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Sheffield Microsystem Coaching Academy
Coaching Workshop
24 May 2017
9.00 – 16.20
Room 2, R Floor, RHH
9.15 – 9.30 Jim
Welcome Agenda
Aim of the coaches workshop
An opportunity for coaches to re-engage
with coaching, refresh and practice tools
and skills, including data and measurement
Great discussions with
other coaches and some
really good interactive
sessions
Really enjoyed
catching up and
discussing issues
with fellow coaches
and trainers.
Coaching Workshop - 24 May 2017
Agenda
. Time Topic Led By Room
9:00 Registration & refreshments Room 2
9.15 Welcome, agenda Jim Room 2
9.30 Excel basics - This session teaches some basic Excel skills including data displays and formulas
Rachael &
Aileen 4a
Patient co-production & experience care mapping – Are we listening to patients? Using FFT data Nick & Laura Room 2
10.30 Coffee Room 2
10.45 Excel pivot tables
An opportunity to have a go at creating pivot tables and manipulating them Garry 4a
A coaching story – 5p’s to PDSA Mark Room 2
11.45 Coaches support meeting (Troika)
An opportunity for coaches to use this model to get a different perspective on their coaching issues Nick Room 2
12.45 Lunch Room 2
13.15 Improvement bazaar – an informal poster session All Room 1
Posters from FLOW, Project Management Office, Hillsborough Nurses Project, SHSC, SCH, Weston
Park, Patient Activation Measure, Coaches Survey, Seamless Surgery, Outstanding Outpatients,
Elective Team
Presenters at
posters Room 1
14.00 Manipulating dates and times in Excel – This session will give you tips on how to do this Garry 4a
What do you measure - A common roadblock is helping teams to measure their changes. This
practical session helps identify practical measures; tips and techniques for collecting data and the use
of balance measures.
Jude & Maria Room 2
Coaching Workshop - 24 May 2017 Agenda
Time Topic Led By Room
15.00 Coffee
15.15 Creating and interpreting a run chart in Excel – how to create a simple run chart in Excel Emma 4a
Jonkoping – Improving ward flow through the ward collaborative Kevin & Tim Room 2
16.15 Close Jim Room 2
9.30 – 10.30
Laura O’Byrne
Nick Miller
Listening to the stories behind the numbers
and coproducing improvement with patients
Today’s session
• What is available to help us listen to patients
• Illuminate real patient experience data that is
readily available
• Explore how to undertake a patient care
experience flow map
• Consider how patient experience relates to our
work
Friends and Family Test dashboard
All STH services
conduct the FFT • A&E
• Outpatient
• Inpatient
• Community Services
• Maternity Services
Everyone in the Trust
can have access to
their FFT results
Positive ratings range
between 80 and 100%
positive in line with
National Performance
Themes for 5 Ps
FFT Comments – qualitative data
Comments reports – patients’ feedback in
their own words
Listening to our patients
Listening for the “but”
How to access the FFT Envoy website
Email Patient Partnerships to request your login
Friends and Family Test Coordinator
Experience based co design
•Kings Fund toolkit
- Step by step guide
- Stakeholder engagement
- How to create patient videos
•Oxford study – trigger films are
effective too
Trigger videos available online
Themes currently available:
• A&E
• Asthma
• Atrial fibrilation
• Dementia
• Coordinating care
• Autism
• Diabetes type 2
• End of life care
• Ethnic minority mental health
• Experiences of unexpected
maternity care
• Indwelling urinary catheter
• Learning disabilities and the
health service
• Lung cancer
• Parkinson’s Disease
• Psychosis
• Raising concerns
• Stroke
• Young parents
• Young people and depression
Nick Miller
Patient shadowing & care experience
mapping
Objectives
• Gain an understanding of how to undertake
patient shadowing and care experience mapping
• Make connections between processes and
patient and family experience
• Link to opportunities for improvement
• Make links to coaching development
Value
Value = Outcome + Patient experience
Cost
• Defined by the patient
- What does our care look like from the patients and
families point of view?
- Do we really know where they go and what they
experience?
- What do they think we do well?
- What do they want us to do differently and better?
- How do we find out?
Value
Patient Shadowing
“You never really understand a person
until you consider things from his point
of view…until you climb inside of their
skin and walk around in it.”
Atticus Finch, in Harper Lee's To Kill a Mockingbird
Patient shadowing guide:
http://www.porthosp.nhs.uk/about-us/Perfect%20Care%20Week/pfcc-patient-and-family-shadowing-guide.pdf
Patient shadowing
• Shows the current state of care from the patient’s
view point rather than our own
• Opportunity for humble enquiry during
shadowing and in improvement meetings
• Opportunity to challenge assumptions and
‘normalisation’
• Helps us question how we communicate with
each other about the process of care
How?
