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Implementing PEWS Sebastian Yuen [email protected] Consultant Paediatrician, George Eliot Hospital, Nuneaton Fellow, NHS Institute for Innovation and Improvement (2008-10) With Peter Lachman, Nikki Davey and The NHS Institute
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Overview
PEWS implementation in The Royal Free Hospital
The NHS Change Model
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The NHS Change Model
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PEWS is Recommended By:
CEMACH NCEPOD NHS Institute NHSLA
NICE NPSA RCN RCPCH
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PEWS Project Steps... 1. Strong Leadership
2. Build the team
3. Clarify the aim and vision
4. Implement change: Model for Improvement
5. Design (localise, improve) the PEWS Form
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PEWS Project Steps 6. Train staff in QI and PEWS
7. Measure & display effectiveness of PEWS
8. Communicate & engage all staff
9. Enhance Sustainability
10. Spread to other areas
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1. Leadership Vision Strategy Communication Listen Be authentic Humility Respect Courage
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"Change will not come if we wait for some other person or some other time. We are the ones we've been waiting for. We are the change that we seek”
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2. Build The Team: Who? Executive Sponsor Lead Paediatrician Lead Nurse / Matron Improvement Advisor Clinical Champions Administrator
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2. Build The Team: How? Stakeholder mapping Network Treat followers as equals WIIFM (What’s in it for me)? Expect challenge: know the evidence Walk the talk Focus and Commitment
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"Leaders are visible, have a vision
and share it, often"
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3. Clarify Aim & Vision Create a sense of urgency (drivers for change) Align with strategic objectives SMART aim: Days between crash calls to 365 within 1 year
Develop compelling vision Carefully limit scope Check readiness for implementation
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Vision Build compelling shared vision of outcome This comes from all staff, not top-down What will PEWS look like on a good day? What difference will we feel / hear / see? Describe in present tense Make it something exciting!
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Vision For PEWS Defines the ideal future situation It guides and encourages the organisation What do we want PEWS to look like in the future? “So easy to use - my mother could do it!” “I use it because it works – I trust it “It saves me time and helps me with patient assessment” “It improves situation awareness and reduces harm”
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Sense of Urgency Create a Sense of Urgency Why do we need to do this, now? Respond to:
o Complaints o Incidents o Patient story o Tight deadline
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“It was a question of jump or fry, so we jumped”
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4. Implementing Change
The Model for Improvement o Rapid start o Evolution, not revolution o Builds will and engagement
Driver Diagram: Overview of programme
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What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make that will result in the improvements we seek?
Model for improvement
Act Plan
Study Do
Aim: how much, by when? k Measurement Frontline staff suggest innovative ideas to overcome problems
Test ideas before implementing. PDSA Cycles are mini-audits
The Improvement Guide: A practical approach to enhancing organizational performance (2nd Edition 2009) Gerard J. Langley, Kevin M. Nolan, Thomas W. Nolan, Clifford L. Norman, Lloyd P. Provost
Model For Improvement
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Eliminate preventable harm
due to deterioration in
children
Identify early signs of
deterioration
Record physiological observations competently
PEWS Guideline
Recording Observations
Training
Calculate PEWS accurately
PEWS Form
PEWS Training
Use PEWS to improve Situation
Awareness
Ward Whiteboard
PEWS Handover
Respond rapidly to deterioration
Follow PEWS Escalation Plan
reliably Use SBAR
Communication Tool
SBAR Handover
SBAR Training @S3bster
5. Design PEWS Form PEWS forms & literature reviewed Started with Brighton, then Cardiff & GOS Multiple versions Led by users Implement as only observation chart
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The PDSA Cycle
Act • How will we test
what we have learned?
• Start planning the next cycle
Plan • Objective • Questions and predictions (why) • Plan to carry out the cycle (who, what, where, when) • Plan for data collection
Study • Complete the analysis of the data
• Compare data to predictions
• Summarise what was learned
Do • Carry out the plan • Document problems and unexpected observations • Begin analysis of the data
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PDSA Cycle Template
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Testing: Start Small 1 patient 1 nurse 1 doctor 1 day
Testing: 1 3 5 All
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Start Next Tuesday!
Year Quarter Month Week Day Hour
“What tests
can we complete
by next Tuesday?”
