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Top 50 quality improvement projects from nationally submitted abstracts

* SPECIAL LAUNCH

Casebook 2012

EDITION 1


Welcome to the first Network Casebook

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Casebook 2012


This Casebook, and indeed The Network itself, are inspired by the realisation that across the country, junior doctors are engaged in innovative, ambitious and dedicated attempts to improve the services they work in, for the patients they serve. The Network aims to create a platform for junior doctors to share their learning and experiences, to gain inspiration, and to celebrate the endeavour shown by so many of you in trying to create change. Many of you will know what it feels like to have tried, but failed to make the changes that you wanted to see. Or perhaps, the changes you made failed to have the impact you anticipated. The absence of impact, to us, does not represent failure, but rather an opportunity to reflect, to build and to move on. Sharing that learning with like-minded health professionals gives you the chance to help others avoid the traps and pitfalls that you uncovered. That is why, in choosing the projects to be included in this Casebook, we purposefully selected some projects that failed to deliver the improvements they hoped for. Please take the time to look at these ones: each one contains reflections that we could all learn from. But this is not all about heroic failure. This is also a celebration of success, and within the 50 projects included are some marvellous examples. You will each have your own personal favourites, but look out for the different characteristics that define each project. Some showed

Healthcare is a knowledge business; it is knowledge that professionals and patients need and use to translate the financial resources of a health service into better healthcare and better health. Major advances have taken place in the management of knowledge in the last decade, but only in two of the three types of generalisable knowledge. Evidence, the knowledge derived from research, is now well managed by a number of services, such as NHS Choices and NHS Evidence, and statistics or information, knowledge derived from the analysis of routinely collected or audit data, is also much better organized but the third type of generalisable knowledge- that which is derived from experience is still neglected and ignored Experience is sometimes used to mean only the years and decades that senior staff have worked, and there is much

Casebook 2012

imagination, others great flair. Some were notable for the sheer tenacity that their authors showed in taking their projects forward. This collection, therefore, not only aims to celebrate the work that the authors put in to these projects, but also to inspire you to have a go, and to learn something more about what works, and what doesn’t. The Casebook is not meant to stand alone, but rather alongside The Network website, as a forum for sharing, connecting and gaining inspiration. If we look at the Casebook as the Summer Ball, then perhaps www.thenetwork.org.uk is the Doctors’ Mess - that place we go to to catch up, to get advice, to ask around and find ideas from. We hope that this is just the first of many such Casebooks, but that depends on you. So read on, have a look at what others have done, and be inspired. And remember - it’s not about knowing the answers before you start. Sometimes, it’s just about having a go. That’s what many of the people behind the projects in this book did. You don’t need permission to make things better, you just need some energy, some good ideas and, of course, a little help from your friends.

The Network Casebook Team

to be learned if their knowledge is harvested, for example by pre retirement interviews but what a doctor in training experiences is also of great importance. Sometimes it is the freshness of their view that identifies a problem and a potential for improvement that more long standing staff have come to accept as ‘just the way it is’. For this reason the QIPP Rightcare Programme decided to tap the knowledge in the Network and the results, the case reports, are amazing. Both the contributors and the organizers of the Casebook are to be congratulated on starting a knowledge service that will help the health service, other doctors in training and, most important of all, patients.

Sir Muir Gray

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The Network Casebook Team Rob Bethune

Riaz Dharamshi

Whist working as a surgical SHO in 2004 I became hugely frustrated at the inefficiency of the operating list. We would never start on time and the right equipment was never ready. This led my surgical consultant to become angry and blame the theatre staff, they in turn retrenched and the situation worsened. By chance I heard a lecture on how the Red Arrows brief and debrief and this reminded me of every game of rugby I had ever played; we always met before hand to introduce new players and discuss plans. What I suddenly realised was that we were not doing this in the operating theatre even though patients lives were on the line. So I set about introducing theatre briefings and debriefings. Initially my consultant was unhelpful (he in fact told me not to bother as nothing would work) so I went to the Chief Executive for support, which he gave. The theatre briefings worked and I transferred them to other hospitals as I rotated. I have since become involved in The Network and the Casebook as I can really see that the care we give our patients could be massively improved if junior doctors, medical students and all other healthcare professionals were able to share and learn from each other’s quality improvement work.

In 2007, many of my friends and colleagues were affected by the new online job application system, MTAS. The confusion and chaos sown by this new system left some people I know without jobs and fearful for their professional futures.

Andy Carson-Stevens Since 2008, I was fortunate to be a medical student within the first wave of graduates of the Institute for Healthcare Improvement’s Open School for Health Professions. The IHI Open School provides students and newly qualified junior doctors with online courses in quality improvement, patient safety and leadership written by world-renowned expert faculty. Charged with new knowledge and skills to improve the quality of patient care, an army now serves to minimise healthcare harm and better the patient experience in the NHS.

In this context, I noticed that many of these highly skilled, articulate and intelligent individuals were struggling to know what to do about the situation. There were plenty of opportunities to moan about the problem, both in the Doctors’ Mess and in online chat rooms, but many were at a loss about how to make any meaningful representation of their plight. The realisation that effective action was not simply a product of high intelligence, but required something more than that encouraged me to learn about clinical leadership. That took me through a number of service development projects, where the satisfaction of seeing my efforts improve patient care led me into the Darzi Fellowship in Clinical Leadership. During that year, one of the things that I enjoyed most was the opportunity to support House Officers and SHOs find solutions to the system issues that affected them every day. The process of supporting these ambitious and talented doctors to improve the care they delivered to patients reminded me that improving systems needn’t be hard, and you don’t need permission to make services better. Improving healthcare is partly about identifying the problems, partly about identifying the solution, but mostly about supporting and engaging the people affected. It is this interpersonal aspect of working towards service development that I love. The experience of empowering people to create their own improvements, to take ownership in the service they deliver, and to know what it means to be able and allowed to take responsibility is what it’s all about for me.

To support the dissemination and growth of this effort, communities of like-minded others have formed ‘Chapters’ at universities and hospitals across the UK. Many of the authors of the abstracts within this Casebook are members of Chapters or certified graduates of the IHI Open School. However, The Network has emerged to become the virtual place where many UK IHI Open School students and graduates go to meet other frontline improvers and innovators. By sharing and discussing my own leadership challenges on The Network’s website with those facing similar struggles, has really helped guide and further my own improvement work. The continued growth and coexistence of the IHI Open School and The Network’s communities inspires confidence that existing and future generations of doctors are sufficiently skilled to serve as architects able to redesign the systems in which they work.

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Casebook 2012


The Network Casebook Team Jonathan Hyer

Nikki Kanani

My experience of trying to improve the quality of service and care of patients is probably not unique - struggling over obstacles and the tide of resistance to change. I found the argument “but this is how we’ve always done things” grated on my sense of the rational. My enthusiasm for innovation and the potential for improvement within healthcare led me to the-network. I was very impressed with the simplicity of the aspiration - doctors need to be better connected. I had come to the same conclusion not long after starting my first rotation as a Foundation Doctor, informed that my rota for the coming weeks was unfinished, yet my friends in other hospitals had their rota for the entire year. In that moment I realised that across the country, hospitals face the same problems. Innovation was not being shared, and I found this profoundly disappointing. My involvement with the making of this casebook has been a pleasure and a privilege. Reading through all the submissions I was able to glimpse through the looking glass into the future of healthcare where we share all our successes and failures.

The eternal revolving door of medical training - millions have been through it, most as passive learners, the medical model learnt inside out. Most develop a holistic, patient centred approach, but few have the time to consider the constraints and inefficiencies of the system in which they work which detracts from their daily tasks. Even fewer decide “I can change that”.

But it is more than this; it is a light illuminating motivated individuals striving to improve the lives of patients and staff. If I am honest, my motivation to help produce this casebook was inspired by you. Individuals like yourself who are reading this casebook or who have submitted abstracts. Individuals who are going to submit abstracts next year.

Zain Sikafi 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.

When The Network was first launched, we gained 1000 new members in 100 days. Now we have over 2000 members from all specialties and professions, grades and parts of the country (and beyond). Together we have started sharing stories, cases, training opportunities, ideas. And we discovered, finally, that we are not alone. We all share the one key principal: “I can change that”. Healthcare is needed by all. There is no perfect method of delivery, no ‘one size fits all’ approach. For too long systems have been used to regulate the output of healthcare professionals but it’s time to turn the tables and realise that people make systems work and more importantly, people can change systems and make them better, dynamic and adaptable to the needs of individuals. What The Network offers is support. Not the “we’ll tell you how to do it” support but the “we’ll give you the tools to build your vision” support. And this casebook is part of that: our gift to you. It is the combined experiences of people who saw something that needed changing and had a go at changing it. Not every idea works, but experience tells us we learn more from our mistakes than our successes. So read, reflect and learn. Look beyond your own patient, beyond your own department or surgery, keep expanding your horizons, and your ideas, your energy and your skills can touch the lives of far more people than you could ever have imagined. Be inspired to see a need, have an idea and implement it so you can say “I changed that”.

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.

Casebook 2012

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Project Title:

Lessons Learnt Building a Safer Foundation

Submitted by:

Maria Ahmed, Sonal Arora, Steph Tiew, Paul Baker, Jacky Hayden, Charles Vincent, Nick Sevdalis

Context:

‘Lessons Learnt: Building a Safer Foundation’(LL) is a collaborative project between NHS North West, Northwestern Deanery and Imperial College Centre for Patient Safety and Service Quality (CPSSQ) involving clinicians, educationalists, academics and safety experts to develop, implement and evaluate safety training for all Foundation trainees(n=1076) across all Foundation Programmes(n=16) in northwest England.

Problem:

Incident reporting amongst junior doctors is poor due to various factors: guilt/shame, lack of time/opportunity and the perception that incident reports enter a ‘black hole’ and nothing is done about them. Internationally there are increasingly calls for the integration of patient safety into health-worker curricula to promote sustainable improvements in patient care. The Foundation Programme curriculum stipulates Patient Safety as a core competency but there is minimal opportunity for trainees to develop ‘safety skills’.

Assessment of problem and analysis of its causes:

A survey of FY1 trainees at my Trust (n=30) revealed the majority agreed/strongly agreed that reflection is a powerful tool for learning from patient safety incidents(PSI)(94%) and that they can learn from each other’s incidents(100%). However, only 55% felt confident in discussing incidents with peers. I secured Foundation Programme Director approval to pilot LL to formalize the opportunity for trainees to discuss and learn from PSIs in a safe facilitated forum. Feedback was very positive with 94% confident in discussing PSIs with peers.

Intervention:

Following the pilot I secured competitive funding to roll-out LL across the Northwestern Foundation School (NHS North West Junior Doctor Innovation Award’(£10,000)). LL comprises monthly 60-minute sessions built into Foundation teaching, wherein trainees discuss and analyse a PSI to identify contributing factors and propose potential solutions, using a validated root cause analysis tool. Sessions are facilitated by expert-trained senior doctors. LL aimed to address the well-documented barriers to integration of safety training through i) developing a sustainable means of delivering safety training, led by trainees for trainees ii) building capacity for safety training through recruiting and training senior doctors as Facilitators in order to: • Improve Foundation trainees’ knowledge, attitudes, skills and behaviours in patient safet • Foster an ‘open and learning’ safety culture across the Northwestern Foundation School

Strategy for change:

The strategy for change focussed on engagement of core stakeholders (Foundation Programme Directors/Administrators, Foundation trainees, prospective Facilitators). This was achieved through the following: • • • • • • •

Measurement of improvement:

08/2010: Recruitment and appointment of i)Foundation trainee ‘Leads’ at every site to lead local implementation(n=34) ii) Consultants and senior SpRs across the northwest to act as Facilitators (n=57) 09/2010: Launch conference inviting stakeholders as above (n=101) from all 16 sites to inform delivery from project initiation 11/2010: Lead and Facilitator training by patient safety experts from Imperial CPSSQ 01/2011: Local LL launches at every site delivered by Leads and Facilitators (standardised launch-pack provided) 02-07/2011: Monthly sessions administered by FPAs with project team support/guidance 09/2011: Feedback conference inviting representatives as above (n=117) to share results and inform development into 2012 Ongoing: wider dissemination including national/international conferences and publications

A combination of bespoke and validated tools were used to evaluate LL. The impact of LL is demonstrable through the evaluation results, its sustainability and transferability and the awards/sponsorship received: Evaluation: • High participant satisfaction • Significant improvement in safety knowledge, attitudes and skills of Foundation trainees and Consultant/SpR Facilitators (pre-post questionnaire). • Organisational impact: Average incident reporting rates doubled amongst trainees. Over 30 trainee-led quality improvement projects completed in 2010-2011 spanning development of clinical protocols/pathways, delivery of userinformed training and improved working conditions. • Senior clinical engagement: 101 Consultants(95%) and SpRs(5%) volunteered as Facilitators; 57 trained in 2010. Additional 105 volunteered in 2012; 63 trained.

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Sustainability & transferability: • All 16 sites continuing LL into 2012. • Interest across UK and internationally: supporting implementation of LL in London and in discussions to implement into undergraduate training in Australia. Awards & sponsorship: • BMJ Excellence in Healthcare Education Award 2012(shortlisted). • Greater Manchester HIEC Excellence in Innovation Award 2011(£5000). • Event sponsorship from medico-legal organisations(£4100). Problems encountered: • Clinical commitments hindering Facilitator attendance at some sessions. • Lack of follow-through of actions by trainees.

