that something is causing an issue for the ward – always check with the ward manager first to ensure this is the right thing to do.

Theatres LO

Capture data as detailed in the responsibilities detailed at Appendix 5. Be the Theatres and Recovery voice and escalate to the Bronze Team if you see/hear/feel that something is causing an issue for the ward – always check with the theatre manager first to ensure this is the right thing to do.

ITU LO

Capture data as detailed in the responsibilities detailed at Appendix 5. Be the ITU voice and escalate to the Bronze Team if you see/hear/feel that something is causing an issue for the ward – always check with the ITU manager first to ensure this is the right thing to do.

Outpatients LO

Capture data as detailed in the responsibilities detailed at Appendix 5. Be the Outpatient‟s voice and escalate to the Bronze Team if you see/hear/feel that something is causing an issue for the ward – always check with the outpatients manager first to ensure this is the right thing to do.

Community LO

Capture data as detailed in the responsibilities detailed at Appendix 5. Be the Community voice and escalate to the Bronze Team if you see/hear/feel that something is causing an issue for the ward – always check with the appropriate community manager first to ensure this is the right thing to do.

Bronze Team (Command and Control) Focus is on the day to day operations of delivering the services to patients resolving the operational issues associated with treating patients across the Trust. Based within the Command & Control Centre. Receives information from Liaison Officers (LO‟s) and escalates as required to Silver Team.

Role Responsibility

Team Leader

The Bronze Team Leader is responsible for the smooth running and management of the team, ensuring that all issues are being managed, captured within the escalation logs and escalated to the Silver and Gold teams where necessary. The Team Leader will lead the daily briefing sessions throughout their shift.

Site Manager Focus is „right patient, right bed, first time‟. The site team is to focus on patient placement and supporting the wards as required.

Clinical Lead

Will make decisions and take appropriate action on all clinical issues escalated to them. Will also signpost to the appropriate Divisional Medical, Nursing or Midwifery Lead. They will ensure the patients are admitted to the appropriate specialty beds within the Trust.

General Manager Will make decisions and take appropriate action on all operational issues escalated to them about the patients/wards and signpost issues that require Divisional decisions.


IT Provide oversight on behalf of IT and deploy the relevant resources when a request for support is received from the WLO, Bronze, Silver or Gold teams.

Communications

Provide detailed Communications briefings throughout each day to disseminate key information to all stakeholders and staff as per the communications plan.

Information Provide oversight on behalf of Information and deploy the relevant resources when a request for support is received from the WLO, Bronze, Silver or Gold.

Data Entry Provide administrative support and data entry into the escalation logs and providing direct support to the WLOs, Bronze, Silver or Gold teams.

Estates & Facilities

Provide oversight on behalf of Estates & Facilities and deploy the relevant resources, particularly portering, transport and domestic support when a request for support is received from the WLO, Bronze, Silver or Gold teams.

Bronze Team (On-Call Roaming)

Focus is on the day to day operations of delivering the services to patients resolving the operational issues associated with treating patients within their Divisional responsibility or support service. Receives information from C&C Centre or LO‟s and escalates as required to Silver Team.

Role Responsibility

Div Medical Lead Will make decisions and take appropriate action on all divisional medical issues escalated to them; ensuring patients are admitted to the appropriate specialty beds within their division and board rounds are carried out.

Div Nurse/Midwife Will make decisions and take appropriate action on all divisional nursing, midwifery, safety, quality and governance issues escalated to them.

Div General Manager Will make decisions and take appropriate action on all divisional operational issues escalated to them about the patients/wards.

Critical Care Provide oversight on behalf of critical care and deploy the relevant resources when a request for support is received from the WLO, Bronze, Silver or Gold.

Therapies Provide oversight on behalf of Therapies and deploy the relevant resources when a request for support is received from the WLO, Bronze, Silver or Gold.

Diagnostics Provide oversight on behalf of Diagnostics and deploy the relevant resources when a request for support is received from the WLO, Bronze, Silver or Gold.

Pharmacy Provide oversight on behalf of Pharmacy and deploy the relevant resources when a request for support is received from the WLO, Bronze, Silver or Gold.

Social Services Social services support has been requested, to advise and support the Trust in providing early discharge of patients where required.

Transportation Provide oversight of all Transport issues and deploy the resources when a request for transportation is received from the WLO, Bronze, Silver or Gold.

Portering Provide oversight all Portering issues and deploy the relevant resources when a request for support is received from the WLO, Bronze, Silver or Gold.

Domestics Provide oversight on behalf of domestics and deploy the relevant resources when requested from the WLO, Bronze, Silver or Gold teams.

Medical Equipment Provide oversight on behalf of medical equipment and deploy the relevant resources when support is required from the WLO, Bronze, Silver or Gold.

Silver Team Role (Tactical)

Focus is on tactical decision making and ensuring the delays to patients discharge are being resolved allowing the Bronze Team to dedicate their efforts on the resolution of their divisional operational issues. Receives information from Bronze Team and escalates as required to Gold Team

Role Responsibility

DDO/DDNG Provide support in resolution of all operational issues escalated by Bronze Teams, have oversight of divisional progress and input and develop action plans to ensure sustainability of the achievements made within the week.

Head of Operations Provide support in resolution of all Site Management issues escalated by Bronze Team, have oversight of divisional progress, input and develop action plans to ensure sustainability of the achievements made within the week.


Gold Team Role (Strategic) The Executive Team will form the membership of the Gold Team; they will be walking the floors across all Wards daily to observe, and be called upon by exception to deal with strategic issues that cannot be dealt with by the Silver team. The Gold Team will be represented by the Lead Exec at the 13.30 brief to make decisions on any escalated strategic issues.

