The Network Casebook II

1Casebook 2012

Quality improvement

projects from nationally

submitted abstracts

2

2 Casebook 2012

This Casebook isalso available online:

www.the-network.org.uk

3Casebook 2012

This is the second Network Casebook and follows on the success of the first. The idea is simple, if we can share our ideas, learn from each other and spread the knowledge as far as we can then we can genuinely improve the care we give our patients. So much great work and innovation is done by the clinicians closest to the delivery of healthcare, but sadly much of it is not known widely. The Network and the Casebooks attempt to change this.

There have been many examples of projects that would otherwise have passed unnoticed being spread far and wide because of the first Casebook and its launch event. As Claire Matthews (a winner from Casebook I and member of this Casebook Team) attests, her ‘Let’s Play Project’ has being copied across parts of the UK based on conversations had at The Casebook I launch in London last year. We sincerely hope the same happens this time.

There are over 250 projects on The Network site (www.the-network.org.uk). They are key word searchable and you can directly contact the author. So before you start you next project, check out the on-line casebooks so you can start

your project using the learning from others who have gone before you. Some of the projects now have short YouTube videos attached to them. Some people like reading the abstracts themselves but we think that most people will be even more engaged by hearing and seeing the project leads talk in their own words. The more accessible we can make the information the further it will spread. So when you finish your next piece of improvement work write the summary but also get a friend to interview you and upload the short video. There will be tips on the site on how to do this well, but all you really need is a smart phone.

Some of the projects did not achieve their aims; however the learning is still there. Heroic failure has as much to teach us as triumph.

The Casebooks are also there to inspire you, see what others have achieved and have a go at improving things yourself. You do not need permission to make things better; you just need energy, ideas and a little help from your friends.

This Casebook isalso available online:

www.the-network.org.uk

The Network Casebook Team

‘Change does not roll on the wheelsof inevitability, but comes from continuous struggle’ Martin Luther King, Jr.

4 Casebook 2012

Rob BethuneGloria Esegbona

Jonathan Hyer

Nikki Kanani Ben BrownClaire Matthews

The Network Casebook Team The Network Casebook Team

During the evening of the first casebook launch I realised the true potential that frontline staff have in transforming the NHS in a way that senior clinicians and central management just cannot. Groups of connected engaged clinicians (and junior managers) working together using social media to spread their ideas will disrupt the hierarchical system that has failed to improve the NHS at the pace that our patients deserve.

The Network Casebook is one way for all of us to share our work and ideas and shake things up. We can be progressively more innovative. We now have several short YouTube clips of individual projects to help dissemination. Have a look on the site for these. The Casebook II projects are fantastic in print but even better in film. Well done to everyone involved, together we can.

As this next edition of the Casebook is published, I feel a collective sense of pride that the energy generated by the first edition has not only continued but has gained pace. This edition has involved a fantastic breadth of disciplines from Allied Health Professionals to Computer Programmers and represents the new paradigm in interconnectedness that we are proud to be contributing to. I am again inspired by the wealth of talent we have available to the NHS amongst our junior colleagues and amongst the wider community dedicated to improving the care of our patients. The messages from each of us involved with the casebook are unsurprisingly similar. Connect people, share knowledge, improve care.

As students it's easy to just do what we do best - follow, observe and generally try to avoid getting in everyone’s way! Sometimes however, from the corner of the clinic room or shadow of the ward round huddle, we are actually in a uniquely privileged position to see areas for improvement. Most of us choose to vent what we see through the always feel-good, easy option of having a nice long rant at faults over coffee with friends. When you are just starting out in medicine it's easy to think you are the bottom of a very, very tall hierarchal tree and your opinions therefore are nothing next to that of your consultants with their years of experience and many letters after their name. However, leadership is not a role nor a responsibility but rather an opportunity. All doctors, no matter how junior, have the ability to shape the system they will qualify into. The casebook is filled with outstanding examples of this - juniors piloting front line quality improvement projects to change the way things work for the better. By sharing their stories, we hope others can learn from their experiences and feel empowered to follow suit.

Zain Sikafi

Yasmin Ahmed-Little

On entering Foundation Training in 2008, I found a clear gap between what I had expected clinical services to be like and that which I found myself part of. I think many of us have had that feeling of being part of a machine, powerless to change anything.

Despite intercalating in Management I had no practical experience of creating change in my local environment. I found support and advice in The Network’s predecessor ‘BAMMbino’ (Junior Division – British Association of Medical Managers). Here fellow ‘juniors’ could share experiences, discuss key topics and providing tool-kits and online forums on all things quality improvement.

Since then The Network has formed, embracing BAMMbino members as well as inspiring many more to join the movement. The same principles of empowerment of junior doctors, networking, sharing experiences and innovation permeate throughout the organisation. I hope this Casebook can provide key learning in each case to doctors across the UK, just as I have learned from Network members. Through this learning and sharing of best practice, there is no doubt we can change the lives of our patients for the better.

The Casebook time of year is always a busy one for The Network team. I am always impressed at the amount of their own time individuals dedicate to making this a success when everybody leads such busy lives. But why do they do it? The team I believe has a passion to help us create a shift in culture where sharing of information, things that worked and things that didn't, becomes routine across the NHS. This needs to happen to really ensure we are providing the best possible care we can. We deserve to be working in such a service and our patients are right to demand it. I dream of a world where the first though of any healthcare person working on a project is to check and see what's been done already as well as going on to share their own experiences and learning. It will be our pleasure if the on-line Network Casebook can facilitate this.

Reading through the projects submitted for Casebook II made me feel proud - not only of The Network, and it's potential to bring people and ideas together, but of the calibre of the people who choose to join. As Co-Chair of the Network since its inception in 2010, I have seen the membership grow to over 2500 and it is clear from this latest round of submissions, that these are not just people making up the numbers, but professionals with a desire to improve healthcare in their environment with a single common purpose - making patient care better, safer, more effective.

What the original Casebook showed was that this desire was being turned into action but what we see here with Casebook II is that it is an ongoing process and this is becoming part of the culture of medical training and working. What keeps me in awe is that most of these submissions are from everyday jobbing clinicians, with no formal training in quality improvement or service redesign - a testament to what can be achieved with an idea and the motivation to follow it through.

We continue to try to support this and make things easier by connecting, inspiring and most importantly giving you the help you need when you need it. Our membership continues to expand across all specialties, grades, professions and localities including internationally. Our database of quality improvement projects continues to grow and we hope to become the first port of call for any project to see if someone has tried it before. And if they haven't? Well then you can use The Network to find someone who can help you make it happen.

The Francis Report on Mid Staffordshire showed us what can happen when individuals start to lose sight of their priorities, how a system failed to support them and how patients suffer as a result. No bureaucracy can deliver a perfect healthcare system. That particular task sits on the shoulders of the men and women who deliver that system - you. Imagine an empowering culture in healthcare which enables you to seek out better ways of doing things and supports you in making high quality sustainable improvements in care. Millions of beneficial changes across the entire health system makes a good NHS great. I know members of The Network will help realise that future.

Jane Runnacles

Damian Roland

Junior doctors have been the NHS' best kept secret. We are motivated, enthusiastic individuals who have the energy to innovate across organisational boundaries, putting our patients at the centre at all times. We are in the best place on the front-line to see where problems lie and suggest workable solutions, learning from other organisations where we have previously worked. However we rarely have the opportunity to celebrate and share our improvement ideas, which is where The Network has a crucial role.

I was immediately drawn to The Network, with the opportunity to connect with like-minded people, learn about interesting events and share quality improvement (QI) ideas through the Casebook. Whilst designing and running a QI educational programme, EQuIP (Enabling Doctors in Quality Improvement and Patient Safety), during my Darzi leadership fellowship at Great Ormond Street hospital, I found the Casebook to be motivating and inspiring.

It has been fantastic to be part of the operational board of The Network since returning to paediatric training this year. I continue to be amazed and inspired by the work submitted to Casebook II and it has been a pleasure to be on the selection panel. Although QI can be challenging and local support remains patchy, I am confident that junior doctors and other motivated healthcare professionals can continue to make a difference with the support of The Network. Remember the first lesson of QI: "Steal shamelessly"!

Improving the quality of health care is central to what doctors do. Not only do we look after the patient in front of us but we are responsible for our future patients and the ones outside of the consulting room. Making services better is the most effective way to achieve this and was my motivatation to help form The Network in 2010 – an organisation that promotes and supports junior doctor leadership.

It’s been said many times that junior doctors are ideally placed to improve health care systems because we’re at the front-line, we see what the problems are and know how to best fix them. We’re also bright and enthusiatic, all of which makes an effective combination. The contributors to this second edition of The Casebook are no different. I’m proud that so much excellent quality improvement work is being carried out across the UK and that The Network can be a part of it.

The aim of collating these projects here is so they can be shared with others. So enjoy reading this second edition of The Casebook and if you see something you think may work in your own organisation please implement it and make things better for your patients.

Change is difficult enough to achieve, let alone improvement. Anyone able to deliver a new way of working or simply optimising an existing one has achieved a great deal. The fact that the initiative has come from "junior" health care professionals is even more impressive and everyone in the casebook is to be congratulated regardless of the overall outcome of their work.

This casebook coincides with NHS Changeday - a project with similar values. To demonstrate to all that combined and shared action can be instrumental in changing the status quo. With the enthusiasm and zest shown in this book, and on Changeday itself, it seems likely that Professor Sir Bruce Keogh's reflection that "I have never seen change not happen where enough people have wanted it" will come to pass.

Having been though the ins and outs of developing several quality improvement projects such as the SMART rota (SMARTr) I believe the Network Casebook is invaluable because of what I call “thinking inside the box”. As a junior doctor if one is unable to express ideas or engage with others with power to effect change in areas they know have a direct impact on patient experiences and outcomes because they are on the inside of the problem, it is the equivalent of being physically constrained in a box. A box at the bottom of a complex NHS structure of knowledge, quangos, and hierarchies. And as just one box in that structure there needs to be engagement with other boxes to bring about improvement. It has taken a lot to get people on board with SMARTr - a customisable rota design which is specific to individual trainees and trusts, with measurable quality outcomes, aligned with trainee involvement, realtionship and role defining, and timed to deliver competence and confident excellence. But the strength has come from understanding challenges and lessons learnt from other improvement projects in the Casebook. The Casebook by virtue of disseminating the thinking that has gone into improvement projects and how this has been translated into action gives it engagement. By giving doctors greater insight into skills and behaviors needed to influence service delivery and effect change within their clinical context. And the courage to “think inside their boxes” boldly at an intuitive level so as to keep going in the face of uncertainty or lack of resources.

5Casebook 2012

Rob BethuneGloria Esegbona

Jonathan Hyer

Nikki Kanani Ben BrownClaire Matthews

The Network Casebook Team The Network Casebook Team

During the evening of the first casebook launch I realised the true potential that frontline staff have in transforming the NHS in a way that senior clinicians and central management just cannot. Groups of connected engaged clinicians (and junior managers) working together using social media to spread their ideas will disrupt the hierarchical system that has failed to improve the NHS at the pace that our patients deserve.

The Network Casebook is one way for all of us to share our work and ideas and shake things up. We can be progressively more innovative. We now have several short YouTube clips of individual projects to help dissemination. Have a look on the site for these. The Casebook II projects are fantastic in print but even better in film. Well done to everyone involved, together we can.

As this next edition of the Casebook is published, I feel a collective sense of pride that the energy generated by the first edition has not only continued but has gained pace. This edition has involved a fantastic breadth of disciplines from Allied Health Professionals to Computer Programmers and represents the new paradigm in interconnectedness that we are proud to be contributing to. I am again inspired by the wealth of talent we have available to the NHS amongst our junior colleagues and amongst the wider community dedicated to improving the care of our patients. The messages from each of us involved with the casebook are unsurprisingly similar. Connect people, share knowledge, improve care.

As students it's easy to just do what we do best - follow, observe and generally try to avoid getting in everyone’s way! Sometimes however, from the corner of the clinic room or shadow of the ward round huddle, we are actually in a uniquely privileged position to see areas for improvement. Most of us choose to vent what we see through the always feel-good, easy option of having a nice long rant at faults over coffee with friends. When you are just starting out in medicine it's easy to think you are the bottom of a very, very tall hierarchal tree and your opinions therefore are nothing next to that of your consultants with their years of experience and many letters after their name. However, leadership is not a role nor a responsibility but rather an opportunity. All doctors, no matter how junior, have the ability to shape the system they will qualify into. The casebook is filled with outstanding examples of this - juniors piloting front line quality improvement projects to change the way things work for the better. By sharing their stories, we hope others can learn from their experiences and feel empowered to follow suit.

Zain Sikafi

Yasmin Ahmed-Little

On entering Foundation Training in 2008, I found a clear gap between what I had expected clinical services to be like and that which I found myself part of. I think many of us have had that feeling of being part of a machine, powerless to change anything.

Despite intercalating in Management I had no practical experience of creating change in my local environment. I found support and advice in The Network’s predecessor ‘BAMMbino’ (Junior Division – British Association of Medical Managers). Here fellow ‘juniors’ could share experiences, discuss key topics and providing tool-kits and online forums on all things quality improvement.

Since then The Network has formed, embracing BAMMbino members as well as inspiring many more to join the movement. The same principles of empowerment of junior doctors, networking, sharing experiences and innovation permeate throughout the organisation. I hope this Casebook can provide key learning in each case to doctors across the UK, just as I have learned from Network members. Through this learning and sharing of best practice, there is no doubt we can change the lives of our patients for the better.

The Casebook time of year is always a busy one for The Network team. I am always impressed at the amount of their own time individuals dedicate to making this a success when everybody leads such busy lives. But why do they do it? The team I believe has a passion to help us create a shift in culture where sharing of information, things that worked and things that didn't, becomes routine across the NHS. This needs to happen to really ensure we are providing the best possible care we can. We deserve to be working in such a service and our patients are right to demand it. I dream of a world where the first though of any healthcare person working on a project is to check and see what's been done already as well as going on to share their own experiences and learning. It will be our pleasure if the on-line Network Casebook can facilitate this.

Reading through the projects submitted for Casebook II made me feel proud - not only of The Network, and it's potential to bring people and ideas together, but of the calibre of the people who choose to join. As Co-Chair of the Network since its inception in 2010, I have seen the membership grow to over 2500 and it is clear from this latest round of submissions, that these are not just people making up the numbers, but professionals with a desire to improve healthcare in their environment with a single common purpose - making patient care better, safer, more effective.

What the original Casebook showed was that this desire was being turned into action but what we see here with Casebook II is that it is an ongoing process and this is becoming part of the culture of medical training and working. What keeps me in awe is that most of these submissions are from everyday jobbing clinicians, with no formal training in quality improvement or service redesign - a testament to what can be achieved with an idea and the motivation to follow it through.

We continue to try to support this and make things easier by connecting, inspiring and most importantly giving you the help you need when you need it. Our membership continues to expand across all specialties, grades, professions and localities including internationally. Our database of quality improvement projects continues to grow and we hope to become the first port of call for any project to see if someone has tried it before. And if they haven't? Well then you can use The Network to find someone who can help you make it happen.

The Francis Report on Mid Staffordshire showed us what can happen when individuals start to lose sight of their priorities, how a system failed to support them and how patients suffer as a result. No bureaucracy can deliver a perfect healthcare system. That particular task sits on the shoulders of the men and women who deliver that system - you. Imagine an empowering culture in healthcare which enables you to seek out better ways of doing things and supports you in making high quality sustainable improvements in care. Millions of beneficial changes across the entire health system makes a good NHS great. I know members of The Network will help realise that future.

Jane Runnacles

Damian Roland

Junior doctors have been the NHS' best kept secret. We are motivated, enthusiastic individuals who have the energy to innovate across organisational boundaries, putting our patients at the centre at all times. We are in the best place on the front-line to see where problems lie and suggest workable solutions, learning from other organisations where we have previously worked. However we rarely have the opportunity to celebrate and share our improvement ideas, which is where The Network has a crucial role.

I was immediately drawn to The Network, with the opportunity to connect with like-minded people, learn about interesting events and share quality improvement (QI) ideas through the Casebook. Whilst designing and running a QI educational programme, EQuIP (Enabling Doctors in Quality Improvement and Patient Safety), during my Darzi leadership fellowship at Great Ormond Street hospital, I found the Casebook to be motivating and inspiring.

It has been fantastic to be part of the operational board of The Network since returning to paediatric training this year. I continue to be amazed and inspired by the work submitted to Casebook II and it has been a pleasure to be on the selection panel. Although QI can be challenging and local support remains patchy, I am confident that junior doctors and other motivated healthcare professionals can continue to make a difference with the support of The Network. Remember the first lesson of QI: "Steal shamelessly"!

Improving the quality of health care is central to what doctors do. Not only do we look after the patient in front of us but we are responsible for our future patients and the ones outside of the consulting room. Making services better is the most effective way to achieve this and was my motivatation to help form The Network in 2010 – an organisation that promotes and supports junior doctor leadership.

It’s been said many times that junior doctors are ideally placed to improve health care systems because we’re at the front-line, we see what the problems are and know how to best fix them. We’re also bright and enthusiatic, all of which makes an effective combination. The contributors to this second edition of The Casebook are no different. I’m proud that so much excellent quality improvement work is being carried out across the UK and that The Network can be a part of it.

The aim of collating these projects here is so they can be shared with others. So enjoy reading this second edition of The Casebook and if you see something you think may work in your own organisation please implement it and make things better for your patients.

Change is difficult enough to achieve, let alone improvement. Anyone able to deliver a new way of working or simply optimising an existing one has achieved a great deal. The fact that the initiative has come from "junior" health care professionals is even more impressive and everyone in the casebook is to be congratulated regardless of the overall outcome of their work.

This casebook coincides with NHS Changeday - a project with similar values. To demonstrate to all that combined and shared action can be instrumental in changing the status quo. With the enthusiasm and zest shown in this book, and on Changeday itself, it seems likely that Professor Sir Bruce Keogh's reflection that "I have never seen change not happen where enough people have wanted it" will come to pass.

Having been though the ins and outs of developing several quality improvement projects such as the SMART rota (SMARTr) I believe the Network Casebook is invaluable because of what I call “thinking inside the box”. As a junior doctor if one is unable to express ideas or engage with others with power to effect change in areas they know have a direct impact on patient experiences and outcomes because they are on the inside of the problem, it is the equivalent of being physically constrained in a box. A box at the bottom of a complex NHS structure of knowledge, quangos, and hierarchies. And as just one box in that structure there needs to be engagement with other boxes to bring about improvement. It has taken a lot to get people on board with SMARTr - a customisable rota design which is specific to individual trainees and trusts, with measurable quality outcomes, aligned with trainee involvement, realtionship and role defining, and timed to deliver competence and confident excellence. But the strength has come from understanding challenges and lessons learnt from other improvement projects in the Casebook. The Casebook by virtue of disseminating the thinking that has gone into improvement projects and how this has been translated into action gives it engagement. By giving doctors greater insight into skills and behaviors needed to influence service delivery and effect change within their clinical context. And the courage to “think inside their boxes” boldly at an intuitive level so as to keep going in the face of uncertainty or lack of resources.

