Process Improvement · Kaizen Event #1 4 Report baseline findings Analyse data and measurements...

Improvement and Transformation

Process Improvement

TTO and Discharge Summary Process Review

Nick Holding

Head of Improvement and Transformation

Summary

• Overall TTO lead time reduced by 67% (3hours)

• Patient TTO delays reduced by on average 10 hours per day (1 ward)

• Potential release of approx. 300 hours per day of bed usage time, across inpatient areas (USC & SC)

• Earlier discharge time

• Care Groups identified TTO and Discharge Summary

process as area of focus, following Breaking the Cycle week

• Ward 27 identified as pilot area

• Collected real time current state data

• Working with operational teams, ran a number of improvement events to test ideas using PDSA cycles over 3 months


What is the problem we are trying to solve?

Improvement & Transformation Team formed to focus on a key improvement for the Trust

Breaking the Cycle week identified TTOs and Discharge Summary as priority

Identified Ward 27 (RSH) as pilot ward to test ideas and experiments

Ward and Pharmacy teams fully engaged as key stakeholders

6 month project timescale to carry out deep understanding of current state, and using PDSA cycles, identify potential new ways of working

Aim to reduce turnaround time of TTO by half


“We believe that a high number of discharges are delayed due to the process of producing TTOs and discharge summaries”

Improvement Methodology

Provide current state information to stakeholders

Ideas for improvement generated by teams

Scientific method used to prove or disprove hypothesis

Using Plan, Do , Study, Act (PDSA) cycles, experiment and measure improvement activity

Review, adapt and retest ideas

Encourage continuous improvement through many small local changes

Support teams to make improvement by providing advice, guidance and facilitative resource

Start small, think big


Project Plan and Timeline


Milestone

Activity

Communications and Engagement

Impacts on project

Phase 1 – Current state understanding

Phase 2 – Report findings and identify opportunities for improvement. Test ideas using first PDSA cycle

Phase 3 – Review experiments and plan for follow up based on findings

Phase 4 – Test follow up experiments to identify all improvement opportunities

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NovemberOctoberSeptemberAugust December January

Complete process follows and direct

observations1

Complete systems data capture for process analysis 2

Analyse all data and measurements 3

Create Current State Value Stream Map

Sense check with

stakeholders

Prepare first Kaizen Event including identifying

activity

Kaizen Event #1 4

Report baseline findings

Analyse data and measurements from

Kaizen #15

Prepare 2nd Kaizen Event including next steps activity (PDSA)

Report PDSA cycle findings

Kaizen Event #2 6

Final report and recommendations

8

Week 1 ALT,

Seattle

Week 2 ALTALT Coursework & Team Training

Supporting KPO Lead, and early value stream work

Supporting USC Urgent Care Recovery Projects

Analyse data and measurements from

Kaizen #27

Feedback PDSA cycle findings

to stakeholders

1:1 updates with stakeholders, patient representative etc. Develop links and networks. Comms messages


01:27 01:0000:4901:10

Total average time taken to process patient’s TTO

=266 minutes

4.4 hours

The time between the

patient being

medically fit for

discharge & TTO

requested

Time between TTO

requested &

preparation started in

pharmacy

Time between

preparation completed

& prescription ready in

pharmacy

Time between

prescription ready in

pharmacy & arriving

on ward

Source. Sema, eScript, Pharmacy dept docs & direct observation

• Followed process over 2 week period • Tracked 50 patients journeys • Average total process (TTO turnaround) lead time =

4hrs 40 mins

What is the current state?

Current State Value Stream Map


Summary

4 main areas where delays occur 1. Ordering TTOs

a. Multiple information hand-offs between staff b. Batching of work

2. TTOs waiting to be picked a. Impacted by Out Patient prescriptions b. Ward priorities based on reactive urgency

3. Delivery of TTOs to ward a. 3 methods of delivery used b. Slowest method used in most cases c. Delivery system designed to be efficient for us, not patient d. Up to 3 hour delay for delivery (if last on list and just missed

delivery run)

4. Discharge Summary production a. Collation b. Completion c. Printing/Sign-off


Focus Areas

Ordering TTOs – Multiple handoffs of information and batching often

results in delays to producing TTO order.

