better for you report

Better for You Report

2013

If you would like this report in a different language or format, please contact us on 0115 924 9924 x70411 or e-mail [email protected]. An e-copy is available on our website at www.nuh.nhs.uk.

Contents1 Introduction ..................................................................................................................1

2 Case studies ...................................................................................................................2Informing bed planning through data analysis ............................................................................................. 2

Children’s champion staff engagement ....................................................................................................... 3

New welcome for new starters ................................................................................................................... 4

Ward receptionists create Service Charter pledge ........................................................................................ 5

Staff ‘just do it’ ........................................................................................................................................... 6

Nottingham Children’s Hospital – Tina’s Tiles, just do it ............................................................................... 6

Maxillofacial Unit appointment process overhaul ......................................................................................... 7

Summary Care Record ................................................................................................................................ 8

Staff-led change key to buy-in..................................................................................................................... 8

Protected typing time ................................................................................................................................. 9

Sterile Services improvements ................................................................................................................... 10

Children’s Outpatients transformation ........................................................................................................11

Better for You highlights timeline – 2013 .................................................................................................. 12

Staff collaboration results in faster CT scanning system ............................................................................. 14

Porters achieve record high efficiency in Radiology ................................................................................... 15

How Better for You helped NUH achieve national recognition for Intra-operative Fluid Management ........ 16

Better organised theatres .......................................................................................................................... 17

Audit of emergency triage process identifies good practice ....................................................................... 18

@betterforyounuh is transforming the way we communicate .................................................................... 18

Improving patient data process delivers greater efficiency for the Trust...................................................... 19

Nottingham Children’s Hospital – communicating values and behaviours ................................................... 20

Trust, Commissioners and GPs join forces to deliver greater patient care .................................................... 22

Wildly Important Goals ............................................................................................................................. 22

E40 Disney window stickers ...................................................................................................................... 23

Transfer to Assess ..................................................................................................................................... 24

Improved efficiency in Cardiac Catheter Laboratories ................................................................................ 25

Improved triage process in Children’s ED ................................................................................................... 25

Nottingham University Hospitals NHS Trust Better for You Report 2013 1

1 Introduction

Better for You (BfY), our established whole-hospital continuous improvement programme, continues to deliver exceptional results. Believed to be the biggest change programme of its kind in the NHS, it is our template for designing change to support all improvement work across NUH.

Building on the achievements since its inception in 2009, BfY continues to evolve in response to the changing needs of our organisation, and the feedback we receive from our patients, their loved ones, carers and staff.

Twelve months ago we brought together our process and system redesign and our Learning and Organisational Development programmes. This is enabling us to better support all of our improvement work across NUH, including those focused on quality, safety, improving value for money, behaviour and culture. We have continued to renew and update our plans to repeat key national developments in the last year. Our priorities have been influenced by publications including the Francis, Keogh and Berwick Reviews.

This report highlights a selection of case studies which demonstrate the variety and breadth of the improvement activities led by NUH staff and our continued progress in identifying problems, developing solutions and introducing change. It tracks our progress since the development of our joint BfY and Learning and Organisational Development strategy in 2012.

In 2014 – five years into BfY – we will ‘take stock’ of all of the improvement activities that make up our wide-ranging transformation programme. Our internal response to the changing external landscape and the views of our patients and staff will guide the future journey for our transformation programme. We will audit the effectiveness of our values and behaviours programme – which also launched in 2009 – by seeking the views of our staff and external stakeholders and will consult extensively with our patients, local community and our staff to create a shared vision for the future of NUH beyond 2016.

Jenny Leggott

Deputy Chief Executive and Executive Sponsor, Better for You

22

2 Case studies

Informing bed planning through data analysis The winter season is traditionally challenging for all hospitals as an increased number of patients with more complex health needs are admitted. The winter of 2011/12 was a particularly demanding. Over 1,000 operations were cancelled due to a lack of bed availability and patients were left feeling distressed and let down.

The Analytics and Intelligence Team believed that analysing bed usage patterns could be used to help create an improved bed capacity planning process and using the BfY approach began working to achieve this goal.

The team found that bed planning was effectively carried out by individual directorates but often the bed situation across the

whole of the hospital was not readily available.

It also found that bed planning was often calculated by examining average usage over a year. The team decided to analyse daily requirements over a year and as a result, a clearer picture of when and where the pressures arose across the whole Trust emerged.

Quarterly reports are now escalated to the senior management teams which gives an overview of the impact that different seasons have on bed occupancy. Analysing this trend year on year helps better anticipate future pressures.

For this work the Analysis and Intelligence Team won a national award for best use of analysis to manage demand and capacity at

the Centre of Excellence Healthcare Analysis in 2013.

Andrew Barraclough, Head of Analysis and Intelligence, said: “I was delighted that the team was recognised for its work in helping to tackle very complex data to help better manage bed capacity. No-one can predict fully the demand on beds from one year to the next; it’s an issue the entire health community has to wrestle with. But now that we have a fuller understanding of how the need for beds varies over the year, we can help ensure that patients don’t face a similar situation to that in the winter of 2011/12.”


Children’s Hospital champion staff engagementMore than 300 staff took part in Octoberfest 2013, considered to be the most innovative staff engagement initiative ever held at the Nottingham Children’s Hospital.

To encourage staff to participate the team held a variety of fun competitions and invited a sharing of ideas as to how they could be made to feel more valued at work. A huge blackboard, post-it notes and opportunity to chat informally all played their role.

Alongside the apparent fun theme to its activities, the open door style October fortnight plays an instrumental role in improving staff involvement and patient care, boosting morale which contributes to helping the hospital shape its strategy.

First launched in 2012 and held in The Hub at the Children’s Hospital,

Octoberfest was designed as an engagement event to review and comment on the Children’s Hospital strategy, check and challenge BfY projects and priorities and identify new ones for the future.

The 2013 event was the ideal forum to report on progress made against Octoberfest 2012 output; staff comments have been used to update the strategy and issues affecting staff experience at work are being addressed. These include improvements in the staff appraisal process, the development of an enhanced new starter experience, training in the areas of teamwork and leadership skills developed.

The two week 2013 programme also invited staff to nominate colleagues for ‘Values and Behaviour Champion’ Awards and was used to launch the 2013/2014 Hands and Hearts campaign, a communication

campaign to help communicate the Trust values and behaviours to Children’s Hospital staff.

One unexpected highlight of Octoberfest 2013 was the visit by a delegation of play specialists from Japan. The team visited the Hub and made its own Hearts and Hands posters to take home.

Julie Beard, Project Lead, said: “Octoberfest is a great way to contact a large number of staff on specific issues. Whilst we recorded 342 staff taking part this year, more than 40% of staff in the Children’s Hospital, further work is still needed to engage staff who did not attend.

“We will continue to work to deliver improvements in staff experience to ultimately improve patients experience and are now focused on analysing feedback from 2013.”

4

CASE STUDY: New welcome for new startersOctoberfest 2012 identified that there was significant room for improvement in supporting newly-qualified nurses and improving retention, and work began immediately to do just that.