6 Casebook 2012

Project Title: The development and implementation of a novel acute electronic referral system to a tertiary referral centre, Great Ormond Street Hospital for Sick Children.

Submitted by: Alexander N, Sharp Z & Jacobs K.

Context: This project was the successful collaboration between a project manager, paediatric surgical trainee and systems developer. At its conception, the primary driver was a unified system for bed management with the emphasis on bed utilisation, patient placement on correct wards and reduction in emergency refusal. The project evolved into an integrated clinically useful system with focus on communication with referring centres ensuring patient safety.

Problem: Referrals to specialist paediatric services from district general hospitals are common and take the form of two pathways; either they are for 1) direct transfer for patient care or 2) specialist advice with patients being managed locally. With the advent of shift systems some or all of the vital patient information may be missed and often the doctors speaking between centres may not be aware of each referral. This project aimed to address both groups of patients:

1) inpatient transfera) accurately record clinical informationb) ensure safety of transfer by placing on the correct wardc) a system where information would be readily available to both clinical, nursing and bed management staff

2) Advice only callsa) ensuring correct clinical information is recorded from referring centreb) ensuring advice given is accurrately relayed and is accessible to all staff who may be called againc) providing and capturing accurate patient advice for the purposes of auditing advice givend) ensuring patient saftely in that advice given is electronically transferred to the referring consultant

Assessment of problem and analysis of its causes:

Communication between referring clinicians and those receiving referrals is notoriously difficult. The referring doctor has the patient in front of them and there is reliance to get information across to referring hospital clinicians, whose clinical judgement is then relied upon to either manage the patient locally or transfer for inpatient management. Frustration often arises from both sides, with referring hospital clinicians often speaking to multiple clinicians at tertiary centres who will not know anything about the individual case through lack of a cohesive system. In addition, patient safety is not infrequently compromised largely through lack of recording of the advice given, which will result in significant complaints from local services about the advice or lack thereof given.

Intervention: A web-based and iPad based software system had been designed by the programmer for this project. The secure initial proforma for collecting patient data contained demographics, referral centre details and basic information for accurate bed management. The project evolved this system to allow the clinical data provided by the referring clinicians to be collected, specific clinical parameters to assess sickness severity, referral centre details including referring consultant email address, and importantly the clinical advice given. Each form generated is the stored on a searchable database allowing all users of the system access to all referrals and the clinical outcome. In the case of advice only calls, the system generates a simple letter to the referring consultant and is emailed by the nhs.net system.

Strategy for change:

The new acute electronic referral system was rolled out by the paediatric surgery team as a pilot project. The project was presented to the unit and accepted wholeheartedly especially as there had been a number of incidents relating to advice calls previously. All acute referrals from outside hospitals were recorded by the accepting on call surgical registrar on a hospital provided ipad device. The form had been designed with user in mind and the majority of input is via drop-down menus. The system was interogated continually by the project team, and the software was updated to its current version through end user feedback.

After two months, the database was interrogated and the results were presented to the paediatric surgery unit in the form of 1) Acute admissions including accurate neonatal numbers and a breakdown of centres which had been referring2) Refused admissions including reasons for this3) Advice calls - previously never formally recorded, these amounted to 40% of the outside acute referrals and allowed audit of the advice calls given.

Measurement of improvement:

On the background of this roll out, the project has expanded to five more specialist services through presentation of the data already collected and live demonstration of the system. The pilot data were interogated further and were used: 1) to target specific referral centres - the data demonstrated a significant referral centre had decreased its acute referrals and in fact this trand had been over the previous year. Examination of this issue led to the realisation that this was a result of poor communication with our institution and allowed focused discussions at a consultant level. 2) Complaint - a serious complaint was made by one trust about advice and management of a particular patient. A rapid response was possible to this through looking up the patient on the electronic database, and provision of both the appropriate clinical information and advice given. It transpired that an error of recording advice locally was ultimately to blame.

Effects of change:

This project has allowed the collection of vital patient information to a searchable database to improve patient safety. The final roll out of the mail merge system sending advice to referring consultants as an email will be the culmination of this continually evolving project. The system has been widely accepted as a positive step forward by both referrers and end user clinicians across specialities, and has been welcomed by the trust board as a vital communication tool. The implementation of this new system required significant active involvement of the project manager, clinician and developer to drive and develop the system in its infancy, but is now within 6 months of its piloting, an independant system running with little active input on a daily basis.

Lessons learnt: The main learning point and success of this novel referral pathway was due to the collaborative successful working between the three active team members, with the support of the bed managers and early end users. The rapid development of a clinically useful tool which has already improved patient safety is entirely a result of the team’s efforts.

Message for others:

The best ideas are incredibly simple, and this project would definitely fit into that mould. This is the culmination of working within a team with different areas of expertise resulting in a measurable improvement in patient safety. A simple system and simple form, have captured information improving communication between DGH and specialist centres, improved patient care at a local level, and provided a level of protection in documentation of advice given by clinicians at tertiary centre which does not exist elsewhere.

Com

munication / Referral

7Casebook 2012

Project Title: Intensive programme to improve oxygen safety in medical patients.

Submitted by: Beardmore M, Winters C & Khan A.

Context: The Royal Oldham Hospital and Fairfield General Hospital are district general hospitals near Manchester. The wards included in our project consisted of medical admissions units, general and specialist medical wards including respiratory medicine. The team overseeing the project included Dr A Khan (FGH), the Oxygen Task and Finishing Group, Dr M Beardmore and Dr C Winters.

Problem: The National Patient Safety Agency published a Rapid Response Report in 2010 regarding patient harm due to poorly delivered oxygen therapy. At a similar time, incidents relating to oxygen therapy locally prompted efforts to improve the safety of this treatment. There was also a notable difference between the oxygen prescription chart in use and that recommended by the British Thoracic Society (BTS). A self-designed baseline audit demonstrated its poor prescription and delivery within the medical division.


Baseline audit assessed 212 patients’ use of and/or prescription for oxygen, of which 36 patients were included. This was devised to assess the root causes of poor oxygen prescription and delivery locally, giving more specific information than the standard BTS audit at the time. It was completed by 2 foundation year doctors in 2010. At baseline, 6% of prescriptions included a target saturation range and 47% of patients on oxygen had no written order of any sort. Simultaneously a multidisciplinary Trust Oxygen Task and Finishing Group (OTFG) was set up to address this issue.

Intervention: Several changes were implemented:

• New prescription charts with a more prominent and fit-for-purpose oxygen section were introduced• New observation charts with a dedicated oxygen section were produced• Colour-coded bedside guides to oxygen prescription and delivery were displayed• An education programme for nurses, pharmacists and physiotherapists was introduced, including posters and screensavers.• Junior doctors received presentations and an e-learning package during induction• Nursing oxygen ‘champions’ for each ward educated local staff


Changes were implemented on several levels. ‘Front-line’ staff received education to increase awareness of oxygen therapy, through e-learning, local oxygen champions and at formal teaching sessions and meetings. At a Trust level, departments were approached to develop e-learning resources and include these in induction programmes, in addition to arranging the development of a new drug prescription chart trust-wide. This was driven by a dedicated group of staff with the title of the ‘Oxygen Task and Finishing Group’.


Repeat audit was performed with the same methodology and personnel in 2011. 223 patients were screened for inclusion, of which 56 were eligible. Use of oxygen and primary medical diagnoses were similar between the two cycles. Oxygen prescriptions including a target saturation range increased to 60% (10-fold change), and the proportion of patients receiving oxygen without a written order fell to 18% (2.5-fold change). There was also evidence that oxygen delivery was more accurate and fewer discrepancies between charts and actual oxygen delivery were found. Results are presented as simple percentages.

Effects of change:

Clear evidence of improved oxygen prescription and delivery was demonstrated following the changes to practice. The changes saw levels of adherence to the relevant national guidance increase to well above national average levels from a relatively low baseline. While there remains room for further improvement, oxygen prescription and delivery within the medical division is now considerable safer. The process of change required the investment of a significant amount of time for the dedicated OTFG. Changes to established documentation and busy induction schedules were some of the more challenging aspects of the process. The conversion from paper to electronic prescriptions will pose a new challenge in terms of consolidating and improving on our changes.

Lessons learnt: Short-term and small improvements can be made with relative ease at a local level, however changing the practice of an organisation requires the dedication and investment of many individuals. Addressing the administrative, cultural and educational aspects of any required change is needed to truly effect improvements. We are pleased that a further 12 months after this work, the rates and quality of oxygen prescription remain high.

Message for others:

In order to effect significant and long-term improvements, changes must be made at several levels of an organisation simultaneously. This was achieved by clear leadership, involvement of both Trust-based and ‘shop-floor’ clinicians with the development and promotion of an extensive education programme. Our short turn-around time from beginning interventions to fully implementing our changes was relatively short and was likely one of the major contributors to success. Measurable improvements have been made to safe oxygen use and should reduce the risk of future harm relating to its poor use.

Education & Training

8 Casebook 2012

Project Title: Improving the safety and efficacy of handover and out of hours care for high risk patients moving from the Medical Assessment Unit to wards at Musgrove Park Hospital

Submitted by: Beasley S.

Context: This improvement project was based in a busy Medical Assessment Unit, working with the multidisciplinary team; in particular nursing staff, senior and junior doctors.

Problem: It was noted that there was no formal handover in place from MAU to the ward, and that when patients were transferred important tasks were not always highlighted and passed over. This had caused anecdotal concerns with many staff members; with unwell patients not being handed over or followed up, key results not being chased and patients having delayed and confused care.


Initially a questionnaire was circulated to junior doctors based on the wards, and our concerns were reflected in their responses. We looked at 6 months of incident forms, and found a few concerning cases- however as doctors rarely write incident forms we thought this may not be the most accurate method of recognising the scope of this problem. We also identified an average delay of 32.5 hours from arrival on the ward to consultant review; when you would expect tasks and concerns to be noted and rectified. We discussed the situation with MAU consultants and the multidisciplinary team; namely the critical care team and the MAU matron. They all recognised the problem and the system aspects which exacerbate it.

Intervention: We ran a series of PDSA (plan, do, study, act) cycles to attempt to improve patient safety through handover. This had multiple approaches, with the most effective a targeted handover of high risk patients. The patients identified for handover would be those in the following criteria: Clinically relevant PAR score >3, complex comorbidities, intuitively unwell and awaiting clinically significant management changing decisions. This was shown over a 5 day period to be 11% of MAU patients (as assessed by MAU consultants). Our current intervention required these patients to be identified and to have a verbal handover prior to transfer. We hope to improve this with further PDSA cycles to include a written handover and to reduce the transfer of these patient out of hours (except to appropriate wards).


These plans were discussed with the MAU consultants, who were very supportive, as were the senior MAU nursing staff and supporting critical care outreach team. We spoke to these groups regularly taking their advice and guidance into account. We presented our results to the junior doctors, who were concerned about the additional time pressures this may cause. I also spoke informally to many of the junior nurses to gain support.


Unfortunately our project did not have lasting success. As none of out project members were rotated onto MAU at the time, we had difficulty generating day to day impetus, and in a busy and pressured environment, staff were reluctant to add to this. We had planned to discuss the impact with nursing and medical staff on receiving wards to see if they had noted a benefit.

Effects of change:

Whilst our system was not implemented, focusing attention on safe handover improved awareness of not transferring high risk patients and handing over unwell and concerning patients. We identified many barriers to change during our project, in particular high workload, increased time pressures, poor unification of MAU team, and that motivation for change was not sufficient for lasting effects.

Lessons learnt: I have learnt that systems can be improved, and the benefit of PDSA cycles as a measure to implement change. I have learnt about the difficulty of changing systems, especially in a pressured environment without direct placement in that environment. I learnt that despite having the approval of senior doctors, without junior staff understanding the importance of a change it will not flourish. I will be based on MAU from April this year and will try to see how I can implement the lessons we learnt in this project during that rotation.

Message for others:

During our improvement project we identified a safety concern and attempted to resolve this with targeted patient handover. Using PDSA cycles enabled us to create a new strategy for this, listening to our multidisciplinary colleagues to make it usable and suitable, Despite support from senior staff, our project requires further work to reach its’ potential. Working within the team will allow me to further evolve this improvement to achieve the target of improving the safety of patient transfer.

Com

munication / H

andover

9Casebook 2012

Project Title: Blood Trolley project

Submitted by: Bordman J, Starmer B & Eyres G.

Context: Throughout Blackpool Victoria Hospital, on inpatient wards.

Problem: As Junior doctors we had found it very difficult to find clinical equipment in store rooms. This problem was highlighted when moving wards or when doing on-call shifts, working on unfamiliar wards. This led to time wasted searching for equipment and essentially delay in treatment of patients in emergency settings.


We agreed upon what items were needed on a day to day basis by clinical staff. We then audited various wards in the hospital, determining whether wards had all necessary equipment and whether it was readily available without searching for longer than 2 minutes. We also gathered the opinions of other doctors and nursing staff as to how we might remedy the problem.

Intervention: We proposed the ‘Blood Trolley’. The ‘Blood Trolley’ is a plan of 4 drawers, containing all necessary equipment on a busy inpatient ward. Each ward would be given a plan of the drawers and a list of required equipment. The drawers were to be kept together in store rooms and would be highlighted by bright green labels. This meant that whatever ward you were on in the hospital you would be able to find any equipment you needed quickly. The key to the idea was a universal uptake of the project throughout the hospital, so everyone would be familiar with the layout.


We initially trialled the project on 6 medical wards. We involved the hospital directorate in our plans and kept them informed of how the project was going and any feedback we had.


We repeated the audit of store rooms following the implementation of the ‘Blood Trolleys’. We also asked feedback from doctors and nurses working on the wards where the ‘Blood Trolley’ had been trialled.

Effects of change:

All 6 wards showed dramatic improvement of accessibility to essential equipment. Not only was more equipment actually stocked in the rooms, but it was also much easier to find. Feedback was very positive, with everyone finding the project useful and suggesting it be rolled out to the rest of the hospital.

Lessons learnt: Next time I would involve senior managerial help earlier. The project moved quicker and more efficiently when we had this help. They were also able to put us in contact with other disciplines that were able to help, and spur on unwilling members of staff.

Message for others:

It is easy to coast along as a junior doctor, but we are working on the front line and as such are often the first to see problems. Instead of moaning about these problems we should make it our responsibility to fix them.

Layout / Equipment

10 Casebook 2012

Project Title: Teaching a Good Ward Round

Submitted by: Bruce C & Powell N.

Context: Busy district general hospital. Survey of junior doctors and students. Teaching sessions were provided to final year medical students in a simulated environment.

Problem: It was observed that documentation of ward rounds is poor, particularly following the induction of FY1s in August. This impacts directly on patient safety through poor handover of tasks, inadequate documentation of a working diagnosis and extends patient stay through inefficient ordering/chasing of required investigations. Junior doctors are also left to lead ward rounds on many occasions. There is no formal ward round teaching at most universities. Understanding of how to conduct a ward round and what constitutes appropriate documentation is poor. A teaching programme in a simulated environment aims to rectify this void in teaching.


Through surveys to both junior doctors and medical students. This focussed on areas such as confidence leading and confidence documenting on a ward round. It also quantified the number of doctors who have received training in how to conduct a ward round safely.

Intervention: The intervention was in the form of a simulated teaching session involving final year medical students from our affiliated medical school. Fabricated patient scenarios were made based on common presentations on the acute medical take. Drug charts, observations charts and medical clerking (complete with post take ward round) were provided. The students worked in a team with one leading, one documenting and the others acting as active participators. The rest of the student group observed and commented on specific factors in order to provide feedback and as a learning experience for themselves.


The teaching programme is to be included in the induction of all foundation year 1 doctors in the trust in early August. My aim is to construct a programme of teaching that will be included on the undergraduate medical curriculum at our affiliated medical school. I have met with our medical director who fully endorses the change.


A post session survey was issued to the medical students after the teaching session. Self rated confidence (assessed on a 5 point likert scale) was assessed against a pre session survey.

Self rated confidence in both documenting and leading ward rounds increased after only one session. Confidence leading increased from 3% to 43% and documenting from 40% to 68%. The session was well received with all of the students finding it useful and 97% rating it as excellent. 92% of students felt that further sessions would be of use and that this teaching should occur prior to commencement of the foundation programme.

Effects of change:

The effects thus far are of markedly increased confidence amongst a cohort of future doctors in both leading and documenting on ward rounds. This will impact positively on patient care once these students being working as junior doctors in August.

Lessons learnt: Simulated teaching programmes are well received and effective means of increasing confidence in this common and poorly taught area of all doctors lives. Through feedback I would teach the students in smaller groups (max 4) in order that they all have a chance to lead and document on the ward round. As the students become more familiar with the setup, over time I will construct more complex clinical scenarios to encounter and work through as a team. This will make the scenarios more realistic and prepare the juniors appropriately for common problems encountered in a busy clincial environment.

Message for others:

A simulated ward round teaching session is an effective and well received means of increasing junior doctors confidence in leading and documenting on ward rounds. The sessions should be integrated into all undergraduate curriculae and should be assessed prior to the commencement of the foundation programme.


11Casebook 2012

Project Title: SurgiNote: A new software program that improves: the accuracy and quality of operation note keeping, Payment by Results and discharge summary compliance

Submitted by: Chiu G.

Context: SurgiNote, a software program, was developed by a Senior Specialty Registrar in Oral and Maxillofacial Surgery at Pennine Acute Hospitals NHS Trust to improve the accuracy and quality of operation note keeping, Payment by Results and discharge summary compliance.

Problem: In 2009, the UK National Audit Commission published results of a UK Audit on the accuracy of coding. In summary, there was £66,000,000 worth of procedure income. They found a 12.8% overall national coding error rate. This resulted in a HRG error rate of 8.1% (1% to 40%). This would have a generated a further £2,600,000 (3.9%) of funds for the NHS. The common theme which affected accuracy was the quality of source of documentation and coding of co-morbidities. The audit commission’s recommendations were: promote coding accuracy by improving source documentation, and ensure clinicians are engaged and involved with validating coding. Upon patient discharge, a discharge summary should be sent to the GP within 24 hours. There is a £5 penalty for each patient with a delayed production of discharge summary.