– Currently, Pharmacist resource is shared between wards

– Some anecdotal information suggested that high number of TTOs were for meds which patient were already on. This has been tested and it applies approx. 10% of TTOs


01:27 01:0000:4901:10


=266 minutes

4.4 hours

Focus Areas

TTOs waiting to be picked – TTO order displayed on Pharmacy order screen waiting

to be picked

– Prioritised over other ward drug orders (non-TTO)

– Outpatients prescriptions prioritised inpatients


01:27 01:0000:4901:10


=266 minutes

4.4 hours

morning afternoon

Outpatient activity highest in

morning, affecting ability to provide

inpatient TTOs early

Focus Areas

Delivery of TTOs to ward – Slowest method used most often (courier)

– Delivery system designed to be efficient for us, not patient

– Up to 3 hour delay for delivery

(if last on list and just

missed delivery run)

– Findings show that at

times meds on ward,

but staff aren’t aware


Results

Mean turnaround time reduced from 4hr 40mins to 1hr 33mins Reduction of 3hrs per patient 67% reduction

100 patient journeys measured Improvements and ideas generated and tested by those who do the work

TTO Turnaround Times


Tested Pharmacist

effect on Ward Round

‘Runner’ used to

deliver TTO to wards

Re-tested previous actions

Introduced 2 productions

lines (OPD and Inpatient) into

Pharmacy

Individual patients

1hr 33mins

4hr 40mins


Baseline (pre-Kaizen) 1st Kaizen Event 2nd Kaizen Event

Mean turnaround time


Where the gains were made

Pharmacist presence on ward round each day

Additional benefits identified Supports improvement in MDT

involvement at Ward Round More responsive to medication

queries and reviews

OPD prescriptions often impact of production of inpatient TTO

2 production lines established to focus on OPD and inpatients separately

Stimulated process improvement within dispensary

Assistant Technical Officer (‘runner’) established to support real time delivery of medication to ward

Established consistent drop off point on ward

Updated PSAG to show TTO on ward

66% reduction

80% reduction

75% reduction

1hr 27mins

29mins

1hr 10mins

19mins

60mins

14mins


Kaizen Plan


Improvement opportunities which have been overcome by experiments, identified by teams

Kaizen Plan shows improvement activity

Takes current state

value stream map and highlights what has been achieved

Shows which

opportunities remain for further activity

Future state map

generated from this

Future State Value Stream Map


Lead time down from 293 mins to 115 mins

Process value

adding time increased from 6% to 17%

Much of process is

back office, therefore non-value adding to patient

However, is

necessary non-value adding activity

Other Qualitative observations

Ward Improved communication between doctors, nurses and

pharmacists

Immediate response to queries between teams

Less time spent by nurses looking for TTO on ward

Ward clerk spending less time chasing TTO (phone calls)

Ward staff not needing to collect TTO from Pharmacy

PSAG TTO flag update gave reporting and tracking capability

Pharmacy Pharmacists contribution to ward round, capturing issues

early and responding to changes

Less phone calls into Pharmacy chasing TTO

Reduced queues for Outpatient prescriptions

Dispensary teams engaged in process improvement and workplace reorganisation

‘Runner’ provided tracking system to enable improvements in TTO location


Benefits realisation Quality Patients not waiting in hospital unnecessarily, enabling them to get home earlier

Reduced risks associated with being in hospital

Bed utilisation improved leading to better quality of care for patients who need admitting

Service Reduced delays in discharge by 3 hours per patient

Release of approx. 300 hours per day of bed usage time, across inpatient areas (USC & SC)

Improve compliance with earlier discharge time (pre 1pm from 9% up to 19%)

Additional 3 patient (on test ward) discharged daily before 1pm

Workforce Assignment of tasks to appropriate roles releases staff time in other areas

Staff satisfaction improved as delays to patients are reduced

Job satisfaction regarding delivery of pharmacy dispensary service

Cost Potential reduced overtime spend in pharmacy dispensary

Potential reduction in ED breaches


Recommendations These recommendations are mainly for RSH where the project was based, however some will apply to PRH

Short term Introduce Assistant Technical Officer (‘Runner’) into Pharmacy with clear job specification

Establish and maintain 2 (possibly 3) production streams in pharmacy dispensing

Establish daily management of non-urgent prescriptions in pharmacy dispensing

Re-establish co-ordinator role within pharmacy dispensing to oversee process flow

Train additional ‘checkers’ to improve ratios in dispensary, avoiding bottleneck

Ensure all C.O.Ws are operational and in use on Ward Rounds

Medium Term Review allocation of ward based Pharmacists to support daily ward round attendance

Carry out 5s review of dispensary work area to improve process flow

Encourage culture of continuous improvement by supporting dispensary teams to make changes to work area and process

Review frequency of nurse presence on Ward Rounds

Longer Term Establish satellite pharmacy in Chemotherapy Day Unit to support improvements in supply

Carry out full analysis of daily demand against resource allocation. Establish daily and hourly Takt time, and allocate resource accordingly


Process Improvement · Kaizen Event #1 4 Report baseline findings Analyse data and measurements...

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