Shortly after Octoberfest, the Clinical Nurse Specialist responsible for preceptorship held a session with a group of newly-qualified nurses who had started in post over the previous four weeks. As part of this session, designed to guide and support all newly-qualified nurses, she asked each of them to write a letter to their ‘future self’ to be read in six months’ time about where they would like to be by then.

The group was asked if they would be happy to share their letters more widely and many said they would. They made sobering reading; the nurses sounded despondent and unsupported.

Working with the matron and a group of ward sisters, immediate action was taken to start putting support in place for that group of staff.

As part of the research process, the BfY team collected a library of staff stories recounted as part of a Staff Experience Project discovery phase; as these included details of experiences staff had when new in post and demonstrated that other groups had experienced similar problems to those being told by the new nurses.

This information, alongside the future self-letters, triggered a sub-project to the staff experience project about how all future new starters in the Children’s Hospital are supported and made to feel welcome.

The clear need for better support for our newly-qualified staff has led to the Clinical Nurse Specialist preceptorship post becoming full time and a key member of the New Starters project team has introduced the following:

• A series of ‘keep in touch’ newsletters to let them know some key contacts and what is happening in the Children’s Hospital before they start work

• Acute care skills course

• Increased clinical supervision

• A ‘buddy’ system

• Action learning

• Changes to shift times in the supernumerary period

• ‘Welcome’ ideas for wards – a welcome card/cake/someone to greet

• Tweeting a welcome to new starters

The same group exercise was held in September with the next group of newly-qualified nurses. You can read the results for yourselves below. This best practice new starter approach is now being rolled out to other groups of staff.

4


Ward receptionists create Service Charter pledgeA fun and highly interactive training day held for 120 ward receptionists has significantly boosted morale and resulted in this team of professionals creating a unique Service Charter pledge.

This was also the first time that group training of this kind had been organised solely around the receptionists’ role which is clerical as well as extremely people focused.

The training session was designed to be informative and remind the team of the difference they can make in helping to deliver the very best in patient care as well as efficiency on the wards.

The receptionists enjoyed meeting others from different departments across the hospital and swapping ideas and thoughts throughout the day long programme.

One of the exercises involved the team splitting into different groups and scoping out what they would like to see in their ideal Service Charter. Each group presented their concepts which were so

exceptional that they are currently being merged to create one single Service Charter commitment, written and produced by Ward Receptionists themselves.

Feedback was extremely positive, including:

“Made me realise how important my role is”

“Encouraging, helpful and supportive”

“A very valuable experience, lots of values shared”

“Helpful, useful and educational”

“Fun, good for morale”

“It was very enjoyable to be made to feel part of a great working team”

“It was lovely to hear that others feel the same as I do. It has helped me evaluate my behaviour in front of patients”

66

Staff ‘just do it’ Our staff are feeling more engaged and empowered to make positive change for the benefit of patients and their colleagues... by ‘just doing it’.

If staff have an idea that can be easily implemented to improve the experience for our patients or the working environment, as the title says, they ‘just do it.’

Twice a year staff present their ideas and their impact on patients and staff to members of our Trust Board and colleagues from other parts of the Trust. At the latest event – held in November 2013 – 19 ideas were showcased. These included:

• Buying disposable coats so patients leave our hospital warm

• Translating patient information leaflets into the most commonly – used languages

• Improving the maternity reception area

• Refurbishing dayrooms

• Better ways of securing confidential information

Purchasing disposable coats

Jane Atkins, Ward Sister, realised that a significant number of patients are admitted to hospital at night when they are wearing their night clothes. If they are discharged relatively quickly, more often than not they have nothing but their night clothes to wear to go home in. This can hold up discharge, compromise dignity and cause a poor patient experience.

Jane decided to buy over 100 disposable coats for the cost of £340 for such patients to wear when they leave our hospital. This is better for patients who feel more comfortable during their stay and better for the hospital as it means patients are going home sooner and beds are being freed up earlier for new patients.

Tina’s Tiles (full case study, below)

Tina Kirk, Housekeeper on Ward E37 in the Nottingham’s Children Hospital has been giving young teenagers the opportunity to engage in fun activity while, at the

same time, helping to improve the décor of bathrooms on our wards.

Tina sourced blank wall tiles from her husband, and young patients have been applying their creative talents to decorate and personalise the tiles that are then used in bathrooms.

Securing confidential information

To help keep patient notes confidential and safe while transferring them from wards to theatres, the City Hospital’s Patient Escort team purchased plastic secure zipped note bags. This simple action has made the notes look more official and has removed the possibility of people being able to glance at any notes that are attached to beds that are transporting patients to theatre.

CASE STUDY: Nottingham Children’s Hospital – Tina’s Tiles, just do it

Tina Kirk, Housekeeper on the Children’s Assessment unit and Short Stay ward was concerned that the children’s bathroom on the ward was dull and not child-friendly. She had the idea of asking children who were patients on the ward to decorate wall tiles, using special tile paints, which could then be used to decorate the bathrooms. Her husband donated some plain white tiles and off she went!

Many of the adolescents, who are often difficult to keep amused in hospital, really enjoyed this activity and Tina found that they opened up and chatted more freely about their concerns whilst engaged in this way.

Tina is currently collecting the tiles so there are enough to cover all the areas she wants to include but examples are shown right.

The project has been advertised in the Children’s Hospital newsletter so more staff are donating spare tiles for decoration. Once Tina has enough tiles for the bathroom the work will continue with a view to including the tiles in the artwork project around the Children’s Hospital.

The children’s bathroom as it is at the moment

Examples of tiles

A number of ‘just do its’ have been made possible thanks to financial support from Nottingham Hospitals Charity.


Maxillofacial Unit appointment process overhaulOur Maxillofacial Unit provides a comprehensive range of services to correct problems with the face, mouth, teeth and jaw.

The Unit is now consistently reaching its target performance for all non-admitted patients following an overhaul of its appointment processes. This ensures that patients are now consistently (over 95% of patients every month) treated within a total of 18 weeks from the referral being received. This is the first time this has been achieved for four consecutive months for well over a year.

Findings uncovered an increasing rise in the number of complex cases being treated by the Unit, which took more time to deal with and a process that was taking on average three weeks for a first appointment date to be agreed with patients. Staff were unhappy with these timescales and following investigations launched a concerted effort to reduce this length of time. This has achieved a

reduction to around two weeks on average, bringing this into line with expectations.

There were also some cases where patients could have been referred directly to specialist clinics rather than being given a general first appointment. Focusing on improving this has reduced the overall length of time it takes to treat many of our patients.

Investigations also revealed that around 10% of patients simply did not arrive for an appointment, reducing the number of slots available to see patients. We discussed reasons for this with the patients themselves and a number of simple improvements were put in place, such as reminder posters in the clinic waiting areas and big yellow stickers highlighting the telephone number to cancel an appointment on the clinic letters.