Role Responsibility

Lead Exec Provide support in resolution of all operational issues escalated by Bronze Teams, have oversight of divisional progress and input and develop action plans to ensure sustainability of the achievements made within the week.

Briefings There will be daily briefings in the Command & Control Centre, Ingredients Seminar Room, 1st Floor Lanesborough Wing, behind Costa Coffee to see what‟s working well, not so well and what still needs to be done in order to regain control of patient flow. The purpose of these briefings is for the Bronze Team to report any of the SAFER metrics that are flagged as Red and to escalate any issues to the Silver Team and Support Services that need their influence to reach a resolution. The „Live‟ Bed State and RAG rated SAFER Metrics will be used as the basis for discussion at these meetings. The 1330 & 1800 Briefs are the forum for to escalate any strategic issues to the Gold Team that needs their influence to reach a resolution. The daily briefing schedule is:

Update Briefing Update Briefing

Shift Handover

Update Briefing

07.30-08.00 13.30 – 14.00 15.00-15.30 18.00 – 18.30

Bronze Team

Silver Team

Gold Team

Support Services

External Agencies

At the end of the Perfect Week there will be an extended meeting on Wednesday 2 April at 1500-1630, in Boardroom H2.6, Level 2 Hunter Wing, where it will be agreed which changes had the most impact and which we will continue from now on. This will then be communicated to the rest of the organisation. During out of hours and weekends, the briefing to the silver and gold teams will be conducted through teleconference with the duty manager and duty director. Bronze Team Handover

The divisional Bronze teams will complete the handover templates and escalations log (Appendix 6) and inform their counterparts working the afternoon shift on any outstanding issues that need resolution. It is extremely important to maintain accurate handover notes at the end of the evening shift. All issues that need to be escalated to the morning shift will be briefed to the overnight site management team.


Information/IT To make this initiative a success will require support from both Information and IT to develop the running scorecard and project it with the „live‟ bed board onto a large screen in the Command & Control Centre, Ingredients Seminar Room, 1st Floor Lanesborough Wing, behind Costa Coffee. Director of ICT has confirmed that the infrastructure required to set up the Command & Control Centre can be completed in time. The measures highlighted at Appendix 1 can, in the majority, already be captured from existing metrics. Head of Information is developing a database and tool and will advise on how these measures and Liaison Officer captured data can be collated and presented into a live dashboard. External Agencies The following external agencies/services have been requested to provide input to the Bronze team as observers: • CCGs for Wandsworth, Lambeth, Sutton & Merton. • Social Services from all local boroughs. • London Ambulance Service. • Selected members of the Patient Reference Group. • Referral DGHs.

PLANNING Action Planning and Project Management This project requires a controlled environment in conjunction with a structured project framework and streamlined management approach that will: • Ensure a robust and effective alignment of all internal action plans within urgent and

emergency care, length of stay and patient flow. • Rigorously track progress against all stated timescales and performance metrics. • Ensure the Trust is able to embed the transformational change resulting from this project

in the most robust and sustainable way possible. • Deliver all benefits stated in a timely manner. The Perfect Week sits under the steering group for the Service Improvement Patient Flow Programme, which reports into the Improvement Programme Steering Group and Board. The planning task team meet on a daily basis to ensure that mobilisation of key staff and setting up of the Perfect Week runs smoothly. The team reports to the Chief Nurse & Director of Operations and Director of Strategy as the Executive Sponsors, twice weekly.


Key Planning Meeting Dates

10 March 11 March 12 March 13 March 14 March 15 March 16 March

1300-1400 Project Team C&C Room

1400-1600 EMT GW 1.052

1200-1300 Exec Spons GW 1.032



1400-1600 EMT GW 1.052

1100-1145 Matron‟s For Hyde Pk Rm

1430-1530 Exec Spons GW 1.032



1400-1600 EMT Anaes S Rm

1200-1300 Exec Spons GW 1.032




1400-1500 Exec Spons GW 1.032




1400-1600 EMT TBC


1430-1530 Exec Spons GW 1.032

The Perfect Week

31 March 1 April 2 April 3 April 4 April 5 April 6 April

The Perfect Week

tbc tbc

1500-1630 Wash-Up Hunter 2.7


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tbc tbc

Task log & Milestones The high-level plan and key task action log is detailed at Appendix 7. The „live‟ log will be kept up to date by the project manager, Andrew Cable, and can be found here.

Risks and Issues The project risk and issues register is held here.


COMMUNICATIONS The communications plan for the Perfect Week is detailed at Appendix 8. Given the scale of this initiative and the short timescale, all members of the Trust management will have to play a part in cascading the key messages of this plan to all their staff. The Communications Team have provided dedicated support to the project to aid in the implementation of the plan.

SUSTAINABILITY The following sets out how the knowledge transfer from the perfect week will deliver a

sustainability model and ensure that all lessons learnt are captured.

It is planned to have the following knowledge transfer sessions.

Three knowledge transfers with a focus on a patient pathway theme – these will

include:

o Fractured Neck of Femur pathway- Senior health

o Diabetic pathway

o Senior Health pathway

o Heart Failure Pathway

There will be discrete feedback sessions on the projects that will be tested during the

week:

o Discharge Lounge: Monday 7.4.13 @ 1200- 1400

o Discharge Processes: Tuesday 8.4.14 @ 1200 - 1400

o Site – Bed Management.: Wednesday 9.4.14 @ 1200- 1400

o Ward Liaison Officers

The sessions will be facilitated by a member of the Service Improvement Team- Greg

Condon- supported by the Project Managers who have been supporting the projects

during the perfect week.