In April 2009, in the department of Oral and Maxillofacial Surgery at Pennine Acute Hospitals NHS Trust, 185 patients were coded as having a surgical procedure. Of these 87 patients (47%) had a coding inaccuracy or incompleteness. This resulted in £12,140 (8%) of lost income in one month from one surgical specialty. In July and August 2010, the average compliance of sending out a discharge summary to the GP within 24 hours was 47%. The clinical coders reported the main problem was the difficulty in understanding illegible handwritten operation notes.

Intervention: Production of surgical operation note software program (SurgiNote) that lists all surgical procedures along with their OPCS codes and patient co-morbidities. This also produces a discharge summary that can be sent electronically to the GP. SurgiNote can be used as an audit tool.


A fully functional software program was developed and introduced and used by the surgical staff from the department of Oral and Maxillofacial Surgery.


The SurgiNote was assessed both qualitatively and quantitatively. This was re-audited quantitatively six weeks after SurgiNote was introduced and again 14 months later.

Effects of change:

Six weeks after SurgiNote was introduced, there was a 34% decrease in overall coding inaccuracy (p<0.00001). In September 2009, 15 out of 168 patients required a payment adjustment resulting in £3,698 of lost income (2% income error). This is a 6% decrease in coding error. The average coding time, from when the patient was discharged to when coded, was reduced from 14 days (range 2 to 91 days) to 9 days (range 0.1 to 48 days) (p<0.0001). The compliance rate of sending out a discharge summary to the of the General Medical Practitioner 24 hours from the patient being discharged has improved from 47% to 76%. Compared to the surgical directorate which remained at 46%.

Of the 60 randomly selected procedures, in the re-audit of December 2010, there were only four errors in coding (6%). Of which only one procedure result in £448 of lost income. Income error was again reduced to 0.6%.

The surgeons producing the operation note; the nursing staff, reading the operation note and the clinical coders were given a questionnaire about SurgiNote. All preferred a typed operation note rather than a handwritten one.

SurgiNote has continued to be used by the Oral and Maxillofacial Unit. To date there are over 16,000 surgical procedures documented. SurgiNote has a search and report facility. So interrogation of any parameter for audit purposes can be used.

Lessons learnt: It is essential for operation notes to be clear, concise and provide accurate information that can be easily communicated to all members of the team. Not only to the clinical staff but also to the administration team that that code the clinical procedures. This full-fills the guidelines set by the General Medical Council and Royal College of Surgeons that Operation Notes need to be: “Clear high quality accurate operation notes” & “Sufficient detail to enable continuity of care by another doctor”.

Message for others:

Accurate coding is essential as it provides remuneration to the surgical department for the work it has performed. This reflects in the justification of the service the department provides. In addition to this, the clinical coding data is used by the Department of Health to publish Hospital Episode Statistics. This information is used by national and local health authorities to estimate service demand and plan health care resources.

The NHS is currently facing a financial crisis as a result of the recent economic recession. This is leading to a £15 billion shortfall in budget. NHS Trusts should be actively encouraging innovation and improving efficiency in ways to make savings, this project is one such proven example. By improving source documentation SurgiNote has improved accuracy and efficiency of coding. SurgiNote has saved income to the Specialty and the Pennine Acute Hospital Trust, that would have been lost through inaccurate coding.

Com

munication / D

ocumentation

12 Casebook 2012

Project Title: Improving the reporting of critical incidences through family engagement in a children’s hospital.

Submitted by: Clausen H, Linkson L, Magness C, Runnacles J, Thomas L, Hothi D & Lachman P.

Context: As part of the Health Foundation’s “SHINE programme” and the Great Ormond Street Hospital programme of “Enabling doctors in Quality Improvement & Patient Safety” (EQuIP) we are currently implementing changes to the way critical incidents are reported by asking families to complete a brief electronic questionnaire aimed at identifying critical incidents during admission.

Problem: Even with the best intentions, hospital health records will not document all critical patient events. Our current hospital database captures few departmental critical incidents and evidence suggests that staff behaviour is unlikely to change significantly in the short run. Seeking new ways of reporting critical incidents is the key to flagging up problems and putting things right.


We will use the current databases and relevant complaints reports as a standard against which family reports will be monitored. Published evidence suggests that reporting of critical incidents can realistically be increased by 25% within our 12-months study period. This should identify clusters of errors, which in turn would allow us to tackle newly recognised clinical problems more effectively. The investigating team will be made up of front line clinical nursing and medical staff. Families will be asked to complete electronic questionnaires 24 hours prior to discharge.

Intervention: We will ask families to complete a brief questionnaire aimed at identifying different types of critical incidents. These include communication failures, medication errors, clinical complications and medical equipment failures. Reporting will be anonymously and voluntary. The questionnaire will be revised throughout the investigation period to ensure adverse events are captured adequately. Reports will be analysed independently by experienced investigators using predefined criteria and results published online. Clinical staff will not be blinded to the process and results will be analysed on a monthly basis using Run / Shewart charts.


Reporting of critical events by families should lead to an initial increase in reports followed by a reduction in the severity of harm through improvement measures. We will update clinical team members and family representatives in regular intervals and listen to their views knowing that front line clinical staff and patient families often have the best ideas of how to fix things. Future reporting systems should capture both family and staff reports leading ultimately to improved patient safety. This project could expand across other specialities if proven effective.


Critical incidents reports capture - by their very nature - sensitive areas of our daily clinical services and expose risks and errors. In order to tackle any problem we need to ‘see with thousand eyes’ and families who are already actively involved in their children’s hospital care can greatly help in this context. Once critical incidents are identified these can be resolved by staff education and training or by eliminating faulty equipment and refining error prone procedures. Our project aims to identify 25% more incidents than existing databases and should lead to improved partnership with families.

Effects of change:

The fear of ‘uncovering terrible things’ or ‘undermining clinical front line staff’ through family reports is difficult to overcome. Though a ‘blame free’ culture is officially established in the studied environment, pockets of resistance to change remain and we aim to address scepticism by providing evidence that our proposed project can work well in our setting.

Our ultimate goal is “zero preventable harm”. Future critical incident reporting could be web based allowing ‘real time’ monitoring of events and enabling rapid responses. This should lead to greater patient and staff satisfaction as the improvement results may become evident very quickly. Even if additional staff and financial resources may be necessary to achieve this, the savings may be enormous for our patients and hospital trust.

Lessons learnt: Adult patients who report poor clinical service quality - such as long waits and delays, poor coordination of care, unprofessional behaviour or lack of respect for patient needs and preferences - may also be at increased risk of experiencing adverse events and medical errors. Reporting of critical incidences by families does work in a children’s hospital setting as recently published. Establishing a supportive and ‘blame free’ environment appears crucial during the initial phase of this project as it touches a very sensitive area of healthcare.

Message for others:

We know it ‘takes guts’ to look our patients and their families in the eyes and ask about the problems they experienced while in hospital, because it can occasionally hurt our feelings and egos. But that is nothing in comparison to the unrecognised daily risks we are exposing our patients to. We strongly believe that we cannot change things for the better if we do not know what is really going wrong.

Patient Safety

13Casebook 2012

Project Title: Significant savings and improvement in the quality of care for patients can be achieved by adopting the model of the National Acute Medicine Programme (Ireland). Submission by: team member on behalf of the National Acute Medicine Programme.

Submitted by: Courtney G, O’Neill S, Keown AM, O’Reilly O, Walford S, Kearns B, Casey A, Enright A, Buckley C & Croke E.

Context: A multi-disciplinary approach involving doctors, nurses, allied health professionals, managers, radiology and laboratory staff was adopted for this project in 33 acute hospitals in Ireland.

Problem: In recent times patients entering the acute hospital service requiring urgent care reported long delays; waiting to be seen by a doctor, with delays in having diagnostic tests performed, to commence treatment and for allocation of a bed on the ward if required. This situation was unacceptable and exposed patients to unnecessary risk and the potential to experience an adverse event.

Assessment of problem:

The problem was quantified by the identification of the number of patients waiting to be seen on trolleys in the Emergency Departments, long delays in transfer to a bed in the ward and in diagnostic tests being performed.

Intervention: In December 2010, the Acute Medicine Programme (AMP) was launched as the leading initiative of the Clinical and Quality Care Directorate (HSE). The programme established a new model of service delivery and effectiveness for the benefit of patients. The AMP enables the appropriate streaming of acutely unwell medical patients away from Emergency Departments into Acute Medical Assessment Units (AMAU). The AMAUs are staffed by senior medical doctors and multidisciplinary teams. This facilitates rapid assessment and diagnosis. Patients are then streamed to; a medical short stay unit, a rapid access outpatient clinic or procedure clinic, discharged home or referred to an appropriate inpatient setting. This entire patient journey should be completed within 6 hours. The AMAUs benefit patients, GPs and front line Emergency Department staff offering more streamlined assessment and treatment options. The AMAU environment affords patients a more dignified and respectful clinical environment in which to receive care. The Acute Medicine Programme Model was introduced in acute hospitals, where patients can be seen by a senior doctor within one hour of arrival at the hospital completing their journey through the urgent care pathway in six hours or less. Increased efficiencies by changing work practices and processes with increased use of ambulatory care pathways will reduce overnight admissions and shorten lengths of stay resulting in significant reduction in bed days used.


A national team - the Acute Medicine Programme (AMP) team was set up with representation from doctors, nurses, allied health professionals, patient group linkages, general practitioners and managers. On each acute hospital site contact was maintained with multi-disciplinary teams. Information was disseminated to other clinical programmes through the National Director for Clinical Strategy and Programmes. Communications were sent to acute sites through the Regional Directors of Operations and Hospital CEO’s. Linkages were made and maintained with contacts in individual acute hospital sites. The Acute Medicine Programme (AMP) ran several workshops for nurses, hospital programme co-ordinators and managers, in conjunction with the Special Delivery Unit of the Department of Health to explain the operational detail of the programme and patient benefits. The AMP also set up an Acute Medicine Nurse Interest Group, an Operational Group for Therapists and the Irish Society of Acute Medicine (ISAM) for new acute physicians to disseminate the new ‘ways of working’ and to aid in the significant culture changes required to deliver the programme successfully. In January 2011 the programme began implementation through the structured delivery of both local and national solutions:1. Formation of local and regional clinical and project governance teams involving multidisciplinary leadership in each acute hospital site. 2. Testing and delivering proof of concept in relation to the AMP model. 3. Conducted comprehensive diagnostic gap analysis for each site undertaking AMP implementation. 4. Development of a nationally agreed, standardised methodology to determine the demand for medical assessment and medical bed capacity required in each hospital. 5. Determination of protocols and procedures for streaming of acute medical patients to the assessment unit within each hospital. 6. Provision of a designated assessment and a short stay unit of appropriate size. 7. Negotiation of consultant and nursing rosters and NCHD allocation to provide senior decision makers to assess patients. 8. Implementation of best practice guidelines to enable effective patient flow, improve discharge processes through bed management and the creation of navigation hubs. 9. Development of Fast Track OPD appointments, rapid access to diagnostics and ambulatory care pathways. 10. Performance improvement support through acute hospital site visits; revisits to review progress and provide advice. 11. Programme delivered improvement workshops, training and coaching. 12. Development and implementation of the National Early Warning Score (NEWS) for early detection and management of deteriorating patients. 13. Established Multidisciplinary professional advisory and working party groups. (Consultants, Nursing and Health and Social care professions). 14. Collaboration with Key Stakeholders e.g. Patient advocacy groups, ICGP and other clinical programmes. 15. Collaboration on development of Information technology project: ‘Urgent Care Information System (UCIS). 16. Allocation of 32 new Acute Physician Consultant posts. 17. Development of Acute Medicine Consultant training programme and 3rd level postgraduate nurse education programme.


A decrease in the number of medical patients on trolleys in Emergency Departments each day, by more than 50% in some hospitals. Almost 60,000 bed days saved (equivalent to €13m.). Eight Acute Medical Consultants positions filled nationally, 15 locums in place and 9 in the recruitment process. This ensures that there are senior doctors in place to assess, diagnose, treat, discharge or admit patients at the earliest time possible in the acute phase of their illness. Marked improvement in the Patient Experience Time (6 hour target) has improved in a number of hospitals.

Effects of change:

The AMP has delivered the most substantive transformational change in the provision of acute medical care to patients in a generation.Significantly improved patient experience with demonstrable change in work practice and culture in a large number of sites. Faster throughput of patients presenting at acute hospitals with acute medical illnesses, increased number of patients discharged home from hospital and shorter lengths of stay for medical in-patients, reduction in elective waiting lists and significant cost savings to the health service.

Lessons learnt: Clinical leadership and governance to support AMP implementation empowers both patients and staff. Encouraging local ownership and accountability through structured programme support is vital. Patients benefit from improved safety and quality of care (reduced trolley waits and length of stay). Resilience and commitment are required to embed and sustain the AMP.

Message for others:

The ‘voice of the patient’ has at all times been front and centre within the design and implementation of the Acute Medicine Programme and will continue to remain so. The programme is engaging with patient representative groups through an appointed patient liaison person in the patient advocacy unit in the HSE. The team aims to support the continuous quality improvement focus informed by patient feedback. Patients must be enabled to continuously influence and determine how acute medical care will be delivered in Ireland in the future. The programme proposes to facilitate a number of patient focus groups, with some additional funding. The desired outcome would be the development of a standardised audit and evaluation tool to enable ongoing patient feedback in relation to acute medical care in Ireland.

Systems

14 Casebook 2012

Project Title: Benefits of near patient ultrasound on the Acute Medical Unit: improving training to improve service delivery

Submitted by: Dachsel R, Powell N & Bruce C.

Context: This service improvement project was undertaken in an Acute Medical Unit (AMU) with 33 beds an 7 assessment trolleys in a busy district general hospital. This project was led by the Medical Registrar (year four), facilitated by consultant in AMU, Consultant Radiologists and Postgraduate Centre. Funding was obtained through Service Improvement for Teaching fund.

Problem: The awareness and application of bedside Ultrasound is having increasing importance in clinical practice. Current guidelines for insertion of central lines and insertion of chest drains require the use of ultrasound guidance which had been further recommended by a report from the National Patient Safety Agency (NPSA) in the UK. Assessment of trauma patients should include a Focussed Examination with Sonography in Trauma scan (FAST scan). There is good evidence that this initial scan can improve patient outcome. Speight and Sanders describe the use of FAST in blunt chest trauma and pericardial tamponade.

Otsuji and Stone describe the use of Echocardiography in the assessment of patients in shock. The exclusion of hydronephrosis in patients with acute kidney injuries and the exclusion of obstructive pyelonephritis are other important areas for ultrasound use in an emergency department. In patients with abdominal pain and signs of shock, an immediate ultrasound can help to exclude a leaking abdominal aortic aneurysm.

The AMU was not in possession of an Ultrasound device, so urgent investigations or drainage of pleural fluid could not be performed with likely negative effects for patients and increase in length of stay. The provision of near patient ultrasonography is likely to reduce bed days due to reduction of waiting for investigation and also likely to increase patients’ satisfaction.


Analysis was made of the patient journey prior to and after the introduction of near patient ultrasound testing on the AMU. Evaluation of waiting time and length of stay was made and cost savings projected. We audited delays of drain insertion over three weeks in this particular AMU and it was identified that through timely drain insertions alone with the availability of an ultrasound device, around 1 hospital bed day per week could be saved. Additional uses with the access to an ultrasound device would provide assessment of critical ill patients to exclude hydronephrosis or perform emergency Echocardiography. This would lead to direct patient improvement with quicker diagnosis and appropriate management plans.

Intervention: Using the opportunity to develop my leadership skills I enrolled in the KSS Deanery leadership programme. I then wrote a business case to apply for Service Improvement for Teaching (SIFT) monies for improving education for medical students. This business case was awarded the largest single amount ever given in our trust and allowed procurement of a portable VScan® hand-held ultrasound device at a reasonable cost. A teaching programme was designed for the dissemination of this skill in order to enable more clinicians to be able to use this device safely to high clinical standards.


In December 2011 the Service Improvement for Teaching (SIFT) money fund for the financial year 2011/2012 was not spent fully and the Board was looking for projects which would be beneficial for the education of undergraduates and doctors in training. I performed market research for a new handheld ultrasound device and found only one offer that fits the financial restraint given through General Electric Healthcare (GE Healthcare) with their Vscan®, a business plan was submitted detailing the projected savings due to reduction in bed days. Over the coming weeks, the teaching programme was developed alongside radiology colleagues. The VScan® arrived at the Acute Medical Unit in April 2012 and has been in use since with teaching sessions for doctors in training and students provided.


Within 3 months of using the Vscan®, 16 chest drains were inserted on the AMU, with projected savings of at least £14,960 per year based on reduced bed days and procedural costs, also reducing the workload for our radiology department. In addition, other bedside tests have been performed including ascitic fluid marking (7 studies), orientating echocardiograms (32 studies) and renal scans (18 studies). As an additional benefit it allows trainees the opportunity to develop their procedural skills.

Effects of change:

The development of physician led ultrasound undoubtedly has benefits for patients and the efficient working of an Acute Medical Unit but it’s use can be rewarding as a specialty skill for trainees. With further work I hope to develop a formal training course in Acute Medical ultrasound that may allow the ‘sign off’ of competencies for trainees of the future.

Lessons learnt: I have multiple learning points from this experience. Firstly, the importance of engagement with all key stakeholders from the beginning of the project to ensure enthusiasm and support. Secondly, to identify an existing gap of the service and to derive innovative changes to address these through an in depth assessment of the clinical and educational need of those who would be impacted from this project. Thirdly, that innovation takes longer than expected to be disseminated in the NHS. Fourthly a leadership project will need a lot of personal commitment. As a result of my busy working schedule, most of the elements of my project were done in my spare time over Christmas break and several weekends, however I believe it was time well spent.

Message for others:

An Ultrasound device for the Acute Medical Unit is a cost efficient, innovative intervention which improved service delivery and training for junior doctors. The initial needs assessment is due to the identification of a service gap as per national guidelines that detailed best practice.

Assessment / Trigger

Prize Winner*

15Casebook 2012

Project Title: The Golden Patient and Theatre Productivity

Submitted by: Farooq A & Qureshi I.

Context: The Golden Patient (GP) programme was introduced into the Trauma and Orthopaedic Department of our busy district general hospital in December 2012. It is a programme in which the first patient on the next day’s trauma list is: 1.) medically optimised for surgery and, 2.) reviewed by an anaesthetist, both of which are done the day before surgery.

Problem: The need for the GP programme followed an initial service evaluation study (October-December 2012) which benchmarked the trauma list start times and assessed whether trauma patients were being fully medically optimised prior to surgery. This first study showed that there was day-to-day variation in trauma list start times, a later trauma list start time as compared to other trauma centres in the local health economy and sub-optimal medical optimisation which delayed the patients being sent for theatre.