Further work is ongoing at present in order to sustain even greater improvements, particularly around

ensuring the right number of clinic slots are available, reducing the number of changes to appointments and reducing the need for expensive initiative clinics to be put on.

Mr Srinivasan, Head of Service, said: “Once we knew why there was a backlog we could do something about it, and we did! We now have a dedicated runner to help facilitate a faster appointments system between consultants and the administration staff. We stick bright yellow stickers, that give the number to cancel or rearrange an appointment, onto letters to make it easier for patients to do.”

This programme of successful improvements is, quite rightly, a source of pride for those working in the Maxillofacial Unit and has stimulated an existing appetite to sustain these gains and go on further improving the service for our patients.

8

Staff-led change key to buy-in The key to embedding change, no matter how large or small, is involving those who are most affected by the change.

A project to redesign the Clinical Warning Score within the GP Assessment Clinic and the Ambulatory Emergency Care Unit has resulted in significant buy-in and support from staff because they play a key role in designing the new system.

Staff compliance with completing the Clinic Warning Score (CWS) has risen from 33 per cent to 95 per cent. As a consequence, there is a much greater understanding of the number of:

• Patients in the clinic

• Expected patients

• Patients waiting longer than 15 minutes

• Occupied trollies

• Patients confirmed as needing beds

• Patients with a EWS score of 3 +, and a clearer picture of the status of the previous hour

The changes to the CWS have moved it away from a paper-based system to a new electronic format which allows key decision makers within the organisation to view performance data that they previously didn’t have access to. This has led to more collaboration with colleagues in the Emergency Department (ED) when it is necessary to escalate some Ambulatory and GP Assessment patients to ED.

Such are the fluctuating demands upon the service, flexibility in terms of reporting issues and problems are now escalated more efficiently. Responses to such issues are now more timely which increases patient safety and the quality of treatment they receive.

Summary Care RecordDirect access to an innovative Summary Care Record (SCR) system that contains patient medication, allergies and adverse reactions has been introduced at NUH, helping to save invaluable time and improve patient care.

When a patient is admitted to hospital, pharmacy teams work to reconcile hospital prescribed medication with medication the patient may already be taking. This is a critical service which ensures patients are not prescribed medication that is incompatible with existing medication that a patient is allergic to, or has an

adverse reaction with. The process of medicines reconciliation also allows hospital staff to ensure that patients continue with medication they are already taking while they are in hospital.

The introduction of the SCR system, which is automatically updated from GP records, allows clinicians to quickly see this data in one place, rather than having to phone GPs and check a number of different patient records which is often very time consuming.

The SCR can also assist where patients are unable to communicate

due to cognitive impairment, language issues or where they are unconscious.

“It has been invaluable to me at times, especially during on calls when it is not possible to contact a patient’s GP surgery to get a drug history, or you are less inclined to sit on hold for 20 minutes, to then have 10 drugs spelt out to you because the person on the other end of the phone has never heard of them.” Junior Doctor, Acute Medicine.

The system was introduced in February 2013 and an audit was carried out over a week in May 2013 to assess new efficiency levels.

The results showed that the use of the SCR had:

• Reduced the average time taken for medicines reconciliation from 20 to 14 minutes

• Reduced the number of calls to GPs surgeries allowing clinical staff to focus on patient care

• Improved the quality of medicines reconciliation identifying greater numbers of medications correctly and ensuring that patients received timesensitive medication e.g. angina spray

8


Protected typing timeProviding timely clinical correspondence from all specialties on a consistent basis has been a challenge for administration teams at NUH. Improving this was the focus of work by the Programme Management Office (PMO) in 2013.

The project initially sought to understand the problems which existed. Through discussions with the Patient Advice and Liaison Service (PALS) the project identified GP and patient complaints about lengthy delays in receiving clinical correspondence. The extent of the consistent back-log in typing in some specialties was also identified. In extreme cases routine typing was taking up to 12 weeks compared to the expected maximum standard of 5 days. To try and cope, agency support was being bought in at significant cost to the Trust.

Administration and clerical staff were invited to take part in research to understand the reasons for the delays – and findings quickly became clear. During a shift, staff would undertake filing, reception and other clerical work whilst dealing with a regular stream of unplanned interruptions; all this while trying to cope with heavy

typing demands was an impossible target. Staff had also become quite demoralised as a result.

The protected typing time project team quickly worked with consultants and staff to introduce a four week pilot scheme which allocated a period of protected typing time for each team member.

Linda Pitchford, Project Manager said: “The trial was a great success and had a huge impact. The typing backlog is down to just a few days and is being sustained. There has been a huge boost in morale and patient complaints have dropped. The need to use agency support has been eliminated, typing teams

across the Trust can support each other with spare capacity and there is even the potential to help other Trusts.”

Plans are now underway to trial the ‘protected’ approach in other areas such as filing.

Debbie, one of the clerical staff from Ophthalmology said: “The new process now in place has improved our time management, morale and general overall delivery which has led to an excellent service on behalf of our patients. One of the key elements of this is the uninterrupted time to finish tasks enabling the work load to be completed on schedule.“

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1010

Sterile Services improvementsIn 2011/12, NUH cancelled a high number of operations, causing distress, inconvenience and worry to many patients and their families.

Some of these cancellations were due to issues around sterile equipment or kit and staff began a thorough review of all key areas within the Sterile Services department, including the ordering, tracking, processing, production, presentation and delivery of equipment.

Initial research found that although the Sterile Services Team was working exceptionally hard in a very demanding environment, some of its processes were no longer viable given the workloads it now faced.

The BfY team worked closely with Sterile Services to trial new ways of working which included standardising processes which made many of the areas more efficient.

A number of key achievements have already been recorded. The Sterile Services Team set itself a goal of washing and packing the equipment and returning it to shelves within 24 hours and is currently achieving 95% of this target. Since this practice was

introduced at the beginning of September 2013, no operations have been cancelled because of equipment concerns.

A system for proactively managing trays containing instruments which may be missing or broken and getting these back into circulation as quickly as possible has also been developed and is underway.

Work is also ongoing to assess the equipment and kit volumes within different operating specialties to ensure that the Trust has adequate volumes to meet demand. This checking process has begun with Elective Orthopaedics. So far, over £200,000 has been invested in additional equipment to improve availability and a rigorous case of need process is being undertaken to approve the remaining items.

Phil Radford, Consultant Orthopaedic Surgeon, said: “Thank you to you and your team for the new arrangements regarding provision of our sterile orthopaedic equipment at City Hospital.

“The new system is so much better than before in that it does seem to have solved the previous issues that we had about not having the kit here at the start of the lists. We now have spare kit here

ready to be used in case of any issues during the lists. I think that it has been a huge improvement, so thank you and keep up the good work!”

Alison Gee of the Sterile Services Team added: “We are proud of the progress we have made but are certainly not complacent. We are focusing hard on understanding our next steps to ensure further improvement and sustainability of our achievements to date.”