The sessions will follow an agreed template and format.

These sessions will be 1.5 hours in duration- 1 hr. as the feedback session and then

the final half hour for the Service Improvement Team to check on learning.

Attendees for the discrete sessions will come from the existing work streams- and will

be invited via the work stream distribution lists.

Attendees for the pathway knowledge transfer sessions will be invited during the week.

These will be drawn from the clinical state involved in the pathway, and patient

Ambassadors.

There will be a final wash up meeting on the Thursday for the Service Improvement

team to consolidate the lessons learnt and actions agreed. To be able to formulate the

final report to EMT. This will be on 10.4.14, 1200- 1500 pm in the Hyde Park Room.

There is a need to ensure that the ECIST action is validated during the perfect week – as a response to ECIST is required for the 24.4.14

APPENDIX 1


PERFECT WEEK OUTCOMES AND SUCCESS MEASURES

Outcome Metrics Success Measures Frequency Measured By

Senior Review

All patients to have a Consultant Board-Round Review before 10am.

No. of Patients, % review by consultant

B<85%, R<90%, A>90%, G>95%

Daily WLOs

95% of ED Patients reviewed and transferred within 4 Hours ED Quality target Measures as per ED

Escalation policy

Hourly

Site Management, Information (iClip)

Assessment

All Patients to have an EDD set on admission, which is entered on iClip, and reviewed in 24 hrs.

% of patients with an EDD B<85%, R<90%, A>90%, G>95%

Daily

WLOs, Information (iClip)

No patients outlying in a ward where there condition is not managed by the ward specialty physicians.

No. of outliers B>20, R>10, A>5,

G<5 Hourly

WLOs, Site Management, Information (iClip)

Positive increase in the number of patients referred from ED to AAA using ambulatory score tool.

No. Ambulatory Score Tools carried out, No. of AAA Admissions.

B<85%, R<90%, A>90%, G>95%

Daily WLOs, Nursing Lead

Flow

All wards to have an up to date live bed board on iClip. % accuracy of iClip bed boards.

B<85%, R<90%, A>90%, G>95%

Hourly WLOs, Site Management, Information (iClip)

Ward occupancy rates below 90% % bed occupancy G<90%, A>90%, R>95%, B>98%

Hourly WLOs, Site Management, Information (iClip)

AMU should start each day with empty assessment beds No. of AMU Assessment beds available at 10am.

G>10, A>8, R>6, B<6 Daily WLOs, Site Management, Information (iClip)

No escalation areas (AAA, Champneys, Amyand, Endoscopy, etc) being utilised.

No. of outliers in escalation areas.

G=0, A>0, R>4, B<6 Hourly WLOs, Site Management, Information (iClip)

No non-clinical bed moves No. of bed moves G=0, A>0, R>4, B<6 Hourly WLOs, Site Management, Information (iClip)

http://stginet/Procedural%20Documents/Patient%20related/Patient_Management/6_0_escalation%20procedure.pdf

APPENDIX 1


Significant reduction in the number of DTOCs. No. of DTOCs B>20, R>10, A>5,

G<5 Hourly

WLOs, Site Management, Information (iClip)

Early Discharge

100% TTO‟s and Discharge Summaries to be completed in theatre for all surgical specialties.

% TTO completion, % D/C Summary completions

B<85%, R<90%, A>90%, G>95%

Hourly WLOs, TLOs, Clinical Lead, Information (iClip)

25% of all clinically appropriate discharges to be completed by 1000

No. of discharges, Time of discharges

B<10%, R<20%, A>20%, G>25%

Daily WLOs, Site Management, Information (iClip)



B<35%, R<45%, A>45%, G>50%




B<65%, R<70%, A>70%, G>75%




B<85%, R<90%, A>90%, G>95%


Regular Review

All patients over 5 days LOS are highlighted to the Clinical Director, DDO and Head of Nursing.

Length of Stay, Management Review

B<85%, R<90%, A>90%, G>95%

Daily DDO, Clinical Lead, Information (iClip)

All patients over 14 days LOS (depending on specialty) are peer-reviewed by Clinical Director, DDO and Head of Nursing.

Length of Stay, Management Review

B<85%, R<90%, A>90%, G>95%

Weekly DDO, Clinical Lead, Information (iClip)

Other Quality Measures

Positive Increase in DSU and Main Theatres utilisation % Theatre Utilisation, start times, turnaround times, finish times.

B<70%, R<75%, A>80%, G>85%

Daily TLOs, Information (Theatreman)

No non-clinical cancellations on day of surgery No. of Cancellations B>10, R>7, A>5, G<2 Daily TLOs, Clinical Lead, Information (Theatreman)

The first patient in the locked list is moved from SAL to theatre by 0820 and with consent completed.

% of First patient in theatre by 0800.

B<85%, R<90%, A>90%, G>95%

Daily

TLOs, Information (Theatreman)

WHO checklist is carried out and signed for having been completed.

% of WHO checklists signed for being completed.

B<85%, R<90%, A>90%, G>95%

Daily

TLOs, Information (Theatreman)

APPENDIX 1


Operations not started without an ITU bed available. No. of ITU beds, G=0, A>0, R>1, B<2 Hourly ITULOs, TLOs, Information (Theatreman & iClip)

No delayed discharges from ITU (6hrs) No. of delayed discharges B<85%, R<90%, A>90%, G>95%

Hourly

ITULOs, Information (iClip)

No discharges from ITU after 8pm No. of late discharges. G=0, A>0, R>1, B<2

Daily

ITULOs, Information (iClip)

100% of ACS patients having the ACS proforma completed and attached to the notes.