Lessons learnt:

• • •

There is considerable appetite amongst senior doctors to learn and teach about patient safety. Junior doctors are powerful agents for change in recruiting peer support and driving local implementation. Offer training on quality improvement methodology to promote follow-through of actions.

Message for others:

Through engaging stakeholders and investing in faculty development, effective training interventions in patient safety can be implemented and sustained on a minimal budget. LL has successfully developed a cohort of junior doctors with the drive and capability to analyse PSIs and action solutions through quality improvement projects. It has fostered a culture wherein senior doctors support their juniors in challenging the system to improve patient care.

Casebook 2012


Project Title:

Improving patient attendance in Radiology at Great Ormond Street Hospital

Submitted by:

Owen Arthurs, Sophie Swinson, Marina Easty, Fiona Ashworth

Context:

This project looked at how to improve the number of children who fail to attend the Nuclear Medicine (NM) department at a specialist children’s hospital; Great Ormond Street Hospital in London.

Problem:

There is currently an 11% did-not-attend (DNA) rate for out-patient NM tests at GOS Hospital. Patients are currently sent letters for their NM appointment to coincide with an out-patient clinic appointment; they often fail to attend for both. As radionuclides need to be ordered individually for each patient, when they do not attend, there are several problems – the radionuclide cannot be reused, wasting precious resources at significant cost, and the appointment cannot be filled by another patient (who would need radionuclide preparation) and so radiography and camera time is wasted, leading to other patients waiting longer for their test. Our aim is zero waste, and zero wait.

Assessment of problem and analysis of its causes:

Most NM out-patient requests in childhood are for renal investigations, either DMSA or MAG-3 scans. Patients are referred from either internal (GOS) or external hospital clincians; anecdotally this was a greater problem for externally referred sources. We thought that we needed to improve communication between the NM department and referred patients: we needed to improve the letters that were sent out (which patients either did not receive or did not understand), and provide a telephone reminder. This would only work if we had well documented up-to-date contact details. We excluded in-patients from this study as communication with the wards is currently not an issue.

Intervention:

Our Radiology IT support searched the database for the data regarding DNA rates: 116 / 1084 DNAs for NM out-patients in 2011 (11%).

Strategy for change:

The first intervention we was to implement a telephone reminder service for all patients, to see whether this would either improve attendance rates, or reveal inherent problems in our documentation systems.

Measurement of improvement:

First PDSA cycle: after searching our hospital database for telephone numbers, one radiographer phoned patients each Friday to remind them that they had a NM appointment the following week. We documented whether phone numbers were available, incorrect, unable to speak to patients but left a message, or able to speak to patients directly. We will now present these results to our department and the Urologists to see whether we can improve contact details. Effects of first PDSA cycle: We contacted 29 patients over a 2 week cycle. Contact

Internal Attendance

(%)

External Attendance

(%)

Overall

(%)

No details

0/1

50

2/2

100

2/3

66

Wrong number

1/2

50

-

-

1/2

50

Message left

5/5

100

-

-

5/5

100

No message facility

2/2

100

1 /1

100

3/3

100

Phoned

13 / 15*

86

1 /1

100

14 / 16

87

Overall

21 / 25

84

4/4

100

25 / 29

85%

* 1 patient did not attend but the parent called the previous day as the child was unwell. Effects of change:

We conclude that most DNA occurs in those patients in whom we cannot contact, either do not have a telephone number, or it is not up to date. We will now try to devise a system to ensure that all clinicians accurately record telephone numbers on arrival to clinics in order to improve patient contact. We will re-evaluate after a 2 week period of improving documenting telephone numbers, to see whether this can improve patient throughput.

Lessons learnt:

We did not change our DNA rates by instituting a telephone reminder system – because we could not contact several patients. Our initial preconception that external hospital attendance was poorer was incorrect. It is likely that if we could improve contact detail documentation for just one or two patients per week, we should be able to significantly reduce the DNA rate.

Message for others:

Trying to implement a telephone reminder system revealed flaws in our documentation system. In order to provide the former, we must first improve the latter. We could not use the same telephone reminder system in another area within Radiology, or another department, with the same deficits in documentation. This must be our first area of improvement. Our second intervention will be to improve the letters sent out, but again, we must make sure we have the correct contact details.

Casebook 2012

*

Prize Winner 7


Project Title:

DAPS Handover Wiki

Submitted by:

Will Barker, Ed Mew, Imran Qureshi

Context:

New technology and shift patterns have meant that whilst services like pathology and x-ray have got better, handover and referrals have got worse. The administrative burden on junior doctors is greater now than it has ever been and most handover and referral processes are unique to hospital firms. Addressing this challenge, this project is based in St Peter’s hospital, with the potential to extension across the UK or internationally. It is ostensibly targeted at junior doctors.

Problem:

Poor handovers due to unfamiliarity with the job lead to mistakes and vital administrative tasks being missed or performed badly. A disproportionate amount of time can be spent looking for the right form or trying to find the right person to send it to. Junior doctors ‘rotate’ frequently, ending up in new jobs they are unfamiliar with knowledge lost between cohorts as how best to do the job. Excessive time is spent adapting to the practical aspects of the new job affecting patient care if investigations are ordered incorrectly or there is a delay in a referral. It also means that junior doctors have less time to spend looking after the medical aspects of their patients’ care.

Assessment of problem and analysis of its causes:

We collected information from a survey of junior doctors at St Peters hospital and found that 7 months after starting at the hospital they still lost on average 40 minutes a day due to unfamiliarity with referrals or forms. It also showed that the main source of information was other doctors, rather than trust guidelines- implying a waste of other doctors’ time. We discussed options with IT and the Clinical Lead for IT at St Peters and also DAPs founder Imran Qureshi and found that this problem was not localized to St Peters but a national problem.

Intervention:

With Imran’s help we created an electronic handover tool accessible from every hospital in the country detailing the roles and responsibilities of all F1 jobs and the information needed to complete technical administrative tasks for the role e.g. booking outpatient echocardiograms or referring to a urology clinic. The site is a private wiki’ allowing it to be edited by nominated doctors from each hospital to keep it rapidly updated. We used pmWiki as the template and followed a set format for job description, thus standardizing the layout to ease navigation.

Strategy for change:

We recruited junior doctors within the hospital and also neighboring hospitals to record the administrative aspects of their job. For expert opinion we approached Imran Qureshi who hosted the service on the DAPs server. We sought the opinion of clinical IT leads and created a template, scalable nationally with examples. We then collected information, which we standardized and regulated. To disseminate the results of the analysis we used email and gave access to the Wiki to doctors. Pending approval, the aim is for a workable handover system to be in place in St Peter’s hospital for the April handover.

Measurement of improvement:

We plan to repeat the questionnaire in the first weeks of the new job in April to assess the usefulness of the new site.

Effects of change:

The project highlighted the issue of poor doctor handovers. It allows much greater continuity between cohorts of doctors and empowers doctors to improve the service they provide using a tool which will be universal between hospitals, saving time and improving quality. Problems we encountered were inertia against a new idea, which manifested with hospital IT afraid to take risks and alluding to problems which they would not substantiate.

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Lessons learnt:

If you can define a process you can refine a process. In this case, the process is that of handover and referral. This tool provides the means for lasting improvement as these developments can be accessible to all junior doctors. The people we saw to talk through our idea were much more receptive when we showed them a workable ‘demo’.

Message for others:

There are ways of using technology which does not breach hospital information guidelines, but be informed and careful. IT can be free, with no paper, no adverts- using open source software. Advances in IT are revolutionizing processes around the world- they should be embraced by medicine. Technology can be better and more lasting than simple paper based solutions. Inefficiencies are not inherent in the system and the obstacles of handover can be overcome. This tool ensures handover that is 100% appropriate- written by doctors doing the job. It ensures that the thoughts/efforts/skills of those preceding doctors don’t get lost. This is part of your solution to improving safety and quality.

Casebook 2012


Project Title:

An analysis of surgical record keeping to improve safety and efficiency of surgical admissions, Musgrove Park Hospital, Taunton

Submitted by:

Hannah Bellord, Jessica Foster, Sarah Hughes, Alice Hunt, Smita Jayaraman, Sarah Page, Rebecca Sexton, Annika Tingay

Context:

An analysis of surgical record keeping identified areas of concern in documentation. This study was implemented to address these areas and implement change to improve efficiency and safety of surgical admissions. The improvement project was undertaken by FY1 Doctors and conducted on the Surgical Admissions Unit at Musgrove Park Hospital, Taunton. Members of the multidisciplinary team involved included all grades of doctors (FY1’s to consultants), nurses and pharmacists.

Problem:

Healthcare workers had raised the following concerns with regards to the admission clerking procedure for surgical cases: 1) Admission procedure lacking efficacy. 2) Lack of standardisation. 3) Disparity in quality and quantity of documentation. 4) Misfiling. 5) Patient risk. 6) Post-take ward rounds hindered by missing information. Qualitative data was collected using an internet-based survey to establish junior doctors’ opinions on the current surgical documentation system and suggestions for improvement. 52% of FY1s stated there was “nothing good” about the notes, 24% stated the notes were “disorganised/missing essential information/misfiled”.

Assessment of problem and analysis of its causes:

Quantitative data was collected by randomly selecting 20 sets of notes from four post-take ward rounds, recording any missing information. This revealed: 15% of notes were missing important blood results, 20% of notes had missing medical imaging results, 55% of ECGs were not commented on, 60% of post-take ward rounds were missing a documented consultant impression and 80% of notes were not filed in order. A questionnaire to quantify interruptions to ward rounds caused by missing information in the surgical notes was used to measure the level of frustration secondary to the recording in the current surgical notes. 89% of FY1s stated the notes were not easy to locate, 89% had to interrupt the ward round to look for missing clerking information. All FY1s stated that generally the notes were not in order and that the notes were felt to be a source of frustration during post-take ward round. We hypothesised that a standard clerking proforma would improve efficiency and patient safety through reliable documentation.

Intervention:

A surgical orientated admissions document was designed. 4 PDSA audit cycles were used to trial the formulated proforma on the admission unit with subsequent alterations in improvement made following each cycle before the final version was implemented. All grades of doctors, pharmacists and nurses were consulted during the trials and their opinions were also used to formulate the new profoma.

Strategy for change:

The proforma was placed on the admissions ward and used by the doctors, nurses, pharmacists and receptionists. Discussion with peers and surgical supervisors enabled feedback on the proforma and approval from those in charge of the surgical division to implement change. The time span from initial idea to implementation of initial proforma was 6months and 1 year to final proforma implementation.

Measurement of improvement:

Re-audit of 25 proformas revealed overall improvement in each aspect of documentation: 100% of notes contained all relevant blood results, 100% of notes contained appropriate imaging results, 100% of notes included a consultant impression and plan and 100% of surgical notes were in order.

Effects of change:

FY1s were asked their opinion of the new proforma. 100% said the post-take ward round was interrupted less frequently with the proforma, to an extent which reduced levels of frustration and improved smooth flow of attendance on the PTWR. When asked how helpful the proforma was in aiding efficiency of their work, the proforma was rated as 8.5 on a scale of 10. The consultants were not aware of the problem raised until it had been highlighted to them. To enable proforma implementation to be approved by the surgical division, the qualitative and quantitative data collected assisted their decision in understanding why change was needed. The audit was conducted through changing FY1 rotations, therefore good communication between our improvement group and those new FY1s starting on the SAU was vital to ensure effective and reliable data collection.

Lessons learnt:

Early implementation of change can lead to a rapidly evolving process with continued positive development and achievement. Junior doctors are able to make change in healthcare improvement. Implementation of a product is more successful if all users of the final product are involved in the decision process. From learning experience of this improvement project, next time, allied health professionals would be involved at an earlier stage. A larger sample size of surgical notes would be analysed and over a longer period of time.

Message for others:

Complete available medical records are essential for the efficient working of a hospital department. This study identified areas of concern for the safety and efficiency of patient admissions to SAU, suggested and implemented improvements with a positive and successful outcome for patient care.

Casebook 2012

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Project Title:

Can nurse-led oxygen management improve the delivery of oxygen therapy in the Acute Medical Admission Unit?

Submitted by:

Gordon Mitchelson Buchanan and Fraser Pryde

Context:

The improvement work was done in the Acute Medical Admissions Unit (AMAU) at Ninewells Hospital in Dundee. The unit is very busy with between 30 and 60 admissions per 24 hours. The project was supported by the Consultants and Senior Charge Nurses who were concerned that there may be delays in oxygen administration because of poor communication between doctors and nursing staff.

Problem:

A report from the National Patient Safety Agency outlined 281 serious incidents between December 2004 and June 2009 relating to inappropriate administration and management of oxygen. Poor oxygen management was attributed to 9 patient deaths and may have contributed to a further 35 deaths. A previous study by medical students at the University of Dundee established that compliance with British Thoracic Society (BTS) oxygen delivery guidelines could be improved by way of feedback using an improvement poster.