“We are proud of the progress we have made but are certainly not complacent.”Alison Gee, Sterile Services Team


Children’s Outpatients transformation

As a shop window to the Nottingham Children’s Hospital, it is important that patients and families receive the right first impression of the Children’s Outpatients department, both in terms of how it looks and feels, as well as how it works.

To ensure that this was the case, staff decided to review the environment and, as a result, have created an additional treatment area, made better use of storage space and introduced new and easy ways of communicating with families and each other.

‘Status at a glance’ boards have been introduced so that all users of the department can easily see what is happening on the day without having to ask other members of staff and therefore reducing interruptions. The team also developed a ‘you said, we did’ board so that families are able to see what action has been taken with their feedback.

However, the biggest transformation of all was the waiting room – an area that was previously

quite dark and looked out on the walls of the ENT building is now a bright and child friendly space. Window stickers mask the view and create the illusion of being underwater and include a ‘Welcome to Nottingham Children’s Hospital’ sign. These were funded by the Nottingham Hospitals Charity along with some colourful, modular seating that children often incorporate into their play.

“Mummy, you can make big chairs and little chairs. Look – this is my pirate ship!”

Freddie, patient, age nearly five years

12

Better for You highlights – 2013…in 2013

JanuaryThe Patient Care Pathway – Administration Project launched to identify the correct level of administrative support required from patient referral to discharge

Started an integrated Care- Co-ordinator project on the Burns Unit, resulting in reduced length of stay from 7 to 3 days over 3 months

March Observation board developed for Children’s Emergency Department (ED) that ensures hourly observations with Paediatric Early Warning scores are completed, improving patient safety and tracking of deterioration or improvement from Emergency Department (ED) to the ward

Summary care record launched at NUH

MayStaff showcase ‘Just Do It’ ideas to Trust Board

Better for You workshop for colleagues from University Hospitals Southampton

MBA students from Lehigh University, Pennsylvania, USA visit to learn about B4U

July Launch of home-based comprehensive geriatric assessment trial

Full evaluation of Caring around the Clock completed after ‘nurse rounding’ rolled-out across all inpatient wards in 12/13

Well-organised theatres now part of mandatory training for theatre staff

Lilian Greenwood MP learns more about the successes of Enhanced Recovery After Surgery during visit to QMC

September Launch of transfer of care (discharge) project to improve timeliness and experience of patients leaving hospital

Falls prevention work, Accountability around the Clock and a patient story about Enhanced Recovery After Surgery presented at our Annual Public Meeting

Health Service Journal visits projects in Children’s and the Intra Operative Fluid Management (IOFM) project

November NUH celebrate World Radiography Day with open days for patients

New Patient Administration System launched across NUH

Protected typing project reduces backlog of patient letters from 11,000 to 50

Digital dictation rolled-out to community paediatric teams, with subsequent benefit to letter delays

NUH win 1st Prize at the ERAS national Conference and IOFM wins 2nd Prize at ERAS conference for poster presentation

New & improved insulin charts launched to support better management of patients with diabetes

Analysis and Intelligence Team won Centre of Excellence for Healthcare Analysis Award for bed-modelling work

IOFM shortlisted for NUHonours (staff) Awards

2013February Children’s Assessment Unit opens – a new way of working to improve safety and flow for Children’s Emergency pathway

Intra Operative Fluid management team invited to present work at the National Innovation Expo

April Lord Lieutenant visits Nottingham Children’s Hospital and sees Caring around the Clock in action

Launched Accountability around the Clock - our nurse handover project

BfY present at the BMJ International Forum on Quality and Safety in Healthcare

NUH embarked on the Acute Transformation Research project with Cranfield Business School and Cambridge University Hospitals NHS Foundation Trust to explore the similarities and differences between transformation change strategies of two large provider trusts

June New initial assessment tool for Children’s Emergency Department ensuring consistency of streaming all day, every day

Work started on the Care Co-ordination Team to assist with ‘supported’ transfers from hospital

NUH launch what is believed to be the first dedicated Twitter account for an NHS change programme @betterforyounuh

August Work began with King’s Mill Hospital to support its nurse rounding programme

Electronic comprehensive geriatric assessment template developed to enable sharing of information between primary and acute care

Hospital staff from Melbourne Australia visit our catheter labs to learn about our cardiology project

Three month pilot started in haematology to improve clinical coding, leading to improvements and an estimated £220K extra income in 14/15

OctoberChildren’s Hospital Octoberfest attracts 342 staff and visitors

Start of bespoke teaching sessions on service improvement for Children’s ED

15 Steps Challenge the highlight of the patient feature zone at the Foundation Trust Network’s annual conference in Liverpool

Visitors from London’s Guy’s & St Thomas’ NHS Foundation Trust

Launch of new ‘Just Do It’ Fund – helping ideas that need some financial support become a reality (thanks to Nottingham Hospitals Charity)

December Staff showcase ‘Just Do It’ ideas to Trust Board for a second time in 2013

Well organised theatres Dragons’ Den event for staff to pitch ideas for Nottingham Hospitals Charity funding to improve patient care and experience within theatres

NUH one of five Trusts shortlisted to hold the annual national ERAS Conference in 2014 theatres

Visitors from Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust experience Caring around the Clock in action

NUH host first international shared governance/network event at QMC


Better for You highlights – 2013…in 2013

JanuaryThe Patient Care Pathway – Administration Project launched to identify the correct level of administrative support required from patient referral to discharge

Started an integrated Care- Co-ordinator project on the Burns Unit, resulting in reduced length of stay from 7 to 3 days over 3 months

March Observation board developed for Children’s Emergency Department (ED) that ensures hourly observations with Paediatric Early Warning scores are completed, improving patient safety and tracking of deterioration or improvement from Emergency Department (ED) to the ward

Summary care record launched at NUH

MayStaff showcase ‘Just Do It’ ideas to Trust Board

Better for You workshop for colleagues from University Hospitals Southampton

MBA students from Lehigh University, Pennsylvania, USA visit to learn about B4U

July Launch of home-based comprehensive geriatric assessment trial

Full evaluation of Caring around the Clock completed after ‘nurse rounding’ rolled-out across all inpatient wards in 12/13

Well-organised theatres now part of mandatory training for theatre staff

Lilian Greenwood MP learns more about the successes of Enhanced Recovery After Surgery during visit to QMC

September Launch of transfer of care (discharge) project to improve timeliness and experience of patients leaving hospital

Falls prevention work, Accountability around the Clock and a patient story about Enhanced Recovery After Surgery presented at our Annual Public Meeting

Health Service Journal visits projects in Children’s and the Intra Operative Fluid Management (IOFM) project

November NUH celebrate World Radiography Day with open days for patients

New Patient Administration System launched across NUH

Protected typing project reduces backlog of patient letters from 11,000 to 50

Digital dictation rolled-out to community paediatric teams, with subsequent benefit to letter delays

NUH win 1st Prize at the ERAS national Conference and IOFM wins 2nd Prize at ERAS conference for poster presentation

New & improved insulin charts launched to support better management of patients with diabetes

Analysis and Intelligence Team won Centre of Excellence for Healthcare Analysis Award for bed-modelling work