No of completed ACS proforma, No of ACS proforma attached to notes

B<85%, R<90%, A>90%, G>95%

Weekly GM Cardiology, ACS Pathway co-ord

No Outpatient appointments cancelled due to lack of patient notes.

No. of Outpatient Cancellations, % Notes tracked

Daily OPLOs, e-tracking, Information (iClip)

APPENDIX 2


DRAFT SAFER Care Bundle (ED)

ENIOR REVIEW

95% of patients to have been reviewed and transferred out of ED within 4 hours

See RAT / Assessment below

Senior review all Resus patients 24/7, Consultant review all Resus Cases 08.00-22.00

Senior review all patients by 3 hrs to direct care plan

S

SSESSMENT

RAT OPERATING 10.30-18.30

Senior decision maker/Nurse/Clerical person in RAT

Ambulance off loads within 15 minutes

observations ,EWS scoring and initial work up complete within 20 minutes of arrival

full assessment by a clinician within 1 hour of arrival –Definitive care Plan by 3 hours

review by a senior competent decision maker by 3 hours if plan not in place

All Walk in patients assessment within 15 minutes including Observations and Pain relief

All Medical patients to have Amb Score Tool applied as part of consultant assessment

A

LOW

RAT to optimise use of AEC/Primary Care Stream

80% of patients requiring admissions to have bed requested (DTA) within 2 hours of arrival

Patients to move to allocated ward within 1 hour of bed request (DTA)

All patients to be ready to move to ward by 3 hours where stable – all invx/ ED management completed

any blocks to achieving transfer within 15 minutes (e.g. lack of portering staff, receiving ward ‘unable’ to take handover, bed spaces requiring cleaning) should be escalated to the site team/POD leads immediately

All patients with Amb Score of 4 or above to be referred to AAA Consultant on BLEEP 7915

F

EXIT

All patients to leave ED within 30 minutes of referral

All walk-in assessments completed within target 15mins maximum 30 minutes

Plans for Majors/ Resus patients – outline by 2 hours and definitive plans by 3 hours

E

EGULAR REVIEW

ALL patients have plan by 3hours

All CDU patients reviewed 08.00, 12.00,16.00 and 22.00 ( As well as other ad hoc reviews)

R

APPENDIX 2


SAFER Care Bundle (AMU)

ENIOR REVIEW

consultant ward rounds should start at 08:00 at the latest with the aim of reviewing ALL patients by 10:00

consultants should liaise with overnight junior medical team and AMU nurse co-ordinator at 08:00 to; - clarify capacity on AMU and the numbers of patients awaiting medical beds in ED; the consultant who

was on-call overnight for Acute Medicine should be informed of any clerked patients they need to review in ED/CDU

- identify the sickest patients on AMU (these should be reviewed FIRST) and any potential discharges (these patients should be reviewed NEXT before reviewing the remaining patients in bed order)

every ward round should conclude with a ‘board round’ involving ALL relevant medical and nursing staff to prioritize critical tasks and indicate preferred ward for admissions

S

SSESSMENT

ALL patients admitted to AMU should have;

- observations and EWS score documented within 15 minutes of arrival on AMU

- assessment by a clinician should commence within 1 hour of arrival on AMU

- review by a senior competent decision maker (usually Consultant or Registrar) and instigation of a definitive management plan within 4 hours of arrival on AMU

A

LOW

AMU should start each day with empty beds (ideally at least 6) and patients should begin to move off AMU to base medical wards before 10:00 every day (including at weekends)

following the morning consultant ward/board round, the AMU co-ordinator should inform the bed manager and POD lead of the numbers of patients requiring beds on specific medical wards

if beds do not become available on those wards within 1 hour this should be escalated to the site team

once a medical bed is allocated to AMU the patient should be transferred into that bed within 15 minutes

any blocks to achieving transfer within 15 minutes (e.g. lack of portering staff, receiving ward ‘unable’ to take handover, bed spaces requiring cleaning) should be escalated to the site team/POD leads immediately

Only patients with EDD of > 48 hours should be referred for admission to the base wards

F

EGULAR REVIEW

admissions to AMU should be reviewed by a consultant in ‘real-time’ between 08:00-21.00 7 days a week

consultants should be available throughout the day (08:00-16:00 weekdays) in ALL areas of AMU to review investigation results as they become available, progress management plans and expedite discharges

a second consultant ‘board round’ should be carried out in AMU during the afternoon at 15.00 hours and at 21.00 hours.

R

ARLY DISCHARGE

a minimum of 4 patients should be discharged from AMU BEFORE 12:00 noon every day

junior doctors should be allowed to ‘leave’ the ward round to complete TTOs immediately after the decision to discharge a patient is made

all patients should leave AMU within 2h of a final discharge decision (this may be dependent upon the results of further investigations); the discharge lounge should be used to facilitate this whenever possible

E

APPENDIX 2


DRAFT SAFER Care Bundle (Wards)

ENIOR REVIEW

All patients will have a daily Consultant Board Round Review before 10am All patients will have a daily morning review by a senior decision maker before 10.00 am

Sick patients and those identified for discharge should be prioritised on each round.

A senior registered nurse will participate on the both ward and board rounds.

Patient review should include review of EDD by a Consultant/Senior Decision maker

All patients will have a weekend plan in the notes including where appropriate criteria led discharge (Friday only)

S

SSESSMENT

All patients will have an EDD agreed and set in Iclip within 24 hours of admission

Daily board rounds will be conducted with the participation of all key multi-disciplinary team members. (08.00-10.00am)

Check whether a patient is medically stable, continues to need inpatient care and that treatment is being progressed in a timely manner and is appropriate to the needs of the individual patient.