Assessment of problem and analysis of its causes:

The staff on AMAU thought that the problem was that nurses were able to identify patients who required oxygen but were unable to administer oxygen because doctors had not prescribed it. The staff perceived that nurse-led oxygen management may improve the current situation. This project aimed to improve nurses’ oxygen delivery knowledge and skills thereby facilitating compliance with the national guidelines.

Intervention:

Two healthcare professionals visited the AMAU every weekday during which time the prescription and Early Warning Score (EWS) charts of every patient were analysed and data taken relating to the correct prescription of oxygen by medical staff and the delivery of oxygen by nursing staff. Using data collected in the first week, weaknesses and errors in these processes were identified. From these, we devised an oxygen bundle and an Oxygen Prescribing and Administration flowchart that clearly identified the role of the nurse and that of the doctor.

Strategy for change:

We implemented our changes one by one with a sufficient time lapse between each intervention. We did this for one then 5 then 25 and then all patients on the ward. This involved testing out changes and then verbally feding back the results (positive and negative) to the staff before the next change was introduced. All tests of change were done using the PDSA cycle within a one month time period.

Measurement of improvement:

We measured compliance with the oxygen bundle each week day on all patients on the AMAU over three weeks following the first week of baseline data collection. We did six PDSA cycles to implement the bundle and guide. These were associated with 90% reliability of prescribing of oxygen but 20-40% of patients who were hypoxic did not receive oxygen. This was because the EWS charts were introduced nationally five years previously and had not been updated after the 2008 National Patient Safety Agency and British Thoracic Society guideline that raised the threshold for normal oxygen saturation from 93% to 94%.

Effects of change:

The Senior Consultant and Senior Charge Nurse were unwilling to authorise a change in the EWS chart because this was a national document. We contacted the Medical Director and Director of Nursing in NHS Tayside who did authorise a change to the EWS chart using a sticker that alerted nurses that 93% saturation was hypoxic. This authorisation was only given in the last few days of the project but we were able to complete two further PDSA cycles to test the new EWS chart.

Lessons learnt:

The project identified a fundamental systems error with the Early Warning Score that explained why hypoxic patients were not having oxygen administered. Even within the limited time available for this project we were able to obtain authorisation for systems change and test an adapted EWS. The staff on AMAU have committed to continue to use the new EWS charts. NHS Tayside Safety Governance and Risk have committed to changing the EWS charts across the whole organisation.

Message for others:

In just four weeks we completed 8 PDSA cycles and 18 days of measures for improvement. Having senior support on the AMAU from the start was important but we found that our tests required higher authorisation. In future improvement projects will be registered with the Clinical Quality Forum, which is the single point of contact for all clinical governance issues in NHS Tayside. A member of the Clinical Quality Forum will be identified who will be available to authorise tests of change during the project and who will take responsibility for ensuring that lessons learned are implemented after project is completed.

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Casebook 2012


Project Title:

Implementation of electronic discharge templates for elective day-case varicose vein surgery

Submitted by:

Shiv Chopra

Context:

The improvement work was carried out at Northwick Park Hospital, London. The hospital holds one of the busiest vascular surgery departments in London and was the focus of our quality improvement. As our work was involved in improving the quality of discharge summaries the groups involved were across the spectrum from patients and their respected GPs to consultants, pharmacists and clinical coders.

Problem:

Patients undergoing elective day-case varicose vein surgery frequently have handwritten paper discharge summaries which are subjectively difficult to interpret by GPs and patients, often incomplete and subsequently incorrectly coded. We sought to objectively determine if implementing an electronic discharge summary template for elective day-case varicose vein surgery improved coding accuracy. Furthermore implementation of a ‘Payment by Results system’ has caused NHS Trusts’ income to become dependent upon complete, accurate and timely discharge summaries. Incomplete handwritten summaries were also negatively affecting Hospital reimbursements. A secondary outcome measure was therefore to investigate the impact of electronic discharge summaries on appropriate Trust reimbursement by the PCT.

Assessment of problem and analysis of its causes:

We liaised with all key staff members involved for their comments on the current system and possible suggestions for change/ service improvement. Using such comments we could refine our assessment strategy and the solutions needed.

Intervention:

Using the hospital’s current software for electronic discharging of patients we created a refined model specific for day case varicose vein surgery. The template contained pre-filled fields and specific drop down options which enabled any clinician to navigate and complete with ease. Examples included reason for the procedure, operation name and site, complications and discharge advice to patient. The selection options also contained the correct ICD-10/SNOMED code were applicable.

Strategy for change:

Once the discharge template had been created, it was showcased to all members of the surgical department, day surgery unit and clinical coding department for review and support. A structured timetable of 4 month for change was also agreed upon so that all staff members had time to familiarise with the new system.

Measurement of improvement:

We retrospectively reviewed handwritten discharge summaries for 19 consecutive patients undergoing elective varicose vein surgery in a District General Hospital (May-August 2009) and a similar cohort of 19 consecutive patients following the implementation of electronic discharge templates (August-November 2009).

We reviewed handwritten discharge summaries for patients undergoing elective varicose vein surgery in a District General Hospital (MayAugust 2009). Clinical notes were reviewed for major coding markers relevant to clinical documentation for the GP on the same patients.

Clinical notes were reviewed for major coding markers relevant to clinical documentation for the GP. Reimbursement received by the Trust for these patients before and after implementing electronic discharge templates were collated and subsequently reviewed. All 19 paper discharge summaries analysed were incomplete having at least one missing major parameter compared to the electronic forms. 3 of those 19 patients had no record of any discharge summary. Financial analysis comparing the paper with the electronic discharges resulted in potential losses in excess of £3500 solely based on missing or incorrectly coded data Effects of change:

The template had a vast effect on all stakeholders from patients being able to take home a clear and detailed letter on their care to Consultants knowing with confidence that their procedures were documented correctly and to a high standard.

Lessons learnt:

That technology applied correctly can assist everyone from the patient to the Trust but clear communication and support is vital for change to occur smoothly and efficiently.

Message for others:

We conclude that electronic discharge templates improve accuracy of major coding markers which directly results in improved communication to both patients and GPs. Moreover it impacts on the Trust receiving appropriate payment for varicose vein surgery.

Casebook 2012

11


Project Title:

Doctors Training Doctors – a small group practical skills teaching model

Submitted by:

Lilli Cooper, Kathryn Ford, Jon Bower, Natalie Blencowe

Context:

This quality improvement project was undertaken at the Bristol Royal Infirmary (BRI), involving current surgical registrars and FY1s. Space was provided by the Education Centre and the project, approved by the Foundation Programme director, was sponsored by a local simulation company.

Problem:

Recent legislation has reduced the clinical exposure of junior doctors during training. This has reduced their opportunity to gain and practise essential technical skills, and has compromised unpressurised, longitudinal contact with seniors. Practical inexperience may impact upon patient care, whilst the loss of senior contact reduces the potential for customized guidance and inspiration, and the optimisation of career progression. The traditional apprenticeship model of British medical training relied upon ad hoc teaching to achieve adequate standards. However, this is no longer reliable with reduced working hours. Senior and junior doctors alike have publicly lamented the change in training structure in recent literature , but few solutions have been proposed. Given that current legislation is unlikely to change, we must develop quality improvement strategies to enhance our acquisition of skills and senior acquaintance within current working patterns. 

Assessment of problem and analysis of its causes:

Preliminary questionnaires suggested that 90% of surgical FY1s at the BRI (n=20) felt that their practical skills and opportunity to learn were poor/moderate. The surgical registrars (n=6) felt that the practical skills of current FY1s were worse than theirs at the same level of training. Over half of FY1s felt that patient continuity of care and their surgical knowledge was only moderate, whereas their handover, recognition of unwell patients and recognition of own limitations was rated relatively highly (see below). Very Poor / Poor

Moderate

High / Very high

Handover

2

7

11

Provision of continuity of care

2

10

8

Recognition of own limitations

0

2

18

Knowledge

2

11

7

Practical skills

7

11

2

Recognising unwell patients

0

5

15

Intervention:

We set up a small-group, practical skills teaching scheme called Doctors Training Doctors (DTD). Attendance by students (FY1s) and tutors (registrars) was voluntary and filled on a first-come-first-served basis. There was a relaxed environment encouraging professional interaction, whilst learning to suture. DTD was sponsored by a local simulation company, and we enjoyed a teaching space away from the wards.

Strategy for change:

We implemented DTD workshops for every new rotation of surgical FY1s at the BRI, adapted subtly to accommodate anonymous feedback. We disseminated our results locally, to the Foundation Programme director, and nationally in a letter to the editor of the Royal College of Surgeons Bulletin. The programme is ongoing for suturing, and has also been implemented with FY1s teaching medical students to cannulate.

Measurement of improvement:

In anonymous questionnaires, 100% of FY1s felt that DTD was an extremely useful teaching tool, and 100% felt confident in a practical skill in which they were unconfident beforehand. Anecdotally they also felt more comfortable with their registrars after taking part in DTD. 17% were considering surgery as a career. There was discrepancy between seniors’ views of their interest in juniors’ development (100% ‘yes’), and that of the FY1s’ perceptions (70% ‘sometimes’ or ‘no’). The registrars regarded themselves more approachable (66% ‘very’) than their juniors perceived them (60% ‘quite’). However, 65% of both FY1s and SpRs recognized that FY1s were only peripherally involved in the surgical team.

Effects of change:

In this quality improvement project, informal practical skills training instilled practical confidence. Time spent together as members of a team may also improve morale. In an anonymised Rosenberg self-esteem assessment twenty surgical F1s averaged clinically low selfesteem. Mazlow’s Hierarchy of Needs (1943) links low self-esteem to poor motivation. It is interesting to note that junior absenteeism has trebled nationally in recent years . The changes to junior doctor training in the UK may affect patient safety through reduced practical skill and lack of team cohesion. DTD is an effective teaching tool, ongoing at the BRI, increasing the quantity and quality of teaching from seniors, and potentially optimising clinical knowledge and skills, relationships and patient outcome.

Lessons learnt:

Currently, teaching does not enjoy the same status as clinical work. In the interests of our patients’ safety, as trainees we must change our attitudes to teaching and mentorship in order to compensate for the reduction in our working hours. As junior doctors, we may implement local teaching initiatives such as DTD, in protected time and space, inviting conscious involvement by those seniors who are interested in teaching and mentoring, with positive outcomes.

Message for others:

As juniors we feel the lack of practical skill and mentoring acutely, and it is detrimental to our patients. In a training system that is unlikely to change, the onus is on us to instill in the training doctors of today a culture of teaching and nurturing by example that will carry forward to the seniors of tomorrow.

12

Casebook 2012


Project Title:

Reducing Waste: Disposable Equipment

Submitted by:

Lilli Cooper, Kate Birschenall and Ed Miles

Context:

This quality improvement audit project took place on the Surgical Admissions Unit (SAU) at the Bristol Royal Infirmary. It involved all staff involved in clinical care.

Problem:

The recent recession stretched the National Health Service economically, and therefore affected patients and NHS employees. The NHS confederation report emphasizes the need for efficiency to overcome financial deficits and maintain service provision at its current standard. Nationally, efficiency measures have been introduced largely comprising of budget cuts. In our experience, an area largely ignored in increasing efficiency is reduction of waste. Reference: Liberating the NHS. What might happen? The Roger Bannister Health Summit, Leeds Castle, 2010, available at www.nhsconfed.org

Assessment of problem and analysis of its causes:

Like so many other areas in the NHS, the SAU was privy to budget cuts. We involved senior staff in discussions about the impact of these cuts on patient care. The SAU matron felt that without compromising patient safety, they could not reduce their available resources. They therefore weren’t able to meet the budget targets imposed upon them, to the detriment of the trust. We offered, as junior doctors, to focus on waste management. One area that we identified as a potential target for waste reduction was disposable equipment use.

Intervention:

Disposable equipment use was audited over eight weeks on the SAU, Bristol Royal Infirmary. We included cannulas, needles, syringes, needles and butterflies. Bright price tags were then displayed on disposable equipment boxes. After 4 weeks’ wash-out we re-audited a further eight weeks’ disposable equipment use, with prices still shown.

Strategy for change:

To implement this change we recruited the help of various parties. The matron helped us by designing the study with us, and giving her permission. The nurse in charge of equipment ordering kindly kept a record of the equipment that she had ordered so that we could ascertain what had been used. We implemented the plan unannounced, so as not to bias staff. The timetable for change overall was 5 months from beginning to end.

Measurement of improvement:

We measured the results by auditing as described above, and comparing disposable equipment use before we put up price tags with use afterwards, with users of price. We were able to identify the numbers of patients admitted to the SAU over the two 8 week periods, and compare them. Table 1: Results comparing disposable equipment use between two eight week periods on SAU. The first was without, and the second with, awareness of item price. 1st 8 weeks

2nd 8 weeks

Difference

# patients

941

987

5 % increase

Butterflies (63p)

844

677

20% decrease

Venflons (65p)

703

816

16% increase

Syringes (2-7p)

4238

4438

5% increase

Needles (2p)

2816

2217

21% reduction

Overall cost

£1239.96

£1194.59

4% saving

£1.32

£1.21

8% saving

Price per patient

Effects of change:

Overall there was a 4% saving overall on the cost of disposable equipment used on SAU, despite there being more patients in the second time period. Per patient, this equated to an 8% saving. We have, through this simple measure, improved patient care on the SAU, as there was no compromise on resources to meet their budget aims. We have presented our findings locally, regionally and nationally. On a larger, political scale, this project has huge implications for a refocus within our over-stretched NHS; perhaps we should be focussing on reducing waste as an adjunct to cutting budgets. We are currently repeating the project on a bigger scale, with more wards and different patient caseloads. We hope that the increased power of our study will lend it enough influence to present to the government as an alternative to budget cuts.