• Who shadow’s and how to get started?
• Visualisation of the shadowing
• Interpretation and coaching
• Meaningful application
• Opportunity for co-production
• Sustaining
Care experience flow mapping
• Define where to start and finish
• Be prepared to shift dependent on what patients tell you
• Display touch points
- Where they go
- Who they interact with
- How long it took
- How it felt
- what was the impact (+ve / -ve)
Experience Matters
Exercise
• At your tables
• Review the process map
• Review the patient story
• Construct a care experience flow map
Check in at
Reception
Sit in
Waiting
Room
Called
to Blood
Room
Height,
Weight,
Urine
Sample
Blood
Taken
Sit in
Waiting
Room
See the
Doctor
Check out
at
Reception
Patient Shadowing
Exercise
• At your tables
• Review the process map
• Review the patient story
• Construct a care experience flow map
15 minutes then open discussion
Discussion
• What did you learn?
• What sense did you have about how the patient
felt, how his son felt?
• What conclusions do you draw for your own
coaching or work area?
Summary
• Experience matters to patients
• Patients want to tell us about their experience-
are we listening?
• There are different ways to start listening and
apply patient experience to enhance
improvement work
10.30 – 10.45
Break
10.45 – 11.45
Mark Adams
A coaching story
Mark
5Ps to PDSA
Case Study –The Neuro Case Management
Service ( SHSC FT)
Meet the team
Work smarter not harder !
https://www.youtube.com/watch?v=2Dj196t5Sb0.
• Coach training cohort 5
• A team with a personal pre existing relationship and from within the same trust directorate
• A small team with an exponential referral rate and facing a challenge to manage the demand for their service
• A team that recognised that it needed to adapt to the demands that it was experiencing and was open to exploring how the MCA approach could be of benefit to them
Background to involvement with the MCA
Pre Phase – The Work Before the Work
• Started MCA training
• Met the operational team manager – expectation setting
• Launch meeting with the team
• Familiar with the work of the team and individual staff
• Agreement from the team to start regular microsystems
meetings
Finding time to meet
• Agreed to weekly hour meetings
• Changed to hourly meetings every other week:
• Enabling staff to carry out actions identified in the meetings
• Initially unable to engage all of the team in attending meetings
• Use of flip charts displayed in the shared office to enable all staff to
participate in key decision making.
Initial Meeting 13th May 2015
• Introduced what we mean by quality & quality improvement
• Introduced effective meeting skills and roles
• Set up the ground rules
59
What worked well?
•Better than expected
•Stayed focussed on the scope
•Agreed scope
•Good timekeeping (people here for prompt time)
•Good attendance
What could be improved?
•Circulate agenda before the meeting
General score: 7/8/9 out of 10
Meeting Evaluation
5P Assessment
Theme
Global Aim
Change Ideas
Specific Aim
Measures
Flowchart
Cause & Effect
The Microsystem
Improvement Ramp Global
Aim
1
2
3
5 P Assessment
Theme
Global Aim
Change Ideas
Specific Aim
Measures
SDSA
P
DS
A
P
DS
A
P
DS
A
PDSA
1
3
2
Dartmouth Microsystem Improvement Curriculum
Global Aim
1
2
3
SDSA
P
D S
A
P
D S
A
P
D S
A
PDSA
1
3
2
Understanding the System
Assessment – 5 Ps
5p’s poster
Purpose
• What is the purpose of the microsystem?
Identification of needs and priorities of an individual as a result of their
neurological condition.
Request and co-ordinate the appropriate response to a particular need
and/or risk.
Provide direction for future management. This ensures an individual, or
service, feels more empowered holistically to guide input in a timely and
efficient manner.
5P Assessment
Theme
Global Aim
Change Ideas
Specific Aim
Measures
Flowchart
Cause & Effect
The Microsystem
Improvement Ramp Global
Aim
1
2
3
5 P Assessment
Theme
Global Aim
Change Ideas
Specific Aim
Measures
SDSA
P
DS
A
P
DS
A
P
DS
A
PDSA
1
3
2
Dartmouth Microsystem Improvement Curriculum
Global Aim
1
2
3
SDSA
P
D S
A
P
D S
A
P
D S
A
PDSA
1
3
2
66
Target pressures
Caseload changes
Impact of service
changes
Key Improvement
Themes
Changes in referral patterns
job satisfaction
Key improvement Themes
Communication within team,
with clients and professionals
5P Assessment
Theme
Global Aim
Change Ideas
Specific Aim
Measures
Flowchart
Cause & Effect
The Microsystem
Improvement Ramp Global
Aim
1
2
3
5 P Assessment
Theme
Global Aim
Change Ideas
Specific Aim
Measures
SDSA
P
DS
A
P
DS
A
P
DS
A
PDSA
1
3
2
Dartmouth Microsystem Improvement Curriculum
Global Aim
1
2
3
SDSA
P
D S
A
P
D S
A
P
D S
A
PDSA
1
3
2
Theme 1: Global Aim • We aim to improve the process of how we catagorise the complexity of
clinical cases.