All patients will have an assessment completed on antibiotic compliance, VTE prophylaxis, Falls, Pressure Ulcers and Nutrition.

A

LOW

Reasons and actions for delayed patient flow should be highlighted at the board/rounds and daily support, conform and challenge sessions

The site management team will contact the Specialist wards before 10.00am with the names of patients identified by the AMU for the wards empty beds

Wards to only accept appropriate patients for admission to their beds (no outliers)

F

ARLY DISCHARGE

Wards teams should ensure that 50% of discharges take place before 12.00pm using the discharge lounge where appropriate.

Ward teams to ensure 25 % discharges before 10.00am, 75% by 14.00pm and 100% by 16.00pm

Plan discharges in advance to ensure patients leave by 12.00pmincluding writing up TTO’s and booking the necessary transport the previous day. (before 14.00pm)

If TTO’s need amending they are to be updated immediately after the Consultants Daily Board Round (before 10.00am)

E

EGULAR REVIEW

Patients with LOS of >5 days will be escalated to the Clinical Director, DDO and Head of Nursing at weekly Dragons Den session.

EDD to be updated following reviews.

Clinical Lead, Discharge Manager and Community Lead will review all patients still on case load >72 hours

R

APPENDIX 2


DRAFT SAFER Care Bundle (Surgical Wards)

ENIOR REVIEW

All patients will have a daily Consultant Board Round Review before 10am All patients will have a daily morning review by a senior decision maker before 10.00 am and all patients who are

medical fit for discharge are to be identified

Sick patients and those identified for discharge should be prioritised on each round.

A senior registered nurse will participate on the both ward and board rounds.

Patient review should include review of EDD by a Consultant/Senior Decision maker

All patients will have a weekend plan in the notes including where appropriate criteria led discharge (Friday only)

S

SSESSMENT

All patients will have an EDD agreed and set in Iclip within 24 hours of admission

Daily board rounds will be conducted with the participation of all key multi-disciplinary team members. (08.00-10.00am)

Check whether a patient is medically stable, continues to need inpatient care and that treatment is being progressed in a timely manner and is appropriate to the needs of the individual patient.

All patients will have an assessment completed on antibiotic compliance, VTE prophylaxis, Falls, Pressure Ulcers and Nutrition.

A

LOW

Reasons and actions for delayed patient flow should be highlighted at the board/rounds and daily support, conform and challenge sessions

The site management team will contact the Surgical wards before 10.00am with the names of patients identified by ED and SAL for the empty surgical beds

Wards to only accept appropriate patients for admission to their beds (no outliers)

No none clinical cancellations on day of surgery

The first patient in the locked list is moved from SAL to Theatre by 08.00am with consent complete

Operations do not start without an ITU bed available

F

ARLY DISCHARGE

Wards teams should ensure that 50% of discharges take place before 12.00pm using the discharge lounge where appropriate.

Ward teams to ensure 25 % discharges before 10.00am, 75% by 14.00pm and 100% by 16.00pm

100% TTO’s and Discharge Summaries to be completed in theatre for all surgical specialties

Plan discharges in advance to ensure patients leave by 12.00pmincluding writing up TTO’s and booking the necessary transport the previous day. (before 14.00pm)

If TTO’s need amending they are to be updated immediately after the Consultants Daily Board Round (before 10.00am)

E

EGULAR REVIEW

Review of all patients with an overdue EDD by Senior Decision Maker and ward team EDD to be updated following reviews.

R

APPENDIX 2


SAFER CARE BUNDLES FOR AAA AND ITUs ARE UNDER DEVELOPMENT

APPENDIX 3


PERFECT WEEK COMMAND & CONTROL LIST OF KEY PERSONNEL

DATE:

Team/Division Role 0730-1530 Bleep/Ext 1500-2200 Bleep/Ext 2200-0800 Bleep/Ext

Bronze Team (Command & Control Centre)

Team Leader Site Manager

Operations

Site Manager Site Manager

Clinical Lead

General Manager On-Call Manager

Support Services

IT IT Helpdesk

Communications

Information

Data Entry 1

Data Entry 2

Estates & Facilities

Bronze Team (On-Call Roaming)

MedCard

Medical Lead

Nursing Lead

General Manager

SNTC

Medical Lead

Nursing Lead

General Manager

CWDT

Medical Lead

Midwifery/Nursing Lead

General Manager

CSW

Medical Lead

Nursing Lead

General Manager

Support Services

Critical Care

Therapies

Diagnostics

Pharmacy

Transportation

Portering

Domestic

Facilities IT Helpdesk

Medical Equipment

Silver Team

Team Leader On-Call Manager

Operations Head of Operations

Div Director DDO/DDNG

Gold Team

Lead Executive On-Call Director

APPENDIX 4


PERFECT WEEK WARD LIAISON OFFICERS

DATE:

Ward/location 0730-1530 Bleep/Ext/Mobile 1500-2200 Bleep/Ext

Allingham Ward

Amyand Ward

Belgrave Ward

Benjamin Weir Ward

Brodie Ward

Buckland Ward

Caesar Hawkins Ward

Carmen Suite

Caroline Ward

Cavell Ward

Champney‟s Ward

Cheseldon Ward

Dalby Ward

Duke Elder Ward

Florence Nightingale Ward

Emergency Department

Frederick Hewitt Ward

Gray Ward

Gunning Ward

Gwillim Ward

Herbeden Ward

Holdsworth HDU

Holdsworth Ward

James Hope Ward

Jungle Ward

Keate ward

Kent Ward

Marnham Ward

McEntee Ward

McKissock Ward

Neonatal Unit

Nicholls Ward

Pinckney Ward

Richmond AMU

Rodney Smith Ward

Ruth Myles Ward

Trevor Howell Day Unit

Vernon Ward

William Drummond Ward

Wolfson & Thomas Young

Gwynne Holford Ward

Laurel Ward

Mary Seacole Ward

Intermediate Care (Adult)