Lessons learnt:

That simple quality improvement measures may be very effective to ameliorate the effects of economic pressures; that it is important to reassess the accepted norm, and constantly strive for new ways to approach established problems; that even as a junior we have a role in leadership and an ability to implement change.

Message for others:

Simply awareness of cost may save 8% of disposable equipment use. There is a huge, and largely ignored, potential to reduce the strain on the NHS by simply addressing waste. This is to our, and our patients’ advantage, and costs very little implement, but a great deal to ignore.

Casebook 2012

13


Project Title:

Burning platforms and blind spots in COPD

Submitted by:

Anisha Doshi, Daniel Hammersley, Priya Shah, David Stanton, and Louise Restrick. Acknowledgements to: Claire Ward, NWCLARC, and Whittington Health

Context:

Whittington Health (WH), a busy district general hospital, has developed hospital-wide multi-disciplinary COPD care pathways. Staff involved include; respiratory clinicians, respiratory nurse specialists, smoking cessation officers, physiotherapists, matrons, and junior trainees.

Problem:

COPD is a major burden for patients and the NHS; 30% of patients are readmitted and 1/9 die within 90 days of discharge following an acute exacerbation of COPD (AECOPD). The two highest value interventions are not used by clinicians as much as they could be: effective smoking cessation support (SCS) and pulmonary rehabilitation (PR).

Assessment of problem and analysis of its causes:

SCS with intensive counselling and pharmacotherapy leads to a 1-year abstinence of 12% at a cost of £2,092/Quality Adjusted Life Year (QALY) in COPD. PR is the only intervention proven to reduce the very high readmission rates in COPD. PR reduces 3 month re-admission from 33% to 7% (Number Needed to Treat (NNT)= 4) and also reduces mortality over 107 weeks (NNT = 6) at a cost of £2,000 – 8,000/QALY. A 2010 trainne-led hospital-wide audit showed that 71% smokers were offered SCS and 77% of appropriate patients offered PR during admission. Although this was higher than national referral rates, as per the European Respiratory Society guidelines, there was still a deficit of more than 1/5 patients. SCS and PR are not commonly taught on trainee curricula. There was a financial incentive to improve delivery of these interventions as they were part of the 2011-12 ‘Commissioning for Quality and Innovation’ (CQUIN).

Intervention:

We devised a COPD bundle which addressed 5 key areas: offer of SCS, PR referral, education on disease self-management, education on inhaler technique and follow up arrangements. The bundle was of simple design, a printed sticker for the back of the drug chart, acting as “a reminder” for all clinical staff to provide the ‘Right Care’. Electronic SCS and PR referral and bundle ‘tick list’ were set up on our testordering-and-results system (Anglia ICE). We launched the bundle on “World COPD Day” with posters, screensavers and an information stand with COPD knowledge questionnaires for staff. The case for the bundle and how to use it was presented at the Grand Round, Medical Audit meeting and trainee teaching sessions and written information circulated by our MDT COPD team.

Strategy for change:

An MDT group was created with respiratory nurse specialist, medical team, manager, IT and pharmacy members to: • • •

Design how the bundle would best work at WH Implement the bundle Raise awareness in, and confidence of, staff in delivering SCS and PR referral as we wanted the interventions to be real not just a ‘tick-box’ exercise.

The multidisciplinary bundle project team continues to regularly meet to ensure continued learning, promotion of the bundle and education on COPD care. Measurement of improvement:

We audited bundle use during the first month by reviewing AECOPD admissions. 31 patients were admitted with a coded diagnosis of AECOPD. However, only 22 of these 31 had a true diagnosis of AECOPD, with the remainder having alternate diagnoses including pneumonia and pulmonary oedema. Of these 22 patients, 20 (91%) had a COPD discharge bundle which was fully completed. The rate of offering SCS at WH therefore increased from 71% to 91% and of offering PR increased from 77% to 91% with the bundle.

Effects of change:

A baseline knowledge-attitude-practice questionnaire highlighted that only 63% of doctors knew how to correctly refer patients to PR services, and only 52% knew the criteria and exclusions as stated in PR NICE guidelines. Therefore we implemented formal education on PR for trainees, developed an online video illustrating PR and access to a book of patients’ comments on their experiences of PR highlighting personal improvement in quality of life. Additonally, there was a lack of knowledge of SCS interventions therefore we distributed example nicotine replacement therapy choices in the form of a “Quit at the Whit” box on wards.

Lessons learnt:

• • • •

Message for others:

14

Education and engaging juniors - There is compelling evidence for high value interventions in COPD and these are not routinely taught to trainees. The importance of a MDT approach - Introducing small scale change, testing its effectiveness and making further improvements was a continuous process that was dependent on collaboration between a multi-disciplinary project team. This fostered the ideal environment for trainee-led suggestions to be implemented.  Changes should be simple, and reviewed continually - We learnt that effective improvement needs to be conceptually simple, feel ‘right’ for patients and integrate easily with current practice.  Inspiration comes from leaders who act as champions for change - Introducing the COPD discharge bundle has made it easier for trainees to ‘do the right thing’ and promoted more colleagues involvement.

Passion to push against inertia as well as determination to make a difference to patients are key to a successful quality improvement project. By involving trainees in the project, we felt empowered to bring about change and integrate this into our clinical practice.

Casebook 2012


Project Title:

Prescription and Wearing of TEDS in Surgical Inpatients at the Royal Devon and Exeter Hospital

Submitted by:

Sarah Dunkerley, Sophie Wienand Barnett, David Birchley

Introduction:

An estimated 25,000 people in the UK die from preventable hospital acquired venous thromboembolism (VTE) each year.1 Approximately 1 in 4 patients undergoing general surgery and not receiving antithrombotic prophylaxis will suffer post operative VTE. Anti-Embolism Compression stockings (TEDS) deliver a distributed amount of compression at the ankle and up the leg, which when combined with the muscle pump effect of the calf aids in circulating blood in the legs. TEDS can be used in conjunction with other pharmacological or mechanical VTE prophylaxis and have comprehensive guidelines highlighted by NICE. 1

Initial Audit:

At the Royal Devon and Exeter Hospital (RD&E) it was perceived that TEDS were not always being worn. We need to ascertain if this was due to the prescription or application of TEDS , so an audit was performed. This was a snapshot of all the general surgical inpatients (elective and emergency) on 26th July 2011. The standard used was the local policy, based on the NICE guideline 92. At the RD&E all surgical inpatients require both Dalteparin and TEDS unless there are any contraindications to either. The contraindications to TEDS were clearly set out in the NICE guideline 92: suspected or proven peripheral arterial disease peripheral arterial bypass grafting peripheral neuropathy or of sensory impairment known allergy to material of manufacture cardiac failure severe leg oedema unusual leg size or shape major limb deformity preventing correct fit

A standardized data collection form was used to collect information regarding ward, age and length of stay. Information regarding the prescription, whether the patient was wearing the stockings, any contraindications (documented or not) and compliance was recorded. Exceptions included patients away from the ward at time of data collection. Results:

78 patients, from 7 surgical wards were recorded. 74% of patients had an appropriate prescription and wearing of TEDS. All of the patients who were wearing TEDS did so appropriately. Of the 17 patients who required TEDS but were not wearing them, 17% were secondary to patient compliance issues, 23% were not prescribed by surgical doctors and 59% were due to the nurses not applying them. The main reasons for nursing staff not applying TEDS were a misconception regarding diabetic patients and an oversight after removal for washing and procedures.

Intervention:

These results were analyzed and the areas of potential improvement were threefold: 1. 2. 3.

Reminder to the nursing staff of reapplying TEDS post wash or procedure Reminder to the junior doctors about the policy of TEDS prescription The education and improved awareness of the specific contraindications to TEDS

The audit findings were discussed with the senior nursing staff. Education of ward staff was carried out informally by senior nurses, and through information emails. The second point was addressed through a presentation at the October 2011 general surgical monthly audit meeting. This helped the junior doctors improve accuracy of their TEDS prescription and increased the consultants’ awareness and reminded them to check the VTE prophylaxis. The third point was incorporated above and was reinforced by producing laminated cards (Fig 2) of the contraindications to TEDS on laminated cards which were displayed around the wards. Re-audit:

A re-audit was carried to assess the changes from the interventions. On 31st January 2012, 54 patients on 6 surgical wards were audited. The same method was used as previously. This showed 93% of patients had an appropriate prescription and wearing of TEDS, (19% improvement). Again all patients who were wearing stockings did so appropriately. There was one incorrect prescription (2%) but the nursing staff had not applied the TEDS, one patient who had not had their TEDS reapplied post wash (2%) and two patients who had refused TEDS but the prescription had not been updated (4%). This was a huge improvement on the previous results.

Conclusion:

We improved the prescription and wearing of TEDS from 74% to 93%. This was achieved through highlighting and targeting improvement in specific areas, namely regarding suitability of TEDS in diabetic patients, replacing TEDS after washing and improved prescription by junior doctors. We learnt that addressing specific areas of weakness and involving the whole multidisciplinary team was the fundamental to improving overall results. A variety of methods were used to initially educate the junior doctors and nurses, including formal teaching sessions, informal discussion, written emails and reminder laminated sheets on the wards. We felt that using this wide range of methods to education and reinforce information was the key to the long term improvement in standards. Our main message is that small and simple interventions can improve the care and safety of patients.

References:

1. Nice Guidelines, Venous Thromboembolism; reducing the risk, Clinical Guideline 92; Jan 2010

Appendix: Page 56

Casebook 2012

15


Project Title:

Safe Intra-Hospital Transfers Project

Submitted by:

Mary Edwards, Steve Hutchinson and Paul Malcolm

Context:

The Norfolk and Norwich University Hospital (NNUH) NHS Trust is a 1000 bedded acute hospital. The projects aim was to improve the safety of patients during intra-hospital transfer. The project team was comprised of a consultant intensivist, consultant radiologist , critical care outreach team nursing lead and involved working closely with ward nursing and medical staff, hospital at night team, IT department and porters.

Problem:

There was a poor understanding of the risks of transfer. Patients were being transferred between wards and departments with out adequate assessment or monitoring and insufficient escorts. This was worse at night when there were less staff available. Harm was apparent from the critical incidents reported, cardiac arrests and deaths of patients in the radiology department.

Assessment of problem and analysis of its causes:

Initially we mapped the process and information gathered to help understand the size and scope of the problem. There are approximately 2,000 intra hospital transfers each week. We studied the intra-hospital transfers in the radiology department over a 2 week period and found that there were 1348 transfers of which 60 were of cause for concern. Questionnaires for nursing staff using theoretical scenarios revealed that the problems were lack of awareness and understanding of the risks, as well as lack of availability of equipment and staff

Intervention:

A risk assessment tool (RAT) was devised, based on the wards Early Warning Score, to measure the patient’s acuity of illness. Risk categories were used to enable staff to identify monitoring and escort requirements. Educational initiatives were introduced into the routine training of all levels of staff, who received training by the Critical Care Outreach Team to increase the awareness of the risks of patients on intra-hospital transfer.

Strategy for change:

The development of the RAT was undertaken with ward nursing staff with daily ‘Plan Do Study Act’ cycles to enable the tool to evolve. It was then trialed within 10 specialist surgical wards and subsequently rolled out over a 9 month period. More monitoring facility was provided for ward staff to access. Staff found the RAT easy to use and it was adopted for use for all in-patients being transferred to theatre, which was beyond its initial remit.

Measurement of improvement:

The radiology department was identified as a key area for data collection where improvement may be measured. Radiology staff collected data on unsafe transfers and this was then peer reviewed according to contributory risk (unstable physiology, lack of monitoring or lack of escorts) see attached chart.

Effects of change:

The first change we saw was a decrease in unsafe transfers. This was related to the implementation of the RAT and showed a reduction in the number of unstable patients. We also saw a fall in the number of issues related to monitoring but this was artificially influenced when new monitoring kit was being trialed. The most challenging issue to resolve has been escorts. We have succeeded in providing a resource for the high risk transfers with site nurse practitioners and critical care outreach team nurses being able to assist. The issue regarding staffing for a lower risk, stable transfers remains a persistent problem. The RAT has however enabled the transfer of surgical patients to be rationalised and this will save on unnecessary escorting of well patients to theatres

Lessons learnt:

The initial ground work is very time consuming but key to getting buy in from those who will be involved in the change process. By working with staff and asking for their assistance refining the system helps the change be owned and accepted by them. It is important that the tool is well tested and works before you move it to a new area. Implementing a change that has to be rolled out across such a large organization can be a lengthy process, but one that is worth doing well.

Message for others:

You need to fully understand the problem and not put preconceived solutions in place. Listen to those who will be using the system you are changing as they may hold the key to its success. Involving all those involved in the patients pathway was vital (porters) and getting the systems in place to support the new change (electronic reminders when ordering the porters). You need to be patient and persistent as embedding a new change may take longer than you first expected.