• In the Neuro Case Management Service by the clinicians
• The process begins at referral or referral enquiry and ends with either
triage of the referral or at a review of the case.
• By working on the process we expect better equity of service to all service
users, less time spent by staff on clinically related administration, clearer
understanding of what case management is and the level of responsibility
that staff have, better prioritisation of staff members clinical caseload, more
efficient use of clinical time, increased clinician job satisfaction, a more
timely response for service users
• It is important to work on this now because of recent changes in referral
profiles and different interpretations of complexity of clinical case between
clinicians.
68
5P Assessment
Theme
Global Aim
Change Ideas
Specific Aim
Measures
Flowchart
Cause & Effect
The Microsystem
Improvement Ramp Global
Aim
1
2
3
5 P Assessment
Theme
Global Aim
Change Ideas
Specific Aim
Measures
SDSA
P
DS
A
P
DS
A
P
DS
A
PDSA
1
3
2
Dartmouth Microsystem Improvement Curriculum
Global Aim
1
2
3
SDSA
P
D S
A
P
D S
A
P
D S
A
PDSA
1
3
2
Target pressures
Caseload changes
Impact of service
changes
Key Improvement
Themes
Changes in referral patterns
job satisfaction
Key improvement Themes
Communication within team,
with clients and professionals
5P Assessment
Theme
Global Aim
Change Ideas
Specific Aim
Measures
Flowchart
Cause & Effect
The Microsystem
Improvement Ramp Global
Aim
1
2
3
5 P Assessment
Theme
Global Aim
Change Ideas
Specific Aim
Measures
SDSA
P
DS
A
P
DS
A
P
DS
A
PDSA
1
3
2
Dartmouth Microsystem Improvement Curriculum
Global Aim
1
2
3
SDSA
P
D S
A
P
D S
A
P
D S
A
PDSA
1
3
2
Specific Aim – September 2015
We will improve the job satisfaction of staff in
relation to the management of their clinical caseload
by 25%, by March 2016
5P Assessment
Theme
Global Aim
Change Ideas
Specific Aim
Measures
Flowchart
Cause & Effect
The Microsystem
Improvement Ramp Global
Aim
1
2
3
5 P Assessment
Theme
Global Aim
Change Ideas
Specific Aim
Measures
SDSA
P
DS
A
P
DS
A
P
DS
A
PDSA
1
3
2
Dartmouth Microsystem Improvement Curriculum
Global Aim
1
2
3
SDSA
P
D S
A
P
D S
A
P
D S
A
PDSA
1
3
2
Fishbone diagram
74
PEOPLE PROCESSES
Risk: to with client and diagnosis Risk
Ethos: working Increase in processes that distract - Values from clinical intervention - Culture Difference of opinion: about care - Professionalism - Internal Reduced Admin workload - External therefore increased workload Feeling more involved in for CM’s Case Management Role face to face - What is it?
Other Services: expectations Allocation Triggers and targets towards Caseload mix leading to less - Improvement the front of intervention - face to face contact how referrals are nothing at the end allocated?
PROBLEM
Knowledge, Skills, Experience, Professional background IT Support
TPP & Insight - Information Non face to face Environment contact - small room
External Services
MATERIAL EQUIPMENT
E.g. Effect of
caseload mix on
staff job satisfaction
5P Assessment
Theme
Global Aim
Change Ideas
Specific Aim
Measures
Flowchart
Cause & Effect
The Microsystem
Improvement Ramp Global
Aim
1
2
3
5 P Assessment
Theme
Global Aim
Change Ideas
Specific Aim
Measures
SDSA
P
DS
A
P
DS
A
P
DS
A
PDSA
1
3
2
Dartmouth Microsystem Improvement Curriculum
Global Aim
1
2
3
SDSA
P
D S
A
P
D S
A
P
D S
A
PDSA
1
3
2
Change Ideas
•
Benchmarking
caseload mix
and develop
staff quotas Develop a
clinical tool to
help clinicians
to manage
their
caseload
Develop a
better system
for allocating
to individual
staff
caseloads
Change
timescale
targets for
different
stages of the
care pathway.