IOFM shortlisted for NUHonours (staff) Awards

2013February Children’s Assessment Unit opens – a new way of working to improve safety and flow for Children’s Emergency pathway

Intra Operative Fluid management team invited to present work at the National Innovation Expo

April Lord Lieutenant visits Nottingham Children’s Hospital and sees Caring around the Clock in action

Launched Accountability around the Clock - our nurse handover project

BfY present at the BMJ International Forum on Quality and Safety in Healthcare

NUH embarked on the Acute Transformation Research project with Cranfield Business School and Cambridge University Hospitals NHS Foundation Trust to explore the similarities and differences between transformation change strategies of two large provider trusts

June New initial assessment tool for Children’s Emergency Department ensuring consistency of streaming all day, every day

Work started on the Care Co-ordination Team to assist with ‘supported’ transfers from hospital

NUH launch what is believed to be the first dedicated Twitter account for an NHS change programme @betterforyounuh

August Work began with King’s Mill Hospital to support its nurse rounding programme

Electronic comprehensive geriatric assessment template developed to enable sharing of information between primary and acute care

Hospital staff from Melbourne Australia visit our catheter labs to learn about our cardiology project

Three month pilot started in haematology to improve clinical coding, leading to improvements and an estimated £220K extra income in 14/15

OctoberChildren’s Hospital Octoberfest attracts 342 staff and visitors

Start of bespoke teaching sessions on service improvement for Children’s ED

15 Steps Challenge the highlight of the patient feature zone at the Foundation Trust Network’s annual conference in Liverpool

Visitors from London’s Guy’s & St Thomas’ NHS Foundation Trust

Launch of new ‘Just Do It’ Fund – helping ideas that need some financial support become a reality (thanks to Nottingham Hospitals Charity)

December Staff showcase ‘Just Do It’ ideas to Trust Board for a second time in 2013

Well organised theatres Dragons’ Den event for staff to pitch ideas for Nottingham Hospitals Charity funding to improve patient care and experience within theatres

NUH one of five Trusts shortlisted to hold the annual national ERAS Conference in 2014 theatres

Visitors from Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust experience Caring around the Clock in action

NUH host first international shared governance/network event at QMC

1414

Staff collaboration results in faster CT scanning system

The conversion of a storeroom, the allocation of a dedicated porter and an improved referral process has resulted in much faster turnaround times

for CT scans in our Emergency Department at QMC.

Last year the team was struggling to meet its targets for performing patient scans and pulled together a multi-disciplinary team to examine the reasons behind the delays.

The team, which consisted of radiology consultants, porters, registrars and Emergency Department staff found much of the process was over-complicated and inefficient. During one week in which 105 head treatments were requested, 510 phone calls were created before the

scans could be completed.

Patients also had to wait for porters from other areas of the hospital and the radiology team members were located in different areas within the department, adding to delays in communication.

A major overhaul of the process included the conversion of a former unused storeroom into two rooms to house the ultrasound and a reporting room. This enabled face-to-face conversations

amongst team members, providing faster access to each other and the patient as well as reducing the number of phone calls needed before treatment could continue.

The Emergency Department allocated a dedicated porter to the team to reduce patient waiting times and the system for head scans has been further simplified by eliminating a number of

unnecessary phone calls.

As a result of the changes, waiting times have improved by 10% year-on-year, despite the team recording a 15% increase in the number of scans requested. This means that the radiology team has almost reached its self-set target of completing head

scan requests within one hour and a fully body scan within 90 minutes.

“This has been a very satisfactory outcome to what could have been a fast deteriorating problem. The

upshot is greater team work and a much faster result for patients and staff alike.”

Kath Halliday, Lead Consultant for project


Porters achieve record high efficiency in Radiology

A determined drive by porters in the Radiology Department to improve communication levels between themselves and the wards has achieved record high levels in portering efficiency.

The 44-strong Radiology Porter Team was aware that the traditional paper message channel between a porter and a ward was long outdated. Trying to manage an old-fashioned system in a new era of technology was simply too inefficient for the needs of its 21st century service. The result was a frustrated porter and ward team, unnecessary levels of anxiety for patients and wasted time for the scanning department.

The porters decided to form a Radiology Improvement Project group and invited different representatives from across the department to join. Its goal was to

improve communication with its internal teams to the benefit of its external customers, the patients.

An initial audit carried out over six days recorded 80 wasted portering journeys. An effort was made to speak to every ward in the department to research the reasons behind the inefficiency and found poor communication systems were the root of the cause.

As part of the change process, the group was invited to present to the Directors’ Group mid-2013 where it highlighted its concerns and proposed solutions. As part of this presentation, the group devised a poem and a series of cartoons which they subsequently used to help communicate its messages to their peers and other staff.

The Improvement Project Team discovered that there was a perfect tool already in use by the

department that would enable it to achieve its goal. This was the ‘Horizon’ communication board, an electronic information system used by all wards at NUH to display patient information including bed number, name, pre-scan treatments required and estimated discharge date. Portering messages could also be posted onto the board in real time and removed the need for paper.

A pilot of the new system was successful trialled by the Interventional Radiology Team and is being rolled out across the rest of the department. Already the baseline of 100 hours overtime needed per month has been reduced to 37 – an improvement of 63% and the number of wasted portering journeys have already been reduced by 15% and continue to decrease.

16

National recognition for NUH Intra-Operative Fluid Management workWe’re leading the way in our fast-growing use of a sophisticated fluid management programme that can help to enhance patient recovery after major surgery.

The technology, called Intra-Operative Fluid Management (IOFM), helps an anaesthetist to optimise the amount of fluid given to a patient during a major operation. A shortage of fluid in the body can delay healing, and too much fluid can cause complications. Using IOFM can help to decrease the risk of both short and long term complications, reduce the length of stay in hospital and aid overall recovery.

The use of IOFM is recommended by the National Institute for Health and Care Excellence (NICE) for high risk surgery and in 2013 became a Commissioning for Quality & Innovation (CQUIN) requirement.

The Trust now uses the technology on 60% of suitable patients, a significant increase from 5% recorded just 12 months ago.

The team has worked closely with the Clinical Commissioners to refine and adapt the national guidelines to ensure they meet the local needs for those living in the NUH catchment area. For example, the technology has now been introduced into emergency surgery to help improve patient outcome during these life-saving procedures. To help with research, it is also collecting and analysing data from the use of IOFM in emergency abdominal surgery and renal transplants.

The Trusts’ growing expertise and understanding of IOFM has resulted in the team now educating other Trusts, advising on national policy and being invited to lecture nationally.

One of the key reasons for the successes of the project is the approach undertaken. The project has been clinically led by two consultant anaesthetists, Dr Adam Carney and Dr Chris Gornall, with BfY providing senior managerial support.

The use of a clear change methodology, supported by robust data collection and analysis, allows the clinicians to focus on staff engagement and education.

The IOFM team was nominated and subsequently shortlisted for the Finals of the NUHonours Awards in 2013, reflecting the success of both the Clinician – Quality Improvement partnership and the local and national recognition that the project has gained.