We undertook a first prospective service evaluation study between October and December in 2012 in which we investigated 35 trauma lists. The methodology involved two parts; 1.) benchmarking different time measurements of the patient’s journey to theatre (time patient sent for, anaesthetic time and time out of recovery), 2.) qualitative data which supplemented the benchmarked time measurements to explore the reasons behind any delay (a comprehensive surgical and medical check-list which itemised the causes of delay, and details of the anaesthetic review). This first study highlighted day-to-day variations in the trauma list start times, reasons behind the delay and sub-optimal medical optimisation.

Intervention: We introduced a specially designed proprietary GP Check-list in December 2012 and January 2013. This included a medical and a surgical check-list designed to ensure a 360 degree medical optimisation of the patient the day before surgery. The GP check-list was designed with input from trainees and senior surgeons which generated a sense of ownership of the GP programme and helped to spread awareness of the benefits of the programme.


We discussed the findings of the first service evaluation project at the Departmental Clinical Governance Meeting in December 2012. There was discussion between the Orthopaedic, Anaesthetic and Nursing departments about the results of the first study, the need for change and the adoption of the GP Check-List from December 2012 onwards as a practical solution and a real-time diagnostic tool.


• 35 trauma lists were analysed pre-GP (October-December 2012) and 35 trauma lists post-GP (December 2012 and January 2013). • The number of patients who had all items of the GP Checklist completed increased from 65% to 98%. • The mean time sent for theatre decreased from 08:43 to 8:20 (p<0.001). • The mean anaesthetic start time decreased from 09:17 to 08:58 (p<0.001). • 7 of the GP trauma lists accommodated an extra operation case.

Effects of change:

• Almost 100% of patients underwent a 360 degree medical optimisation the day before surgery• Patients were being sent for theatre earlier• More patients were operated on as a result of increased theatre time

Lessons learnt: The introduction of the GP to our trauma lists has made a significant improvement to theatre start times. This simple concept has the potential to increase the productivity of trauma centres and to increase theatre capacity.

Message for others:

We will strongly consider the use of the GP Checklist in improving the efficiency of our elective lists and share our experience with other surgical specialities and other Trusts within our regional health economy.

Com

munication / D

ocumentation

16 Casebook 2012

Project Title: Improving Patient Experience in the DVT Pathway, West Middlesex University Hospital

Submitted by: Ha J, Woodward-Stammers E, Skirrow H, Ryan O, Babb A, Burgess H.

Context: Whilst working as a member of the Acute Medical Unit a series of frustrations were noted amongst staff and patients alike regarding the patient pathway for DVT investigation and treatment. Stakeholders including healthcare professionals, patients and the Patient Affairs lead were consulted to determine the problems and devise solutions.

Problem: Through the undertaking of staff focus groups, patient interviews and working with patient affairs it was established that a recurring problem was a lack of patient information once commenced upon the pathway. These included incomplete understanding of disease, treatment, risks and benefits and logistical problems such as finding the Medical Day Unit where treatment is administered.


The intended outcome of the project was to address the deficiencies in the DVT pathway and to provide a holistic approach to improvement in patient experience. Furthermore, staff frustrations were explored with the intention of achieving a mutual benefit through provision of suitable information to patients. The overall aim was to achieve improvements in efficiency of the DVT pathway with management of patient expectation in a well-established process. To do this a patient information pack was designed to address the issues of logistical and medical information and lack thereof.

Intervention: First the demand for change was established through staff focus groups, patient interviews and discussion with the Patient Affairs lead. Stakeholders within the DVT pathway were consulted in addressing the main issues that arose.


It was decided that improved information was required regarding VTE, risks and treatment; particularly in the ambulatory care setting where access to healthcare professionals was not immediate. Furthermore, logistical difficulties in finding the Medical Day Unit were addressed through the inclusion of a clear map.


With the implementation of a qualitative intervention the main focus of measuring the change was through staff experience and the decrease in frustrations of patients that was noted. On-going work was established to carry out patient interviews who had followed the DVT pathway; their input being integral to the devising of the patient information pack. Further staff and patient survey was planned to facilitate on-going improvements in the process.

Effects of change:

Through liaison with the stakeholders of the VTE pathway it has been established that the improvement in patient experience is crucial to underpinning further changes to the process. Through determining the deficiencies and frustrations in the process the intervention was seen to be addressing these issues. With on-going work the revised Patient Information Pack will be incorporated into the pathway ensuring that all patients commenced on the DVT pathway will receive it. Furthermore, a further investigation into the pathway and experience will be carried out to update and improve the pack.

Lessons learnt: The project has underlined the importance of establishing and defining the problem in order to address it. Meaningful research and involvement of a wide range of stakeholders is needed in order to determine issues as well as methods to address them. Such pathways, which are common to many acute foundation trusts, should collaborate in the knowledge gained in order to standardise and improve the experience of patients.

Message for others:

Ensuring focus on patient experience and management of patient expectation has facilitated an improvement whilst the clinical aspect of management has remained largely unchanged. In view of the financial restraints faced by the NHS and the wider economy it would appear churlish to overlook these inexpensive and perhaps unglamorous changes to pathways that could results in an overall improvement of patient experience and satisfaction without compromise of patient safety.


17Casebook 2012

Project Title: ‘I See You’ A Baby to Parent Communication Website

Submitted by: Holt S, Guratsky V, Lee D, Ritchie G, Smith J, Hardwick N, Crombleholme N & Rackham O.

Context: A project to harness information technology and mimic popular social networking to allow parents and families to view their baby via a secure website during their stay on a neonatal unit.

Problem: Parents are encouraged to spend time with their infant during their stay on the neonatal unit. However, this can be challenging for a number of reasons. Tertiary neonatal units are often busy and some infants will be born and receive their initial care at a centre a long way from home. Some mothers are unwell following the birth of their child and may be in a distant hospital or simply unable to be moved to visit the NICU. Others will be unable to drive for six weeks following a caesarian section, which may make visiting difficult as they rely on partners and friends for transport. Onsite accommodation is provided for families but may be impractical for some with older siblings, those who act as carers or self-employed business people.

Additionally, visiting is very restricted to prevent the spread of infection and parents would not be allowed to visit if they themselves were unwell.

The psychological impact of having a preterm or extremely preterm infant cannot be underestimated. It has been shown that mothers of preterm infants are more likely to suffer with post-natal depression than mothers of healthy full-term infants. Current research is focusing on interventions aimed at supporting parents through improved information sharing, improved communication and alleviating stress. It is hypothesized that with better parent experience comes improved infant outcomes and a reduction in length of stay on the neonatal unit.


We are currently auditing the opinions of parents with infants on the unit and the members of the facebook group who are all former parents.

We audited the nursing staff for their opinion.

Intervention: The ‘I See You’ website is simple in design with low maintenance costs. The upload process is quick and easy with safety checks built in to ensure the correct information is uploaded to the correct patient. A protocol will provide guidance to nurses as to the frequency and content of the messages. When the patient leaves the unit, the data will be deleted so no information will be stored. Alternatively, the data will be copied to a disc to give to parents at their request. The website will not contain any clinical information nor will it replace the current means of communicating with parents.


The website is currently under construction with our local informatics department. Go live date is 01/03/13.

We have a core of 5 nurse champions who will help role out training to other nurses.

Initial funding has been secured from NHS Northwest to buy the internet security certificate for two years.


We will continue the same audit after the project has commenced.

Effects of change:

To be updated soon.

Lessons learnt: Parents, nurses, doctors and managers have shown massive support for this project. The next phase is to build an iPhone and android application to allow families access from handheld devices.

Message for others:

The Wirral University Teaching Hospital NHS Foundation Trust has core values including: ‘Patients are at the heart of everything we do.’ This business proposal hopes to use the latest technology to keep patients and their parents connected even when apart.

Com

munication / Inform

ation Technology

18 Casebook 2012

Project Title: Maximising the Value of Significant Event Reporting

Submitted by: Jenkins R.

Context: One Medicare is a primary care service provider operating registered GP practices and Primary Care walk in centres in the Midlands, Yorkshire and Humber regions. We have salaried GPs, Advanced Nurse Practitioners, practice nurses, HCA and administration and management staff and all were involved in the project. Our centres see around 100,000 walk in patients per annum and we have circa 35,000 registered patients attending our centres from various demographics and all centres were involved in the project. This means the project covered both registered GP practices and unscheduled and urgent primary care facilities and patients.

Problem: Significant Event Reporting has been used for many years in Primary Care to identify occurrences that could be improved and best practice shared. However, it is recognised that many events reported do not go on to reliable improvements and indeed, many outcomes of significant event reviews give actions based on the concepts of improved vigilance and hard work. It is also recognised that this is a flawed approach and human factors and human error research supports this. Vigilance and hard work is not a reliable improvement strategy.

We felt that we were not maximising the value of our reports and not offering our patients reliable improvement strategies to improve care quality and safety. It took time to undertake SER reviews and build the culture of safe reporting and to then waste information was clearly ineffectual and we decided this should be addressed. We also wanted reporting to be from everyone in the group, not just the clinical staff to improve our ability to get a holistic view.


One Medicare prides itself as a continual improvement organisation with strong integrated governance and our SER, complaints and compliments are recorded and tracked on a time line basis using information from all of our 9 centres. This allowed us to review trend analysis of the events and led us to recognise that we were not getting events reported by the non-clinical teams and the events we were receiving were not using human factors or reliability to get sustainable improvement outcomes. On reviewing our SER trends and outcomes it became apparent that we were also adopting the hard work and vigilance approach with SER outcome advice.

We send a monthly SER newsletter to all our staff and used that to begin to explore the reasons for this. We asked staff why they didn’t report and if they did whether they felt it was adding value. We then undertook visits to all centres and met with both the clinicians and the non-clinical teams to refresh the SER programme and seek feedback on how it could be improved. We aligned this with the Human Factors expertise in the Integrated Governance Committee and felt that the current SER form and reporting was not supporting our needs and should be refreshed.

Intervention: The planned change was to support all staff in the reporting of events and then subsequently in extracting the best reliable and sustainable change improvements on analysing and reflecting on the event with the teams.

The first intervention was to answer the concern raised by many of our staff that the form took too long to fill in and this was preventing them reporting as much as they might like. All staff felt the form was easily accessible on our Group Desktop intranet but that filling it in took too long. We went to our teams and asked for improvement ideas and with the support of our IT team designed an electronic tick box form with pre-determined sections meaning the staff could tick the relevant boxes rather than write the event in full. We discussed the risk of missing information but felt the volume of reports would outweigh this and in fact the tick boxes gave more information than many of the written forms which were restricted by time pressures. Those sections that did need narrative text we encouraged short bullet points. This went through several tests of change before being agreed by a selection of clinical and non-clinical testers.

The second intervention was designed to answer the problem of hard work and vigilance being the chosen outcome. We wanted to support staff in to thinking of human factors and those elements that are considered error and violation causing conditions. We based this on the London Protocol of Dr Vincent at Imperial.

Our first efforts used the James Reason 3 bucket model but the feedback on initial tests of change was this wasn’t sufficient for detail and staff actually found it confusing. We then tested further tick boxes utilising human factors elements aligned to the London Protocol. This gave staff the ability to quickly fill in a form and supported thinking into those contributing factors that are more likely to lead to reliable and sustainable change. This was aligned with short education sessions on human factors thinking. This second phase of the intervention was tested and met with much more success. Additional elements were added from reviews with patient safety colleagues both in the UK and internationally using IHI and other forums including Linked In groups to seek comments and advice.


Our strategy was based around 2 improvement concepts: Human Factors and The Model for Improvement. Human Factors is a strong feature in most high risk industries but historically not health care and offers the opportunity to consider the possible reasons contributing to human error and violation. We have found staff relate to this easily and using the human factors elements allows more constructive thought around how we might change the systems and processes plus the environment and other human factors to make improvements rather than expect staff to simply pay more attention and remember everything without making an error. It is clearly proven that human error happens: human factors can reduce that.

We also adopted the small test of change model for improvement. We had a champion and identified friends to support the testing and we had very rough and ready test phases of the form to allow quick testing without using considerable resource. Our test SER forms looked very basic, had no colour or excess content and was easily changed and reviewed without resource or upsetting someone who might have taken days designing a comprehensive, attractive looking form. Our tests were reviewed and changes made quickly allowing the new form to develop before being spread. We also utilised media and the internet to get reviews from experts outside of our own team to consolidate our tests which proved both successful and straight forward suing platforms such as Linked In and the IHI discussion area.


Much of our measurement was with rapid feedback from staff verbally and electronically via email. During the test phase we were seeking metrics on how the form felt to use, how long it took to complete and subjective opinions on whether staff would be more likely to use it. On-going metrics include the proportion of clinical to non-clinical reporting and any improvement in the non-clinical reporting rates. This data is not complete at the time of submission. We are tracking the type of events we are seeing reported allowing trend analysis and divisions include clinical care, confidentiality, staff conduct, etc. Longer term metrics will be on the success of the improvements made. At the time of submitting this it is too early to get clear metrics but the narrative and feedback from teams is positive and human factors discussions and new ways of approaching improvements are already evident.

Incident Reporting

19Casebook 2012

Project Title: Maximising the Value of Significant Event Reporting (continued)

Submitted by: Jenkins R.

Effects of change:

Strong qualitative evidence form the centres that they are starting to think differently about events and the chosen approaches to improve as a result of reviewing an event report.

As an example, when a clinician left a used needle in a visit bag the initial response was to remind them not to do that and a reminder of the infection and sharps policy. With the revised form the clinician was able to see how it made the team feel and the team understood that the clinician had to use a needle but didn’t know where to put it as there wasn’t a sharps box in the visit bag. Then they got back to surgery with the intention of disposing of it safely but were distracted and forgot. The usual response would not be reliable. The human factors solution after using the new form was to get as small sharps box for each visit bag: simple and sustainable.

This is being noted at all sites and by all members of the teams and very encouraging that the culture and mid set is starting to change to really think of the contributory factors and not just the error and violation.

Lessons learnt: The main lesson learnt is that all staff, both clinical and non-clinical can easily understand the concept of human factors and use those concepts to make better improvement plans following event reporting reviews.

We would strengthen our metrics earlier in the process if we did this again as we know internally it is working but currently struggle to demonstrate this externally although that should improve as the metric time line progresses.

Our plans have been led from the top with Director leadership from the Integrated Governance Committee and although that senior sponsorship is key we would make more effort to seek local leads next time in each centre.

Message for others:

Human factors are easy and they work. Health care is unusual as a high risk industry as we haven’t embraced them to date but combining them with our reporting systems has been a very positive experience.

Please feel free to copy, change and use our SER form in your own organisations.

Incident Reporting

20 Casebook 2012

Project Title: Introduction of Iliaco-Fascial Blocks to Improve Pre-Operative Pain Relief in Patients with Neck of Femur Fractures

Submitted by: Kalraiya A, Buddhdev P, Rokadiya S, Davies N & Basu D.

Context: Neck of femur (NOF) fractures are life threatening injuries, with approximately 80,000 fractures presenting in the United Kingdom every year costing the NHS approximately £2 billion. In 2011, approximately 350 patients with NOF fractures presented to the co-authors’ workplace, Watford General Hospital (WGH). A plethora of national guidelines advocating timely, multi-disciplinary care resulted in WGH creating an obligatory NOF pathway to ensure recommended standards are met. Furthermore, the Best Practice Tariff was introduced in 2010 to provide financial incentives to encourage NHS Trusts to improve the quality of care delivered to this vulnerable group of patients.

Problem: Preoperative pain relief is core to the pathway because elderly patients (>80 years) are susceptible to the adverse effects of opiates (Codeine, Tramadol, Morphine) such as constipation, delirium and respiratory depression. Additionally, a large percentage of such patients have a degree of dementia thus are often unable to proactively communicate their analgesia requirement to nurses. Unmanaged pain leads to poor patient care and distressed families.


It was felt WGH could offer a better experience of pain relief, leading the authors on a path to discovering iIiaco-fascial blocks which provide a novel technique for doctors of all grades to inject local anaesthetic into an anatomical space near the hip which blocks three nerves; the femoral nerve, obturator nerve and lateral cutaneous nerve of the thigh. It is easier, cheaper and safer than other methods, with pain control found to be significantly better compared to opioids.

Intervention: The aim of our service improvement project was to introduce the iliaco-fascial block for pain relief in NOF fracture patients in WGH. The impact of this intervention would be established by comparing visual analogue pain scores and opioid requirement by patients who received the block with those who did not.


We implemented the iliaco-fascial blocks by training all junior doctors on the Orthopaedic team how to administer the block. Nurses on the wards and in A+E were encouraged to remind doctors to give the blocks. We put up posters across the hospital to notify people of the proposed idea. We worked over a six month period during which time A&E and the wards increased their stock of local anaesthetic.


We prospectively studied 80 patients who presented to our hospital with acute NOF fractures. The first 46 patients received regular oral analgesia and oramorph 1-2 hourly as required, the subsequent 34 patients received an iliaco-fascial block on presentation to the emergency department and the same regular and PRN analgesia. Patients’ visual analogue pain scores were measured immediately pre-operatively and drug charts were reviewed to assess the frequency and dosing of PRN analgesia (Oramorph).

Effects of change:

The average age of our patients was 84.2 years (range 68-104 years). 62 patients (77.5%) were female. There was no difference in the time from presentation to surgery between the groups. The average consumption of Oramorph in the group receiving no iliaco-fascial block was 110 mg pre-operatively compared to just 20mg in the group who did receive iliaco-fascial blocks. There was also a statistically significant improvement in the visual analogue pain scores in the group receiving the blocks. Patient satisfaction was thus improved.

Lessons learnt: We learned that large scale improvements to the patient experience can occur with a simple intervention, however it is important to enthusiastically get buy-in from multiple stake holders and parties involved in order to get the idea off the ground.

Message for others:

The introduction of iIiaco-fascial blocks at WGH provided fantastic pre-operative pain relief for patients with acute NOF fractures and objectively improved their hospital experience. Furthermore, the introduction of our intervention not only reduced the anxiety experienced by visiting family members who may otherwise have seen their relatives in states of distress, but the reduction in Oramorph requests meant nurses had more time to concentrate on other critical aspects of patient care.

Medications / Prescribing

21Casebook 2012

Project Title: Antibiotic Prescribing in Surgical Patients at a District General Hospital: A Completed Audit Cycle

Submitted by: Kumar P & Stewart N.

Context: Antibiotics are among the most common medications prescribed in hospitals, not only contributing to rapidly rising rates of antimicrobial resistance but also placing a huge financial burden on trusts across the country.

Problem: Poor prescribing practices by doctors was common in the surgical department at Milton Keynes General Hospital. This adversely affected patient care by giving patients inappropriate or unnecessary antibiotics, possibly increasing the rate of adverse reaction and resistance. These practices also lead to a waste of resources, not only in terms of the cost of the medications, but also the cost in terms of nursing time and procedural equipment.


