04/03/2016

1

Jonkoping Microsystem Festival

Session B3 – 30 minutes

3rd March 2016

People power - Improving inpatient care at

Sheffield Teaching Hospitals

04/03/2016

2

Overview

• Sheffield MCA

• Respiratory Change Room

• MCA Ward Collaborative Overview

Sheffield MCA • Hosted by Sheffield

Teaching Hospitals

• Train QI ‘team’ coaches

(143 so far from several

organisations)

• 6 month programme –

action learning

• Coaches work with

microsystem teams to

make improvement and

build capability over 12

months+

04/03/2016

3

Initial Testing in 2009 -10

Falls Clinic & More

2010

Shine Grant 2011 – TDMIA (2 CITs)

MCA bid Feb 2012

Cohort 1 – Sept 2012 (27 CITs)

Cohort 2 – Feb 2013 (19 CITs)

Cohort 3 – Sept 13 (14 CITs)

Cohort 4 – June 14 (21 CITs)

Cohort 5 – Feb 2015 (29 CITs)

Cohort 6 – October 2015 (30 CITs)

MCA timeline 2009 - 2015

5

Initial

testing...and

failing

Coaching

and success

Dartmouth

training

MCA HF bid

STH and

SCH with

Dartmouth

SHSCT join

WHSCT (NI)

join

Sheffield

CCG &

Lanarkshire

join

East Kent,

UCLP &

Tower

Hamlets join

Some Numbers

• 143 Coaches have graduated from the MCA –

Cohorts 1 - 6

• 619 Staff have attended the ‘Introduction to Quality

Improvement’ courses

• 140 microsystems have worked with an MCA coach

• The MCA website was hit over 14,564 site users

from 10 countries - 61,653 page views last year.

• 220 staff attended MCA expo in June 2015

04/03/2016

4

RHH

S

WPH

JW

OSSCA Spec Med &

Rehabilitation

Head &

Neck

Emergency

Care

Corporate

Surgical Services

Emergency

Care

Surgical

Services

Spec Med &

Rehabilitation

SYRS

Corporate

LEGION

Combined

Community & Acute

Corporate

MSK

MSK

Combined

Community & Acute

CC

04/03/2016

5

Dr. Jennifer Hill

The Respiratory CHANGE room

Where are we from?

• Brearley 1-4

• Respiratory Medicine

Wards

• Northern General

Hospital

04/03/2016

6

HOW DID THE

JOURNEY START?

Rita’ story

‘On MAU they did tests, blood tests and that, and I had a chest x-ray. Then I had the same tests again

here, more blood tests. I was asked the same set of questions in A&E,

MAU and then here, over and over. It’s what happens when you come in here—same questions, same

tests over and over.’

‘A Doctor told me last week she

thought I’d be home by the end of

the week. I said I hope so! But I’m

still here a week later. Nothing

really happened over the weekend’

‘I’ve been in here quite a few times but I wish they knew about your medical history. It always

surprises me that nobody knows about you, what tablets you are on, so you get asked the same

questions over and over’

04/03/2016

7

Visit to Bolton……..

What we agreed

• Ownership not buy In

• ‘Mesosystem’ – 4 wards work together to learn

and share ideas

• Create a space for the meeting and to share the

metrics that matter – the CHANGE room

• Coaching Support from MCA

(Steve and Garry Fothergill)

04/03/2016

8

People Power - December 2011

The CHANGE Room

04/03/2016

9

CHANGE room Improvement

- The structure

Assessment - 5Ps

Change Ideas

PDSA

SDSA

‘Standardise’

Define Themes

5Ps – Identifying themes

• Understanding the system -

Discharges By Day Of The Week (01/11/10 - 06/11/11)

0

50

100

150

200

250

Mon Tue Wed Thu Fri Sat Sun

Brearley 1

Brearley 2

Brearley 3

Brearley 4

Discharges By Hour of the Day (01/11/10 - 06/11/11)

0

20

40

60

80

100

120

00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23

Brearley 1

Brearley 2

Brearley 3

Brearley 4

‘I’ve been in here quite a few times

but I wish they knew about your

medical history. It always surprises

me that nobody knows about you,

what tablets you are on, so you get

asked the same questions over and

over’

Brearley 1 - On the scale below please indicate what you would change to improve the

experience for pat ients and staff .