Global Aim
1
2
3
SDSA
P
D S
A
P
D S
A
P
D S
A
PDSA
1
3
2
5P Assessment
Theme
Global Aim
Change Ideas
Specific Aim
Measures
Flowchart
Cause & Effect
The Microsystem
Improvement Ramp Global
Aim
1
2
3
5 P Assessment
Theme
Global Aim
Change Ideas
Specific Aim
Measures
SDSA
P
DS
A
P
DS
A
P
DS
A
PDSA
1
3
2
Dartmouth Microsystem Improvement Curriculum
Equity of service to all
clients?
Meeting externally set targets for timescales for service delivery?
Cost per case ?
Staff job
satisfaction
Value Compass
Stakeholder
perspective
78
We will improve the job satisfaction of staff in relation to the
management of their clinical caseload by 25%, by March 2016
Job Satisfaction Questionnaire
• 10 Questions including,
•How satisfied are you with using the current system of
categorising client complexity (resource requirement)levels?
Very unsatisfied 1 2 3 4 5 6 7 Very satisfied N/A
•How satisfied are you with your caseload mix?
Very unsatisfied 1 2 3 4 5 6 7 Very satisfied N/A
79
Global Aim
1
2
3
SDSA
P
D S
A
P
D S
A
P
D S
A
PDSA
1
3
2
5P Assessment
Theme
Global Aim
Change Ideas
Specific Aim
Measures
Flowchart
Cause & Effect
The Microsystem
Improvement Ramp Global
Aim
1
2
3
5 P Assessment
Theme
Global Aim
Change Ideas
Specific Aim
Measures
SDSA
P
DS
A
P
DS
A
P
DS
A
PDSA
1
3
2
Dartmouth Microsystem Improvement Curriculum
PDSA - Plan
• Development of a tool for clinicians to use with service
users to consistently evaluate the challenges to
delivering an effective care plan.
• 2 Neuro case managers to pilot the use of this clinical
tool at referral triage, before allocation to all 4 case
manager caseloads.
• Evaluate using a job satisfaction questionnaire specific to
the management of their clinical caseload. To be
completed by staff prior to implementing the caseload
management tool and then repeated after the
introduction of the tool.
Clinical caseload management matrix
Patient
Name: DATE: / /17
NHS No: Assess
ment
Domains Risk totals
Risk Care and
Support Rehab Medical Equip &
Accom Future Care
Planning Advocacy Max score=12
Non engager 0 0 0 0 0 0 0
Over engager 0 0 0 0 0 0 0
Unrealistic expectations of client /
family 0 0 0 0 0 0 0
Insight / denial 0 0 0 0 0 0 0
Social Breakdown 0 0 0 0 0 0 0
Social care needs (inc CHC) 0 0 0 0 0 0 0
Multiple Co-Morbidities 0 0 0 0 0 0 0 Rapidly deteriorating condition 0 0 0 0 0 0 0
Mental Health 0 0 0 0 0 0 0
Mental Capacity 0 0 0 0 0 0 0
No identified Care Planner 0 0 0 0 0 0 0 Effectiveness of Services 0 0 0 0 0 0 0
Safeguarding 0 0 0 0 0 0 0
Domain Totals Max score = 26 0 0 0 0 0 0 0 Total
score Care and
Support Rehab Medical Equip &
Accom Future Care
Planning Advocacy
VALUE
Notes at
time of
completion:
0 = No involvement or concern
1 = low risk
2 = high risk
Descriptors Feb 2017
Evaluating the outcome of the pilot
5P Assessment
Theme
Global Aim
Change Ideas
Specific Aim
Measures
Flowchart
Cause & Effect
The Microsystem
Improvement Ramp Global
Aim
1
2
3
5 P Assessment
Theme
Global Aim
Change Ideas
Specific Aim
Measures
SDSA
P
DS
A
P
DS
A
P
DS
A
PDSA
1
3
2
Dartmouth Microsystem Improvement Curriculum
Global Aim
1
2
3
SDSA
P
D S
A
P
D S
A
P
D S
A
PDSA
1
3
2
Standardise
•Following a review of the job satisfaction
questionnaire and reflective discussion it was
agreed to standardise the use of the caseload
management matrix.
•All 4 Neuro case managers use the clinical tool at
referral triage prior to caseload allocation, with
training on its use and written guidance.
•An STH team has adopted it’s use and SCC are
looking at it’s use within one of the social services
teams.
85
Guidance on completing the matrix
86
Risk Factors Definition Low High
1. Non-engager
Evidence of capacity to make decisions
and chooses not to engage with
services despite a need and to the
detriment of the management of the
condition. This is usually a chronic non-
engagement problem.