Intra operative fluid management: successful implementation of the CQuIN…in 2012

November 2011The Trust received first information from SHA re money available to support the development of Intra Operative Fluid

February 2012 NUH team meets with SHA to discuss implementation of Intra Operative Fluid and application of Regional Funding

April 2012 NUH IOFM team first and only Trust asked to blog on Innovation Health and Wellbeing site on internet

July 2012 NUH IOFM team meet with NHS Technology centre to discuss interpretation of Adoption Pack

September 2012 Nottingham Hospitals Charity agrees to fund a further 5 Intra-operative fluid monitoring devices

November 2012 New Intra-operative fluid monitors arrive at NUH and are placed in identified theatres

March 2013 NUH data for Intra-Operative fluid usage agreed and forwarded to SHA for final report

April 2013 NUH achieves pre requisite requirement for the Intra operative fluid CQUIN

May / June 2013 NUH team succesfully negotiate a 3 year trajectory and appropriate use of the technology with the CCG’s

December 2012 Commissioning for quality and innovation (CQUIN): guidance received in the Trust

June 2012 NHS Technology centre launch Intra Operative Fluid Adoption Pack

February 2013 NUN Intra Operative Fluid team is invited to present work at the National Innovation Expo

March 2013 NUH Intra-operative fluid team lead the way at a regional meeting to discuss Intra Operative Fluid implementation across an acute Trust

July 2013 NUH Anaesthetist invited to speak about our experience of implementing IOFM monitoring at three national evidence-based peri-operative medicine conferences organised by

201320122011

April 2012The IOFM project team is created. This includes a project lead and two consultant anesthetists (one from each campus)

May 2012 IOFM team presents challenges and benefits to Directors’ Group

July 2012

July 2012 NUH orders 2 LiDCORapid monitors to help anaesthetists optimise and individualise fluid therapy intra-operatively using Regional Innovation Funding

November 2012 NUH team brief anaesthetic colleagues about current IOFM usage, relevant evidence and possible imlplications of NHS adoption pack to their practice

Post-operative length of stay: All patients

Mean LOS Median LOS

20.0

13.6

9.0

17.2

10.0

ControlIntervention

16.0

12.0

8.0

4.0

0.0

Future plans …

• Embed• Expand

• Educate• Evaluate

NUHteamarefirsttrusttoevaluatenon-invasiveIOFMinrenaltransplantoperations

NUH total IOFM use per month

0102030405060708090

Sep-12

Oct-12

Nov -12

Dec-12

Jan-13

Feb-13

Mar-13

Areaofinnovation Criteriaforproviders

Localcommissionerassurance

Intra-operativefluidmanagement(IOFM)

Demonstratetocommissionersthat2013/14trajectoriesforthetechnologyareinplacewhichareconsistentwithNationalTechnologyAssessmentCentre(NTAC)guidance

Providerswillneedto:• establish2013/13baselineuse• putinplacetrajectoriesfor2013/14.Planswillneedtobebasedonthenumberofspecificprocedureslistedinappendix3oftheNTACguidance.BasedonthenumberofrelevantlocalOPCScodedprocedures,providerswillneedtoidentifyalocaltargetofatleast80%.WhilstthetargetitselfbasedontheOPCScodedprocedureslistedintheNTACguidance,theactualplanneduptakecaneitherbeforprocedureslistedintheNTACappendix3offorotherrelevanthighrisksurgery

RelevantNTACguidancecanbefoundonwww.innovation.nhs.uk

Ensureproviderplanfor2013/14,includingbaselineassessmentisrobust

Providertypes

Acuteservicesprovider

✔

Communityservicesprovider

n/a

Ambulanceservicesprovidern/a

Mentalhealthorlearningdisabilitiesservicesprovider

n/a

Enhanced Recovery Elements

ReferralfromPrimaryCare

Pre-Operative

Intra-Operative

Post-Operative

Followup

Admission

•Minimallyinvasivesurgery

•Useoftransverseincisions(abdominal)

•NoNGtube(bowelsurgery)

•Useofregional/LAwithsedation

•Epiduralmanagement(incthoracic)

•Optimisedfluidmanagementindividualisedgoaldirectedfluidtherapy

•Plannedmobilisation

•Rapidhydration&nourishment

•AppropriateIVtherapy

•Nowounddrains

•Cathetersremovedearly

•Regularoralanalgesia

•ParacetamolandNSAIDS

•Avoidanceofsystemicopiate-basedanalgesiawherepossibleoradministeredtopically

•Optimisingpre-operativehaemoglobinlevels

•Managingpre-existingcomorbiditiese.g.diabetes

•DXwhencriteriamet

•Therapysupport(stoma,physio)

•24hrtelephonefollowup

•Admissiononday

•OptimisedFluidHydration

•CHOLoading

•Reducedstarvation

•No/reducedoralbowelpreparation

•Optimisedhealth/medicalcondition

•Informeddecisionmaking

•Pre-operativehealth&riskassessment

•PTinformationandexpectationmanaged

•DXplanning(EDD)

•Pre-operativetherapyinstructionasappropriate

NUH total IOFM use per month

0102030405060708090

Apr-12

May-12

Jun-12

Jul-12

Aug-12

NUHidentifybaselineIOFMusageatapproximatelycasespermonth


Better organised theatresA united effort by more than 800 staff working to improve workspace efficiency across 47 theatres is helping to save staff time and increase patient safety.

Working under the ‘Well Organised Theatres’ initiative, the aim is to keep theatre areas across both NUH sites, uncluttered and orderly in layout. As a result, any member of the theatre team should be able to see immediately what is needed within three seconds.

The focused programme was launched in summer 2012 and stems from the ‘Productive Operating Theatres’ initiative which followed on from success of the NUH Productive Ward initiative.

It has already produced financial benefits to the Trust. Within weeks of the initial launch stock levels increased as unwanted

items, returned by each theatre, replenished supply levels. Ongoing financial benefits are successfully being maintained by this more efficient storing of appropriate stock levels.

Maria Shallow, Deputy Clinical Lead for Theatres, explains: “Keeping theatres well organised is an important part of our preparation for patients to ensure we have the right equipment in the right place at the right time.

“Staff can get frustrated and patients can get anxious if delays occur. These can be due to a variety of reasons including delays in finding equipment or stock. Using the well organised principles helps staff organise their work areas and in extreme cases, if a patient deteriorates on a theatre table, you need to be able to put your hands

on what you need straight away and not have to search around wasting time.

“At a practical level, introducing a new initiative to this number of staff, working across different shifts as well as different sites, takes time and a lot of great co-ordination. It is a credit to the determination of the theatre staff and the Better for You team that they have made such a big difference.”

Effective training and regular communication has been the backdrop to the success of this initiative. Champions are working tirelessly in all areas, almost 300 staff have been trained to date and plans to ensure effective continuation of the ethos, including a clear audit process, will be launched, in early 2014.