We audited the documentation and appropriateness of antibiotic prescriptions (parameters analysed: mode of delivery, indication, temperature, WBC & CRP at time of prescription and at audit) and adherence to antimicrobial trust policy. We assessed drug charts and notes of 102 (primary audit) and 98 (re-audit) patients.

Intervention: Our interventions included introducing an ‘antibiotic documentation stamp’ that was used by on-call junior doctors when starting newly-admitted patients on antibiotics. This encouraged all junior doctors to document the antibiotic, the indication and review date in the notes. We also produced screen-savers rolled out throughout the trust, and placed posters in doctors rooms in the relevant surgical wards.


We allowed 6 weeks in between implementing our interventions and re-auditing the data. Once our results were finalised, we feed these back to the surgical department and the junior surgical doctors via the local surgical audit meeting and the antibiotic stewardship meeting.


We carried out a re-audit once the interventions had been in place for 6 weeks. Improvements were seen in adherence to trust policy (30% → 69%), as well as the documentation in the notes of the antibiotics (42% → 56%) and indication (62% → 87%).

Effects of change:

Not only was patient safety improved but due to more appropriate use of antibiotics, £750 was saved when comparing the two cohorts. When extrapolated to all antibiotic prescriptions in the surgical department over a longer time period, this figure represents only the tip of the iceberg.

Lessons learnt: Junior doctors are responsible for their prescribing actions. Simple and cost-effective interventions can ensure that doctors prescribe antibiotics in a safer and more appropriate manner.

Message for others:

These simple interventions improved documentation of antibiotics and adherence to trust guidelines, thus leading to a decrease in inappropriate antibiotic use.

Such interventions are potentially applicable to other departments and hospitals and should be considered as a cost-effective strategy to decrease inappropriate antibiotic use whilst maintaining patient safety.


22 Casebook 2012

Project Title: Improving completion of the medicines reconciliation on admission to the acute surgical receiving unit in Ninewells Hospital Dundee.

Submitted by: Linden K, Falconer E & Gray J.

Context: This quality improvement project was completed in the acute surgical receiving unit (ARSU) in Ninewells Hospital, Dundee. Changes to the existing medicines reconciliation form were tested to see if rates of completion and accuracy of completion could be improved.

Problem: The Scottish Patient Safety Programme stated that there should be 95% accuracy in medicines reconciliation documentation. This target was not being achieved in Ninewells ASRU resulting in a risk to patient safety due to incorrect drug prescription during their time on the unit and on discharge.


We audited the medicines reconciliation forms of 19 patients admitted in one week to the ARSU to obtain baseline data for our project. Four areas were audited which were: 1. Completion rate of the medicines reconciliation form (95%) 2. Use of more than two sources to complete the medicines reconciliation form (58%). 3. Accuracy of drug prescription (77%). 4. Plans for drugs recorded (62%). We spoke to the lead pharmacist on the ARSU about what changes she felt were necessary to improve these figures. We also consulted the junior doctors and advanced nurse practitioners, who are responsible for completing the forms, on what changes to the form could help improve these figures.

Intervention: We made several small adjustments to the medicines reconciliation form which aimed to improve the rate of completion and accuracy of completion of the form.

1. We added a section at the top of the form where staff were prompted tick the sources of information they had used to complete the form and we added a reminder here that at least two sources should be used.

2. We added three tick boxes alongside the space for each drug’s name which prompted the user to document a plan either, stop, hold or continue. This was designed to encourage the documentation of a plan for drugs.

3. We added a section for recently discontinued medications and space to write any comments regarding these. This was aiming to improve the completeness of the information gathered regarding patients’ drugs.

4. We added a prompt for the staff member completing the form to sign it and leave a contact number. This aimed to increase accountability of staff for the documentation of the drugs and also to allow any questions regarding the patient’s medication later to be directed to the appropriate staff member.


We completed a small test where one modified form was given to one member of staff and the accuracy with which this was done was recorded. After this test of change we realized staff education on the changes to the form and the reasons behind them could improve its use so we implemented this change. We gave four forms to four members of staff and explained the changes we’d made and the reasons behind them at this point.


We completed two plan, do, study, act (PDSA) cycles in order to audit the result of the changes we’d made. The first of these helped us discover what additional changes could improve the rates further. The second cycle gave us our end results. In the first PDSA cycle we wanted to see if changing the layout of the medicines reconciliation form used in the ASRU would improve the accuracy with which it was completed. We also wanted to see if the use of two sources and the documentation of a plan for drugs would improve as a result of the changes. We tested the new form on one staff member found accuracy to be 0%, use of two sources 0% and documentation of a plan 100%. This result was obviously not the improvement we’d hoped for so we made some changes for the second cycle. In the second cycle we tested whether staff education with the distribution of the forms would improve the accuracy, use of sources and documentation of a plan for drugs. We tested the new form along with education on four staff members and found accuracy to be 100%, use of two sources 100% and documentation of a plan 50%. Two members of staff who tested the form were not qualified to prescribe and so could not document a plan. 100% of plans were documented by qualified staff.

Effects of change:

As a result of the changes we made to the medicines reconciliation form accompanied with staff education accuracy, completion rate and use of two sources to complete the form improved. This improvement has implications for patient safety on the ARSU. Good medicines reconciliation ensures that patients receive the right drug at the right time. It also ensures that patients continue to receive the right drug at the right time through transfers of care during their admission and on discharge. These events during the care of patient can pose a risk as good documentation is relied upon as a communication aid. If the improvements seen continue this will impact positively on patient safety on the ARSU in the future. The problems with the medicines reconciliation form on the ARSU were not completely rectified. The documentation of the plan for medications did not improve and this is an area for further work to focus on. We are hopeful that this will happen as we had positive feedback from staff regarding the changes made so far. We encountered some difficulties when implementing the changes. Some members of staff were resistant to change and needed more reassurance that the changes would not increase their workload and in fact could lessen it. Due to the high staff turnover on the ARSU education posed a problem as it was difficult to get them together for this. This happened in an opportunistic fashion which was not ideal. Lastly, the advanced nurse practitioners on the ARSU were unable to prescribe at the time of the project which affected the documentation of plans for medications. They will soon be receiving nurse prescriber training and so this problem should resolve following this.

Lessons learnt: This project highlighted the ongoing problems with completion and accuracy of the medicines reconciliation form on the ARSU. We learnt that simple changes in documents can make a big difference to the way they are completed. We also learnt the value of involving the individuals who the change you are trying to make will involve in your plans. We were able to make much better progress when we talked staff through our changes and made them aware of the impact the improvements could have on patients. If we were to do further wok in this area we would trial the form on a larger scale to really test its success. If it was successful we would aim to gain the approval of the departmental lead and spread the form throughout the unit. We would suggest that education of new foundation doctors on the ASRU should be given at start of rotation. Finally we feel that incorporating medicines reconciliation onto ward rounds could improve staff compliance rates greatly and we recommended that this be done.

Message for others:

Small changes in the medicines reconciliation form with staff education appeared to be appropriate and effective in a small scale test. The accuracy of the medicines reconciliation and use of two sources improved in this test. This will improve the delivery of the patients’ pre-admission regular medications while they are in hospital. Avoiding errors made in admission documentation can avoid errors being made during a patient’s stay and at transfers of care.


23Casebook 2012

Project Title: Promoting the use of evidence-based guidelines in the management of acute severe asthma: harnessing the power of social media

Submitted by: Mukherjee T, Bennett J, Agnihotri R, Clarke S & Green R.

Context: Glenfield Hospital is a tertiary centre for management of respiratory disease and receives many cases of acute severe asthma. This project has used social media (YouTube, Twitter and Facebook) to provide an innovative and low-cost approach to medical education of healthcare professionals and medical students in the management of asthma and ultimately improve patient care.

Problem: A recent audit of 58 healthcare professionals (including 42 junior doctors) across University Hospitals of Leicester (UHL) highlighted a lack of knowledge in the management of acute severe asthma.


Only 62% of staff were aware of the existence of UHL guidelines for the management of asthma and only 45% of staff actually used these guidelines. 67% of people felt comfortable grading the severity of acute asthma and when asked to classify a number of clinical scenarios, severity was correctly graded in 83% of the 5 clinical scenarios described. However, despite 79% of staff stating they were confident managing acute asthma, when objectively assessed on various aspects of asthma management, knowledge was in fact poor. In some cases only 25% were able to correctly answer true / false statements relating to asthma management, including indications for chest radiograph, use of oral steroids, nebuliser use, criteria for safe discharge, and target oxygen saturation. (See attached graph).

The disparity seen in the ability of junior staff to grade severity and the lack of knowledge in managing acute severe asthma illustrates the important of management guidelines in directing patient care. When questioned as to why the guidelines were not being used the most common reasons were the use of alternative clinical judgment or lack of time. This highlighted a need for an educational tool which was easily accessible, memorable and appealing to staff.

Intervention: The UHL Guidelines for the Management of Acute Asthma were completely re-designed using the British Thoracic Society guidelines as a reference but improving user friendliness. The use of flow charts, information boxes and checklists now allow staff to quickly and easily access important information to grade patients and initiate appropriate management. Since these guidelines provide the information staff need for immediate patient management, it is paramount that they are accessed and utilized, thus this project has focused on staff education and publicizing these new guidelines to ensure they are accessed regularly.


To gain popularity and awareness amongst the UHL community, the new guidelines were disseminated using social media. An innovative educational music video to improve the management of acute severe asthma was created. The guidelines were translated into memorable lyrics and sung over the music to a well-known popular music song. We filmed an accompanying humourous, yet educational video featuring consultants and multidisciplinary staff acting as patients, doctors and nurses. We designed a viral advertising campaign using a series of humorous trailers released via social media including YouTube, Facebook, Twitter, email and text messaging to build interest across UHL prior to release of the educational music video. The video was also taken up by the BBC, NICE, and Department of Health and publicized on their websites.


A different cohort of 55 UHL staff (43 doctors) participated in the repeat audit in June 2012. The results were compared with the pre-intervention audit, and analysed using Fisher’s exact test. Awareness and use of the asthma guidelines significantly improved, with 100% awareness following the release of the new guidelines and music video compared to 62% before (p<0.001). There was significant improvement in all aspects of asthma management knowledge (p<0.01). Areas of most significant improvement were the indications for a CXR and the target oxygen saturation range (p<0.0001).

Effects of change:

The project attracted interest from the Department of Health, NICE, and large multinational companies such as GSK. At one point it was within the top five most viewed news categories on the BBC National News. Hospitals around the UK adopted the video for use in teaching of junior staff in the management of Asthma. At Glenfield Hospital, 100% of staff who participated in the repeat audit were now aware of the New Asthma Guidelines.

Lessons learnt: Educational tools such as eLearning, lectures and induction meetings can be time-consuming. As our audit illustrated, in a time pressured NHS, they may not always be well received or effectively change existing clinical practice. In a financially pressured NHS, where important information needs to be disseminated both quickly and efficiently, alternative ideas need to be explored. The low-cost approach we have explored here should be considered by other Trusts once our re-audit data becomes available.

Message for others:

We encourage others to consider harnessing the power of social media and embracing innovative ideas to provide low-cost yet effective forms of communication and education.


Appendix: Page 38

Prize Winner*

24 Casebook 2012

Project Title: Improving the Availability of Patients’ Notes for Dental and Maxillofacial Surgery Outpatient Appointments

Submitted by: Neil M.

Context: Dental and Maxillofacial Surgery Outpatient Department at Great Ormond Street Hospital for Children.

Problem: Approximately 30% patients’ notes were found to be unavailable at the beginning of outpatient appointments in the Dental and Maxillofacial Surgery Department. This was causing issues such as delays, not only for the patients concerned, but also others on the same clinic. Absence of notes may, on occasion, lead to cancellation of the patient. An EQuIP Quality Improvement project was initiated and is currently in progress to improve the availability of patients’ notes for all Outpatient appointments in line with the Great Ormond Street Hospital’s Transformational goals of, “no waits, no waste and zero harm”.


The number of notes missing each day, reason for this and location is recorded. A Driver Diagram was used to identify influencing factors needed to be improved and what should be measured. As a result of this Medical Records staff were involved in the Quality Improvement Project. PDSA (“Plan, Do, Study, Act”) cycles have been completed during which meetings were arranged with the relevant staff from Medical Records. This was to discuss the project and problems involved and to establish solutions to ensure better availability such as improved access to the Dental and Maxillofacial Surgery Department for Medical Records staff and labelling of tracking locations within the department for clarity.

Intervention: With joint cooperation from the Dental and Maxillofacial Surgery Department and Medical Records the following improvements have been introduced:

• Notes arrive by 4pm the day before Dental and Maxillofacial Surgery appointments.• Improved communication from Medical Records regarding difficulties and timing involved in locating notes.• Appropriate escalation method for notes which can not be located.• The number of notes missing and the reason for this is recorded each day.


A SMART aim was developed and this was to improve the availability of patients’ notes to 90% (i.e. only 10% unavailable) within a 3 month period of pursuing this Quality Improvement Project. PDSA (“Plan, Do, Study, Act”) cycles have been completed to review changes made with regular meetings with Medical Records staff.


The SMART aim which was to improve the availability of patients’ notes to 90% (i.e. only 10% unavailable) within a 3 month period of pursuing this Quality Improvement Project has been achieved.

Effects of change:

The availability of notes is to continuously be monitored, to ensure this high standard is maintained. A further PDSA cycle with another meeting with Medical Records is in progress and to be completed this month.

Lessons learnt: This project illustrates that to introduce long lasting change multiple PDSA cycles with continual monitoring is effective. It also demonstrated the impact of a Driver Diagram which helped identify the need to include Medical Records staff in the Quality Improvement project. A SMART aim gave the project focus.

The project has also highlighted hospital wide issues including the importance of tracking the location of notes correctly.

Message for others:

To ensure enduring change multiple PDSA cycles with continual monitoring and team work involving everyone involved is effective.

Com

munication / D

ocumentation / Record Keeping

25Casebook 2012

Project Title: Empowering Prescribers in the Quest to Reduce Errors

Submitted by: Piper K.

Context: Koala Ward at Great Ormond Street Hospital (GOSH) for Children, London, serves the neuroscience specialities (acute neurology, epilepsy surgery, neurosurgery, craniofacial and ophthalmology). There are 24 beds and an average of 532 bed days per month. Medication for in-patients is usually prescribed by the ‘junior doctors’ i.e. those at ST3-8 level, comprising mainly of 16 doctors from the neurology team. Electronic prescribing (EP) has been used in this hospital for 6 years. Drug and fluid infusions are prescribed separately on paper charts. On average 469 items are prescribed on EP per week for patients on Koala Ward. The ward pharmacist and nurses note down any prescribing errors detected, and seek adjustments from the doctor from the relevant medical team. Every 6 months, as happens nationally, a new group of doctors start in March and September. Doctors receive one hour of induction training on how to use the Electronic Prescribing (EP) system.

Problem: “To Err is Human” and it is well recognised that medication errors occur every day in The NHS and remain a risk to patient safety. A study by the GMC in 2009 found 9% of all hospital prescriptions contain errors. The majority of these are noticed by the pharmacist or nurse before reaching the patient, however, the potential exists for significant harm. Different commercially available EP systems can be purchased by an NHS Trust, and each can contain varying functions. The system currently in use at GOSH is not linked to a formulary, and does not verify doses or have maximum dose limit warnings. Prescribers must identify the correct hospital prescribing policies or use the British National Formulary for Children (BNFC) to calculate the correct dose. Studies have shown that EP can reduce errors compared to handwritten charts, particularly those due to “unclear, illegal, and incomplete orders”. However EP can introduce additional systems errors and appear complicated to the unfamiliar user. Drug errors have the potential to cause significant harm, even death, to a patient. The 3 drugs which were most likely to be inaccurately prescribed on Koala ward were morphine, paracetamol and amikacin, which can cause respiratory depression, liver and renal toxicity in overdose. As well as the physical effects, parents are often very upset when told their child has been the subject of a drug error, and it erodes their trust in the healthcare team.


On Koala Ward, from June- September 2012, there were an average of 4.2 prescription errors per week, recorded on paper ‘log sheets’, kept in the drug room. Analysis of the errors recorded showed that similar errors were frequently repeated by the same or different prescribers, confirming our suspicion that there did not appear to be group learning. Senior nurses on the ward have described this as frustrating, and commented that the prescribers appeared ‘disengaged’ from the effort to help reduce errors. Patient safety is a key priority for GOSH Trust, with ‘Zero Harm’ remaining one of its strategic objectives. Each clinical unit is responsible for demonstrating a reduction in medication prescribing errors, with an annual target of 25% reduction in errors for all drugs, and 100% reduction for high risk medications. An initiative aiming to reduce prescribing errors was already underway in the neurosciences department. When the prescriber committed two errors, an email was sent to the prescriber and supervising consultant to prompt a discussion of the error through a learning tool. However, this method had proved ineffective at reducing the error rate. Furthermore, feedback from prescribers and supervisors demonstrated issues with perception (undermining), lack of group learning and blame culture. During the project, the following reasons were identified by the group of neurology junior doctors, in liaison with nursing staff and the pharmacist, as causes of EP error:

• selecting the wrong patient or drug • miscalculating the dose or using an inaccurate weight• typing mistakes, which can cause 10x or more of the intended dose to be prescribed• misinterpreting the information in the BNF/ formulary• duplications of doses, particularly if the child received antibiotics in theatre and doses/ timings were not communicated to ward

doctors• changing route of administration without altering dose• certain unique functions of electronic prescribing e.g. using the PO/IV/PR route.

Some of these errors may be due to rushing or carelessness, and more common if distracted by a busy environment, or by multi-tasking. Other errors may be due to lack of knowledge of local prescribing guidelines, or poor communication between medical specialities. The training on EP at induction is generic and not specific to Koala ward. There was little ongoing education on prescribing. Lack of knowledge of the electronic system meant some doctors mistakenly believed EP checked doses to avoid overdosing. The previous feedback system (individually via email to prescriber and their supervisor), was assessed by survey to both junior doctors and consultants. Feedback was often delayed by weeks, and the supervisors felt they often did not have enough EP training to help their junior. There was no group learning so repeat mistakes were common and the prescriber felt overly criticised so it affected morale. Nurses were discouraged from reporting errors by not seeing any benefits.