0%

20%

40%

60%

80%

100%

Clin

ical

Out

com

es

Pat

ient

Care

and

Dig

nity

Pat

ient

Saf

ety

Hosp

ital e

nviro

nmen

t - c

lean

lines

s

Hosp

ital e

nviro

nmen

t - la

yout

Ward

Org

anisat

ion

and ro

utin

es

Ward

Rou

nds

Hand

over

s and

con

tinuity

of c

are

Com

muni

catio

n

Info

rmat

ion

availa

ble

for p

atie

nts

and re

lativ

es

Pro

tect

ed m

eal t

imes

for p

atients

Med

icin

es m

anage

men

t

Sta

tuto

ry m

eal b

reak

s fo

r sta

ff

Sta

ff w

orking

pat

tern

s/hou

rs

Ava

ilabl

e equ

ipm

ent

Inte

rface

with

allied

hea

lth p

rofe

ssio

nals

4 - Large change required 3 2 1 0 - No change required

04/03/2016

10

5Ps - Learning

• Lots of variation in ward round, ward and MDT

processes across the four wards

• Communication highlighted as an issue by all the

staff

• Discharges peaked late in the day delaying flow

• Drug rounds were regularly interrupted

• TTO process caused delays

04/03/2016

11

CHANGE room

Improvement - The structure

Assessment - 5Ps

Change Ideas

PDSA

SDSA

‘Standardise’

Define Themes

CHANGE

Themes

Ward rounds and

MDT processes

Coding Medicines

Management

Q

04/03/2016

12

Brearley Ward Process map

First PDSA – BOARD ROUNDS

• Specific aim - to achieve daily 9am MDT

face to face communication and problem

solving across all 4 Brearley Wards 100%

of the time for the successive 2 weeks.

04/03/2016

13

4 Step Board Round Structure

Diagnosis

Medically fit? Y/N

Sick needing immediate

review? Y/N

Social issues? Y/N

NB. Please prioritise sick patients and those who are

medically fit with no social issues for review first on WR

- and do TTOs immediately

Do you think the daily board rounds should

continue?

0

5

10

15

20

25

yes

no

don't know

04/03/2016

14

CHANGE room

Improvement - The structure

Assessment - 5Ps

Change Ideas

PDSA

SDSA

‘Standardise’

Define Themes

CHANGE room

Improvement - The structure

Assessment - 5Ps

Change Ideas

PDSA

SDSA

‘Standardise’

Define Themes

04/03/2016

15

STANDARDISATION ON

WARDS

04/03/2016

16

04/03/2016

17

PDSA’s tested

to date

Idea PDSA StandardisedOngoing

work

Board rounds & Huddles Yes Yes Yes

Pharmacy run Yes Yes

Virtual checking station Yes

Labelling notes trolleys Yes Yes

Bed Wizard Yes Yes

White boards Yes Yes

Stock Room standardisation Yes Yes

Near INR patient testing Yes

Drug omissions Yes Yes

Baseward summary Drs sheet Yes

Ward round check list Yes Yes

Medicines reconciliation Yes Stalled

Drug rounds Yes Yes Yes

Nurse handover Yes Yes

Paperwork filing Yes Yes

On-line anticoag appointments Yes Yes

Open visiting Yes Yes

Red ‘social’ folder Yes Parked

D2A Yes Yes

TTO delays Yes Yes

Admission HCA protocol Yes Yes

WHAT HAS THE CHANGE

ROOM CHANGED?

04/03/2016

18

Outcome – Length of Stay

Outcome - HSMR

04/03/2016

19

Outcome – Expected death rate

Data from Dr Foster

04/03/2016

20

Stocktake in 2016

Successes Ongoing Testing

Board rounds Patient information

Bed wizard Oxygen prescription

Drug Rounds Front door processes

Discharge to assess Nurse led discharge

Standardisation on wards Electronic requesting

Open Visiting Increased use of IT on wards

Stock storage Upskilling support workers

Nursing handover

Visual management

Drug Omissions

Weekend handover sheet

Ongoing work – flow through the system

04/03/2016

21

What are we learning from this approach -

Strengths and ‘challenges’

+

• Engaging staff

• Measured improvements

_

• ‘mesosystem’

• traditionalists

• ‘Lifestyle change’