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PEWS Cycles 1-9
A P S D
A P
S D
A P S D
A P
S D
Cycle 1: First draft of modified Brighton PEWS – 1 nurse, 1 child, 1 shift
Cycle 2-4: Design of PEWS form improved. Tests similar to Cycle 1
Cycle 5: PEWS form now incorporated into observation form
Cycle 6-8: Design of PEWS form improved. Tests similar to Cycle 1
Cycle 9: PEWS design simplified Tests increase from 1-3-5-all
Result: Increased buy-in from stakeholders
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Format of PEWS
Usability Testing
Addition of section to audit action & added
to safety briefing
Link to SBAR & handover
Change Concepts
Multiple PEWS Cycles @S3bster
PDSA PEWS Forms @S3bster
PDSA PEWS Forms @S3bster
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Observation Charts Transformed
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6. Train staff in QI and PEWS Model for Improvement & PDSA Cycles Measurement for Improvement PEWS SBAR (RFH & NHSI DVD) How to measure vital signs Recognition of the sick child Remember new, night & temporary staff!
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"Some is not a number.
Soon
is not a time."
IHI 100,000 Lives Campaign
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7. Measurement Process Measures Outcome Measures
Crash Calls Transfers to PICU
Balancing Measures Review missed cases, deaths, incidents
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PEWS Process Bundle
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Measurement @S3bster
Measurement: Process @S3bster
Measurement: Outcome Interval between Crash Calls on The Royal Free Paediatric Ward
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8. Communicate Frequently – every opportunity! Match your message to this audience Tell patient stories Ask questions with genuine curiosity Listen! Posters announcing: PEWS is coming! Explain why (rational / evidence / emotional) Celebrate success!
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Capture Learning PDSA Forms Diaries Cameras
Share Learning with… Staff Families Executive sponsor Network
Spread Learning: Measures, Posters, Stories
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Engagement
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Engagement The team must want to implement PEWS They cannot be forced to do it Listening, trusting and empowering are key Communication in different ways is crucial Important to continue to engage the team It must make their lives better It must be easy to try and easy to do
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Sustainability @S3bster
9. Enhance Sustainability Handover SBAR Safety Briefing Resuscitation scenarios Audits The Productive Ward
Ward whiteboard Mandatory training Induction Involve parents Quality dashboard
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PEWS-SBAR Handover Sheet
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Patient Status At A Glance
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PEWS-SBAR Card 1
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PEWS-SBAR Card 2
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Spread of Innovation
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10. Spread Emergency Department Paediatric Neurological PEWS Form Neonatal PEWS Form Spread in UK Spread via Partners in Paediatrics Spread via the NHS Institute Spread to Slovenia and Uganda
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Rigorous Delivery Week 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
2
Team
M
eetin
gs
Mea
sure
s Co
mm
s
Review Meeting
Plan Next Steps
Review Meeting
Core Team Setup Meeting
1
Pre-measures
PDSA
PE
WS
Form
PDSA 4 3 PDSA 5
Project Team
Trai
ning
All Staff New / Temporary Staff
Project summary to team
PDSA summary after each
cycle
Launch email to all staff
PEWSletter 1: Why PEWS?
PEWSletter 2: What is PDSA?
PEWSletter 3: Why Measure?
PEWSletter 4: Progress
PEWSletter 5: Next Steps
Laun
ch
PEW
S
Week 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
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All truth passes through 3 stages:
1st it is ridiculed.
2nd it is violently opposed.
3rd it is accepted as being self-evident.
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#SocialEra #SoMe #RCPCHEPA13
@hesham_abdalla
@Nadeem_Moghal
@PeterLachman
@RCPCH_President
@KathEvans2
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@Damian_Roland
@ingridjohanna66
@CheungRonny
@Runnacles_J
@Qualityknitting
LinkedIn: The Running Horse Group
@PIPSQC
Paediatric QI Resources 1. www.pipsqc.org 2. RCPCH Quality Improvement and Patient Safety series:
http://ow.ly/lyX15 3. The Running Horse Group on LinkedIn:
http://ow.ly/lyXgA 4. Institute for Healthcare Improvement 5. Patient Safety First Campaign 6. The Health Foundation @S3bster
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Learning Points Implementation more important than the tool Align with priorities & other projects Co-produce from the beginning Executive leadership support essential MfI enables rapid start & builds will PDSA Cycles maximise learning Measurement helpful, but must lead to action Engage all team-members, often
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