Delivering improvements

Using Lean Principles

Dr Brian Bradley , Michaela Bowden Bolton Respiratory Team

Cindy WaltonBolton Improving Care System

• 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!

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%)

The Bolton Improving Care System

UnderstandingValue Learning

To See

RedesigningCare

DeliveringBenefit

Why Change?

• Difficult Winter• Care unsafe• 98% not being achieved• Stressed Staff• We needed to change

Concept of Flow

• Applying concept of flow • Value adding steps • How could it we apply to ward activities• Batch –common way • One piece flow would not be possible on

ward• One decision flow

One Decision Flow

• Right People present to make decisions flow

• Ward Rounds – Daily Consultant Lead• Board Rounds Daily• Decisions being made on a daily basis by

the right people• Not Traditional

Bolton Respiratory Team

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

Respiratory Team Vision

• Timely, equitable inpatient access to respiratory services

• Best cost-effective outpatient multi disciplinary team (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

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 hours

Straight 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 + non

consultant hospital doctors (NCHDs)

• Physiotherapy • Occupational Therapy• Pharmacy• Social Workers• External (to the process)

4 Day Event!

• Gap Analysis• Agree new ways of

working• Support this Standard

work model• Devise a model to sustain

the changes

Gap Analysis: As reported by staff

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 / To take out drugs for patients on discharge from hospital (TTOs)

• Interruptions –40% of time delivering

• Drugs -i.v. antibiotics• Handover / prioritise work • Social work referrals and

discharge planning

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 tasksNursingJunior 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.

8Identify patients for Discharge Process TTOs 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

Room PatientName

Actions from Rapid Improvement Event (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 outpatients (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 Go Go

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

Septe

mbe

r 08

Octobe

r 08

Novem

ber 0

8

Decem

ber 0

8

Janua

ry 0

9

Febru

ary

09

Mar

ch 0

9

April 0

9

May

09

June

09

July

09

Augus

t 09

Septe

mbe

r 09

Octobe

r 09

Novem

ber 0

9

Decem

ber 0

9

Month

Nu

mb

er o

f D

isch

arg

es

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

24 hrs

24 hrs24 hrs

24 hrs

24 hrs

25-50 hrs

25-50 hrs

25-50 hrs25-50 hrs

25-50 hrs

0%

20%

40%

60%

80%

100%

30 days60 days90 days Mar-10 Sep-12

Time to specialist wards

Non electiveDirect admissions

25-50 hrs

51-+ hrs

Elective direct

140 random patients reviewed March 2010

50 random Patients September 2012

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.

jul aug sep oct nov dec Jan Feb Mar Apr May Jun Jul0

10

20

30

40

50

60

70

80

90

20092010 /11

Num

ber

of

hom

e v

isit

s

34.5% in-crease in home visits

Average 58

Average 38Pre Event 800 miles / month

Post improvement 624 miles / month 22% re-duction per month on average

Home Visits

Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-120

100

200

300

400

500

600

700

800

900Specialist Nurses Respiratory Team mileage January to September 12

Average 459 / month

Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-120

50

100

150

200

250

Respiratory nurse visits January to August 12

Average 147 / month

0

50

100

150

200

250

HSMRLinear (HSMR)

New Ways of working RNS May 2010

Pneumonia mortality

Pneumonia RAMI- April 11- June 12

Bas

elin

eJu

neJu

ly

August

Septe

mbe

r

Oct

ober

Nov

embe

r

Dec

embe

r

Jan-1

1

Feb-

11

Mar

-11

Apr-1

1

May

-11

Jun-1

1

Jul-1

1

Aug-11

0%

10%

20%

30%

40%

50%

60%

70%

80%

COPD Pneumonia Asthma Bronchiectasis ILD

Patients seen by RNS (new way)

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

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

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

Current Community Working Disease Management Team

Instant Access – October 2012

Better Community Working

• General Practitioner with Special Interest in Respiratory Disease Respiratory Clinics Supports Community Team Consultant liason

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

• Pulmonary Rehabilitation Poor community uptake – need to broaden access

• Education Events on End of Life Care Gold Standard Framework

• Shorten Clinic waiting times: Routine referral 24-48hrs

Exacerbations – same day review

• Immediate telephone advice 7 days for primary care

• Impact: Better Care 2-3 less A/E patients per day

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

• Agreement in principle with Commissioners

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 Aug, 146 per month

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 community

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

This would not have been possible without the hard work of all the staff supported by the tireless energy of

Cindy Walton and the rest of the BICS team.

Thank you