MCA Ward Collaborative

04/03/2016

22

Ward improvement work pre Ward Collaborative

• Attempted by 8 coaches and ward teams in C1-4

• Majority said it was worthwhile but high failure

rate by 12 months

• Main issues – time to meet, leadership

engagement and enablement, coach support

• Only the Respiratory team achieved sustained

system level change

5P Assessment

Theme

Global Aim

Change Ideas

Specific Aim

Measures

Flowchart

Cause & Effect

The Microsystem

Improvement Ramp

Effective Meeting Skills

Global Aim

1

2

3

SDS

A

P

DS

A

P

DS

A

P

DS

A

PDSA

1

3

2

Global Aim

1

2

3

5 P Assessment

Theme

Global Aim

Change Ideas

Specific Aim

Measures

SDSA

P

DS

A

P

DS

A

P

DS

A

PDSA

1

3

2

Dartmouth Microsystem Improvement CurriculumPre Ward Collaborative MCA

‘Ward’ teams at 12 months B3

F1

Green - Active

Red - Inactive

04/03/2016

23

MCA Ward Collaborative Aims

• To support up to 10 wards at STH to improve care for the patients

they serve by March 2016.

• To build quality improvement capability with the staff on those wards

so that quality improvements can be maintained and improvement

becomes continuous during this period.

• To support and develop new MCA coaches working in the ward

environment by buddying them with experienced service improvement

coaches.

• To create an opportunity for wards to learn from each other, share

improvements and good ideas to accelerate the rate of improvement

for patients

• To spread the approach and learning from the improvement approach

adopted in the Respiratory wards

Ward Collaborative Overview

04/03/2016

24

Learning Session Overview

Session 1 Session 2 Session 3 Session 4

Introduction to the

collaborative.

QI and

microsystem

fundamentals,

Effective meeting

skills,

understanding

your system using

the 5Ps

Process mapping,

Patient

involvement.

Story from the

field. (CHANGE

room).

Progress reports

from all teams,

Feedback and

sharing on the

5Ps,

Themes and Aim

statements,

Change Ideas and

PDSA,

Measurement

basics.,

Story from the

field. (Hadfield 6)

Planning Time

Progress Reports

from all teams,

Psychology for

improvement

Run charts and

Variation,

5s,

SDSA and

sustaining

improvement.

Planning Time

Progress Reports

from all teams as

posters and

presented case

studies.

Capacity and

demand basics.

Behaviour Change

Planning multiple

improvements

using driver

diagrams

Celebration and

certificates

Learning Session Overview

Session 1 Session 2 Session 3 Session 4

Introduction to the

collaborative.

QI and

microsystem

fundamentals,

Effective meeting

skills,

understanding

your system using

the 5Ps

Process mapping,

Patient

involvement.

Story from the

field. (CHANGE

room).

Progress reports

from all teams,

Feedback and

sharing on the

5Ps,

Themes and Aim

statements,

Change Ideas and

PDSA,

Measurement

basics.,

Story from the

field. (Hadfield 6)

Planning Time

Progress Reports

from all teams,

Psychology for

improvement

Run charts and

Variation,

5s,

SDSA and

sustaining

improvement.

Planning Time

Progress Reports

from all teams as

posters and

presented case

studies.

Capacity and

demand basics.

Behaviour Change

Planning multiple

improvements

using driver

diagrams

Celebration and

certificates

04/03/2016

25

Learning Session Overview

Session 1 Session 2 Session 3 Session 4

Introduction to the

collaborative.

QI and

microsystem

fundamentals,

Effective meeting

skills,

understanding

your system using

the 5Ps

Process mapping,

Patient

involvement.

Story from the

field. (CHANGE

room).

Progress reports

from all teams,

Feedback and

sharing on the

5Ps,

Themes and Aim

statements,

Change Ideas and

PDSA,

Measurement

basics.,

Story from the

field. (Hadfield 6)

Planning Time

Progress Reports

from all teams,

Psychology for

improvement

Run charts and

Variation,

5s,

SDSA and

sustaining

improvement.

Planning Time

Progress Reports

from all teams as

posters and

presented case

studies.

Capacity and

demand basics.

Behaviour Change

Planning multiple

improvements

using driver

diagrams

Celebration and

certificates

Learning Session Overview

Session 1 Session 2 Session 3 Session 4

Introduction to the

collaborative.

QI and

microsystem

fundamentals,

Effective meeting

skills,

understanding

your system using

the 5Ps

Process mapping,

Patient

involvement.