Intermediate Care (Paeds)

WLO Reserve 1

WLO Reserve 2

WLO Reserve 3

WLO Reserve 4

WLO Reserve 5

WLO Reserve 6

WLO Reserve 7

WLO Reserve 8

WLO Reserve 9

WLO Reserve 10

APPENDIX 4


PERFECT WEEK THEATRE LIAISON OFFICERS

DATE: Wednesday 26 March 2014

Theatre/location 0800-1800 Bleep/Ext/Mobile

Day Surgery Unit 1

Day Surgery Unit 2

St James‟ Theatre 1

St James‟ Theatre 2

St James‟ Recovery

Lanesborough Theatre

Paul Calvert Theatre

AM – Neuro

AM – Cardio

SAL

TLO Reserve 1

TLO Reserve 2

PERFECT WEEK ITU LIAISON OFFICERS


ITU/location 0800-1800 Bleep/Ext/Mobile

LO NICU

LO GICU

LO CICU

LO NNU

LO PICU

PERFECT WEEK OUTPATIENT LIAISON OFFICERS


Outpatients/location 0800-1800 Bleep/Ext/Mobile

LO St James

LO Lanesborough

LO QMH

LO St Johns

LO Reserve

PERFECT WEEK Community LIAISON OFFICERS


Community/location 0800-1800 Bleep/Ext/Mobile

District Nursing Services

LO Community Ward 1

LO Community Ward 2

LO Community Ward 3

LO Community Ward 4

APPENDIX 5


WARD/THEATRE/ITU/OUTPATIENTS/COMMUNITY LIAISON OFFICER CHECK LIST

Daily Tasks on the Ward/Clinical Area Each day you should run through these tasks with the shift co-ordinator/ward manager/senior sister.

Remember the key is to challenge any waits or delays and not to accept that patients waiting

is normal.

Task Done

Report into Lecture Theatre F at 07.30 or 15.00

Familiarise self with WLO pack

Complete the data collection sheets in the WLO pack

Collect communication bulletin from Bronze Team at 12.00 and share with Ward Manager

Refer to escalation process for guidance and attempt to resolve locally in the first instance. If issue remains unresolved escalate to the Bronze Team

Attend daily wash up session at 1500 (for both early and late) in the Lecture Theatre F

Keep a record of all activities you perform on the ward – please bring a notepad and pen with you.

Handover Sheet

Attend Board Rounds

At the end of shift for late 22.00 bring data collection sheets to the Operations Room

Escalating process to the Bronze Team. When calling the Bronze team (on extension 5065) or visiting in person, you will be asked some pertinent questions by the Bronze Team Leader / Co-ordinator; this is so they can understand your issue in detail and ensure the usual process has been followed before escalation can occur. If your call is regarding a patient need please ensure you have the answers to the following information;

Patient Name

What is the issue regarding?

What has been done so far to resolve the issue? E.g. package of care, social services, nursing home assessment, transport, TTA, blood results, senior review, post op check, diagnostic tests, therapy review, ECHO (cardiology test). If your call is regarding an environmental need please ensure you have the answers to the following information;

Ward Name

Log or reference number

When was the call logged?

What impact is the issue having on the ward that affects the delivery of patient care or needs of the staff?

Annexes: A. Escalation Sheet. B. Ward Liaison Officer (WLO) Frequently Asked Questions and Answers (FAQ‟s).

ANNEX A TO APPENDIX 5


ESCALATION SHEET

Please ensure you refer to the following flow chart to escalate any issues during the Perfect week event. If in doubt, please ask a member of the Service Improvement Team, who is looking after you for the day. Issue/s require escalation

Can they be sorted at clinical- area level? Yes

NO

Complete form and bring to the Operations room or telephone this through

YES

Bronze team have 2 hours to sort – data base issue on central Log

Escalate to Silver Team

Silver Team have 2 hours to sort YES NO

Escalate to Gold Team

Fee

dba

ck to

issue ra

iser a

nd c

lose

YES

NO

Action plan solution- for resolution in sustainability plan

Gold Team to sort in 2 hours

NO

ANNEX B TO APPENDIX 5


WARD LIAISON OFFICER (WLO) FREQUENTLY ASKED QUESTIONS AND ANSWERS

(FAQ’s)

1. What is the Perfect Week?

Is aimed at addressing issues that prevent the Trust from providing excellent care and ensuring safety for our patients e.g. pressure on our staff. The Trust will implement an initiative (“Perfect Week) to generate energy for change by doing things differently to support “patient flow” and consequently improve patient experience, safety and staff engagement.

2. So how will the perfect week run?

Wards and clinical areas across the Trust will run their day to day clinical operations as normal during the Perfect Week. The difference will be that specific support will be provided from back office staff to try to unblock problems in “patient flow”, also clear measures of performance around patient activity and clinical outcomes will be used and an escalation process put in place, should the patient flow be affected.

3. What is Patient Flow?

“Patient Flow is the movement of patients, information or equipment between departments, staff groups or organisations as part of a “Patient's Care Pathway”. Patient Care Pathway is the route that a patient will take from their first contact with an NHS member of staff (usually their GP), through referral, to the completion of their treatment. It also covers the period from entry into a hospital or a Treatment Centre, until the patient leaves. You can think of it as a timeline, on which every event relating to treatment can be entered. Events such as consultations, diagnosis, treatment, medication, diet, assessment, teaching and preparing for discharge from the hospital can all be mapped on this timeline.