Will engage with a service who
CMS can liaise and link with re
management of situation /
manage risk and domain.
Evidence of multiple times of
non-engagement
Doesn’t engage with any service
despite seeing the need.
Difficulties exist due to
complexities across many
domains.
1. Over-engager
Frequent, inappropriate contact with
multiple services
Previously identified and
there’s a plan in place
Patient driven referrals to multiple
agencies and / or no plan in place
1. Unrealistic expectations patient/client
Psychological blockage / unrealistic
thought process that does not allow
progression of onward referral,
engagement of services etc. This may
trigger a referral to N/Psychologist
within CMS or LTNC Team. Unrealistic
expectation of what services can
provide (outside of service criteria)
Expectations can be managed
by education and concrete
explanations. Patient / care
system can self-manage the
outcome of education
Multiple attempts of explanation
with no change in expectations.
Indicates need for review of
system management due to
continued challenge
QUESTIONS?
11.45 – 12.45
Nick
Coaches Support Meeting
Using Troika Consulting
This Session
• Learn a new approach to support others
• Get some practical help and advice from the
wisdom of colleagues in the room
Troika Consulting
• Get Practical and Imaginative Help from
Colleagues Immediately!
• A 30 min process.
• http://www.liberatingstructures.com/
Troika Consulting
“To listen is very hard, because it asks of us so
much interior stability that we no longer need to
prove ourselves by speeches, arguments,
statements or declarations.
True listeners no longer have an inner need to
make their presence known.
They are free to receive, welcome, to accept.
Henri Nouwen
Troika
In quick round-robin “consultations,” individuals ask
for help and get advice immediately from two
others.
Peer-to-peer coaching helps with discovering
everyday solutions, revealing patterns, and refining
prototypes.
This is a simple and effective way to extend
coaching support for individuals beyond formal
reporting relationships.
How it works
Explore Problem & Help?
Space
• 3 chairs
• No table
3 Rounds • 1 Client
• 2 Consultants
Sequence of Steps and Time Allocation
1. • Share and reflect on the consulting question
• 1 - 2 min
2. • Consultants ask the client clarifying questions
• 1 min
3. • Client turns around with his or her back facing the consultants
4. • Together, the consultants generate ideas, suggestions, coaching advice.
• Client takes notes.4-5 min.
5. • Client turns around and shares what was most valuable about the experience.
• 1-2 min.
6. • Groups switch to next person and repeat steps.
Benefits to the approach
•Refine skills in asking for help
•Learn to formulate problems and challenges
clearly
•Refine listening and consulting skills
•Develop ability to work across disciplines and
functional silos
•Build trust within a group through mutual support
•Build capacity to self-organise
•Create conditions for unimagined solutions to
emerge
Have a go…preparation (5 mins)
Think about a coaching problem you
want some advice or new thinking on.
Write down your problem in a sentence
Do you have any ideas/solutions?
Note them to quickly share
Have a go (30 mins)
1. Form groups of three.
2. 7-10 minutes per person.
3. Spend 1-2 minutes sharing your problem and
any ideas you have.
4. Turn your back. Spend 5-7 minutes receiving
feedback and advice from your consultants –
take notes
5. Turn back, and share what was most valuable –
Note the best ideas and suggestions on the
worksheet
6. Thank the consultants and switch
Coaching Support Round Issue Ideas & Suggestions
1.
2.
3.
Have a go (30 mins)
1. Form groups of three.
2. 7-10 minutes per person.
3. Spend 1-2 minutes sharing your problem and
any ideas you have.
4. Turn your back. Spend 5-7 minutes receiving
feedback and advice from your consultants –
take notes
5. Turn back, and share what was most valuable –
Note the best ideas and suggestions on the
worksheet
6. Thank the consultants and switch
TROIKA DEBRIEF
Uses
•Problem solving at beginning or end of meetings
•After a presentation, for giving participants time to
formulate and sift next steps
•To help one another and to promote peer-to-peer
learning
•In the midst of conferences and large-group
meetings
•As a self-initiated practice within a group
12.45 – 13.15
Lunch
13.15 – 14.00
All
Improvement Bazaar
14.00 – 15.00
Jude and Maria
Measurement - When you don’t know what to
measure
Structure of session
• Types of measure
• Case study example
• Your scenario and context
Get a baseline
• Looking back
• Start now
• Guestimate
Make it simple
• Is the data already
collected somewhere?
• Make it easy to collect
and with clarity
What to measure? – Process
What to measure? - Outcome
What to measure? - Balance
Exercise
• In groups around your table
• Read the scenario and answer the questions (10 mins)
- How would you approach getting a baseline?
- What would you measure for this change and how would you
approach this?
- Which of these measures could be used to measure the change?