Story from the

field. (CHANGE

room).

Progress reports

from all teams,

Feedback and

sharing on the

5Ps,

Themes and Aim

statements,

Change Ideas and

PDSA,

Measurement

basics.,

Story from the

field. (Hadfield 6)

Planning Time

Progress Reports

from all teams,

Psychology for

improvement

Run charts and

Variation,

5s,

SDSA and

sustaining

improvement.

Planning Time

Progress Reports

from all teams as

posters and

presented case

studies.

Capacity and

demand basics.

Behaviour Change

Planning multiple

improvements

using driver

diagrams

Celebration and

certificates

04/03/2016

26

Ward Collaborative Teams & Coaches

Team & Wards Faculty Coach MCA Coach

GSM

(B5,6 & 7, RH5 & 6

NGH)

Jim Claire

Gastro

(RH3 & RH4 NGH) Nicola Davlyn

Spinal (Osborn 2) Maria Donna

Spinal (Osborn 3) Kevin Tim

Infectious Diseases

(E1 & E2 RHH) Nick Colin

Orthopaedics (F1 RHH) Jo Laura

Cardiology CCU Paul Aileen

Team & Wards Themes PDSAs

GSM

(B5,6 & 7, RH5 &

6 NGH)

Communication, Noise

Board Round redesign

E-discharge

Case note standardisation

Gastro

(RH3 & RH4 NGH)

Patient Flow (timely

discharge), Patient

Entertainment, Patient

Nutrition

Daily Board Rounds and Ward Rounds.

Junior doctor induction pack..

Patient entertainment – availability of a

newspaper/sweet trolley and working TV’s

Spinal (Osborn 2) Organisation, Ward

Processes, Food

MDT ward round standardisation

Patient information & Food storage

Drug round redesign

Spinal (Osborn 3) Team Work

Ward documentation

Improving flow of ward round

MDT communication tests

Standardisation to reduce time wasted

Infectious

Diseases

(E1 & E2 RHH)

Ward attenders

Overall process redesign. New labelling for

tests, diary system, blood result redesign, patient

tracking

Orthopaedics (F1

RHH)

TED Stockings Process

Pain Management

Patients belongings

Tested stocking aid reducing delay in discharge.

Test re X ray process to improve pain

management and immediately start

physiotherapy.

Cardiology CCU Left collaborative after learning session 2

04/03/2016

27

5P Assessment

Theme

Global Aim

Change Ideas

Specific Aim

Measures

Flowchart

Cause & Effect

The Microsystem

Improvement Ramp

Effective Meeting Skills

Global Aim

1

2

3

SDS

A

P

DS

A

P

DS

A

P

DS

A

PDSA

1

3

2

Global Aim

1

2

3

5 P Assessment

Theme

Global Aim

Change Ideas

Specific Aim

Measures

SDSA

P

DS

A

P

DS

A

P

DS

A

PDSA

1

3

2

Dartmouth Microsystem Improvement CurriculumPre Ward Collaborative MCA

teams at 12 months B3

F1

Green - Active

Red - Inactive

5P Assessment

Theme

Global Aim

Change Ideas

Specific Aim

Measures

Flowchart

Cause & Effect

The Microsystem

Improvement Ramp

Effective Meeting Skills

Global Aim

1

2

3

SDS

A

P

DS

A

P

DS

A

P

DS

A

PDSA

1

3

2

Global Aim

1

2

3

5 P Assessment

Theme

Global Aim

Change Ideas

Specific Aim

Measures

SDSA

P

DS

A

P

DS

A

P

DS

A

PDSA

1

3

2

Dartmouth Microsystem Improvement CurriculumWard Collaborative MCA teams

at 12 months GSM

x4

F1

Green - Active

Red - Inactive

04/03/2016

28

Example results - GSM

'It was good to know

that everyone was

finding it tough, it

helped us keep

going, and we will

keep going!"