16

Casebook 2012


Project Title:

Simple and effective - improving thromboprophylaxis post-discharge in patients with fractured femoral neck

Submitted by:

Hugo Farne

Context:

Our improvement work focussed on prevention of venous thromboembolism (VTE) in patients with fractured femoral neck. In 2010 more than 400 patients with femoral neck fractures were admitted to North West London Hospitals NHS Trust, comprising two district general hospitals serving a population of over 500,000. All patients were under the joint care of the orthopaedic and orthogeriatrics teams alongside multidisciplinary colleagues.

Problem:

VTE is a well established source of avoidable morbidity and mortality in patients with a fractured femoral neck. The National Institute for Clinical Excellence sets out clear guidelines for VTE prevention in this group. We wanted to ensure our practice was consistent with this, in particular in those patients who had not completed 28 days of thromboprophylaxis as an inpatient, and address any shortcomings.

Assessment of problem and analysis of its causes:

We audited our performance over a three month period in 2009 and found that only 44% of patients were discharged in accordance with best practice guidelines. The 56% not receiving appropriate prophylaxis were placed at unnecessary increased risk of VTE, readmission to hospital and death, and this represented poor practice. Anecdotal evidence suggested doctors were aware of the guidelines but would need prompting to improve compliance.

Intervention:

The electronic discharge software was updated to include a mandatory response field asking the doctor to consider post-discharge thromboprophylaxis. In this way at every discharge the doctor is prompted to consider whether thromboprophylaxis is indicated postdischarge, aiming to increase the proportion of patients discharged on optimal therapy.

Strategy for change:

The hospital IT department made the changes to electronic discharge template. The current work has been to assess its value in improving practice. Since the completion of this study we have presented findings to colleagues in medical, nursing and pharmacy teams to increase awareness further.

Measurement of improvement:

After the electronic prompt was introduced we repeated the audit using the same design in the same period in 2011. For both audits we used hospital records of hip surgery to establish our study population, and performed retrospective observational analysis of the data. Of the 75 patients discharged during the 2009 period, only 44% (n=33) were compliant with VTE guidelines. After the introduction of the electronic prompt, 88% (n=84) of the 95 patients discharged during the corresponding period in 2011 were compliant. Using Fisherâ&#x20AC;&#x2122;s exact test and a null hypothesis that the electronic prompt made no effect, we found that proportion of patients treated as per guidelines was significantly higher in 2011 (p<0.0001).

Effects of change:

Double the number of patients received optimal thromboprophylaxis after the electronic prompt was introduced. The current studyâ&#x20AC;&#x2122;s design precludes a conclusion of specific cause and effect, and other factors may be involved, but the electronic prompt remains the most direct substrate, and this correlates with experiences described elsewhere. Moreover, there have been no problems or incidents reported from the intervention.

Lessons learnt:

This study has highlighted the importance of VTE prevention and the role of clinical decision support in improving quality of care. We are exploring the possibility of creating an automatic link between the VTE prompt and initiation of the prescription, to avoid a situation where a doctor acknowledges the prompt but still fails to make the appropriate prescription, as is possible in the current system.

Message for others:

VTE remains an avoidable cause of postoperative complication in patients with a fractured femoral neck, and this work has shown a simple, inexpensive and easily reproducible intervention can dramatically improve compliance with thromboprophylaxis guidelines. The benefits for patient safety are clear, and we hope that colleagues can apply our findings to their own practices.

Casebook 2012

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Project Title:

Junior Doctor Led Quality Improvement Project: Reducing Adverse Events From The Prescribing Of Warfarin

Submitted by:

Kate Fletcher

Context:

Organisation: Salford Royal Foundation Trust a large teaching hospital in NW England Clinical area: Cardiology ward F2 Patient group: Patients on warfarin for atrial fibrillation (AF) who needed to have an international normalised ratio (INR) between 2 and 3

Problem:

Inappropriate prescribing of warfarin which resulted in patients’ INR results falling outside the desired range of 2-3 ie. causing either over or under coagulation.

Assessment of problem and analysis of its causes:

Between September and November 2010, 10% of all INR results recorded for inpatients on warfarin for atrial fibrillation (AF) were greater than the desired therapeutic change. Furthermore, an unfortunate incident secondary to over coagulation was an additional driving force behind the project.

Intervention:

We conducted a project meeting with the pilot ward team and asked them to identify barriers to appropriate warfarin prescribing • •

inadequate education/training of the junior doctors warfarin prescribing left as an on call responsibility due to:

1. 2. 3. 4. 5.

Delayed identification of patients on warfarin Delayed INR requests Delayed venepuncture Delayed results 6 pm dosing--- often doctors had gone home by this time

The following tests of change were implemented. Each test of change superimposed on the previous. 1. 2. 3. 4.

Education – We provided an intense teaching session on the prescribing of warfarin from the anticoagulant nurses who run the outpatient anticoagulant service. Patients on warfarin were identified on a daily basis at 9am. Blood for the INR was taken before 10am in order to ensure that the result was available by early afternoon. Warfarin was dosed at 2pm rather than the traditional 6pm.

Strategy for change:

The tests of change were implemented over an six week period. To implement our tests of change it was crucial that we met with the ward team and were seen to be on the ward at least once a week Weekly emails were sent to the whole team outlining the new test of change and weekly posters were put up on the ward. Our results were disseminated via departmental and board meetings.

Measurement of improvement:

Our project target was target to reduce the number of INR results <2>3 over a 4 month period by 50%. We tracked our progress by counting the number of INR results which remained outside of the desired range for each of the test of change weeks and for 3 weeks afterwards. The results were plotted on a run chart.

Effects of change:

• • • •

Lessons learnt:

1. 2. 3.

Message for others:

We reduced the number of INR <2>3 by 33.3% during the 4 months of the project. By reducing the number of patients with INR results outside the desired range we reduced the risk of thromboembolic or haemorrhagic events. No thromboembolic or haemorrhagic event relating to inappropriate warfarin prescribing occurred in our patient population during the project. The biggest challenge was maintaining the interest and momentum of the project with our project ward. A further great challenge was overcoming resistance when changing the time of warfarin dosing. 6pm is when warfarin has historically been dosed however there is no clinical reason for this. Engage the whole ward team- especially the nurses as they are often the staff which remain the longest on any one ward. Doctors/ pharmacists often rotate round Plan meticulously Visit your pilot ward regularly to offer support and get feedback on how to improve the project

Think simply, make small changes gradually and be patient.

* 18

Prize Winner Casebook 2012


Project Title:

‘Scared to Prepared’ – An induction programme for new foundation year 1 doctors

Submitted by:

Christopher Gee, Rebecca Aspinall, Natalie Blencowe, Rob Bethune, Clare Van Hamel

Context:

This programme was designed to improve induction and shadowing for all new foundation year 1 (FY1) doctors commencing work for the University Hospitals Bristol NHS Foundation Trust. The programme began in 2009 and continues to be developed utilizing feedback each year.

Problem:

It has been well documented that junior doctors often do not feel prepared for commencing work and there is evidence that there is an increase in morbidity and mortality in August. This has lead to the common saying ‘don’t get sick in August’. Further to this there is now a television series detailing the challenges of commencing work as an FY1 doctor. It was our concern that the shadowing and induction programme prior to commencing work was not satisfactory. Our opinion was that an organized and structured induction programme could improve patient safety and care.

Assessment of problem and analysis of its causes:

The 2008 cohort of new FY1 doctors were asked to complete an anonymous questionnaire detailing clinical incidents they had been involved in and how prepared they felt for becoming an FY1. It was clear that there was a high frequency of clinical incidents with 93 incidents in the first 3 months of work and many felt under prepared. It was also clear that 50% of the doctors came from outside the Bristol region and were unfamiliar with the hospital.

Intervention:

A 1 week induction programme was introduced aiming to give targeted training on the previous mistakes made, providing familiarisation with the hospital and providing safe handover for the care of patients. This occurred in the week before commencement of employment. One day of simulation training was provided, giving experience in managing common medical problems in a constructive and confidence building environment. All doctors spent two days shadowing the outgoing FY1 doctor to gain familiarity with the ward, the patients and the common day to day challenges of the particular job. A 1 day course was developed utilizing small group teaching. The focus of this course was on the common clinical errors that had occurred historically. This included sessions on human factors, prescribing, fluids, blood gas interpretation, handover, common bleeps, chest x-ray and ECG interpretation. The majority of the faculty chosen for the course were current fy1 doctors and specialists were included where appropriate. All teaching sessions were discussed with and approved by the foundation programme director. The final day of the induction week allowed for specialty induction and a last half day of handover where it was anticipated that the new FY1 doctor would effectively take over the job, with supervision. Within this programme there were also talks given from the foundation programme directors, and outgoing foundation year 1 doctors detailing what is expected during foundation training. Finally social events were organized with the local mess to allow the new FY1 doctors to get to know each other.

Strategy for change:

The aim for this project was to implement a significant change. The initial results detailing the problem were presented to the trust. This lead to funding from the trust for all the new FY1’s to be contracted to attend the induction week. Local meetings with department heads and the FY1 doctors discussed methods of improving induction and the programme described above was introduced in 2009. Results were presented to the South West SHA in 2010 and in 2011 the results were presented at BMA forum for Innovation and Safety.

Measurement of improvement:

Further anonymous questionnaires following implementation demonstrated a significant reduction in incidents by 45%. Further to this feedback from the 1 day course demonstrated a rise in confidence from 37% to 81%.

Effects of change:

The induction programme has had a significant impact on patient care. Firstly, patient care has improved locally by reducing clinical incidents. Further to this, the induction programme was adopted by the South West Region in 2010 and from 2012 the Department of Health are making it compulsory for all trusts within England and Wales to provide a similar programme.

Lessons learnt:

This piece of work was a major commitment from all involved. In fulfilling my role I believe I took on too many responsibilities and have learnt now how better to delegate tasks within a team.

Message for others:

This project demonstrates that through perseverance and the development of a suitable induction programme it is possible to significantly impact the confidence and preparedness of junior doctors when they commence work in August. This project has had a major impact on patient care across the country and continues to do.

Casebook 2012

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Project Title:

Improving consent in patients undergoing surgery for proximal femur fractures through the introduction of ‘consent cards’ for junior doctors

Submitted by:

Efstratios Gerakopoulos, Simon Humphry

Context:

The improvement was done in our Orthopaedic Department in Gloucester Royal Hospital, Gloucester and there were mainly the junior doctors involved, with the valuable support from our consultants.

Problem:

Documented consent for risks/complications of patients undergoing surgery for proximal femur fractures has been shown to be poor. This could lead to poor information given to the patients and to an increase in the complaints and litigation to our department.

Assessment of problem and analysis of its causes:

We assessed and quantified the problem by auditing consent forms for adult patients (with capacity) undergoing surgery for proximal femur fractures.

Intervention:

We introduced a “consent card”, listing risks/complications of the procedures for fractures of the proximal femur. We used as a gold standard the guidelines from the British Orthopedic Association. The cards were easy stored in pockets / behind identity badges for quick access of the junior doctors in the emergency environment. The “consent cards” are Credit-card sized, cheap and easily produced, they are also memory prompt, allowing individual changes and most importantly portable (unlike pre-prepared consent forms).

Strategy for change:

We presented the results of our primary audit to our colleagues (SHOs) through an oral presentation and made obvious to them that we need to implement some change in our practice. We made sure that they had become familiar with the use of the “consent card” and we gave them a period of 2 weeks as a timetable to start re-auditing the change.

Measurement of improvement:

We re-audited the consent forms for risk/complications after the implement of our change. Our results were: Primary audit: n=24. Consenter grade: >SHO=8%, SHO=92%. Proportion of risks/complications documented: 56% (>SHO=SHO=56%). Re-audit following introduction of ‘consent card’: n=38. Consenter grade: >SHO=11%, SHO=89%. Proportion of risks/complications documented: 90% (>SHO=69%, SHO=92%).

Effects of change:

Through provision of ‘consent cards’ to SHOs a significant improvement in consent standards has been achieved. . Whilst further changes are anticipated (particularly regarding SHO inductions) it is hoped that ‘consent cards’ will improve SHO confidence in consenting. Through this process of improvement we had to modify our gold standard according to a departmental consultant survey in our department.

Lessons learnt:

The basic lesson that we learned from our work is that consenting for risk/complications of patients who are undergoing surgery for proximal femur fractures is mainly undertaken by junior doctors in the acute environment. It is a procedure that can be greatly time consuming if the SHO is not confident in doing it. Through the very simple implement of providing the “consent cards” to the junior doctors in our department and teaching them how to se them we have made our everyday practice a lot of easier and more effective and appropriate towards the patients. From now on we are planning to distribute these cards during SHOs inductions.

Message for others:

The main message that can be conveyed to others is that by using some really simple steps we, the junior doctors, can make our practice easier but also more effective and appropriate. This process also can help as keep up to date and prevent our department from being litigated. It can increase our patients’ satisfaction that they are being treated appropriately, which will lead in the diminishing of the complaints towards our department.