Intervention: The change focussed on a different method of feedback of errors, combined with education of all prescribers and non-prescribers i.e. engagement of the whole team, rather than individuals. A weekly discussion of all prescribing errors reported on Koala Ward has been held by the junior neurology doctors. An investigative, non-blame approach is used to help establish underlying causes of error. This discussion generates a ‘message of the week’ which is emailed to all prescribers, senior nurses and key improvement personnel. The project is dynamic and evolving, and when new sources of error are identified, strategies are put in place. Leadership for the meeting rotates amongst the neurology registrars, and all junior doctors engage in the process. Parents have been consulted and now the ‘message of the week’ appears on a ward message board. Strategies for reducing errors, which have occurred as a direct result of this project are: induction training has been enhanced by writing neurology/ neurosurgery specific case scenarios to test/ teach all the significant EP errors so far identified and alert new users to limitations of the software. The doctors organised an extra teaching session by a trainer on advanced use of EP, and enhanced their prescribing area with printed guidelines e.g. the antibiotic policy. Several potential safeguards within the EP system have been identified, such as warnings when maximum doses are exceeded, or linkage to the BNFC. The relevant managers have been alerted to the benefit of incorporating these safeguards into an upgraded EP version.


The project leader received training on improvement methodology in October 2012 through EQUIP, and made contact with the neurosciences and pharmacy improvement managers. Records of the previous EP errors were obtained from the ward pharmacist. The project was supported by the neurology consultant who leads the ‘pastoral care’ of the junior doctors, and already met weekly with the neurology juniors every Wednesday morning for 40 minutes. The discussion of prescribing errors was integrated into this meeting, which the project leader (a neurology registrar) was already attending. The ward pharmacist and neurosciences improvement managers were both happy to also attend this meeting to aid the discussion. The first discussion was held on 10th October 2012. A ‘message of the week’ was communicated via email and also written on a message board on the ward. Any new strategies for improvement occurred in real time, such as organising extra EP teaching, or pinning up posters with prescribing guidelines, and these would be mentioned in the weekly email.

Medications / Prescribing / Patient Safety

26 Casebook 2012

Project Title: Empowering Prescribers in the Quest to Reduce Errors (continued)

Submitted by: Piper K.


The project was presented at both the Medicines Management Meeting and Neurosciences Modernisation Meeting in November, and to the Hospital Management Board in December 2012. There was approval from all these bodies. On January 16th 2013, the reported prescribing errors were analysed, 14 weeks into the project. The manager of Datix provided the EP error data, and an analyst completed the necessary statistical tests. Questionnaires were sent out in mid-January to junior doctors, consultant supervisors and lead nurses on Koala Ward, to obtain feedback on the project from those directly involved. The results are presented below, and shall be fed back to the multi-disciplinary team in a presentation in February 2013.


Our objectives were to engage all the junior neurology doctors in the prescription error discussions, achieve additional learning about EP, encourage prescribers to be more aware of potential errors and take greater care, and make fewer errors as a result. In addition, we aimed to receive positive feedback and engagement across the team. These outcome measures were assessed using three separate structured computerised questionnaires, emailed to junior neurology doctors, consultants and senior nurses respectively. Results were pooled to make individual answers anonymous, encouraging honesty. 13 of 15 (87%) neurology juniors returned the questionnaire. 100% agreed with the statements: “I learnt new things about prescribing on EP” and “this has made me more careful when prescribing”. 92% thought “the messages were relevant” and 73% felt they made fewer errors because of the weekly discussions (27% neutral). 85% felt the messages of the week helped them avoid making errors. All junior doctors engaged with the project. 80% of consultants reported that they learnt something new about EP and agreed that the messages helped the team avoid making prescribing errors. 100% of junior doctors and consultants preferred the current method of feeding back errors and 89% felt it was more effective at reducing errors (11% unsure). Repeat errors were significantly reduced. Nurses reported that the project had an overall positive effect on morale and there was a greater confidence that reported errors would be acted upon.

Process measures were: the number of different causes of EP error identified, how many ‘messages of the week’ were generated, and number of specific interventions put in place to reduce the likelihood of repeat errors. Balancing measures were: the time taken for the weekly discussions and time needed by the project leader to implement improvements. Ten separate causes of EP error were identified and twelve messages generated. Six specific interventions were put in place e.g. extra teaching session, induction improvements, guidelines posted. Time taken for discussions averaged ten minutes per week, plus one hour for the project leader to implement improvements. The average number of EP errors per week were recorded over the 14 weeks of the project, with an objective of reducing the weekly average from 4.2 to 2.1 errors, by 16 January 2013. The results showed that compared to the 12 weeks before the project started, the number of reported errors changed from a weekly average of 4.2 to 3.4, a 19% reduction (p= 0.41). However, the start of this project coincided with a management decision to record all errors on the computerised Datix system, abolishing the paper log sheets. There were efforts to educate staff on how to use Datix and improve completeness of error reporting, therefore the weekly rate of reported errors was affected by variables other than this improvement project. On the questionnaires, 63% of respondents agreed they were more likely to report an error on Datix, so a greater fall in weekly errors may have been seen if the reporting method had not been changed during this project.

Effects of change:

The project was successful in engaging prescribers in efforts to analyse causes of errors, and provide interventions to reduce them. As reported above, 73% of the neurology junior doctors felt they made fewer errors because of the weekly discussions and 85% felt the messages of the week helped them avoid making errors. Although this did not lead to a statistically significant reduction in reported errors on the ward, this was possibly because of a change in the reporting method, and efforts to improve completeness of reporting. During the period of this project, no serious errors (those which could cause temporary/ permanent harm to the patient) were repeated, showing group learning from previous incidents. This is significant for the patients, because any serious error can cause physical harm, discomfort, emotional upset and prolonged hospital stay. Morale amongst junior doctors had been affected by the previous feedback system, who found it “undermining” and contributing to blame culture in the department. By empowering the prescribers to tackle the causes of prescribing errors themselves, improved morale was reported, amongst doctors and other staff on the ward. The greatest problem encountered for this project was the change in method of recording errors from log sheets to Datix, soon after the project began. This affected the most objective outcome measure, rate of reported errors, so that it is unclear what happened to the true rate of errors on the ward. Otherwise, there was no opposition to the project or the changes we implemented.

Lessons learnt: We learnt that junior doctors are uniquely placed to understand the reasons behind their own prescribing errors and are willing to engage with this process, if a ‘blame culture’ is eliminated and positive learning environment is fostered. Empowering prescribers to work towards safer prescribing practices increases awareness of errors and promotes careful prescribing. A multi-disciplinary, collaborative approach is beneficial and working together as a team towards a joint goal is rewarding. Nurse morale on the ward can be improved when doctors listen to their concerns and make improvements. This project showed that a very simple intervention, which had no additional cost implications and minimal time commitment, could produce a beneficial change. Thorough induction training and ongoing education of prescribers is crucial in reducing error rates. This project was made possible by careful planning, enthusiasm to get it right and liaison with key personnel. It was a definite advantage to have the project recognised through EQUIP, and the additional training and support from improvement personnel was invaluable. A collaborative approach between doctor colleagues ensured group buy-in to the project, and all were willing to take part. We were supported by consultants, managers, a statistical analyst, Datix manager and, crucially, our ward pharmacist, who will take this project forwards and ensure sustainability. Next time, I would present my project to the Medicines Management Board whilst it is still in the planning stage, rather than after starting the intervention. Then I would have realised their plan to change the method of error reporting partway through my project, and used a different target objective. I also learnt that many problems in the NHS cannot be fixed quickly. Further improvement work is planned in another EQUIP project, to examine the prescribing interface between theatres and the wards, as a direct result of issues uncovered by this project.

Message for others:

Prescribing errors risk causing harm to patients, and it is the responsibility of all health professionals who provide care to patients, to help in efforts to reduce the likelihood of errors occurring. The causes behind mistakes are multi-factorial and prescribers themselves are uniquely placed to investigate why errors occur. Empowering prescribers to initiate changes in a timely manner can reduce serious and repeat errors. By creating a non-blame culture, where patient safety is promoted, prescribers are willing to engage in efforts to improve prescribing practices, and this can improve morale for junior doctors, and for the multi-disciplinary team.

Medications / Prescribing / Patient Safety

Prize Winner*

27Casebook 2012

Project Title: Reducing readmissions and re-attendances to Emergency department due to physiological jaundice in newborns under a week of life

Submitted by: Ponnusamy V, Williams D & D’Amore A.

Context: This project was done as a part of Addenbrookes’ Chief Resident Project in Women and Children’s directorate in Cambridge University Hospitals NHS Foundation trust. The project involved a multiprofessional team of community and hospital midwives, medical and nursing staff from the neonatal unit and paediatrics. This was supported by Cambridge Judge Business School.

Problem: Up to 60% of newborns have jaundice within the first week of life. Significant jaundice necessitates readmission to hospital and very high levels if not treated are harmful. NICE produced guidance on neonatal jaundice in May 2010 recommending checking bilirubin levels and not relying on visual inspection alone. This led to increased numbers of babies with jaundice attending the Emergency Department (ED) and increased numbers of readmissions within the first week of life. We aimed to address these reattendances and the rising readmissions to the children’s wards.


Our data on readmissions for babies under 1 week of life showed that the proportion admitted with jaundice increased from 50% (2009) to 84% (2011) (Table 1) Most readmissions occurred in term breastfed babies and the length of stay increased for those infants discharged early after birth.

Transcutaneous bilirubinometers (TCB’s) enable the measurement of jaundice but due to limited availability within ED all babies had to be referred to hospital for a bilirubin measurement. We identified that if Community Midwives had TCB’s this screening measurement could be done at home thereby decreasing referrals into ED.

To highlight the importance of establishing early breastfeeding in jaundice prevention we wrote a business case for nursery nurses on the postnatal wards to facilitate and improve breastfeeding. This could avoid readmissions and decrease length of stay leading to cost improvements.

Intervention: TCB’s were obtained in May 2012 through charity funding. Community midwifes were trained in the use of TCB’s and guidelines developed to help use of TCB’s in the community. Due to financial constraints, we were unable to pursue the business case for nursery nurses. Alternatively, we have developed a video through charity funding (Addenbrookes Charitable Trust) to educate parents about physiological jaundice and breast feeding and we are currently in the process of uploading it to hospital website to make it readily accessible. This will be used to show to parents before discharge from postnatal ward.


We wrote and disseminated a guideline for the use of TCBs and produced an integrated care pathway and allowed adequate time for training. We audited the number of readmissions and attendances to the ED pre and post the intervention. The results from the project was presented locally within the trust and regionally in perinatal networks.


We collected data on reattendances to ED, readmissions and the financial implications for both. Finances were calculated based on the trusts’ tariff for the total cost incurred. Post TCB’s use, the number of attendances to the Emergency Department over 1 month fell from 40 to 16, reducing the PCT billing from £16,916 to £1,744. The average monthly number of days of readmissions fell from 26 to 22, reducing the billing from £14,495 to £7,931 (Table 2).

Effects of change:

Use of TCB’s in the community reduced the reattendance rates to ED, but did not significantly affect the rates of readmission. Audiovisual media was aimed to promote awareness on jaundice and improve breast feeding support. Further analysis post implementation of the AV media is needed.

Lessons learnt: This project was headed by a senior trainee doctor in the role of Chief Resident, alongside her main stream work. There were practical difficulties of writing a strong business case, the challenges of working with and implementing changes across multi-professional teams, understanding finances, regulations in making AV media within the NHS, perseverance and time needed for a service improvement project.

Message for others:

To institute any change local ways of working have to be studied. Improvements must be based on the local set up. Usually multiple interventions are needed to make a change in large organisations. It is important to persevere and adapt to changing circumstances and to focus on all possible ways when trying to implement change within the NHS.

Table 1: Readmissions of infants < 28 days of life

Table 2: Re-attendances and readmissions: pre and post TCB use

TCBs-Transcutaneous bilirubinometers; ED-Emergency Department; PCT-Primary Care Trust

Education & Training / Equipm

ent

June - Sep 2009 Sep - Dec 2010 Aug - Nov 2011

Numbers of readmissions of infants <28 days of age N / A 72 82

Number of readmissions for babies < 1 week of discharge 26 42 / 72 (58%) 73/ 82 (89%)

Proportion readmitted for ‘jaundice, poor feeding or weight loss with jaundice’ 13/26 (50%) 28 /42 (66%) 62/73 (84%)

Pre TCBs

01/12-03/12Monthly average PCT billing

Post TCBs introduction06 / 2012

PCT billing

Time in months 3 months 1

Re-attendances to ED 122 40.6 £16,916 16 £1,744

Readmissions 28 9.3 8

Days of admission 78 26 £14,495 22 £7,931

28 Casebook 2012

Project Title: Improving VTE Assessment Rates in Elective and Emergency Gynaecology Patients

Submitted by: Prentice J & Miller S.

Context: We undertook a prospective Audit Project within the Gynaecology Department of Milton Keynes General Hospital. Observation identified that a significant proportion of elective and acute Gynaecology patients were not being assessed for risk of thrombo-embolic events (VTE) despite local and NICE guidance stipulating that 100% of patients should be assessed at admission. If proven, poor VTE assessment potentially posed important risks to patient safety; over 25,000 people in England die per year from hospital contracted VTE much of which is preventable.

Problem: To quantify the problem we undertook an initial prospective audit in the Surgical Assessment Unit and Ambulatory Care Unit where MKGH emergency and elective patients are based. The initial audit proforma gathered information on the number of patients who were assessed and given thromboprophylaxis over a two week period. Results demonstrated only 6.6% of admissions were receiving VTE assessment; a serious risk to patient morbidity and mortality.


We presented the initial findings at the Trust Audit Half Day. Consultants were surprised at our findings and automatically felt further action was needed.

Intervention: The disappointing results of the initial audit were felt to be largely a result of lack of awareness amongst Doctors, despite the efforts of Nursing staff to get them to assess their patients. The first part of our intervention therefore consisted of regular VTE education for all Doctors rotating to Gynaecology. Copies of the VTE proforma and its importance were included in Gynaecology induction booklets and the audit results were presented to staff, alerting them to the patient safety issue. The second part of our intervention focused on policy change. We collaborated closely with the Matrons and Trust Co-ordination and Improvement group (CIG) and were able to implement the policy that 100% of surgical patients should have a VTE assessment completed before being allowed to enter theatres; We therefore anticipate our policy has resulted in improvements throughout the surgical directorate.


Consultant support gave us confidence to escalate the initial audit results to the Matrons who then discussed the concerns at CIG. Consequently we were able to implement our proposed junior doctor education and policy changes. Our timetable for change was limited by the availability of slots to present the audit findings and the process of adding them to the CIG discussion agenda. Following discussion however, all Doctors, Ward and Theatre Nursing staff were quickly made aware of the new assessment policy verbally and via email.


To measure the effect of our education and policy changes, we completed a re-audit one year later. Our results (Graph 1) demonstrated that our combined education and policy interventions had led to significant improvement in VTE assessment rates; 100% of elective patients were risk assessed compared to 6.6% one year earlier. Interestingly our re-audit also highlighted that although there was significantly increased awareness of initial VTE assessment, the 24 hour reassessment rates within the department were only 44% whereas NICE stipulate that VTE risk should be reassessed within 24 hours of admission or whenever the clinical situation changes [1]. Consequently our re-audit also demonstrated scope for further improvements to be made.

Effects of change:

The education and policy interventions enforced mean that Elective VTE assessment rates are now 100%, in line with NICE Guidelines1. As a result of our intervention patient safety with regard to VTE assessment is now a priority for staff within the department. Consequently, patients will receive appropriate prophylaxis reducing their risk of morbidity and mortality as a result of thromboembolism.

Lessons learnt: This project demonstrated that simple, well thought out audits can lead to improvements in patient safety and that doctors at a junior level can make important improvements to patient care.

Message for others:

Our audit’s success has given us motivation and confidence to continue audit practice to provide evidence to help drive these improvements; Junior Doctors can and should act as agents for change within the NHS. Our main frustration was the time taken for change, and only through excellent Consultant and Matron support were we able to effectively implement policy changes; Junior Doctors should have therefore have confidence in their project results and feel able to approach more senior colleagues with them.

Assessment / Trigger

29Casebook 2012

Project Title: Lets Actually Use the Computer! Using the Model For Improvement to Better Manage Microbiology Results in an Acute Service.

Submitted by: Prosser-Snelling E, Churchman I, French K, Raje G, Cameron M & Sule M.

Context: Set at the Norfolk and Norwich University Hospital. 6000 deliveries a year, busy emergency Gynaecology service. Medical/Nursing/IT staff project. On the emergency gynaecology ward many patients have vaginal swabs taken for chlamydia, gonorrhoea or culture and sensitivities. Some of these patients are in early pregnancy, some have acute abdominal pain. The sequelae of untreated chlamydial infection can include infertility, pelvic inflammatory disease and intraabdominal adhesion formation. In pregnant women, the identification of group b streptococcus is important, as it is an indication for intravenous antibiotics during labour, with the aim of preventing GBS sepsis in the neonate.

Problem: A critical incident occurred when a patient who had been seen as an emergency was subsequently followed up in Gyanecology outpatients three months later. At the outpatient appointment her test results were reviewed and she was found to have a positive Chlamydia swab result taken at the time or her emergency attendance, which had not been checked or followed up and she had not received appropriate treatment.


To check that this problem was being reproduced, we followed the last ten days of patients moving through our service, and identified that 60% of them had not had their microbiology tests recorded for follow up at all. We consulted key stakeholders on the ward, and mapped out the process for results being taken, checked and reported to the patient. The group consisted of a consultant gynaecologist, the ward matron, two SHO doctors, a member of the IT project team and a registrar. We defined the scope of the project to be limited to the emergency gynaecology ward. Initially we planned to only look at ensuring that results were logged and checked, and then to develop the system to report results back to patients. We decided that the parameter we would measure for improvement would be the percentage of results filed and communicated to patients. This would be done on a daily basis and plotted on an SPC chart. ( We later revised this to a more useful data set ). Our process map identified the “Swab Book” as being the unsafe step in our process. (See process map). These books were untidy, frequently inaccessible and often lost or restarted with no record. They did not identify who was responsible for reporting the test to the patient.

Intervention: We created a driver diagram which outlined our PDSA cycles. Initially it was suggested to send all results through the secretaries, but it was made very clear that there was not enough resource to do this. The first change was to use the electronic pathology (ICE) system to check for swabs taken on a particular day. The second change was to record using an electronic signature who has checked the result, and is therefore responsible. This is indefinitely, retrospectively auditable. The third cycle was to check that results were being communicated to patients.


We outlined an approach which we feel reduced reliance on vulnerable human factors. We used an educational approach, with forcing steps and a supervision and feedback process. We presented our initial results of our audit, and the critical incident at a local clinical governance meeting attended by all levels of staff. SHOs to be using the system were given dedicated IT training, and support in using the system. The consultant in charge fed back to SHO’s who were not reporting results as requested. We tested the system on a small scale on one day, then extended to three days. After this we removed the old system - the swab book - and went to the completely electronic system. Our forcing measure was to make the pathology system flag up old results that had not been filed that were generated from the ward. We aimed to introduce the whole system over a one month period.