Example Results – Osborn 2

0

10

20

30

40

50

60

70

80

90

100

26

.Oct.1

5

02

.No

v.15

09

.No

v.15

16

.No

v.15

23

.No

v.15

30

.No

v.15

07

.De

c.15

14

.De

c.15

21

.De

c.15

28

.De

c.15

04

.Jan

.16

11

.Jan

.16

18

.Jan

.16

25

.Jan

.16

01

.Feb

.16

08

.Feb

.16

15

.Feb

.16

% o

f p

atie

nts

Number of Patients which are discussed, seen and have agreed actions within 12 minutes per patient at the Osborn Monday morning

MDT

No MDT (Boxing day

(x) number of patients discussed were within 30

0

10

20

30

40

50

60

70

80

90

100

26

.Oct.1

5

02

.No

v.15

09

.No

v.15

16

.No

v.15

23

.No

v.15

30

.No

v.15

07

.De

c.15

14

.De

c.15

21

.De

c.15

28

.De

c.15

04

.Jan

.16

11

.Jan

.16

18

.Jan

.16

25

.Jan

.16

01

.Feb

.16

08

.Feb

.16

15

.Feb

.16

Tim

e s

pe

nt

(min

s)

Time taken to transfer relevant information about each patient agreed at the Osborn Monday morning MDT to the Osborn 3 nursing staff

“Ward round is now a lot

quicker and more efficient

than it used to be, which

means I can spend more

time treating patients”

“For me….it’s much less

stressful to be the

recorder in ward round.

Everyone is not talking at

the same time. It is now

far more focused,

succinct, and efficient”

04/03/2016

29

Example Results - Gastro

What are we learning - Positives

People power – over 100 front line staff engaged

Collaborative helps build capability, rhythm and

pace for sustained improvement.

Develops QI understanding and ownership.

Co-coaching model helps support ‘novice’

coaches and aids ‘resilience’.

Teams regularly sharing ideas and challenges

supports spread and sustain.

04/03/2016

30

What are we learning - Challenges

Conditions remain challenging – operational

pressures do not always allow staff to meet and

work on improvement

Communication to the wider team from the core

improvement group is problematic and variable

Timing of sessions is tricky – teaching what the

teams need at the right time

Measurement is a challenge – outcomes are

measured but many ward processes are not

routinely measured

Participant comments “There is real value in

feedback, sharing ideas

and in reassurance

about pace”

“The Co-coaching

has been most

valuable, instant

feedback - asking did

I talk too much!”

“We’ve realised that this is

not linear & QI doesn’t fit

into boxes, we took it

back to basics and met

the ward where they are

at and tried to keep things

simple”

“It has been great

to see what

happens with a

whole system

view”

04/03/2016

31

What’s Next?

• Celebration with posters

to STH leadership on

Tuesday 8th March 2016

• Evaluation – Qualitative & Quantitative with case

studies for MCA website

• Follow ups sessions with teams at 3, 6 and 12

months

Microsystem – Geriatric & Stroke Medicine

Board rounds - guidance

Background Changes madeThemes of e-discharge, noise and board rounds

Following a 5p’s assessment the team identified e-discharge, noise , case notes and board rounds as themes. Global and specific aims were established for each of these themes.

A new discharge checklist was introduced to remind staff about the e-discharge button in red.

The average time to complete the e-discharge has gone down from 41 hours to 12. 65% were now completed in 48 hours, this was 40%. Three Brearley wards have been measured for noise using a device. Brearley 5 was significantly quieter than 6 and 7. This work is on going.

Current board rounds were discussed using De Bono Six Thinking Hats. As a result this guidance and evaluation was produced:

The Geriatric and Stroke Medicine Wards include Brearley 5,6, 7 and Robert Hadfield 5 and 6. This is a collaborative Microsystem of all five wards. They provide ongoing care for elderly patients with dementia and patients that have suffered a stroke.

Future plans

To continue to meet weekly to look at noise and board rounds on the GSM wards.

What’s Next? – Outpatient Collaborative

• 6 Outpatient clinics across STH

• Dec 2015 – Nov 2016

04/03/2016

32

FLOW

Team Coaching

Improvement

Science

Pathway

What’s Next? - Improving Flow

QI

Global Aim

Themes

‘Post-it

Frenzy’

Build a Big

Room

Specific aim

Change

Ideas

Brainstorming

Change Concepts

Benchmarking and

visits

Process/Value

Stream Map

Fishbone

Spaghetti

Diagrams

Selection criteria &

Multivoting

Change

idea

Standardise

A P

S DDefine

measures

Pre-

Phase

A P

S D

Coached weekly

meetings

Patient

stories

System

data

Reflective

learning

A P

S D

More Information? www.sheffieldmca.org.uk

04/03/2016

33

Join us for....

6th & 7th June

2016

Sheffield

MCA

expo ’16