18

Audit of emergency triage process identifies good practice A recent audit of the emergency triage process within the Haematology Daycase Unit identified positive results.

It found that 50% of self-referring patients are currently being discharged on the same day. This is extremely encouraging and is thanks to the triage process in which patients are seen by a nurse, triaged and investigations (such as blood tests) are carried out. Patients are then assessed by a doctor and a treatment plan is developed.

Further to this effective way of working, additional improvements are being explored with the support of the BfY programme. In 2014 a new self-referral hotline will be

introduced which will replace the current bleep system thus reducing the number of steps a patient has to follow before they speak to a nurse specialist. If funding allows, a new triage system may be explored.

The Haematology Daycase Unit provides important care for emergency self-referring patients.

Fran Wadelin, Consultant Haematologist, commented: ‘We want to make sure that every patient who contacts the service is provided with expert advice and support, and those patients who need to be assessed in hospital are seen as soon as possible in the most appropriate place.”

@betterforyounuh is transforming the way we communicateSince its launch in 2009, one of the key objectives of BfY has been to share information and best practice to raise awareness and enable learning, not only within NUH itself, but with the wider health community.

How people, organisations and communities share information has radically changed – even in the short time since the launch of BfY.

BfY rewards innovative thinking and new ways of working. And so what better way to engage with others than by embracing social media. Thanks to increased Twitter activity from BfY project leads, @betterforyounuh now has over 350 followers. But it’s not all about quantity – quality is key. BfY is now followed by some of the most influential thinkers in the NHS, journalists and celebrities including Don Berwick, Helen Bevan, Alan Maynard, Duncan Gunstone (Head of Corporate Productions for ITN), the Campaign for Action and Elizabeth Clemons (wife of US Rock Royalty, Clarence Clemons, and founder of besthealthcare.com in London).

Don Berwick was a prize catch as he is followed by 997 key influencers throughout the world so a retweet from him is priceless.

Those who have engaged with the account are benefiting from tapping into professional networks to share ideas, seek advice and engage in conversations about change

management in healthcare. Plus, BfY outcomes are being broadcast nationally and internationally to far larger audience than ever before.


Improving patient data process delivers greater efficiency for the TrustCoded data of patient activity is used to appraise the Trust’s performance, monitor clinical effectiveness in many areas and generate income.

Inaccurate or incomplete clinical information or coding will have a detrimental effect on all of these areas.

Our clinicians instigated a review of the process and working alongside finance, process redesign and business analyst colleagues identified areas of weakness in the existing data recording process.

The team scoped out the issues, identified a solution and completed a trial to confirm and deliver the benefits. The pilot took place between August and October 2013 and resulted in an improved understanding of the illness and complexity of patients being treated by NUH. This, in turn, is enabling better planning and discussion with commissioners and colleagues to

ensure maximum benefit to patient care and appropriate funding for the Trust.

The improved approach has been adopted Trust-wide and complemented by a number of other activities. This includes the rolling-out of a training and awareness programme on the importance of the changes, as well as ongoing audits and regular reviews to ensure any improvements continue. They also ensure that any new issues are identified and tackled at the earliest opportunity. This new methodology has been adopted Trust-wide.

Andy Haynes, Consultant Haematologist/Emergency Pathway Lead said: “Not only does the improved system help the team better care for patients through improved clinical effectiveness, it has also provided a more accurate picture of the expertise and capabilities of staff at the Trust.”

“This is a fantastic result that would not have been successful without the Better for You team involvement and just shows what can be achieved by working together.”Andy Haynes, Consultant Haematologist/Emergency Pathway Lead

20

CASE STUDY: Nottingham Children’s Hospital – communicating values and behavioursThe Children’s Hospital Staff Experience project discovery phase highlighted that people do not always adhere to the trust values and behaviours which can have a negative impact on staff. The BfY team wanted to find a way of communicating the trust values and behaviours in a meaningful way for the Children’s Hospital staff.

Three of the ways this is being done in the Children’s Hospital are:

• Hands and Hearts posters

• The values and behaviours story

• Values and behaviours Champions

Hands and Hearts posters

The BfY team decided to build on the Caring around the Clock video which showed what staff in the Children’s Hospital wanted to say to their patients. The Communications Team developed poster templates that could

be used around the children’s hospital with pictures of staff using the Hands and Hearts idea to communicate the values and behaviours that were important to them.

It has been clear from the photos that teams have had fun doing them and the feedback from families has been great – they like the message on the pictures but, above all, like that fact that staff look happy.

Values and behaviours champions

During Octoberfest 2013 the team asked staff to nominate their ‘Values and Behaviours Champions’ There were 210 nominations

for 127 different people. Each Champion was presented with a personalised certificate saying why they were nominated; some nominees, like the example below, were nominated many times over:

There has been very positive feedback from the recipients, some people were very moved to have been nominated.


The values and behaviours story

The BfY team have been supported by Colin Moorhouse from Learning and Organisational Development when discussing how to communicate values

and behaviours in the style of the Children’s Hospital. Colin suggested using a story, the team developed this idea further by using cartoon strips:

Staff feedback about the cartoons has been great.

22

Trust, Commissioners and GPs join forces to deliver greater patient careNUH joined forces with Commissioners to improve GP access to specialist clinical advice. This aims to ensure patients receive the right care from the right people at the right time and avoids patients potentially being admitted to hospital unnecessarily.

The project was instigated by GP and Acute Medical consultant colleagues who recognised that the route by which patients are navigated from primary ‘community’ care to secondary ‘hospital’ care could be greatly improved.

The group has completed initial research steps to start fully scoping out the issues. In a short four week study results showed that the

clinical needs of 60% of patients referred to the Acute Medical Unit could have been met by:

• Directing the patient to a medical service that already exists

• Directing the patient to a non-medical service that ready exists

• Diverting the patient to an outpatient clinic

An assessment of what services and clinical and non-clinical pathways are currently accessible by GPs is underway. This is being complemented by a concurrent stage of research, which is asking doctors what data and services are needed to help them deliver optimal care for patients.

Dr Guy Mansford, who sits on the working group for this project said: “This project is an exciting collaboration between commissioners and providers across the health community.

Its work is of utmost importance and will ensure improved efficiency and good use of money that will reap benefits for GPs, hospital services and those in our communities that have need of both.”

The whole process follows the BfY ‘5 step’ methodology. Next steps will be to evaluate all research and agree and manage trials and changes.

Wildly Important GoalsA Wildly Important Goals (WIG) initiative has become a focus of attention for staff in the Paediatrics Diabetes Clinic who have applied the concept, studied during recent development training, to deliver key projects and reduce overwhelming workloads.

WIGs tend to relate to necessary but time-consuming tasks that need to be done. Often involving heavy paperwork and mundane planning, the motivation to start a task is understandably low when more seemingly urgent demands are made on time.

However, the team recognised that it was often the boring tasks that made the biggest difference and committed to delivering a number

of WIGs through collaboration with each other.