4. How long will the Perfect Week run for?

It will begin on Wednesday 26th March 2014 at 12:00 and end on Wednesday 2nd April 2014 at 12:00.

5. What are the shift times?

The working day will be spilt into two shifts. The early shift will be 7.30-15.30 and the late shift, 15.00-22.00.

6. That is a long day and I do not want to work from 07.30 to 22.00.

We do not expect you to do both shifts on the same day, only one. However we would appreciate volunteers providing as much of their availability as possible so we can ensure wards and clinical areas have a WLO during the week.

7. I would like to volunteer, but due to childcare or other arrangements, I can only work my

normal shift (or 9-5). Should I still volunteer?

Yes. The capturing of data and meaningful information requires full attendance through the shift. However there may be potential for volunteers to be used for other tasks. If this is the case, those volunteers will be contacted. We welcome commitment from volunteers and therefore please still submit your interest.

8. When I arrive for my shift, where do I go?

Depending on the shift you are allocated, you will be expected to attend Lecture Theatre F (based in Hunter Wing, 1st floor) to report in and to be briefed by a Liaison Co-ordinator. The times for reporting in are 07.30am (early) and 15.00 (late). However, if you arrive at 09:00am, report to the operations room, 1st floor Lanesborough Wing, “Ingredients” via Costa Coffee.



The Liaison Co-ordinators are Trust employees and work with our Service Improvement team. They will be visible to ensure you understand your role and answer any concerns you may have. You will then be directed to the clinical/Ward you are allocated to.

9. The hospital is big. I may get lost and be late?

Upon arrival to Lecture Theatre F the WLO Co-ordinators will direct you and if needed, will provide you with a map of the hospital to assist you in getting to your clinical area on time.

10. What do I do on the day and will I be on my own?

You will be provided with a WLO pack. This will include;

Your role and a list of your responsibilities

A checklist

A form for you to sign and confirm that you have read the relevant Trust policies to

ensured Health & Safety adherence at all times.

A flow chart outlining the escalation (for concerns) process

A data collection sheet for you to complete

A CRB declaration form for you to complete and sign

Useful contact numbers

Only one WLO will be allocated to a ward/clinical area therefore you will be expected to be on your own. However the Ward Manager and WLO co-ordinators will be available to support you. There is also a clear process for you to follow to escalate concerns (Q&A 14).

11. What are the relevant policies and will I have time to read them on the day?

The Trust policies are Hand Hygiene, Dress Code and Security, all of which can be found on the Trust‟s intranet page. Students and volunteers will be given these beforehand (via email). You must ensure you read these beforehand to 1) ensure the safety of both you and our patients and 2) the policies are lengthy, therefore there will be no time on the day to read the policies in their entirety.

12. What is a CRB declaration form?

As an employer responsible for care to vulnerable adults and children, we have to ask you to declare all current ‘unspent’ criminal convictions or cautions (including eprimands and final warnings. You are not required to disclose convictions or cautions which have become ‘spent’.

Your personal information will be kept confidential and will be shredded after the event. Any questions answered „yes‟ will not necessarily mean you will not be able to act as an WLO and an informed decision will be made in conjunction with our HR department.

13. What do I have to do?

As a WLO, you will be working with clinical staff to provide safe care and the timely discharge of patients. You will need to be responsive to the needs of the ward and keep a keen eye on any issues that may affect patient care. Some of the duties will include:

Reporting delays to discharge

Checking daily completion of ward standards

Chasing broken medical equipment

Helping with lunch, tea and coffee for patients

General support for the ward staff

Recording a variety of data (data collection sheet)

Escalating any outstanding concerns to the appropriate individual team



14. What do you mean by issues and how do I raise them?

Any of the above bullet points set out in Q&A you observe are impacting on the care of the patient.

15. I have been allocated to the late shift. I do not want to be inputting data at 22.00?

You will not have to. It will be acceptable for you to submit your data collection sheets to the Liaison Co-ordinator/s located in operations room.

16. When I am not entering data during the times provided on the data collection sheet, what

should I be going?

You will be supporting the ward/clinical area in other duties outlined in Q&A 12.

17. I am slightly worried; I have never worked on a ward or in a clinical area before?

You will be fully briefed. There is a briefing session on Tuesday 25th March 2014 (10.00-12.00 and 14.00-16.00) to be held in Lecture Theatre F. The Ward Manager/Nurse in Charge will be expecting you on the day of the Perfect Week. Wards and clinical areas consist of Consultants, Junior Doctors, Nurses, Healthcare Assistants, Administrative and Clerical Staff, domestic staff and most importantly our patients. If you have any concerns or questions you will need to refer to the Ward Manager/Nurse in Charge who will be able to support you or for you to raise any concerns to.

18. What if the Ward Manager/Nurse in Charge is not available and/or they are not listening

to me?

You will be expected to escalate your concerns to the “Bronze Team”. They are a team of senior staff who will, if needed address your concerns in aid of finding a solution. You can either call them on extension 5065 or leave the ward and go straight to where they are based in the Operations Room in “Ingredients” (restaurant, 1st floor Lanesborough Wing).

19. Do I get a tea break or a lunch break? I also smoke, am I able to pop out when needed?

Yes. Tea and coffee will be available from 9.30-11.30 and then 14.30-20.30. Costa will be open until 21.00.

20. I would like to note this experience for my appraisal/Continuous Professional

Development (CPD).

