the clock was ticking……………… - day hospitals australia · 17 18 time 7am 7.30am 8am...

The Clock was Ticking………………

• Private Haematology/Oncology Day Hospital • Over 19,000 presentations per annum

• Over 600 Apheresis procedures per annum

• Average 75 patients/day

• 27 treatment areas

• Pharmacy on-site

• Co-located with the Mater Private Hospital

• Practice Management - 12 VMO’s• Over 33,000 consults per annum

Icon Cancer Care South Brisbane

Picture this…………………..

• Nurse Manager only

• Nurse allocated to 6 patients/8 hour shift

• Nurse Workloads – fight for chairs

• No extra staff to fall back on

The way it was…………….

• Add on patients and treatments

• Staff very stressed, negative, unhappy

• Anxious and frustrated Patients

• Long Wait Times – sometimes >2 hours

• Offsite pharmacy supplier

• Lack of allied health support

We looked old and tired…………

Booking Scheduler

Daily nurses allocation list

It wasn’t all bad news………..

• Dedicated, committed staff

• Providing excellent nursing care

How to make the change happen….

John Kotter’s 8 steps to Lead Change

‘Waiting over an hour to start

treatments’

‘Waiting to see doctor

about tests’

‘Nearly 2 hours waiting time. ’

‘Running behind for whatever

reason and your appointment gets put back, you get anxious

and nervous, and it is prolonged’

Patient Survey Results‘Expectations around wait times were met’ = 42%

‘A less pleasant experience being wait time’ = 34%

1. Create Urgency • Patient – Feedback cards / Satisfaction Surveys• Staff – Satisfaction Surveys / Staff Turnover Rate > 50%• Implementation of CHARM

2. Form a Powerful Coalition • Focus Group - representatives from all groups on site• Consumer Representation

3. Create a Vision for Change

• “Exceptional Cancer Care for Everyone”• Realistic Targets• Safety of the Patient

4. Communicate the Vision

• Engage staff in the process and solutions• Communication, Communication, Communication• Listen, Listen, Listen• Staff needed to believe it!

Suellen video

3. Create a Vision for Change

• “Exceptional Cancer Care for Everyone”• Realistic Targets• Safety of the Patient

4. Communicate the Vision

• Engage staff in the process and solutions• Communication, Communication, Communication• Listen, Listen, Listen• Staff needed to believe it!

5. Empower Action

Introduction to team nursing…• Clinic zoned into areas

• Staff allocated to areas from roster

• Each team includes a Team leader

• Each RN responsible for 2/3 chairs

• Team Leader supported by Clinical Nurse Consultant with regular ‘HUDDLES’

Results

• Patients always aware of who is responsible for their care

• Nurse had patients visible to them at all times and supported by others

17 18

Time7am

7.30am

8am

8.30am

9am

9.30am N7

10am

10.30am

11am

11.30am

12pm

12.30pm

1pm

1.30pm

2pm

2.30pm

3pm

3.30pm

4pm

4.30pm

5pm

5.30pm

6pm

6.30pm

7pm

7.30pm

8am - 6.30pm (10hr) : 1 staff (Team Leader)

7am - 3.30pm (8hr) : 5 staff (one Team Leader) 9am - 7.30pm (10hr) : 1 staff (Team Leader)

7am - 5.30pm (10hr): 3 staff (one Team LEader) 10am - 6.30pm (8hr) : 1 staff

8am - 4.30pm (8hr) : 1 staff 11am - 7.30pm (8hr) : 2 Staff

7am - 5.30pm (N 11)

7am - 3.30pm (N12 & T/L)

8am - 4.30pm (N13)

11am - 7.30pm (N14)

21 2613Treatment Area

16 19 20 211211109876P1543

Nurs

e 13Nu

rse

9 &

10

Fast Chairs

Nurs

e 11

Nurs

e 11

Nurs

e 11

22 23 24 25

Add

on ch

air -

NO

BOOK

INGS

Nurse 4

Nurse 3

7am - 5.30pm (N5)

7am - 3.30pm (N6)

9am - 7.30pm (N7 & T/L)

10am - 6.30pm (N8)

7am - 3.30pm

(N9)

7am - 3.30pm (N

10)

7am - 5.30pm (N1)

7am - 3.30pm (N2)

8am - 6.30pm (N4 - T/L)

11am - 7.30pm (N3 - cover

lunch & end of shift)

Nurs

e 13

Nurs

e 13

Nurs

e 12

Nurs

e 12

Nurs

e 14

Nurs

e 14

Nurs

e 1

Nurs

e 1

Nurs

e 1

N7

Nurs

e 8

Nurs

e 8

Nurse3

Nurs

e 6

Nurs

e 6

Nurs

e 6

Nurse 7

Nurs

e 5

Nurs

e 5

Nurs

e 5

Nurse 14

Nurs

e 2

Nurs

e 2

Nurs

e 2

Roster Requirements

Team Leader Role

• Team Leaders allocated to each area• Leadership role• Coordinates care• No direct care for a period of 4hrs/day• Communicates to Clinical Nurse Consultant and Doctor• Participates in ‘huddles’ with Clinical Nurse Consultant