Process, Outcome, Balance
• Feedback and discussion (5 mins)
15.00 – 15.15
Break
15.15 – 16.15
Tim and Kevin
Improving wards through two different
approaches to spreading and sustaining
improvement
Sheffield MCA
•Hosted by Sheffield Teaching Hospitals
•Train QI ‘team’ coaches (143 so far from several organisations)
•Central team within the trust
•Organised into sub teams
• Project Management
• Building Capability
• Elective
• Non-Elective
Different views of the same thing..
Everyone sees part of
a more complex
reality……….
Sheffield Teaching Hospitals very own
Elephant!
1,035,094
112,855
152,539
1,188,903
Out-patients
treated
Inpatients treated in
2015/16
Contacts with Community patients
Accident and Emergency
Attendances
16,000 Staff employed
70+ Different professions
Each of us has seen and been part of exceptional
care and caring. But Improvement is hard to
sustain…and hard to link together
The challenge of sustaining improvement is well
documented. How can we do more, to enable teams
to improve more services for more patients?
Collaborative approach -
wards
Two different approaches
Programme approach -
theatres
Aims of the Ward Collaborative
•To spread the approach and learning from the improvement approach adopted
in the Respiratory wards
•To build quality improvement capability with the staff on those wards so that
quality improvements can be maintained and improvement becomes
continuous during this period.
•To support and develop new MCA coaches working in the ward environment by
buddying them with experienced service improvement coaches.
•To create an opportunity for wards to learn from each other, share
improvements and good ideas to accelerate the rate of improvement for patients
•To support wards to improve care for the patients they serve by March 2016.
122
Timeline and Structure
Wards, Themes and Tests
TTO’s
Ward Environment
Daily Board Rounds
Case Note Standardisation
Senior Review
Patient Experience
E- Discharge
Noise Levels
Patient Information
Improved MDT Communication
Blood Result Redesign
Discharge Checklists
Improved ward flow Documentation
Junior Dr Induction and information Gastro
(RH3 & RH4)
GSM
(B5,6 & 7, RH5 & 6
NGH)
Spinal (Osborn 3)
Spinal (Osborn 2)
Infectious Diseases
(E1 & E2 RHH) Orthopaedics (F1 RHH)
Communication Noise
Ward Process
Team Work
Pain Management
Discharge
Drug Round Redesign
Improved discharge
Summaries
Board Round Redesign
A clearer perspective….
Timely Assessment
Pull the right patient from assessment
units
Specialty consultants in teams –
consultant of many days, ward based
consultant.
All patients have a clear plan
Daily review of care plan to agree plan for
the day and daily goals.
Consultant approved care plan within 14 hrs of admission.
Regular MDT review of plans for patients with extended length of stay – home first
mindset. D2A
Improved ward flow and MDT
working
Daily Board rounds
One stop MDT morning ward
rounds
Ward round checklists
’E-Whiiteboard and handover
Patient Experience
Patient and carer involvement in ward
round, discharge planning.
Clear verbal and written
communication of the plan of care.
Patient involvement in improvement.
Shared Understanding of Opportunities and Challenges
Individual ward teams engaged in regular improvement meetings
Mesosystem
Microsystem
Before the ward collaborative….
Good foundations for sustainability?
• Co-coaching model helps
support ‘novice’ coaches
and aids ‘resilience’.
• Teams regularly sharing
ideas and challenges
supports spread and
sustain
“The sharing events - it was very useful to know that most other groups were struggling with participation
and that it could be overcome.”
“I hope it will become part of our culture that we pick up. There are lots of other things
that we need to apply the same principles to..”
“We have been doing some new things in the department and that is possible
only because there is a sense of direction that has been created by the Trust
and by our own local leadership”
“Interesting hearing from other wards – hearing stories, difficulties and
challenges.”
Team & Wards Themes PDSAs
GSM
(B5,6 & 7, RH5 & 6
NGH)
Communication, Noise
Board Round redesign
E-discharge
Case note standardisation
Ward Environment
Gastro
(RH3 & RH4 NGH)
Patient Flow (timely discharge),
Patient Entertainment, Patient
Nutrition
Daily Board Rounds and Ward Rounds.
Junior doctor induction pack..
Patient entertainment – availability of a
newspaper/sweet trolley and working TV’s
Drug Rounds
Spinal (Osborn 2) Organisation, Ward Processes,
Food
MDT ward round standardisation
Patient information & Food storage
Drug round redesign
Spinal (Osborn 3) Team Work
Ward documentation
Improving flow of ward round
MDT communication tests
Standardisation to reduce time wasted
TTO’s
Discharge Processes
Infectious Diseases
(E1 & E2 RHH) Ward attenders
Overall process redesign. New labelling for tests, diary
system, blood result redesign, patient tracking
TTO’s
Orthopaedics (F1
RHH)
TED Stockings Process
Pain Management
Patients belongings
Tested stocking aid reducing delay in discharge. Test re
X ray process to improve pain management and
immediately start physiotherapy.