By simply using the computer we ensured that 100% of results were recorded, as all requests were made electronically there was a digital footprint to follow. This directly solved our initial problem. The challenge was to make sure these results were actioned in a timely fashion, and not left over for other members of staff. We created a run chart, which recorded the number of results reported to the patient minus the number of results reported by the lab. Theoretically every day should be zero, because the numbers should cancel each other out. The chart is useful ( see attached ) because numbers below zero indicate results not being sent to patients, and numbers above indicating a “catch-up” effect. We looked at the factors affecting these days to identify what constituted a “bad” day and what a “good” day. We can also cross-check against the SHO rota and provide targeted feedback and information gathering from individuals about what went wrong on a particular day. We looked at our first 25 days following the introduction. We identified the presence of special cause variation and are currently trying to determine its exact cause. We suspect that highly abnormal activity levels on the unit (bank holiday), missed training by SHOs or lost/forgotten passwords may be responsible. This is one day out of 25, otherwise our process appears to be in control. Our balancing measure was number of missed results - we did not want this to increase.

Effects of change:

We achieved our primary goal of making sure results taken on the ward were checked. We immediately improved the number of results checked from 60% to 100% and sustained this over 25 days. We are on our way to achieving our secondary goal of ensuring that results are communicated to patients in a timely way. We are now working towards sustaining that improvement, by formally incorporating our changes into departmental guidelines for managing results. Patients are now more protected against missed results. We are still trying to standardise the reporting of results to patients. We will have more detailed analysis data, as well as the results from our future PDSA cycles.

Lessons learnt: Junior doctors are more willing and able to use IT systems than many consultants, this should be used to the patients advantage! Involvement of all stakeholders early on, as well as the key one’s with authority, makes a project run smoothly.

Message for others:

Try to make your IT system work for you as it is. We suspect that talking to the IT professionals involved was a key step in our success - they really were very helpful! Be very clear about what you are measuring, and make sure that improving it is going to have a useful effect. It took us a long time to work out exactly what to measure.

Appendix: Page 38

Results/Investigations

30 Casebook 2012

Project Title: The Quality of Gentamicin Prescribing and Therapeutic Drug Monitoring at Royal Liverpool University Hospital Trust

Submitted by: C Rice, E Hoyle, E Hughes, E Nsutebu, A Neary, K Barnett, K Vaudrey & J Folb.

Context: A two-week prospective audit of new gentamicin prescriptions on non-admission wards within large inner city hospital (Royal Liverpool University Hospital Trust) was carried out in October 2011 and was pioneered by two Foundation Year 1 doctors, in association with hospital antibiotic pharmacists and a microbiology consultant. Gentamicin has a narrow therapeutic index and is known to cause nephrotoxicity and ototoxicity. Aminoglycosides reliably covers 90% of gram negative blood culture isolates locally, consequently gentamicin is heavily relied upon despite its narrow therapeutic index.

Problem: The authors noticed that the hospital policy on gentamicin prescribing was complicated and difficult to follow especially in acute situations. The authors approached members of the Antibiotic Management Group with a patient safety concern regarding gentamicin prescribing. Poor gentamicin prescribing was identified as an on-going issue leading to sub-therapeutic effect or toxicity in patients.


The audit assessed the accuracy and appropriateness of prescribing and therapeutic drug monitoring of gentamicin prescriptions according to the hospital antibiotic policy. New prescriptions were identified by ward pharmacists, medical and nursing staff and by regularly reviewing inpatient paper drug charts and electronic prescriptions.

Dosing accuracy was assessed by calculating the appropriate dose, according to Trust policy i.e. 5mg/kg based on Ideal Body Weight (IBW) or Obese Dosing Weight (ODW). Appropriate dose divided by the dose prescribed formed the ‘dosing index’. A 10% margin of error each way was considered appropriate.

It was found that the majority of patients were prescribed gentamicin for prophylaxis during catheter manipulation (23/38 patients), for which no hospital policy existed and dosing was variable. Of the remaining patients, the majority (94%) of prescriptions were indicated according to the hospital Policy, however not a single dose was prescribed, monitored and/or repeated appropriately, according to hospital policy. For the 10 patients (12 prescriptions) with sufficient data, 50% of prescriptions were overdoses, 33.3% were under-doses, and 16.6% were accurate according to the hospital policy (see graph in appendix). Dosing according to actual body weight accounted for two-thirds of overdoses. Of the six patients receiving more than one dose, four had inappropriately short dosing intervals, increasing the risk of toxicity. One patient had accurate therapeutic drug monitoring.

Intervention: The following interventions have been implemented:

1. An online gentamicin dose calculator tool, based on the current hospital policy, has been introduced which recommends a dose and an appropriate dosing interval. This had to be designed and thoroughly tested; eventually approval was gained from the medical devices department, the Medical Director and the hospital Trust Board.

2. A formal policy for prophylaxis during catheter manipulation has been introduced following consultation with the urology, orthopaedics and vascular surgery departments.

3. All indications for gentamicin in the hospital antibiotic policy were reviewed and several have been removed. 4. Electronic prompts on the electronic prescribing program, now installed throughout the hospital, were introduced to alert clinicians

and nurses not to exceed the maximum recommended dose, to check for previous stat doses, and to avoid repeat doses within 24 hours.


The results of this audit and the implementation of its recommendations were given the highest patient safety priority rating of red and were escalated to the Trust Board. The Antibiotic Management Group took responsibility for implementing the interventions for improvement. The audit was presented at the hospital Grand Round and has been specifically included in the Foundation teaching program for junior doctors. Although the timetable for change has been pushed back somewhat, all interventions have been in place for at least 6 months and we are now completing the audit cycle to assess their effectiveness.


A re-audit of new gentamicin prescriptions, including medical and surgical admissions wards, is currently being undertaken at the hospital. The same outcome measures are being used as in the initial audit with the additional data required to validate the dose calculator tool.

Effects of change:

Interim results from the re-audit show that of 23 patients, 4 received doses for catheter manipulation, a significant reduction, 10 of the remaining patients had sufficient data to calculate dosing, 4 were dosed appropriately, 2 were under doses and 4 were overdosed. We noted a transient increased awareness of Trust Policy on gentamicin prescribing amongst junior medical staff most likely due to the Hawthorne Effect. Awareness of gentamicin prescribing, therapeutic drug monitoring and the dose calculator tool are being assessed by end-user surveys to help us assess and improve our interventions. There has also been increased vigilance for potentially toxic dosing intervals on the daily microbiology Acute Medical Admissions Unit antibiotic ward round. As a consequence of the audit, gentamicin prescribing will continue to be under the scrutiny of the Trust Board as a major patient safety concern.

Lessons learnt: Discussing issues directly with the policy makers can lead to effective change in practice. The most accurate policy is useless if it cannot be utilized within the context of a busy ward. We are in the process of surveying the end-users to assess the effectiveness of the dose calculator tool and determine what if anything can be improved.

Message for others:

Addressing areas where service could be improved with the directorate or policy-makers can help improve outcomes for patients throughout the hospital. Policies should be accessible and designed with the end-user in mind to improve compliance and patient safety.

Medications/ Prescribing

Appendix: Page 39

31Casebook 2012

Project Title: Improving Orthopaedic Post Take Ward Round Dictations.

Submitted by: Robinson P, Baker R & Livingstone J.

Context: Trauma & Orthopaedic Department, Bristol Royal Infirmary, University Hospitals Bristol NHS Foundation Trust. Post Take Ward Round (PTWR) dictations are consultant led, with secretarial typing and filing. Typed dictations are used by junior doctor and nursing staff as a crucial guide to the history and initial management plan. PTWR notes are also sent to GPs informing them of the admission, injury and management plan. Additionally typed dictations are useful for coding individual patient events, crucial for hospital funding. Both the Royal College of Surgeons and Physicians publish guidelines outlining good practice for medical record keeping.

Problem: It was noted that dictated PTWR notes were variable in terms of layout, content and filing position in the notes. It often took several days for a dictation to by typed and filed. There was not always a hand written entry in the patient notes. This was of particular concern because until the typed dictation arrived there was no record of the PTWR to stipulate the management plan for each patient.


The initial audit was performed to quantify the extent of the problem. All inpatient orthopaedic medical notes (n=75) were examined on 2 orthopaedic wards daily over a 2 week period in January 2009. The presence of a dictated note was recorded (only in 49% of notes). Each dictation was analysed for:

1. Presence and accuracy of patient details, date, name of dictating surgeon (all 100%).2. Clear diagnosis stated (92%).3. Comorbidities stated (65%, of which only 50% under a clear separate heading).4. Clear management plan stated (97%, of which only 56% under clear separate heading).5. Accompanying written entry in patient records (57%).6. Dictated note filed in chronological order (14%).

The main concerns identified were absence of a dictated note in over half the cases, very low percentage of an accompanying written note, inconsistent filing of notes and variability of note contents.

Intervention: The initial audit was presented at the departmental audit meeting. The issues were discussed with consultants, juniors, secretarial and ward staff. Department guidelines were drawn up suggesting a standard template for each dictated note clearly stating under separate headings: 1. Diagnosis 2. Comorbidities 3. Management Plan.

Each dictation should be on separate purple sheets of paper, allowing clear identification. Additionally it was agreed all dictations should be prioritised for the same day typing and filing, which should be in the ‘letters’ section of the notes. It was agreed that the junior doctor present should also record a hand written entry at the time of dictation to ensure a clear plan until the dictation was typed and filed. All consultants were consulted prior to dissemination of the guidelines.


A sample letter was sent to all consultants and secretaries suggesting the standardised layout and content. Posters were placed above all note trolleys on the wards as an aid memoire. All this information was also disseminated at each junior doctor at the departmental induction. A time scale of 11 months was left before the re-audit, enough time to allow several changes of junior staff, thus any improvements seen could be assumed to be ingrained in the department.


A similar re-audit was performed in November 2011 over a 2 week period, again assessing all inpatient orthopaedic notes daily (n=53) over a 2 week period. The improvements were as follows: Presence of a dictated PTWR note - 72% vs 49% (before). 100% on purple paper, with 82% filed correctly (vs 19% before). Dictation content:

1. Clear diagnosis stated (100% vs 92%).3. Comorbidities stated (85% vs 65%).4. Comorbidities stated under separate heading (73% vs 50%).5. Clear management plan stated (100% vs 97%).6. Plan under separate heading (82% vs 56%).7. Accompanying written entry in patient records (97% vs 57%).

Effects of change:

Our results show very good overall improvement and standardisation. Of note the presence of a typed dictated PTWR note had increased and these were easy to find. The content was clear, with particular emphasis on the key points of diagnosis, comorbidities and management plan. Of particular note was the improvement in the presence of a hand written accompanying entry. This audit did not measure the effect of this intervention on patient care directly, however by improving departmental adherence to good clinical practice guidelines regarding good record keeping a positive effect would be expected regarding patient care and in particular to minimising risk. The problems encountered with implementing change here mainly revolved around influencing and changing long standing individual practices of dictation and note content.

Lessons learnt: The key lesson learnt here was the importance of engaging the entire department in approving change.

Message for others:

When implementing any change, by involving those affected in the decision making process we found we could achieve a high level of compliance with our new guidelines.

By taking time to analyse patient notes, and particularly here the dictated orthopaedic PTWR notes we realised how poorly entries can be documented, this emphasised how important good note taking is to guide safe practice and appropriate patient care. With fairly minimal intervention it is easy to greatly improve matters and maintain change to guide good clinical care.

Com

munication / D

ocumentation

32 Casebook 2012

Project Title: Improving heart attack care: A bottom up approach to improve administration of pain relief

Submitted by: Shaw J, Jones G, Virdi G, Moore F, Whitbread M, Thomson N & Donohoe R.

Context: The London Ambulance Service NHS Trust (LAS) is the UKs busiest emergency ambulance service. It is also the only London-wide NHS Trust and is committed to developing and improving the service provided to the large, ethnically diverse population of London. The LAS is composed of 70 different ambulance stations and split into three areas (East, South and West) consisting of 26 complexes.

Cardiovascular disease (CVD) is the most common cause of death in the UK, with patients often presenting to the ambulance service with a heart attack. Of the one million patients the LAS attend each year, approximately 3,000 patients are experiencing a heart attack. Early treatment for these patients can prevent death and influence the patients’ future health. As a result, CVD is a priority area for pre-hospital quality improvement, involving 3,500 pre-hospital clinicians in developing their care provision.

Problem: The assessment and management of pain is a recognised area in need of improvement for ambulance services nationally and is especially important for heart attack patients where analgesia provision can have additional benefits in reducing cardiac demand.


Findings from an initial retrospective clinical audit identified pain management as a considerable area of concern for the LAS: two pain scores were recorded for 84% of patients, and only 49% of eligible patients received analgesia. Root cause analysis was used to determine the cause for poor administration of pain relief and pre-hospital clinicians’ perceived barriers to effective pain management. The barriers included: clinician belief regarding patients’ pain or patients’ inability to communicate pain due to language barriers, lack of availability of a pain assessment tool, and confusion regarding analgesia administration.

Intervention: Focussing quality improvement initiatives on pain assessment and pain relief for heart attack patients, LAS clinicians developed a pain scoring and management tool. ‘Plan Do Study Act’ (PDSA) audit cycles were used to trial the tool in the pre-hospital setting with subsequent alterations made following each cycle before 5000 copies of the final version were printed and disseminated to every pre-hospital clinician in the Service. A training session was designed for use at ambulance stations and LAS training schools. This was supported by a poster and a heart attack audio podcast for the LAS intranet. Clinicians also developed a flowchart for heart attack care, highlighting the importance of pre-hospital pain management. Throughout the project the LAS raised awareness of the importance of pain management for heart attack patients through several newsletters and unique 3D poster boards highlighting project progress and compliance. A champion at each station spread awareness to colleagues locally and articles in the service-wide ‘Clinical Update’ publication ensured pre-hospital clinicians were aware of best clinical practice and progress of the project.


A paramedic was recruited in January 2011 working one day a week to identify and implement changes to clinical care. A small group of volunteers formed a support group for the paramedic and took part in several workshops which involved process mapping to determine areas for improvement. Several quality improvement initiatives were developed aiming to improve care specifically in pain assessment and management. This group was supported by the LAS Clinical Audit Leads, and relevant members of the LAS Medical Directorate. The improvement project was launched at the host complex in September 2011. The launch involved the same root cause analysis and process mapping exercises used previously, training sessions and raised awareness of the need for improvement. Following the launch, each initiative was distributed to staff at the host complex. Much like the pyramid scheme, a volunteer champion was recruited from the majority of the remaining 25 complexes across London. The champions spread quality improvement initiatives at their own complexes and distributed interventions, such as the pain assessment tool. Some complexes also developed their own quality improvement ideas locally. To ensure the project was supported Service-wide, awareness of the project was raised with the Senior Management Teams through presentations to the Trust Board and senior level committees.


End of project findings from February 2012 demonstrated great improvement in LAS clinical practice for heart attack patients. Two pain scores were recorded for 84% of patients, and 85% of eligible patients received pharmacological pain relief. This shows a 36% improvement in analgesia administration. Additional initiatives have been identified to further improve clinical practice across the LAS; ensuring improvements continue and are sustained. The project has also been shortlisted for a Clinical Audit for Improvement award (2013).

Effects of change:

There were many challenges in ensuring that successful initiatives were spread across the whole of London. Developing the initiatives often took time and the project was often seen to lose momentum to those not involved on a regular basis. Everyone involved in the project was expected to participate in their own time and a lack of funding meant that there was a need for creativity with the initiatives by using left over equipment to create the 3D poster boards and negotiation to gain sponsorship to print the 5000 pain tools. The ground work for the project was time consuming and as demand on the Service increased planned meetings and training sessions were often postponed. However, despite this it was rewarding to see patient care improve across the whole of London.

Lessons learnt: There is a real enthusiasm in the Service for improvement and the ‘bottom up’ approach was a huge success as staff felt ownership of the initiatives. Offering training is a great incentive to getting staff involved in such projects, especially in an organisation where when demand increases training can often be cancelled. Developing and implementing such significant changes takes a considerable amount of time. It is important patient care is monitored throughout to ensure the change has achieved its objective.

Message for others:

Even with a minimal budget it is still possible to make substantial improvements to patient care. It is important to ensure care is reviewed continuously and to listen to the staff who will be providing the care.


33Casebook 2012

Project Title: The ‘Black Hole’ for ECGs

Submitted by: Smith C, Curry F, Robinson S & Bodagh I.

Context: Data was collected at Southampton General Hospital from the Emergency Department, Acute Medical and Surgical Units & Elderly Care and Surgical wards. This Quality improvement and Patient Safety project was completed by Foundation Doctors, supervised by an Elderly Care consultant. There was subsequent involvement from Trust Management to aid implementation of interventions. Key members of the Multi-Disciplinary Team (MDT) were involved to ensure widespread dissemination of results.

Problem: ECG’s are an integral component of a medical clerking on admission to hospital. Admission ECG’s assist in forming a differential diagnosis, contribute to immediate management decisions and are frequently referred back to. Our clinical team noted that following transfer to a ward admission ECG’s were not easily locatable within a patient’s notes. It was recognised by the audit team that many ECG’s therefore require repeating which wastes time, energy and resources for staff and patients. Furthermore, this can become a patient safety concern when a change in clinical situation occurs, for example a patient develops chest pain, and a repeat ECG cannot be compared to the admission ECG because it has been lost in a ‘Black Hole’ between admission and transfer to the ward.


The audit team quantified the problem by recording whether patients had an ECG on admission, and if those same ECGs were available in the patient notes once they had transferred to the wards. Non probability, convenience and quota sampling were used. This data was initially collected from the Acute Medical Unit (AMU), n= 60, and again from medical wards post transfer, following the ECG on their journey through the hospital. To ensure continuity when collecting the data, the audit team member marked the ECG they saw in AMU, to ensure that we were following the same ECG up to the ward. Results illustrated 35% of ECG’s seen by the audit team on AMU vanished by the time the patient had been transferred to the ward.

Intervention: Our first stage intervention following this initial audit was multi-modal education across the MDT to highlight the problem and the implications. Through this we increased awareness of the ‘Black Hole’ for ECG’s and encouraged timely and accurate filing. Additionally we produced a poster and a sticker to put onto the ECG machines as a reminder of the need for immediate filing. We subsequently audited other departments (Surgical Assessment Unit (SAU), Emergency Department, n=60 per department) to get a more global view of ECG record keeping and documentation across the hospital.