Huddles

• 10am and 1pm with CNC and all Team Leaders

• Alerts to potential chair waits

• Identifies pressure on staff ie breaks and overtime

• Allows CNC to visualise clinic as a whole to enable decisions on:

* Potential add ons

* Delays in chairs (hospital transfers/unwell pts)

* Ability to swap patients or release staff to other teams

Team Shift Time Name Chair Allocation Handover toMiddle Section

T/L:

(Closes @ 6.30pm)

7am – 4.30pm (N1) 1, 2, 3

6.45am – 3.15pm (N2) 4, 5 & P1

8am – 6.30pm (N4) T/L & from 5pm 1, 2 & 3

1.30 pm – 7.30pm (N3) Help & from 3pm 4, 5 & PR1

Front Section

T/L:

(Closes @ 7.30pm)

7am – 3.30pm (N5) 6, 7, 8

6.45am – 3.15pm (N6) 9, 10, 11

9am – 7.30pm (N7) 12 & 13 until 10am – then T/L

10am – 6.30pm (N8) 12 & 13

9am – 5.30pm Float & Help

Fast Area &

Add On

(Closes @ 3.30pm)

7am – 3.30pm (N9) 16 & 17

7am – 3.30pm (N10) 18 - & Help

West Wing

T/L:

(Closes @ 5.30pm)

6.45am – 5.15pm (N11) 22, 23 & 24 until 11am

7am – 3.30pm (N12) 19, 20, 21

8am – 4.30pm (N13) 25 & 26

11am – 7.30pm (N14) 22, 23, 24

Daily Staff Allocation

HUDDLES IN NURSES STATION @ 10am & 1pm

ALL TEAM LEADERS MUST ATTEND

Scheduling Appointments

• Accuracy of length of appointments• Discussed current issues

• Reviewed data: • Correct time allocated: 36%

• Too much time allocated: 22%

• Not enough time allocated: 42%

ARRIVED SCH TIME TREATMENT TOTAL CARE TIME

11/10/2016 6:47 206 240

11/10/2016 6:49 361 180

11/10/2016 6:51 210 240

11/10/2016 6:51 196 180

11/10/2016 6:53 147 90

11/10/2016 7:04 247 240

11/10/2016 7:05 308 180

11/10/2016 7:10 85 180

11/10/2016 7:20 140 210

11/10/2016 7:23 278 180

11/10/2016 7:28 167 120

11/10/2016 7:29 183 180

11/10/2016 7:35 474 270

11/10/2016 7:50 74 60

11/10/2016 7:50 146 240

11/10/2016 7:58 173 180

11/10/2016 8:02 183 180

11/10/2016 8:16 123 210

11/10/2016 8:22 245 240

11/10/2016 8:23 101 150

11/10/2016 8:27 174 180

11/10/2016 8:30 350 360

11/10/2016 8:34 235 180

11/10/2016 8:51 143 150

11/10/2016 8:52 226 150

11/10/2016 8:53 204 60

11/10/2016 9:11 57 60

11/10/2016 9:11 245 120

11/10/2016 9:16 28 30

11/10/2016 10:01 215 240

11/10/2016 10:02 335 300

11/10/2016 10:03 22 60

11/10/2016 10:03 427 60

11/10/2016 10:18 145 150

11/10/2016 10:20 126 180

11/10/2016 10:21 185 180

11/10/2016 10:25 175 180

11/10/2016 10:32 220 180

11/10/2016 10:36 309 240

11/10/2016 10:36 215 240

11/10/2016 10:40 389 180

11/10/2016 10:57 223 120

11/10/2016 10:58 261 270

11/10/2016 11:01 86 30

11/10/2016 11:04 301 90

Results• Nurse involvement in planning• Nurse’s predicting future appointments• Add on’s – discussions with Doctor’s • Unwell patients

October 2016 - Sample of Appointment Time Data

CHARM

• Scheduler Patient allocated to chair not nurse

Visual display of where pts are and how long they will be in chair Aids with add on procedures

• Pathways VMO’s order the patient pathways

Pharmacy responsible for chasing orders in advance

Allows add on products by VMO’s at any time

Easy understanding of patients treatment plan/diagnosis

CHARM Test Screen

“DO NOT BOOK” Chair• 1 chair that is not allocated any patients

• Managed by Clinical Nurse Consultant

• Utilised when other chairs become under pressure

Fast Chairs• Open from 7am – 3.30pm

• 30 minute procedures

• 1RN and 1EN

• Treatments/ Procedure: include: Access device care – flush/dressings Venesections S/C and IM administrations, Short IV chemo administration

6. Create Quick Wins

References:2016 Data Taken from Total Care2017 Data Taken from CHARM – Appointment Time V’s Actual Start Time

Cost Savings – Nursing Overtime

Renovations

Patient and Staff Video

7. Build on the Change & Make it Stick

• Onsite Pharmacy – mixing on site

• Bone Marrow Clinic

• Pathology the day before

Where to from here…..

**Consolidate, Promote, Consistency!!

This could not have been done without them….