Storyboard Entry Form 2015Main author: Ann PriceEmail: neva_annie@hotmail.comTelephone: 079519238020

Co-AuthorsLawrence Tamalong – Charge Nurse C4 EastPaul Mizen – Consultant Physician

Follow the detailed instructions in this template for writing your storyboard. Add your information in each section below and save this completed storyboard document. Please not amend this template.

Follow the instructions in the Information Guide for Authors to submit your storyboard.

The word limit is 1500 words including references. Your storyboard will not be accepted if you exceed the word limit.

1. Storyboard title: a clear concise title which describes the work

BOARD matters – Collaboratively speaking

Establishing multi-disciplinary/multi-Agency safe, sustainable, visual communication systems (Patient Status at a Glance –PSAG) boards to enable collaborative and integrated discharge planning during a ‘Discharge Hour’

2. Brief outline of context: where this improvement work was done; what sort of unit/department; what staff/client groups were involvedThe improvement work was undertaken in Aneurin Bevan University Health Board (ABUHB) on an acute Gastroenterology ward. The multi-disciplinary team was involved in the project as part of the ‘Transforming Care’ programme.

The ward was chosen to lead this as it had just completed a ‘Safe & Timely Discharge Home’ multi-disciplinary project focusing on, right patient, right ward. The charge nurse had expertise in quality improvement methodologies and the team had awareness and understanding of data collection and change management.

Medical staff supported the drive to work collaboratively on daily board rounds, where the nurse / doctor relationship was open, honest, challenging and supportive of communication through the use of visual management. (PSAG boards)

Facilitating a safe journey home, within the pressures elicited by demand management, financial balance and quality of patient care are a daily battle for all. Patient flow is prioritised, but there is disconnect between times of admissions and discharges across wards and emergency departments.

NHSWA.15.29

Peaks occur at inappropriate times causing medical staff to work OOHr’s, nursing staff to manage extra demand with pre-emptive patients above their bed capacity, and extra workloads from patients unable to be discharged.

To manage and facilitate discharges, communication needs to be deep and wide across multi-disciplinary services. This is often challenging and complex.

PSAG boards are designed to provide, information at a glance to all disciplines involved in patient care. They provide a snapshot of the patient’s journey to promote prudent healthcare that is co-produced from patient discussion and assessment transferred to a visual tool.

At best they are an effective communication tool to aid discharge planning, quality of care, assessments and daily actions to enable a safe and timely discharge, at worst they are just another document to complete.

Getting it right is vital!

The board was co-created by a team of Band 7 from across the ABUHB. A standard for the PSAG board was agreed and has now been rolled out across acute and community divisions, ensuring safety and reliability remain paramount. Multi-disciplinary and multi-agency teams will use the same standard wherever they care for patients.

Admission to Discharge is captured with patient centricity at its core:

Generic information about the patient Discharge planning

NHSWA.15.29

Fundamentals of Care Quality data – assessments & interventions Daily action plans

The information is live and updated throughout the shift by all staff of every grade and any health professional that may needs to input into the patients journey of care.

4. Assessment of problem and analysis of its causes: quantified problem; staff involvement; assessment of the cause of problem; solutions/changes needed to make improvementsManaging these complex issues is difficult and delays in assessments, care delivery, co-ordination, investigations, interventions and discharges are not uncommon, impacting on beds, transfers of care and effective use of resources such as nursing and medical time.

Patient experience, carers input, multidisciplinary and multi-agency professional decision making, nursing and medical leads were required to come together integrating knowledge skills and expertise to enable safe and timely discharges home for patients.

Standard operating procedures (SOP) were devised: a tool known to facilitate safe practices by setting standards that can be audited and measured for safety, reliability and use.

One for the daily board meetings that focused on:

Sick patients Daily discharges Potential discharges Outstanding work – TTH, Bloods, Transport Delayed transfers of Care

One for ‘How to’ use the boardTransforming Care - Patient Status at Glance (PSAG) - Standard Operating Procedure (SOP)

‘Discharge Hour’ - Daily Board meetings – Medical / Nursing joint daily patient reviews

Discuss at board Nurse & Medical team

NHSWA.15.29

Pre BdMeeting

Senior Nurse / Ward Sister / NIC - to review and agree staffing levels / skill mix /Variable pay

1 Commence daily board meeting / Medical / Nursing - ‘Discharge Hour’

Ensure ward CWS print out is up to date with all changes Ensure PSAG board up to date and mirrors CWS list (Medical & nursing team agree)

2 Discuss patient’s causing concern – 1st for review on ward round - Patients with News’ score 3 or above (Discuss single or multiple scoring) Rx of anti-biotic therapy (IV to oral) Patients Not for resus – review / concerns or new patients to discuss Concerns regarding any other treatment plans

3 Actual Discharges: Are they Medically Fit for Discharge or Transfer and Clinically Stable for Discharge or Transfer All discharge needs met and completed / Nursing / Medical / Social/EDD/TTH/POCNote Total No of definite discharges:

4 Potential Discharges: Number of Potential Discharges / Transfers MFFD / CSFD but still need medical / other review to finalise discharge plans –Discuss actions outstanding for each patientNote Total No of potential discharges:

5 Patient Flow: Review any Admissions TCI – E Care / MAU / Other wards Repatriations required identified by medical team (top 3 names) Specialist Direct Admissions – Day cases / other

6 Cubicle patients – Discuss patients already in cubicle / Reasons for being thereIdentify any ward patients who need a cubicle Patients TCI from another ward needing cubicle

7 Any other specific concerns / Professional / Confidential issues POVA / DOLLS / Consent / Capacity MDT / CHC / Best Interest meeting Relative / Carers / Patient concerns

8 Complex list: (Access via Grape)Prepare names and reasons for waiting discharge ready for board meeting/ Discuss reasons – share with Hub / staff / DLN s to facilitate dischargeFollowing board meeting, ‘Medical Team’ prepare for consultant ward round. Prioritise patient reviews utilising information discussed at the board meetingFollowing board meeting, ‘Nurse in Charge’ prepare for HUB meeting using ‘Standard Operating Procedure for Hub / Attend HUB at allocated time / Use pro-forma to take information to HUBSenior Nurses to undertake Daily Quality Rounds and attend joint board meeting – ‘Discharge Hour’

6. Measurement of improvement: details of how the effects of the planned changes were measured Process and outcome measure were initiated to measure length of stay (LOS) and

am discharges. Throughout winter pressure months the ward maintained their LOS whilst all other wards declined. Am discharges initially increased but other ward changes impacted on the ability to maintain this. The project did however

NHSWA.15.29

enable us to recognise this and factor it into the ongoing work. These measurements are ongoing.

Audit of handover times have been collated since before the implementation of PSAG to evidence changes / improvements.

Audit of attendance at the daily board meeting for the discharge hour medics and nurse in charge is also audited. This is now embedded in practice

Creating the PSAG board was only the first step in this process. The board design was complete, but staff needed to collaboratively use the information in a safe and effective manner. Evidence of staff education maintained safe use of the boards

7. Effects of changes: statement of the effects of the change; how far these changes resolve the problem that triggered the work; how this improved patient/client care; the problems encountered with the process of changes or with the changesThe initial focus was visualising care on the PSAG board for professions to see and input into the patient journey. This is now custom and practice as OT, Physiotherapists, Social workers, pharmacists and many others use the board to communicate and understand where the patient is in relation to discharge planning.

Efficiency, effectiveness has enhanced communication supporting the reduction of interruptions to nursing staff saving time and waste. This frees up time to spend with patients.

The length of stay remained static but the number of morning discharges increased. Discharge is high on the agenda providing care that is prudent but safety focused. The data does fluctuate but can be correlated to other ward pressures, such as movement of staff, sickness and vacancies.

Positive improvements were made in quality indicators such as compliance with, MUST scores, News, Waterlow scores, MRSA screening and activities of daily living. These are displayed on the board providing evidence.

Change has not been easy, but has been managed well using a change model to guide progress. This ward was ready for change due to their involvement in the previous project; they recognised the need and were ready for action.

NHSWA.15.29

8. Lessons learnt: statement of lessons learnt from the work; what would be done differently next time

More education before board was established Engagement of Consultants before starting Greater time spent with medical teams preparing for the project Closer alignment with other projects Tighter working with patient flow team Engagement of Senior Nurses from start

9. Message for others: statement of the main message you would like to convey to others, based on the experience describedWith the acuity of our patients and staffing levels remaining the same until further recruitment, the role of PSAG plays an important part in our day to day activities.

It identifies and prioritises sick patients who need to be seen first It enables us nurses to plan our day It provides us with a communication tool that all can see and use It allows us to maximise our time It supports our efficient use of resources

PSAG is like our ‘Satellite Navigation,’ we use it all the time to direct us, help us cope with the challenges we face in a very busy arena The ‘Discharge Hour’ and ‘DAILY BOARD MEETINGS MATTER’Visual and Multi- disciplinary discussion aids - Collaborative planning, acting and listening – COLLECTIVELY SPEAKING

10. Please summarise how your entry reflects the principles of prudent healthcare: you can find out more about prudent healthcare at http://www.prudenthealthcare.org.uk/For the patient:The principles of PSAG align with prudent healthcare to minimise interventions, in consideration of timeliness, safety, and equity of care that is outcome focused.

For professionals:It develops peer support and learning from sharing, where all parties are valued. It creates a culture of reciprocity, by recognising that we all need each other to maximise patient safety and quality of care

The NHS Wales Awards are organised by the 1000 Lives Improvement service in Public Health Wales.

www.1000livesi.wales.nhs.uk

NHSWA.15.29