Joint School
Active PDSA’s
Geriatric and Stroke Medicine
The team used a
fishbone diagram to
identify the reasons for
e-discharge delays.
E-discharge is used to
essentially inform the GP
about the patients
medication and history .
A new discharge
checklist was introduced
and reminders were also
put up on the wards.
E-discharge compliance improved from 37 hours to
11.
An intervention was introduced in
November: Consultants were asked to
release junior doctors from the board
and ward round to write TTOs early for
any patient identified for D/C that day.
This was only when staffing numbers
allowed. 4 juniors is considered
minimum staffing levels (1 junior per
team) when a junior can not be
released from the ward round to do
TTOs. This table shows the number of
junior doctors available on the ward
round and afterwards to do jobs. This
is a significant barrier to sustainability
of this improvement
Gastroenterology
Spinal Injuries
Weekly ward rounds were chosen as an area for specific improvement to address key challenges:
•Meetings not starting on time
•Not all MDT members recording feedback
•Difficulties around disseminating information gathered/discussed in the ward round meeting
•Not having a clear set of actions from the discussion
•Not fully understanding/appreciating other professional roles
• 100% of patients who have clear set
of actions agreed during the MDT.
• 30% increase in number of patients
that are discussed, seen, and have
agreed actions within 12 minutes
per patient.
• Significant decrease in time spent
to disseminate outcomes of MDT to
nurses caring for these patients on
the ward
The future……
Collaborative approach -
wards
Two different approaches
Programme approach -
theatres
134
Microsystem Improvement work in theatres
Identify Available Technology
Process mapping of scheduling
and planning processes
Staff and Patient views
Best practice internally
and externally
135
• Consultant Anaesthetists &
Surgeons
• Senior theatre managers
• Theatre flow experts
• Service Improvement experts
the vision…
“To create a best practice, truly patient centred experience of elective surgery
where the referral to recovery process is right first time”
13 Seamless Surgery Principles
Once listed for surgery dates for future appointments (e.g. for pre-op or for surgery) agreed with the patient present or over the phone.
All appropriate patients will use electronic pre-operative assessment (ePAQ-PO)
Escalation plans are in place to address issues with upcoming lists (e.g. lack of equipment, staff or patients)
Scheduling meetings take place every week with staff from theatres, the Directorate with clinical input to plan theatre capacity ahead and review the lists for the following two weeks
Weekly root cause analysis is undertaken of the previous weeks on day cancellations
Electronic diaries to manage lists and to enable effective communication between teams
Alturos is used to plan lists in conjunction with the operating surgeon
Lists are uploaded to ORMIS two weeks before they take place
All patients are called four days prior to their planned admission, to ensure the they are fit, ready and able to attend
List orders are finalised and fixed 48 hours before admission
Operating teams are consistent with a regular core and appropriately skilled team
Operating teams agree and standardise the organisation of the theatre, equipment needed and specific staff roles
Theatre teams are supported to ensure lists start on time, turnaround times are minimised and the list finishes on time
The Launch – July 2016
• Half day theatre shut down
• Over 300 staff attended launch/workshop
• Senior Executive Presence and Support
• Mix of presentations, videos from patients and staff and opportunity to work in
MDT teams to discuss action plan
Post Launch
• Continued quality improvement training with focus on elective pathway
• Interactive game, helps staff see full pathway and experience from patient
perspective
• Set up weekly/fortnightly meetings to continue working on action plans
• Seamless Surgery Board
Seamless Surgery –
Post Launch
Neurosurgery
Perfect Lists
Electronic Pre-operative assessment has
enabled a one stop service for 450 patients
per month, whilst freeing up 430 hours of
face to face slots, delivered by senior
nursing staff
50% reduction in on day
cancellations in Orthopaedic
Surgery from 6% to 3%, meaning an
additional 3 cases per week
Improved
planning
meetings
Eradicated cancellations for high
blood pressure in Ophthalmology
through implementation of new
policy
ENT amended their waiting
form to include additional
information such as
procedure length and
overnight stay
New briefing process has reduced
late starts in many theatres across
NGH and RHH
Ophthalmology
get an inpatient
report to reduce
cancellations
Pre-op staff are working
towards standardised
working to reduce
variation in patient
experience and waiting
times
Cardiac theatres have
made lots of small
changes to their
processes to reduce
wound infections to 0
Seamless Surgery -
Next Steps…
Improved Visibility of
Key Metrics
Development of SOPs
for key parts of
Elective pathway
Reduction in
Patient
medication
waste
Electronic waiting
list forms Continued roll out of
new briefing
process to reduce
late starts
Escort support
workers to assist
patient movement
Increased focus to
reduce on day
cancellations
Sharing and
Celebration Event
More Information….