You will be provided with a St George‟s Healthcare NHS Trust participation certificate to acknowledge your commitment given to the Trust. This certificate will be signed by Miles Scott our Chief Executive. There will also be an opportunity to win a £50 Marks and Spencer‟s voucher.

21. Will I get extra pay?

No. There is no additional payment for giving your time as a WLO. For employees of the Trust you will not be expected to work more than your working hours for that day. It would be normal to take time in lieu if needed but must be agreed by your line manager in the first instance. For students and volunteers, the Trust will not be able to remunerate you for your time given. However, for all volunteers who have contributed to making this week a success, the Trust is committed to ensuring your contribution is recognised (see Q&A 20).

22. What do I do if a patient speaks to me or asks me a direct question?

You should do what you would do as normal. Explain who you are and that you will find an appropriate clinical member of staff, to ensure they are cared for. If there is a waiting time for assistance you should let the patient know someone will be with them shortly.



23. Will this work?

Many other hospitals have successfully used the Perfect Week to make long-lasting improvements to their services. The underlining principle is that if the patient needs to be admitted then it‟s: „Right Bed, Right Patient, First time’.

APPENDIX 6


ID Date entered on Log Raised by Role Issue Impact Risk Score Comment Escalated to Owner Status Closed report - outcome

PF1

APPENDIX 7


PERFECT WEEK ACTION PLAN

Task Outcome & time frame Resources

1 Describe perfect week to all staff through the project brief and drop-in sessions, similar to CQC briefings. Set up like major incident with Gold, Silver, and bronze command. Use the SAFER bundle to demonstrate safety & flow.

Executive team willing to invest time to brief

Perfect week project brief Venue to be booked for briefing

Executive rota for briefing

2 Decide on what “dedicated time from key staff, both clinical and managerial, during the week” means for individuals.

Executives sign up to commitment of cancelling

meetings, significant reduction in email trail by

12 March 2014

3 Engagement period where directors brief senior teams and get buy in. This is all hearts & minds stuff but a really useful tool to give them is presentations from other trusts which are all on the L drive under perfect week. They will be convinced by things such as available empty beds, cardiac arrest rates, mortality rates, turnaround times for diagnostics. Use the videos from the other Trusts

2 weeks Ongoing

4 Medical director to task all consultants with pulling together plans that will ensure daily board round is carried out on all wards by 10am.

Give 1-2 weeks to pull this together

5 Bronze, Silver and Gold Team rota and nominations to be populated and finalised.

21 March 2014

6 Service Improvement Team in conjunction with Directors of HR, Finance, Performance & Information, Estates & Facilities to co-ordinate the ward liaison officers. Most of these should come from finance, HR and corporate teams. As a back-up, Medical, Nursing and Midwifery students will be approached.

All selected by 24 March Training will be

undertaken the day before and packs gone through to make roles

clear

Ward Liaison pack

APPENDIX 7


7 There needs to be a mechanism for measuring that patients know their EDD and next steps of their journey. This will be detailed in the SAFER Bundle. Additional training in iClip may be required.

1-2weeks Ward managers need to get used to using these

the week before and have enough printed out

8 Provide designated data lead from the Information team that will sit in Bronze and help populate the metric database and log for the SAFER bundle.

2 weeks

9 Meet with COMMs to agree a strategy of how the Trust will communicate daily briefs and also co-ordinate a video of the impact on staff. Also need a facility for feedback on how staff “feel” perfect week has impacted

Immediate

10 Set up Bronze command on Friday before perfect week and ensure that live bed board and metric scorecard are both projected onto the wall. Ensure enough desk spaces, computers, telephone access points and bleeps are available.

2 weeks IT and Information.

Telephone points, computer access and bleeps

11 Put up rota‟s, names of ward liaison officers and their ward within Bronze Command. SAFER bundle and bundle of “ 5 things for improvement from each area to be displayed on walls. Ensure phone line and number is available on all ward liaison officer packs and given out through COMMS.

APPENDIX 8


PERFECT WEEK COMMUNICATIONS PLAN

Media Message Target Audience By Whom Date

E-mail to all staff, and eG (Complete - see Annex A)

Informing staff about the Perfect week initiative and dates.

All Staff CEO 6 March 2014

EMT Brief Project Brief on the format, outcomes and measures. EMT Hd Service

Improvement 10 March 2014

Cascade Brief via email, eG, Intranet and website.

Project Brief on the format, outcomes and measures. All Staff, via

DDOs, GMs and Clinical Directors

Hd Service Improvement

10 March 2014

Letters Request for support, advice and input into the Bronze Team.

CCGs, Social Services, LAS, DGHs, Patient Reference Group

CEO, drafted by Hd Service


Verbal Presentation Project overview DDNGs Chf Nurse 12 March 2014

Posters Project overview, key dates and personnel All staff Hd Communications 12 March 2014

Banner stands to be put at key entrances to the Trust & QMH

Project overview All Staff Hd Communications 15 March 2014

Ward Walking and verbal presentation

Project overview and SAFER Care Bundle development

All wards, theatres and ITUs

Hd Service Improvement & Project Manager

20-15 March 2014

Screen savers and MITIE screens

Project overview, key dates and personnel All Staff Hd Communications 15 March 2014

Verbal Presentation Project overview and SAFER Care Bundle development

Matron‟s Forum Hd Service


Drop-in Sessions Project overview All Staff Exec Team & Hd

Service Improvement

17-21 March 2014

Twitter/Facebook/Miles‟ Blog Regular Project updates and countdown to the start All Staff, Patients & stakeholders

CEO, drafted by Hd Communications

Daily

Video Video diary of before, during and afterwards for use as a case study.

All Staff, Patients & stakeholders

Hd Communications Daily