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Casebook 2012


Project Title:

Faxing is so 90s - Introducing an electronic system for inpatient inter-specialty referral in a district general hospital (Musgrove Park Hospital, Taunton)

Submitted by:

Edward Gomm, Guy Morris, Taylor Davis, Ben Pritchard, Mazin Abdalla, Clementine Fraser, Alan Smallwood, Rachel Vince

Context:

With the increasing complexity of medicine, there is a need within all hospitals to access another specialty’s input into patient care following admission. In many hospitals the systems for inpatient specialty referrals are disorganised, frustrating to use and rely on outdated technology. Poor systems can result in delay of treatment, patient safety issues and adversely affect the patient experience. As a group of junior doctors responsible for making these referrals within our organisation we undertook a project to improve the current system (termed “Redtop”) in our hospital (Musgrove Park Hospital, Taunton).

Problem:

Initial foundation doctor focus group discussion and analysis of the faxed-based system found it to be unstructured, frustrating to operate and inefficient. This experience was universally shared. Slow referral processes were felt to have effects on patient care and patient flow. Moreover, the time taken to fax referrals impacted on the time junior doctors had available for direct patient care.

Assessment of problem and analysis of its causes:

We set about collecting pilot data to assess the magnitude of the problem (“Redtop day”). Typically 35 referrals were made daily throughout the hospital, averaging 14 minutes to write and send (5-23min). This equates to the working day of one junior doctor (8 hours).

Intervention:

Our team met every 2 to 3 weeks and through an iterative process of PDSA cycles developed an improved version of the referral form using the SBAR (Situation, Background, Assessment, Recommendation) format. From here we used the hospital’s intranet and existing email technology to develop a simple electronic system, accessible from all workstations.

Strategy for change:

As newly qualified employees of Musgrove Park Hospital, we offered a fresh perspective on the challenges faced in day-to-day ward work, and potential areas for improvements. We identified the specialty referral process to be full of inefficiencies for both the referring team and the receiving specialty. Issues with the system had also been identified by hospital executives regarding patient safety, experience and flow. Here we were able to improve the referral process directly and create a faster system enabling specialties to organise their services to provide appropriate input in a timely fashion. This project was run at grass-roots level with high-level support.

Measurement of improvement:

Initially we trialed the new electronic system with 3 specialties, the remainder continued to use the old fax system. Subsequently we collected data on referral time to directly compare the two systems (see graphic).

Effects of change:

As a direct result of this service improvement project we developed and tested an electronic system for inter-specialty referral. The process has been streamlined and made more user-friendly with improved clarity and efficiency. Referrals are now made using the SBAR format, with the focus on asking specialties a clinical question. Our intervention has halved the time taken to make a referral and we believe that a quicker referral process allows for timely specialist opinion, thus enhancing patient care and potentially reducing delays on discharge. Moreover, the system keeps an electronic record of all referrals, which will allow audit of referral load in the future and subsequent service planning.

Lessons learnt:

• Implementing a change is difficult. Familiarity with the old system, despite its flaws was a barrier. • Teamwork was paramount. Regular group meetings allowed for the constant generation of new ideas and solutions to tackle problems as we encountered them. • New systems need not be more complex and do not necessarily require new technology. Our new electronic system was kept simple and used existing hospital software. It involved no new cost to the hospital.  Successes: As foundation doctors we have delivered a new electronic referral system in our hospital. The system was presented at grand round and to trust executives and has been adopted hospital wide by all specialties except those who operate off site.  Weaknesses: We cannot control the specialty reply to a referral. There is great variability in the way each specialty runs their services to deal with referrals.  Threats to change: We did encounter resistance from some senior doctors, and had one incidence of a lost referral attributed to the new system, which damaged confidence in the process. This was remedied through better communication with clinicians. 

Message for others:

Some hospital processes rely on outdated technology making them frustrating and difficult to use. This can ultimately impact on patient care. We have developed a new, structured system for inter-specialty referrals at our hospital. We have demonstrated this to more than half the time taken to make a specialty referral, thus freeing time for direct patient care and ultimately improving the patient experience.

Appendix: Page 56

Casebook 2012

21


Project Title:

The Overnight ENT box

Submitted by:

Anthony T Gough, Tim C Biggs, Abubakar Mohammed, Ash Sachdeva, Timothy Kane

Context:

An ENT department in a busy tertiary hospital aimed at surgical trainees covering on the hospital at night rota.

Problem:

With the introduction of hospital at night teams ENT cover is often the responsibility of junior trainees with no previous ENT experience1,2. This commonly results in up to half of the working on-call time being covered by inexperienced doctors, using unfamiliar treatment areas, potentially increasing the time it takes to respond to emergency ENT calls. This is highlighted within the University Hospital of Southampton where of the 22 surgical trainees contributing to the hospital at night team over the course of a year, only 1 had been exposed to ENT postgraduate training previously. This is echoed throughout the country where approximately 68% of SHOs covering the hospital at night teams have no previous ENT experience3. Taking into account the reduced likelihood of previous ENT experience and the potential for unfamiliar clinical encounters, coupled with having to work in ENT treatment areas that contain a variety of implements and instruments and may not be set out in the most logical of orders, it’s unsurprising that this can cause increased anxiety and stress4.

Assessment of problem and analysis of its causes:

We surveyed the SHO’s who were solely responsible for covering ENT in the Hospital at Night team. 100% of the trainees felt that organisation of equipment in a more user friendly manor would be beneficial to them while being the only on site cover for ENT in the large tertiary hospital.

Intervention:

The ENT trainees constructed an overnight ENT treatment box. There were several key attributes that were required. It needed to be easily accessible and transportable to other wards within the hospital as well as to the emergency department. It also needed to contain equipment that would commonly be used by the hospital at night team and be clearly recognisable for trainees not using the equipment on a day to day basis.

Strategy for change:

The morning nursing staff in the ENT treatment room added the overnight box as part of the morning equipment checks. This provided a failsafe to ensure stocks of used equipment were replenished as after a 12 hour night shift highlighting the equipment used overnight can be not top of the list of priorities.

Effects of change:

Despite the reorganising of equipment and ease of accessibility of correct equipment the ENT overnight box failed to be used on a regular basis. There was encouragement from the hospital at night team, whom the overnight box was aimed at, in the questionnaire prior to the setting up of the overnight box. It also improved the access to equipment in the treatment room, which along with many clinical areas, has multiple storage cupboards, draws and trolleys making it easy for an infrequent user to get flustered when looking for equipment. The reasons behind the poor usage of the ENT box are potentially because of position in the treatments room, lack of required intervention overnight – nosebleeds are often already packed down in ED, unwell patients requiring theatre management would lead to the registrar attending hospital negating any intervention by the hospital at night SHO or lack of patients overnight who require surgical intervention by an ENT junior.

Lessons learnt:

The ENT box is remains in the treatment room and continues to be checked religiously every morning by the ENT treatment room nurse. All the hospital at night SHO’s are aware of its position in the treatment room and what it contains. Even if one patient benefits from the ease of access to equipment by an overnight trainee the box will have served its purpose.

Message for others:

The box is easily replicable and enables the junior trainee covering overnight to have easy access to the correct equipment which can be taken to a more familiar environment if required. This has greatly increased the ease with which ENT emergencies can be handled overnight. A photograph demonstrating the instruments included in the overnight box is included (figure 1). We hope other hospital at night teams across the UK find this potential solution useful.

References:

1. 2. 3. 4.

Gallagher P, McLean P, Campbell R, Gallacher S, Kennon B. (2009) Medical training and the hospital at night: an oxymoron? Med Educ. 43(11), 1056-61. Sharpe D, Farboud A, Trinidade A. (2009) ‘Is that the ENT SHO?’: concerns over training and experience of juniors expected to crosscover ENT at night. Clin Otolaryngol. 34(3), 275. Biswas D, Rafferty A, Jassar P. (2009) Night emergency cover for ENT in England : a national survey. J Laryngol Otol. 123(8), 899-902. Harrington JM. (2001) Health effects of shift work and extended hours of work. Occup Environ Med. 58, 68-72.

Appendix: Page 57

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Casebook 2012


Project Title:

A Junior Doctor led approach to Cost Effective Prescribing

Submitted by:

Paul Grant

Context:

How can we be more cost effective when it comes to in-patient prescribing? KCH spends over £11 million pounds a year. When resources are limited, giving one patient an expensive drug with no added value when cheaper alternatives exist stops other patients getting treatments they need. As a group of junior doctors on a medical firm we wanted to ensure that we were prescribing safely, responsibly and cost effectively.

Problem:

We wanted to analyse the potential for drug substitution and ask the question - Are there best practice approaches to prescribing habits that would include a move to the use of more generic / cheaper alternative medications where clinically appropriate?

Assessment of problem and analysis of its causes:

A suggestion for best practice in prescribing for in-patients is that all patients should have their medications reviewed and changed, when safe and appropriate, to a cheaper, similarly efficacious, generic equivalents unless there are good clinical grounds for not doing so (1). A relatively small number of changes could save considerable money. Experience of switching already exists at all levels of healthcare after more than two million patients had their statins switched. We reviewed the drug charts medical in-patients at KCH. The total daily cost of the current medication was calculated using prices from the BNF which uses the net cost used in pricing NHS prescriptions dispensed in 2010. Each individual medication type was then assessed in the clinical context and where believed appropriate and practical an alternative medication (of lower cost) was substituted. The average in-patient drug cost bill per patient was £8.72. 40 % of the medications in this population were found to be suitable for adjustment to a cheaper alternative and this represents an average saving of £2.24 pounds per patient (a 26% reduction in cost). Scaled up to the whole in-patient population this would potentially represent a saving of £2.8 million pounds per year. Although only a snapshot of in-patient prescribing costs, analysis of the data suggests that there is huge potential for the reduction of drug costs when more attention is paid to the issue.

Intervention:

We identified 10 common medications that would be suitable for switching and then promoted this to fellow junior doctor colleauges in the trust using the ‘Are you a Responsible Prescriber?’ campaign and by the lead investigator assuming a representative role on the trust Drug Expenditure Committee.

Strategy for change:

Increased awareness and changes to systems. Computerised prescribing offers a partial solution. It makes the selection of generics / cheaper medications easier via the use of alternative suggestions (eg. Scriptswitch) and the provision of cost information to aid more cost effective prescribing. An override should be available to allow justification of more expensive options on clinical grounds when warranted. Recommendations for cost effective prescribing; 1. The first step is to ensure that hospital pharmacy’s only stock one version of a particular medication and opt for the generic or cheaper equivalent. 2. On a hospital wide basis, it is important to initiate a debate around prescribing behaviours to engage doctors with regards to better, more cost effective prescribing practice. The development of a local prescribing policy relating to acceptable prescribing practice based on the above – this needs to be related to both the clinical evidence and experience. 3. Each directorate should find a couple of drugs to switch / preferentially prescribe as an exemplar. 4. One of the responsibilities of ward based pharmacy teams should be to identify drugs appropriate for consideration for change. They can do this by flagging up alternatives to the admitting medical team and highlighting more cost effective alternatives. 5. Drug cost information needs to be added to electronic medication ordering to enable an awareness and understanding of relative drug costs.  6. Identify via prescribing data, which medical teams habitually generate the most cost in terms of in-patient prescribing and work with them to identify patterns of prescribing that could be modified to become more cost effective.

Measurement of improvement:

The goal is to look at prescribing rates and costs for our 10 example drugs from one financial year to the next.

Effects of change:

We have had a lot of positive feedback from both pharamcists and junior doctors, people mention how surprised they are at the cost differences between various drugs and that when you start to put a price label of medications it makes you a much more judicious prescriber.

Lessons learnt:

Junior and senior doctors and pharmacists need to work together to address the issue. Success of the above proposals requires the recognition of a problem, deep commitment across directorates, changes to traditional prescribing practices and support from clinical staff.

Message for others:

We need to raise awareness of the issue amongst junior doctors who do the majority of prescribing – importantly it relates to professionalism and taking responsibility for resources.

Casebook 2012

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Project Title:

Producing a proforma to guide the repatriation clerking and examination of post-angiography patients.

Submitted by:

Edward Green and Salman Gauher

Context:

The project was carried out on the Coronary Care Unit (CCU) of the West Middlesex University Hospital (WMUH) in West London. It was conceived to aid the on-call team in clerking patients returning from angiogram procedures at Hammersmith Hospital (HH).

Problem:

The majority of patients are classed as â&#x20AC;&#x2DC;same day treat-and-returnâ&#x20AC;&#x2122;, travelling to HH, undergoing their angiogram, and returning to WMUH all on the same day. These patients often return after hours, necessitating the on-call team carrying out the post-angiogram clerking. Unfortunately, most of the Juniors are unfamiliar with the specificities of this type of clerking, resulting in variations in the clerkings and some important elements being missed.

Assessment of problem and analysis of its causes:

It was clear from talking to fellow Junior Doctors that they felt uncomfortable clerking patients returning from angiograms. They were not clear what was required of them, and often did not understand many of the terms used in the procedure reports. It was also apparent, from talking to senior Cardiologists, that important aspects of a standard post-angiogram clerking were commonly being missed, especially the palpation of distal pulses. This was increasing the risk of patientsâ&#x20AC;&#x2122; post-operative complications not being picked up until the ward-round the following day.

Intervention:

We produced a simple two-page clerking proforma, in conjunction with Senior Cardiologists, who provided input on what the requirements of a high-quality clerking would be. The proforma incorporated patient details, reason for angiography referral, procedure results, post-operative symptoms, observations, details of examination requirements (ie. cardiorespiratory examination, inspection of the access site (radial/femoral) with distal pulses), post-angiogram ECG, and post-angiogram plan (anti-platelet therapy, blood tests, risk-factor management).