@seamlesssurgery
www.sheffieldmca.org.uk/seamless-surgery
“While the literature often portrays an organization’s quest
for change like a brisk march along a well-marked path,
those in the middle of change are more likely to describe
their journey as a laborious crawl towards an elusive,
flickering goal, with many wrong turns and missed opportunities
along the way. Only rarely does an organization know
exactly where it’s going, or how it should get there.”
Kanter R.M., Stein B.A., Jick T.D.: The Challenge of Organizational Change:
How People
What we are learning…
Microsystem improvement engages people and help build motivation and improvement capability to tackle strategic challenges.
Building on this for wider system level improvement:
•No one size fits – different contexts need different approaches.
•Stick to the improvement principles whichever approach.
•Build a shared purpose.
•Clinical and managerial champions creating the conditions.
•Opportunities for teams to learn together and share.
•Simple organisational drivers/principles
•Visible metrics that matter.
Common Challenges
“It’s a bit like steering a super tanker isn’t it. You can’t just spin the steering wheel and turn it round You’ve got to do
gradual changes to make the whole thing improve. But people struggle to see what on a daily basis”
Communication
to wider team
“And you’d like to get different people to come
and get an experience but you really want
continuity because otherwise you spend half an
hour telling people what you’ve been doing the
week before. So it needs to be similar people
each time”
Resilience under
pressure
But its still getting them, oh I need this, I need to care
for this patient, I need to do that, and its difficult to
argue when you’ve not got many staff………..So we
are going to keep doing it , we will get better eventually,
we’re going to keep meeting every week and were
going to keep doing it. That’s what we’ll do”
Leadership
support
“We have been doing some new things in the
department and that is possible only because
there is a sense of direction that has been
created by the Trust and by our own local
leadership; if we apply the same principle it
should work.
Common Challenges
“It’s a bit like steering a super tanker isn’t it. You can’t just spin the steering wheel and turn it round You’ve got to do
gradual changes to make the whole thing improve. But people struggle to see what on a daily basis”
Timescales
“It’s a bit like steering a super tanker isn’t it.
You can’t just spin the steering wheel and turn
it round You’ve got to do gradual changes to
make the whole thing improve. But people
struggle to see what on a daily basis”
Opportunity and
Capability
In fact one of the most vociferous and active
members of our team is a support worker, very,
very, very good. She was the one who led the
survey and formulated the ballot boxes,
Measurement
I found it all really useful, stuff that I have
never thought of in such a way that you
analyze your work, obviously because there is
no point in doing a change and not actually
looking at whether it’s made a difference or not
A chance to reflect…
•What experience can you share about each of
these different challenges?
•As coaches what do we need to pay attention to?
•What ideas do you have about how to support
teams with these challenges?
• How can you share learning – what ideas do you
have?
Common challenges as coaching
opportunities? •Communication to the wider team is problematic and variable - paying attention to who and when is key to ownership and engagement
•Opportunities to build capability exist – finding ways in partnership with teams to allow the right people to attend meetings is helpful
•Leadership support – different style of leadership – teams need permission
•Timescales are difficult to define – leaders and teams have a role in describing and linking the strategic direction and operational challenges with improvement work.
•Measurement even when the ward was going through some bad patches, the coaches persisted with encouraging the rest of the team. The persistence actually paid off
“And you’d like to get different people to come and get an experience but you really want continuity because otherwise
you spend half an hour telling people what you’ve been doing the week before. So it needs to be similar people each
week.”
“It’s a bit like steering a super tanker isn’t it. You can’t just spin the steering wheel and turn it round You’ve got to do
gradual changes to make the whole thing improve. But people struggle to see what on a daily basis”
“We have been doing some new things in the department
and that is possible only because there is a sense of
direction that has been created by the Trust and by our own
local leadership; if we apply the same principle it should
work. There’s no reason why it shouldn’t work.”
Back to Sheffield Teaching Hospitals very own
Elephant!
16.15
Jim
Close
Reflections
Share your thoughts on the day…
Post it evaluation:
Dates for the diary
MCA Expo '17
5-6 June 2017
Sheffield Hallam University
Charles Street Building
MCA Connect
13 July 2017 (9.15-16.30)
Mayfield, SHSC
The next workshop in six months time – keep
an eye on the website