Post on 15-Oct-2020
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+
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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
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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’
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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)
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8
People Power - December 2011
The CHANGE Room
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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
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15
STANDARDISATION ON
WARDS
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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
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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
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Join us for....
6th & 7th June
2016
Sheffield
MCA
expo ’16