1. Education: Presentation of the initial audit results to the acute admissions department and the ward based departments separately, to increase awareness and promote accurate filing and documentation. Discussion of implication of results with members of the MDT (nursing/HCA/ward clerks) who are integral in performing and filing ECG’s. These meetings took place over a course of two months, the main rate limiting step was setting up meetings with the appropriate staff to present the findings and suggest future change. The results were also published via the SUHT audit database which can be accessed trust wide. 2. Further data collection: Audit of surgical department, following patient’s ECGs that are recorded on the SAU and then transferred onto surgical wards. Audit of the Emergency Department, recording proportion of patients who have an ECG on admission to hospital (pre AMU/SAU) and their documentation. 3. Increasing awareness: Production of an awareness poster and a sticker to place on the ECG machine.


The initial audits in medicine and surgery indicate there was decrease in the percentage of ECGs found in the notes on the ward compared to on admission. Around one third of ECGs were lost in transit between AMU/SAU and their respective wards. A re-audit of the medical department was completed four months post first stage intervention, illustrating a 12% reduction in missing ECG’s on the wards. The audit data from the Emergency Department highlighted a potential second stage intervention of our Quality Improvement project. Whether the paper copy of the original ECG taken in the ED was available in the patients notes on AMU or SAU was irrelevant, as every ECG taken in the Emergency Department is scanned onto file and is available electronically - e-ECGS! This would provide the clinician with an initial admission ECG that is available for comparison during further inpatient care, and indeed if the patient returns to hospital on a separate admission, increasing patient safety and quality of care, as well as time efficiency. Implementation 2: Design and implementation of a business plan for introduction e-ECG’s trust wide. The audit team have discussed this change with service improvement management and IT to implement an electronic ECG system across the trust. Further planning and gaining funding for this phase is in progress once in situ (estimated to take 4-6 months) a final re-audit will be completed to close the audit loop.

Effects of change:

Preventing ECG’s from going missing will lead to better patient care and improved patient safety alongside a reduction in loss of valuable staff time and resources. The multidisciplinary team were happy to comply with this project as it served to solve a common annoyance. The first intervention of education reduced the size of the ‘Black Hole’ of ECGs, but did not close it altogether. Therefore the implementation of e-ECGs is underway within the service improvement management and the IT department, to further reduce the loss of ECG’s, and ultimately improve patient care.

Lessons learnt: Heads of department are keen to be involved with quality improvement projects, especially those involving patient safety as an issue. Foundation doctors are well placed to identify gaps in the provision of service to patients and to implement change where necessary, as they have first-hand experience of problems encountered on the ward. It is important to include all clinical areas that are affected by a problem when commencing data collection, to strengthen data and provide a more accurate representation of the impact of a problem within the trust. Allowing fluidity of quality improvement project design, allows new data to shape your project and reach better outcomes for patient safety and improvement of quality of care.

Message for others:

Listening to our clinical team working on the shop floor identified a large gap in record keeping and documentation of ECGs. Discussing our concerns with our MDT on the wards indicated this was a common problem that needed improving. Multi-modal education is effective, but is time consuming and takes time to set up. This can be supported by emails and publishing audit data for staff within the trust to access. Broadening our patient group data (surgery and ED), provided us with our next step intervention with the aim of improving statistics further.

% ECG on admission % ECG documented in clerking proforma % ECG located on ward post transfer % ECG located on ward post education

Acute Medicine Unit 92 90 65 77

Surgical Assessment Unit 45 <1 71 -

Emergency Department 68 18 100 -

Record Keeping

34 Casebook 2012

Project Title: Introducing non-medical prescribing and an inter-disciplinary Prescribing Governance Framework for all Prescribers in a Substance Misuse Team.

Submitted by: Turner S, Roberts H & Andrews A.

Context: The project brief was to implement non-medical prescribing (NMP) within a substance misuse treatment service in order to increase flexibility of resources for delivery of care. To do this effectively all prescribers needed to work together.

Problem: Doctors and Nurses had different prescribing governance structures. To improve access to services in a rural area. To maintain, develop and audit quality evidence based prescribing and improve medicines optimisation.


Need for accessible high quality prescribing resources across a wide rural area.

Intervention: • A Project Lead and Project Manager.• Inter-disciplinary engagement.• Stakeholder mapping and engagement.• Project plan.• Development and implementation of a Governance Framework for all Prescribers in the service, linked to the NPC Competency

Framework for all Prescribers.• A lean approach to the project (e.g. no additional meetings!) PRINCE lite!


• An internet-based information hub for all prescribers in the service• A new MEDS INFO resource for all prescribers, giving quick access to key information• Education slots in existing meetings• A presentation at a large CPD session, the theme being quality• The proposed development of quarterly action learning workshops, with a long-term plan to run these as interprofessional sessions• Specific interprofessional CPD sessions• Audits looking at the views of service users on prescribing, performed before and to be carried out 6 months after the launch of NMP.


• Prescribing audits (various levels)• Service User audit pre- and post- live• Review of incidents and near misses

Effects of change:

• Inter-disciplinary Prescribing Governance Framework ratified and in operation.• NMP went live without a hitch.• Initial service user audit positive.

Lessons learnt: • Dedicated resources, and a structured plan, are needed help develop non medical prescribing (NMP) effectively on a large scale across organisations

• Projects such as this benefit from being approached as interdisciplinary ‘prescribing’ projects rather than NMP projects• The use of change management techniques helps identify and remove barriers and increases stakeholder engagement• Robust overarching governance arrangements underpin the success of large scale implementation of NMP• The introduction of NMP creates an opportunity to develop sustainable educational resources and strengthen interdisciplinary working

Message for others:

Integrated high quality prescribing resources are much needed and will improve the patients experience, reduce risks and can save money.

Nurses, Pharmacists, Doctors and AHPs need to work together on this; use the NPC Prescribing Competency Framework for all Prescribers, and link up on governance and on education / CPD whenever appropriate.


35Casebook 2012

Project Title: Improved medication safety by reducing interruptions during medication and structured antibiotic prescribing

Submitted by: Venkataraman D & Venkatesh M.

Context: Background: Prevention of drug errors is a government priority as well as a clinical necessity. The neonatal intensive care environment is recognized to be particularly high risk environment for the occurrence of medication errors, and interruptions are common in intensive care environment. Interruption affect staff cognitively, interfering with their working memory, causing lack of focus, invoking feelings of frustration and stress and can directly/indirectly lead to medication errors. Paediatrics and Neonates, unlike other specialities have a 24 hour prescribing policy, whereby medications can be prescribed throughout the 24 hour clock, which often leads to missed doses and reduced efficiency of drug administration. Project area: Tertiary level Neonatal Unit, Princess Anne Hospital, employing over 160 staff, with a turnover of 800 intensive care admissions per year

Problem: 1. Observed 180 drug preparation and administration cycles: types and patterns of interruptions identified. 50% of drug cycles were interrupted, and on average 0-9 interruptions per drug preparation cycle were observed. 2. A variety of factors lead to interruptions including culture. 3.Antibiotics were precribed throughout the 24 hours clock, with no structure to the process, leading to missed doses/ drug errors/ reduced efficiency


The in-depth analysis of medication errors over 3 years pertaining to neonatal unit provided the information regarding trends and common drugs involved: The drug error rates had remained unchanged over the last 3 years. Moreover, few drugs were responsible for majority of drug errors and focussing educational strategies around these drugs would be very useful. High levels (50%)of inetrruptions during medication process. The key causes of interruptions were: 1. Staff related interruption (22%), Interruption by parents: (5%). 2. Equipment and Information related interruption (20%) 3. Interruptions due to search for keys to drug cupboards (13%). 4. Telephone related interruptions: (5%). 5. Interruptions related to patient status( alarms/ patient deterioration) ( 27%): these were value add interruptions

Intervention: Telephone related interruptions were reduced by introducing streamlined communication by Nov 2011: ie Parents provided with direct numbers to specific areas, use of alternative systems of communication(Vocera), and clarifying pathways so that the right person is contacted. Key related interruptions were tackled by introduction of digital key safes in the common area (Nov 2011) as well as intensive care areas (Feb 2012) in neonatal unit, leading to 0 interruptions as a result of keys. Visual colour coding system introduced for storage of equipment and medications. Layout of the wards was changed to set out clear medication areas and administration areas. Lean principles of 5S were used to make medication areas organised, leading to reduced interruptions. Interruptions due to Staff: Drug tabards were successfully introduced into the neonatal unit In January 2012, following initial buy in and engagement with staff regarding the benefits of Tabards. Structured Antibiotic Prescription: In order to reduce missed doses and remove prescribing during nursing handovers and Midnight (00:00/ 24:00hrs), and odd hour prescribing was introduced following agreement via key stakeholders. This was successfully introduced in January 2012, with improved structure to medication administration and reduced missed doses


Telephone/ key/ equipment related interruption need to be tackled initially before tabard introduction, as work and environmental factors were responsible for 46% of interruptions. Introduction of regular monthly teaching sessions using simulation/ drug based discussions to raise awareness of interruptions: strategy to bring about culture change and obtain buy-in from key stakeholders( ie Doctors/ Nurses/ Other staff/ Pharmacy/ parents). Carefully plan an approach for introduction of each intervention/ change with regular meetings/ updates/ engagement and allocation of responsibility/ accountability. Information dissemination was done via dedicated meetings, teaching sessions, departmental seminars and use of Audio-visual systems within unit. Carefully identify specific measures which will help to demonstrate an improvement/ change in practise for each intervention, and use of PDSA cycles to assess improvement.


Initially 180 drug cycles were measured to identify interruption rates and the type of interruptions, using a custom made interruption counter. This formed a baseline for future measurements. Drug errors over 3 years was analysed to identify trends and patterns. Excel Pivot charts and Minitab was used for statistical analysis and production of SPC. A. Telephone interruption rates were measured by the type and quantity of calls over 4 days before and after intervention. B. Key interruption rates were measured before and after introduction of digital key safes. Motion charting was conducted to identify time spent in motion looking for keys before/ after intervention. C. Tabard: The interruption rates after tabard introduction was compared with those before to identify change/ improvement. D. Activity follows( RTTC): Minute by Minute activity charting was done at the start of project to identify the time spent in Direct clinical cares/ motion/ medication/ administration/ breaks/ discussion/ personal hygeine. Overall 96 hours of activity follow was done before/after introduction of change.This was re-measured after introduction of change, and showed a 6% increase in Direct clinical care and 3% reduction in medication management time. Data was entered in Excel and pivot tables/ Minitab was used for statistical analysis

Effects of change:

Following above changes, 20 drug cycles were observed with ‘0’ interruptions in all of the above areas. A 64% reduction in telephone calls (reduction of 1850 calls per month!). Activity follows totalling 98 hours of 6 nurses before and after introduction of change showed an efficiency improvement of 6% with release of time towards patient care, with 3% reduction in medicine management time, and overall 45 minutes of release of nursing time to direct patient per nurse per shift (Equivalent to employing 5 additional nurses!). The project ultimately benefits patients due to better and higher quality nursing care and reduced medication errors.

Lessons learnt: 1. A good understanding of systems/ processes is required to understand the key issues before change can be introduced. In our project it was essential to consider work and environmental factors( Telephone/ keys/ layout) and improve these before introducing tabards. If tabards had been introduced initially( without changing the issues related to high call volumes/ key interruptions etc), they would not have been successful in reducing interruptions. This needed careful understanding of systems. 2. Engagement and key stakeholder buy-in is essential to bring about improvements. 3. Sustainability aspects need to considered right from the start of the project.

Message for others:

1. Responsibility charting should be used at key stages of change to ensure clear roles and responsibilities. 2. Project aims and objectives were cleraly acheived via careful strategic planning of the project. 3. The project ultimately benefits patients due to better and higher quality nursing care and reduced medication errors.


36 Casebook 2012

Project Title: Post-Operative Antibiotic Prescribing in Orthopaedic Surgery

Submitted by: Wickenden S & Leighton P.

Context: Trauma and orthopaedic department of a large teaching hospital

Problem: It had been noticed by on-call SHOs in trauma and orthopaedics that several calls overnight are regarding perioperative antibiotics and yet there is a clear hospital guideline on this subject.

In several cases the nurse receiving the patient from recovery had noticed the antibiotics were mentioned in the operation note but not prescribed. They then call the on-call SHO to prescribe the antibiotics before they can give them. This can lead to a delay in administration of the antibiotics.


As a group of two SHOs we carried out an audit to assess this problem. We collected data on post-operative orthopaedic patients and assessed:

A) Antibiotic regime requiredB) Whether this was written on the operation note and ,C) The drug chartD) The person prescribing the antibiotics on the drug chartE) The delay, if any, in the patient actually receiving the antibiotic

We found 81% of patients recevied antibiotics and met our standard but only 48% doses were given correctly and nearly 1 in 5 doses are missed entirely.

Intervention: We presented our findings at the departmental audit meeting and highlighted the problem to our seniors. They decided it was ultimately the operating consultant’s responsibility but conceded that practically it was often an SHO who prescribed. Therefore this information needed to be handed over to new juniors each time they rotated through the department.


We updated the handover booklet in time for the next 4 monthly changeover of juniors. We included information on peri-operative antibiotic prescribing and recommended this was done pre-operatively where possible.

The consultant in charge was also made aware so that reference could be made to antibiotic prescribing during his formal departmental induction talk.


We repeated our audit following the departmental presentation to seniors and changeover of juniors. We found an improved rate of antibiotic prescribing and administration (81% to 95%) after our intervention.

Effects of change:

Our secondary analysis demonstrated a fewer delayed doses and missed doses. This meant we had reduced the problem we initially set out to solve. This directly improved patient care because more patients were receiving their post-operative antibiotics correctly.

Lessons learnt: We have learnt that miscommunication between team members can lead to errors. The intention for prophylactic antibiotics to be given during the WHO checklist in theatre does not necessarily correspond to the prescribing of post op doses of antibiotics.

Message for others:

Effective handover between teams at changeover of jobs every four months can lead to improved patient care.


37Casebook 2012

Project Title: Assessing the quality of Primary Clinic appointments at Portsmouth Disablement Services Centre

Submitted by: Ostler C, Hatfield A, Cole A & Gilbertson A.

Context: The project was undertaken in the Portsmouth Disablement Service based at the Queen Alexandra Hospital. This is a multi-disciplinary team working across both acute and community Trust. The patients are those who have had a recent amputation and had been referred for prosthetic rehabilitation. The primary clinic appointment is the first time the patient will meet the prosthetic MDT and discuss limb wearing.

Problem: In 2009 Portsmouth’s Disablement Services centre (DSC) had a 4 month waiting list for primary assessment appointments and an attendance rate of only 80%.

The department needed to assess if all patients were receiving the same quality assessment and provision of information? They also needed to assess if patients were receiving this assessment at the correct point in their pathway?


A clinical audit was undertaken with the aim of assessing if the primary assessments adhered to BSRM (2003) guidance and locally agreed standards? The objectives were:

1. To improve the primary clinic process. 2. Reduce non attendance at appointments. 3. Ensure appropriate MDT staff involvement. 4. Ensure information is available to the team for decision making. 5. Appropriate forms of information provided to patients.

The audit included 44 patients over a 3 month period (25% of annual referrals). The audit findings were: 1. There was a 4 month wait for an appointment. 2. There was only an 80% appointment attendance rate. 3. Areas of good practice - 4 of the 10 standards were achieved (Patients were seen within 15 mins of their appointment time, expectations and goals were discussed with all patients, all patients were medically fit enough to attend their appointment. 85% of patients who were ready to cast for their first prosthesis were cast on the same day).

Areas of concern that were identified, however were that: 1. Patients didn’t seem to be at the right point in their pathway. 2. Only 46% ready to begin prosthetic rehab. 3. No nurse was available to provide specialist wound care. 4. Counseling was only discussed in 48% of assessments. 5. No supplementary written information was available. 6. Only 67% of patients had an MDT assessment. 7. Often not enough clinical information available for decision making. 8. Only 67% of referral forms were complete. 9. Only 36% of patients had information provided from local physio.

Intervention: • Restructure the primary pathway and appointment structure• MDT Triage of all paper referrals• Allocation of patients to complex, non complex and monitoring• Liason with therapists across the referring region• Rolling education programme• Update referral form• Set up full MDT clinics• Nurse led clinics• Informal counselling session offered to every patient• Training on adjustment following amputation for all staff• Produce a written information package and DVD to cover the patient journey


An action plan was put in place with the following elements::

1. Restructure the primary pathway and appointment structure. 2. MDT Triage of all paper referral. 3. Allocate to complex, non complex and monitoring. 4. Set up liaison with regional therapists. 5. Update referral form, Liaison across region, Rolling education programme. 6. Set up full MDT clinics. 7. Nurse led clinics. 8. Informal counselling session offered to every patient. 9.Training on adjustment following amputation for all staff. 10. Produce a written information package and DVD to cover the patient journey.


In 2011, the service was re-audited usig the same tools. The findings were that 9 out of 10 standards now achieved: 1. Waiting times had reduced to 4 weeks (from 4 months). 2. Attendance was now at 95% (from 80%) 3. 82% were ready to begin rehab (from 46%). 4. 89% had a nurse availabe for wound care(previously there was no nurse). 5. 100% received counselling (from 46%). 6. 100% received written information (previously none available). 7. 83% had an MDT assessment (from 67%). 8. In 84% of cases, the correct clinical information was available (65%).

Effects of change:

After the re-audit, 18 patients completed a satisfaction survey after their primary MDT consultation.

KEY RESULTS:• 94% of patients reported the consultation met their expectations • 100% of the patients felt listened too and felt their important questions had been answered. • 94% of patients were very satisfied with the information they received• 100% rated their consultation as excellent or good.• 100% of patients felt the consultation was about the right length of time

PATIENT COMMENTS: “Exemplary reception from this team. All made most welcome, positive attitudes and professional courtesy.” “A very informative session with ladies who really listened and understood our needs.”

The Clinical Implications are: 1. Able to ensure the patient saw the right people at the right point in their pathway. 2. Increased the clinical quality of primary clinic appointments. 3. Improved the experience of our patients. 4. Increased efficiency and cost effectiveness of the service.

Lessons learnt: That audit enables the issue to be quantified and highlights areas that need improving. The use of patient feedback following service changing was perticularly powerful.

Systems

38 Casebook 2012

AppendixPromoting the use of evidence-based guidelines in the management of acute severe asthma: harnessing the power of social media

Lets Actually Use the Computer! Using the Model For Improvement to Better Manage Microbiology Results in an Acute Service

39Casebook 2012

Lets Actually Use the Computer! Using the Model For Improvement to Better Manage Microbiology Results in an Acute Service

The Quality of Gentamicin Prescribing and Therapeutic Drug Monitoring at Royal Liverpool University Hospital Trust

40 Casebook 2012

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The Network Casebook II

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Transcript of The Network Casebook II