Strategy for change:

The proforma was copied and placed in a labeled draw on the CCU. The CCU nurses were informed of the whereabouts of the forms, and that they were now to be used by any doctor carrying out a repatriation clerking of a post-angiogram patient. When this was by an on-call doctor who may not be familiar with the unit, we ensured that the nurses knew to provide them with a proforma. The proforma was also publicised to the WMUH staff via the hospital intranet, in order to familiarize them with the post-angiogram clerking procedure and the presence of the new proforma. It was hoped that by exposing them to the proforma in this way, they would actively seek it out when clerking a post-angiogram patient on CCU, without the nursing staff having to prompt them.

Measurement of improvement:

A sample of 15 post-angiogram clerkings were selected from before we introduced the proforma, and the frequencies of missing data in each of the clerking sections (ie. reason for referral, angiogram report, examination, post-angiogram plan) were recorded. The task was repeated for 15 of the new clerking proformas. The most frequent omission before the introduction of the proforma was palpation of pulse(s) distal to the access site during examination, followed by prescription of the appropriate anti-platelet therapy, and then requesting (and taking) the correct blood tests. The contrast dose used during the procedure was omitted in all but two of the clerkings, both of which were completed by a member of the Cardiology Team when on-call. Once the clerking proformas were introduced, there were no incidences of incomplete pulse examinations, incorrect/incomplete anti-platelet therapy prescriptions, or required blood tests not being requested. Contrast dose recording did not significantly improve, most likely due to the obscure location of the dose on the angiogram report.

Effects of change:

The intervention has reduced the incidence of incomplete information being elicited from the clerking of patients returning from angiograms, and therefore will in turn reduce the frequency of post-procedure complications (for example haematoma, pseudoaneurysm, contrast nephropathy) being missed during this clerking. After initial difficulty in ensuring the proformas were used during the clerkings due to lack of awareness of their existence, the work of the CCU nurses was central to them becoming standard in the repatriation process. Publication on the hospital intranet was also extremely valuable in advertising the presence of the proforma to Junior Doctors.

Lessons learnt:

The project has highlighted to all the important features to elicit from the history and examination of a post-angiogram patient, and also the typical post-procedure plan with regards to medications and blood tests.

Message for others:

This clerking proforma has been a simple and extremely effective method of guiding Junior Doctors in their repatriation clerking of patients returning from angiograms. Important details are now rarely missed, and at the same time, the proforma has meant that time is not wasted eliciting irrelevant details from the history or examination of these patients.

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Casebook 2012


Project Title:

Cholecystectomy Pathway Improvement Project

Submitted by:

James Haddow

Context:

This project was lead by a surgical registrar over one year in the general surgery department of a London district general hospital. The local context was overall supportive: the Trust’s top priority was to ‘improve the patient experience’ and future commissioning intentions were focused on improving hot cholecystectomy rates. However the current contract was on a block basis, preventing access to the best practice tariffs.

Problem:

Patients were experiencing unacceptably long waits and cancellations for their elective cholecystectomy: the commonest operation. Whilst waiting many developed complications from biliary colic to pancreatitis. As a result their eventual operations were more difficult with a higher risk of complications and a longer recovery.

Assessment of problem and analysis of its causes:

The project was planned using the action research model (Cummings and Worley 2009). Scouting: initial conversations were had with the general surgeons in their business meeting, and full support was expressed. Stakeholder mapping demonstrated three key stakeholders: general surgery, radiology and theatres. Contracting: 21 stakeholders were interviewed. These included the clinical director, general manager, consultant surgeons, some registrars, a consultant urologist, the clinical lead for radiology, pre-assessment sister, assistant director for patient safety, costing accountant, admissions manager, theatres general manager, project management office lead, medical director and director of nursing. There was a unanimous consensus of the main problem. Fifteen root causes were offered including unnecessary clinic looping and reduced operating capacity. Implementation of changes was expected by six months, the start of the next financial year. Diagnosis: a focus group of seven patients with relatives was run. They were purposively sampled (Silverman 2001) to represent a wide demographic. An independent doctor with extensive experience in qualitative research methods facilitated discussions using a semistructured format. Thematic analysis was informed by the Institute of Medicine (2001) definition of patient-centred care. Overall, patients were understanding about waiting but wanted to have a smoother journey. The pre-operative process was confusing and cancellations were often close to the date of surgery. There were some experiences of good communication, but also some poor around considering preferences. The current pathway was mapped. Previous audit data was reviewed and the hospital databases interrogated. A literature review was undertaken against which results were compared. Planning and negotiating: the findings were presented to the executive board and the department of surgery. Five objectives to be met by 1st October 2012 were proposed: 1. 2. 3. 4. 5.

Increase the percentage of patients treated by cholecystectomy within 8 weeks of referral from 5% to 95%. Increase hot cholecystectomy rates from 5% to 20% of total cholecystectomies. Increase the day-case rate from 4% to 21% of elective cholecystectomies. Improve facilities in the admissions lounge to ‘club-class’. Improve on qualitative feedback on patient communication across the whole pathway as evidenced by a repeat focus group.

Proposed changes included increased operating capacity, hot cholecystectomies, and day-case as the norm. The potential benefits were preventing 46 unplanned admissions, and saving 135 bed-days and £85,353 per annum. Intervention:

Despite a favourable context and a detailed strong case for change, the project failed to implement any changes. In retrospect this was due to: 1. 2. 3. 4.

Lack of a team: although the lead consulted many stakeholders he did not build a project team. This was due to naivety and an assumption that others were unwilling to help with the work. Lack of a champion: the department lacked a strong clinical lead, mainly due to the disjointed consultant body. Mission creep: the project first started from an idea around one-stop clinics, but then grew into a large whole pathway project. Protracted timeline: the diagnostic phase of the project took too long because the most comprehensive approach was taken.

When the findings were presented, although they were received with gratitude, there was no structure underneath to take things forward. The lead then rotated to another Trust and the project died with his departure. Lessons learnt:

A well-constructed case for change involving all stakeholders is not enough to ensure a successful quality improvement project. From the outset, sustainability needs to be addressed: a strong project team needs to be built; a champion should be adopted; the scope should be well-defined and maintained; and accept ‘good enough on-time’ instead of ‘perfect but too-late’.

Message for others:

Unless sustainability is carefully considered from the beginning of your project there is a real risk that all your hard work will eventually come to nothing.

Casebook 2012

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Prize Winner 25


Project Title:

The Implementation of A Patient Safety Information Board – Paediatric Department, Queen Alexandra Hospital, Portsmouth.

Submitted by:

Lynnsey Michelle Hamilton, Bryony Jane Sales, Kate Pryde

Context:

This project was undertaken within the paediatric department at the Queen Alexandra Hospital, Portsmouth. This is a dynamic department seeing 8500 acute paediatric medical cases per year. The project was initiated by two GP trainees under the supervision of a paediatric registrar, following a multi disciplinary meeting involving senior nurses, doctors, pharmacists and midwives and aimed to improve patient safety within the busy department.

Problem:

Junior doctors frequently rotate through different departments and are sometimes unaware of many of the safety issues within the departments. If junior doctors are unfamiliar with these it is likely many other staff members are also, potentially putting patients at risk. The aim of the project was to design an information board to raise awareness and communicate important patient safety issues, thereby educating staff within the paediatric department.

Assessment of problem and analysis of its causes:

A short survey to ascertain the level of knowledge of paediatric staff regarding safety matters (n=18) was conducted. Surveyed staff included doctors (consultant to foundation year two (F2) level), nurses (sisters, staff nurses, student nurses) and pharmacists. Results demonstrated many staff were unaware of important safety issues including the different tools and action plans used to improve safety following clinical incidents. To improve knowledge, a patient safety information board was implemented. Following discussions with a multi disciplinary team on the content for the board, a design was created displaying data on: hand washing audits, National Patient Safety Audit data (NPSA) and the Global Trigger Tool (GTT). The top three monthly Adverse Incident Reports (AIR) were also included with information regarding subsequent action to reduce further errors.

Intervention:

Key information on the topics mentioned previously were organised into a user friendly, clear and concise format in PowerPoint demonstrating current departmental work. The data compiled was displayed on three identical boards (approx 2x1metre). These were sited in the staff rest room, the doctors’ room as well as a portable board for moving around wards. Boards were updated regularly (every two months).

Strategy for change:

To raise awareness of the project, the information collated was presented at a monthly lunchtime information sharing session, a meeting aimed at all health care professionals in paediatrics. Emphasis was placed on the boards representing a ‘work in progress’ and would develop as health care professionals provided feedback and suggestions for further topics. The initial timetable for change was four months, after which, new rotating junior doctors could take responsibility for the project, improving their understanding and further educating staff. The project has been presented at a Patient Safety Working Group trust meeting at Queen Alexandra Hospital, where it was decided to implement the patient safety information board in other departments in the hospital.

Measurement of improvement:

After the board had been updated twice the original staff survey was repeated to ascertain whether knowledge had increased (n=15).

Effects of change:

The second survey showed an increased awareness of safety issues (see figure 1), along with emerging improvements in reductions of serious critical incidents. The project was well received by colleagues who acknowledged they had a responsibility to educate themselves on this important topic. By encouraging all health care professionals to do just that, it is anticipated that patient care and thus patient satisfaction will improve

Lessons learnt:

The boards have highlighted some of the excellent work completed monthly by multiple health care professionals within departments; encouraging all staff to take responsibility to make patient safety their concern and responsibility. Only by raising awareness of clinical incidents can staff learn and prevent further similar mistakes. On reflection, monthly updates of new information may have improved the effectiveness of this project. Involving a wider representation from the multi disciplinary team, may also have increased the board’s potential utility.

Message for others:

In the short time since the introduction of this project, staff awareness and knowledge has shown improvements. The patient safety board is a cost effective and simple way of disseminating important information available (although sometimes difficult to access) to all health care professionals. This project has the potential to be implemented to a wider population of staff both in primary and secondary care to improve patient safety.

Figure 1: Table to demonstrate percentage improvements in health care professional’s knowledge following implementation of the patient safety board. Pre and post project questionnaire data shown. Percentage awareness presafety board (n=18)

26

Percentage awareness post safety board (n=15)

Percentage awareness Improvement

Hand washing protocol

94

100

6

Awareness of hand washing audits

39

67

28

Knowledge of GTT

28

87

59

Awareness of drug errors

78

93

15

Casebook 2012


Project Title:

Improving the educational climate of a DGH – A junior led approach

Submitted by:

Thomas Hanna, Marcos Kostalas and Mirna Khouri

Context:

The aim of the improvement project was to raise the quality of the surgical teaching and was carried out at North Devon District Hospital (NDDH), a small DGH in Barnstable. NDDH has 12 surgical consultants in colorectal, vascular, urology and breast specialties. The project was initiated by a three surgical trainees and focuses on patient based education for the whole department

Problem:

Historically surgical teaching was poorly attended, with little structure and often cancelled. The perceived educational climate was poor with learning usually taking place on an ad hoc basis and within, not across surgical teams. The care of patients was not routinely discussed in an open educational forum and the experience and knowledge of surgical consultants had little opportunity to filter through to the junior ranks. Morale amongst surgical trainees was low as there was little support for their MRCS exams and several had expressed concern with the present system. Few in the department had opportunities to demonstrate their teaching abilities or develop the educational side of their portfolio

Assessment of problem and analysis of its causes:

Initially we explored the issue informally by discussing with colleagues and seniors. Next we conducted an on-line survey of the surgical department with three aims: firstly, to obtain a baseline of the perceived quality of the current teaching, against which future improvements could be measured. Secondly, to identify systemic problems with the current teaching programme and finally to identify mechanisms by which we can improve and maintain the quality of teaching.

Intervention:

We made several interventions in order to change the culture of education at NDDH. We expected each to have a small impact, but anticipated a cumulative effect would be enough to make a lasting change. 1. Ownership: In our survey we asked everyone in the department if they would be happy to deliver a teaching session. 100% of respondents replied ‘Yes’. We split the MRCS syllabus into 24 topics and allocated all Consultants (12), SpRs (6) and SHOs (6) a topic each. We published a timetable including dates, topics and presenters well in advance. We asked the medical director to deliver the first teaching session so as to lead by example. 2. Pre-emptive feedback: We introduced a mechanism to ensure that the teaching is relevant, useful and interesting. The feedback form contains a pre-emptive feedback section where attendees request in advance which particular areas of the given topic they would like to learn about. This information was then complied and sent to the presenter a 2 weeks in advance. 3. Peer group benchmarking: Every week each presenter is scored in 6 teaching domains by the rest of the group. Their average score is then feed back within the ‘teaching report’ after the weekend. They are also benchmarked against their peers in all domains. A presenter will easily be able to identify their strengths and areas for development 4. ‘Teaching award’: To encourage high quality teaching we have appealed to the competitive nature of surgeons and established an award: ‘The NDDH Teaching Prize’ to the highest overall scoring presenter. 5. Sponsorship: The ‘MDU’ kindly agreed to sponsor the teaching programme. They provide lunch every week and deliver an educational medico-legal talk before the morbidity and mortality once a month. 6. ‘Protected’ teaching: Bleeps are fielded by the Medical Education Center to reduce interruptions 7. Preparation: The journal ‘Surgery’ covers the MRCS syllabus in monthly editions. We made a stand in the doctors’ office to hold the edition which is relevant to upcoming topic in teaching. Junior doctors are encouraged to read it during the week, so on Friday they can benefit from and contribute to the teaching. 8. Education: We organized a talk to be given to the department from the course director of MA Education at Plymouth University. This outlined the concepts of medical education. The department was encouraged to assess learning needs, plan their session and experiment with different teaching styles and techniques. 