It decided to focus on three key projects that would make the biggest difference in the workplace. Individual staff members were nominated to a selected WIG and were supported by weekly meetings which discussed what progress had been made. Any problems in delivering the project were highlighted at the meetings and relevant support was organised.

The initiative has delivered some great results to date. A single training day for more than 50 schools and other professions working with children with diabetes has been held. This has saved the team visiting each relevant individual in the catchment area.

It now plans to ensure it delivers three of these days a year going forward.

The team had also long recognised that it needed to recruit a clinical support worker. The necessary paperwork was completed, interviews were held and a new team member is now in place allowing nurses to spend more time caring for patients.

Finally, a fun-packed sports day for children and young people with diabetes was held for more than 30 children to find out how playing sports affected their diabetes. The children, aged between nine and 16 enjoyed a variety of games including football, Zumba, table tennis and basketball.

“This project is an exciting collaboration between commissioners and providers across the health community.”Dr Guy Mansford


E40 Disney window stickersA wall of large windows in a children’s ward at QMC has been given a magical facelift thanks to the determined initiative of ward staff.

E40 is a 12-bed neurosciences ward on the fifth floor of The Nottingham Children’s Hospital. Its windows overlook a bare side wall of an older building which is a favourite home for pigeons. As a result it is consistently coated in bird droppings.

The shabby outlook was having a negative effect on the long stay patients and resident parents and the ward team agreed that it needed to find a way of improving the view.

It looked at various options and spotted the new window stickers that had recently been fitted in the Outpatients Department of the Children’s’ Hospital. It was unanimously agreed that these stickers would be a great solution and without doubt, would help to transform the windows.

A local supplier was found and the Nottingham Hospitals Charity agreed to fund the costs.

The result is a much-improved ward environment for the children, their families and the staff. the ward staff chose a Disney theme and fun and colourful characters such as Rapunzel, Beauty and the Beast, Monsters Inc, Tarzan and Toy Story now decorate the windows.

Feedback from patients and parents has been extremely positive. Some children try to copy the pictures when drawing. Others ask if they can lie by a particular character such as ‘the Princess’ or ‘Tarzan’.

Before

After

24

Transfer to Comprehensive Geriatric Assessment (CGA)Helping elderly people to stay living at home rather than being moved to live in a care home following a hospital admission is high on the agenda at NUH.

This focus is the result of a seven month trial which aimed to reduce the number of direct admissions to long term care from NUH

We already knew that older patients in Nottinghamshire were being sent to care homes two to three years earlier compared to the rest of the UK and that in many cases patients did not need the 24 hour care facility that this move provided but instead could live at home with support. A different approach was needed to ensure a better quality of life at home could be enjoyed by more.

The outcome was a suggestion for additional time to better consider a patient’s needs after initial treatment. It was identified that a community hospital, rather than

the acute teaching environment of NUH, would be best placedto undertake this role.

Here patients could undergo one multi-disciplinary team assessments to determine what they would need to enable them to return home. The holistic designed assessment, called a Comprehensive Geriatric Assessment (CGA), looks at all aspects of the patient such as function, medication, mobility and mental health and helps determine the bespoke requirements of each patient.

If a care home did prove to be the best outcome for the patient, the move into a community facility would also give families time to develop the most appropriate care package and give the patient time to adjust to the idea.

Between May 2013 and November 2013, a trial study involving 85 patients took place. The evaluation revealed that through this pilot

scheme, 26 direct admissions to long term care from NUH were avoided. Following a period in the assessment facility, these patients were discharged home with appropriate support programmes in place.

Not only is there a positive patient outcome but the team also estimates that avoidance of these admissions has saved Nottinghamshire’s Health and Social Care organisations £64,000. This can be invested back into community services to further benefit the community.

The team plans to adopt this approach for a wider audience and is compiling the full results of its recent successful trial to ensure that this happens.


Improved efficiency in Cardiac Catheter LaboratoriesA recent review of patient care and processes in our Cardiac Catheter Laboratories has resulted in greater efficiency, enhanced patient care and a boost to staff morale.

The labs have also been identified as one of the most productive in the country, as part of a national audit.

The four Catheter Labs are used to examine the arteries and chambers of a heart, make a diagnosis and carry out procedures to treat any abnormality found.

The multi-disciplinary teams involved in the work carried out in the catheter laboratories treat a complex mix of both in and out patients.

The teams recognised that there were inefficiencies in the patient experience, including delays in treatment and unnecessary ward transfers, and called on the BfY team to help structure a more effective way forward.

The labs are acknowledged as a key hub of the hospital’s operation

and any delays in carrying out their high numbers of procedures impact heavily on other parts of the hospital. This includes delayed admittance to wards and late patient discharges which reduces the number of beds available for new patients.

The first step in assessing the situation was to map out the process of patients arriving into the area to identify where delays were occurring and why.

The pilot study took place in 2011/2012 and focused on patients with a particular type of heart problem.

Each area of this particular patient pathway was found to have its own issues and as a result, the pathway was dismantled and a new process developed using a fresh step by step approach of who did what, why and when.

To ensure success, it was agreed that each team discipline would set its own goals and regularly measure and evaluate. This is the first time that this has happened and the

proposal was well received by team members.

John Walsh, Consultant Cardiologist, gave an example of one of the goals: “When a patient arrives for treatment, consent should have already been given by the patient to the ward team. If not, this creates an immediate delay in the lab while this process is completed before treatment can be given. We were reaching only between 30% and 40% of patients arriving with consent which rose to 92% once the new performance measurements were introduced.”

The new process has had a significant impact across the service that the labs offer; the level of patients treated within a three day pathway has increased from between 5-10% to over 90% and the six day wait for urgent angiography has now been reduced to two. A saving of £300,000 has also been achieved for the Trust.

The revised process is being rolled out across Cardiology.

Improved triage process in Children’s EDThe triage process at Nottingham Children’s emergency department (ED) has been enhanced to create a more efficient and consistent approach to treating children when they first arrive at the hospital.

The children’s ED team was aware that the existing initial assessment process needed to be updated to meet local needs.

It scoped out findings from two key areas to help develop the updated approach. The first was to identify lessons learned by the triage teams in the Adult Emergency Department who had recently undergone a similar process. The second was to record the inefficiencies in the daily operation of the department and look at what could be improved and how.

An updated assessment procedure using a combination of observations, what happened to the child and symptoms was introduced in May 2013. It has standardised documentation, category and process which ensures that every child is assessed in the same way, 24 hours a day. This has resulted in different nurses agreeing on the same triage category, 98% of the time using the new tool, in comparison to 71% of the time before the tool. The new procedures also enable a more accurate reflection of the acuity of the patients.

In a separate improvement project, the standard of hourly observations has also been improved. Following a number of process trials the team settled on using a white board as a

visual observation board to identify when observations and treatments are needed in each bay. This was initially supplemented with a daily spot check to ensure that the board was up to date, and the observation charts were completed at least hourly.

This increased our standard of hourly observations and Paediatric Early Warning score from 44% to 90% and is now tracked with a weekly audit of 10 charts.

better for you report

Documents