Strategy for change:

The results of the survey and proposed changes to the teaching programme were complied into a document. Two weeks before the launch date the document was e-mailed to the whole department and a large poster display was also put up in the doctors’ office. The survey findings and the new programme were also presented to the department in a power point presentation at this time. We informally consulted senior Consultants regarding the new programme and were given universal support.

Measurement of improvement:

After the six-month programme has been completed we plan to repeat the survey and compare perceptions of teaching quality with the results we have from the baseline survey. At present we do not have objective data to demonstrate improvement in quality of teaching.

Effects of change:

Since its introduction the new teaching programme has been a source of enthusiasm reflected in teaching attendance increasing by approximately 50%. Attendees have been using the pre-emptive feedback to suggest current inpatients as a case based teaching session. The presenter then uses management decisions, current imaging (MRI, CT, XR), operative pictures (laparoscopy) and observation charts to facilitate teaching of the given subject. Future management decisions of complex cases are discussed in an open educational forum crossing specialties. This approach has allowed juniors to become more involved with the care of inpatients and encouraged an evidence-based approach to clinical care. As there is a significant amount of cross cover at weekends and evenings from other teams, in-depth discussions and learning across specialties makes for a safer clinical environment.

Lessons learnt:

Some of the most successful changes we made to the teaching programme were not our ideas. A section of the feedback form is dedicated to organizational issues for the attendees to make their own suggestions on how to improve teaching. This has been an invaluable source. A continuous feedback loop has been essential for us to fine-tune the new teaching programme. We encountered problems which we had not anticipated but fortunately were easily resolved by suggestions from attendees. I had not appreciated how much a healthy educational climate within a hospital can focus patient care.

Message for others:

If you feel that something could be done better, then it probably can be, and should be. We identified the problem of poor educational provision by informal chatting amongst junior colleagues. We were told by seniors that several attempts had been made in the past to change the teaching but had failed. We tried not to be discouraged by this and put in feedback mechanisms to identify and correct problems early. Our goal was always to have the best teaching in the country. We haven’t got there yet but hope by continually acting on robust feedback mechanisms we can make stepwise progress towards this goal. 

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Project Title:

Successful implementation of an electronic model of mandatory risk assessment for venous thromboembolism in patients admitted to Burton Hospitals NHS Trust

Submitted by:

Humayun Ahmad, Nick Ford, Petula Paul, Israa Kaddam

Context:

This project was done in Queens Hospital-Burton on Trent, and it involved the development and implementation of an electronic system of Venous thromboembolism (VTE) risk assessment which is fully integrated with our hospitalâ&#x20AC;&#x2122;s electronic patient record, with tools to provide reminders and alerts to the healthcare workers to review VTE status and prescribe thromboprophylaxis when indicated.

Problem:

Venous thromboembolism (VTE) is a serious disorder with multifactor aetiology. It has a high prevalence amongst hospitalised patients and it is responsible for significant mortality, and causes an estimated 25,000 death each year in the UK hospitals. Despite being a preventable problem, with appropriate prophylactic measures, studies have shown that many patients do not get appropriate thromboprophylaxis, despite being at risk of developing VTE.

Assessment of problem and analysis of its causes:

Historically, though clinicians took interest in prevention of VTE, there was no formal method of risk assessment or quantifying the number of patients risk assessed for VTE. We had about 26 percent of in-patients receiving Enoxaparin to infer the efforts of VTE prevention at our hospital.

Intervention:

An electronic system of VTE risk assessment was designed and implemented. It is fully integrated with our hospitalâ&#x20AC;&#x2122;s electronic patient record, that houses electronic ordering and prescribing, a VTE risk assessment tool was added to the order entry screen, and its completion is mandatory to progress with the ordering of any investigations on the admitted patients. If thromboprophylaxis needs reviewing, then the system sends alerts to health workers to remind them to reassess the need for it. Also Links to more detailed lists of risk factors and contraindications to thromboprophylaxis were built in to promote education and empowerment of all healthcare workers, and makes VTE risk assessment easier.

Strategy for change:

A VTE risk assessment tool was added to the order entry screen. The completion of this brief step was mandatory in order to progress with the ordering of any investigations on the admitted patients. A system of computer based alerts and reminders was created. These appeared in the electronic prescribing section to encourage timely prescription of thromboprophylaxis (TP), where appropriate.

Measurement of improvement:

Results showed that more than 95% of inpatients staying for longer than 24 hours are being risk assessed for VTE, 66% of these were assessed at risk and TP was indicated. Of these 65% received TP in the form of Enoxaparin. However, as the patients stay longer in the hospital the rates of risk assessment and TP improve. Nearly 100% of patients with a length of stay greater than 72 hours were risk assessed for VTE and of these 78% were considered at risk. 70 to 80% of these were given TP. This is reassuring, considering the rising risk of VTE with increasing length of stay.

Effects of change:

Our work has shown that electronic model of VTE risk assessment is successful in implementing documented risk assessment processes and improves thromboprophylaxis, as 95% of patients staying for 24 hour have been VTE risk assessed and 100% of those staying for more than 72 hours have been risk assessed. This in turn improves the rate of TP prescription and administration. However, it is interesting to note that despite a robust tool for VTE risk assessment and an elaborate reminder system, approximately 20 -30% of at risk patients still did not receive thromboprophylaxis.

Lessons learnt:

Timely risk assessment for VTE is a necessary step in improving TP to prevent VTE in patients admitted to hospital. Although reminders are helpful, a degree of policing and accountability is required to achieve complete success in any VTE prevention program.

Message for others:

VTE risk assessment and thromboprophylaxis prescription is a very important step in ensuring safety of patients admitted to the hospital, and systems of mandatory assessment for VTE risk will enable health care workers to provide appropriate TP to those at risk. This also requires improving understanding of VTE risk amongst health workers as well as leadership from the clinicians and accountability at management level.

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Project Title:

Avoiding Prescribing Errors Committee: a bottom up approach to improving patient safety

Submitted by:

Sarantos Kaptanis , Nick Ward, Martha Bonney, Joanne Perera and Sonia Damle

Context:

Medication error is the most common kind of medical error. In the UK junior doctors are, according to recent research1, responsible for most of these, however error rate is similar across grades (5.9%-10.3%).

Problem:

In our Trust, medication error is an important concern both for healthcare professionals and for our patients, as indicated in Just-AMinute patient survey cards. Promoting an open culture for error recognition, reporting and correction is important for patient safety and the education of health professionals.

Assessment of problem and analysis of its causes:

It is important to develop clinical leadership among junior doctors at an early stage, applying the Medical Leadership Competency Framework.2 Acts of leadership can come from anyone within an organisation, irrespective of whether they hold a designated leadership role; in fact, the concept of shared leadership shifts the focus to the achievement of the group rather than the individual.3 An initiative to improve prescribing practice in our Trust (an important service target with clear benefits for patient safety) would begin with FY1 doctors.

Intervention:

Based on the UK EQUIP study, a complex intervention was implemented in our hospital, described in detail below.

Strategy for change:

On starting employment, a prescribing test is taken by all FY1 trainees and further support provided to those who fail. Pharmacists daily check patient charts and all prescribing errors are logged into a centralised database (DATIX). Following each prescribing error by an FY1 trainee, there is a Case-Based Discussion (CbD) with their Registrar or Consultant, to reflect on the error and provide feedback. An Avoiding Prescribing Errors (APE) committee convenes monthly, led by FY1 trainees supported by senior doctors and pharmacists, to discuss errors made in the previous month and suggests ways to improve.

Measurement of improvement:

In the first two months, the committee has convened regularly and participation from FY1s has been enthusiastic. 75% of FY1s surveyed would like to continue to participate, 86% felt comfortable sharing their opinions. Patient safety education has been implemented in the FY1 teaching curriculum. An antimicrobial guide was designed by the APE committee and handed out, and more than 95% of juniors refer to it for their prescribing needs more than once a week (survey data).

Effects of change:

There is a continuous audit of prescribing errors which will demonstrate the practical short- and long- term effects of our intervention. To facilitate the audit, all FY1 trainees have been provided with prescribing stamps. APE meetings are regularly held after FY1 compulsory teaching sessions, making it easier for junior doctors to participate and embrace changes. Regular surveys measure the impact of changes and their effect on all FY1s, and feedback informs further interventions.

Lessons learnt:

CbD, and workplace-based assessment in general, is an formative tool to support experiential learning. Reflection on prescribing errors and positive feedback from senior clinicians and pharmacists can lead to improvements in practice.

Message for others:

Success of any patient safety intervention depends on active engagement of all clinical and non-clinical staff involved. We strive to achieve this inspired by the five promises to the people of Croydon: you feel cared for, you feel in safe hands, you feel confident, you feel itâ&#x20AC;&#x2122;s getting better, you feel we value your time.

References:

1. 2. 3.

Dornan T, Ashcroft D, Heathfield H, Lewis P, Miles J, Taylor D, et al. Final report: An in depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education. EQUIP study. London: General Medical Council 2009 Gillam, Stephen. Teaching doctors in training about management and leadership. BMJ 2011;343:d5672 Academy of Medical Royal Colleges. Medical Leadership Competency Framework: Enhancing Engagement in Medical Leadership Third Edition. Coventry: NHS Institute for Innovation and Improvement 2010.

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Project Title:

Hot Clinic – Avoiding unnecessary hospital admissions with a next-day surgical assessment clinic

Submitted by:

Vasha Kaur, Caris Grimes, Ian Swift

Context & problem:

The pressures on hospital beds have never been greater than in the current economic climate. With hospital closures, rising costs and repeated bed crisis, the hospital bed has become a precious commodity. With prices for an in-hospital stay per night per patient varying from £225 - £355 across the United Kingdom; pathways to avoid unnecessary admissions are being explored. In addition, evidence suggests that patient outcome is poorer when hospitals operate at above 85% of capacity.

Assessment of problem and analysis of its causes:

We hypothesised that a select group of patients presenting acutely to the Emergency Department for general surgical admission could be managed safely and effectively with Hot Clinic, a next-day surgical assessment clinic.

Intervention:

We developed the Hot Clinic, a next-day surgical assessment clinic at our hospital to allow assessment and management of select patients and avoid admission. To develop this clinic and run it efficiently, the surgical team worked closely with the Emergency Department, the Radiology Department and the Surgical Day Admission Ward. We also disseminated information about the clinic to increase awareness prior to launching the clinic. Furthermore, we ensured that patients enlisted for the clinic were given sufficient information in the Emergency Department and the following day when they attended the clinic.

Strategy for change:

All patients below the age of 55 years who presented to the Emergency Department with symptoms necessitating General Surgical review were considered for Hot Clinic. The clinic was aimed at patients who did not have a definitive diagnosis clinically and in whom further review and targeted investigations would be useful. Patients with a definitive diagnosis and patients who did not require further review were excluded from this study. For patients to be eligible for Hot Clinic they (1) had to be comfortable enough to be discharged home with oral medication (2) did not have persistent vomiting (3) were haemodynamically stable (4) with a temperature below 37.5’C and (5) had normal or near-normal bloods. Pre-menopausal females also had to a have a negative pregnancy test. They were then allowed home with a responsible adult with instructions to return to the Emergency Department if they became more unwell. These patients were then excluded from Hot Clinic. Hot Clinic patients presented the following morning for re-assessment by the surgical team. If warranted, patients were investigated with repeat blood tests and ultrasound scans. A pre-intervention audit suggested that 1 to 2 patients every 24 hours could be managed this way and hence two ultrasound slot were reserved for Hot Clinic patients every weekday morning. Following assessment and investigations, patients were discharged or admitted depending on clinical need.

Measurement of improvement:

We carried out a pilot study only on weekdays over a six-week period. Twenty patients were seen in the Emergency Department and deemed eligible for Hot Clinic during this period. The mean age of these patients was 37.2 years and the male: female ratio was 3:17. Eight of these patients presented with right iliac fossa pain, eight with upper abdominal pain, two with wound infections, one patient had testicular pain and one patient a painful anal lesion. Of the twenty patients, one patient re-presented with worsening pain overnight and another patient did not attend the following morning. The remaining eighteen patients were reviewed in Hot Clinic the following morning. Fourteen patients underwent ultrasound scanning the same morning. One of these patients had a diagnostic laparoscopy the same day and was discharged later the same day. Only 2 patients needed admission – one patient had a laparoscopic appendicectomy the same day and was discharged home the following day. The other patient was admitted with localised guarding in the right upper quadrant and underwent a CT scan the same day. No abnormal findings were seen, his pain settled and he was discharged home the following day. There were no re-admissions.

Effects of change:

During the six-week study period, at least 19 bed days were saved. At our centre, an acute surgical bed costs £270 a night and consequently, this admission avoidance exercise has already saved our trust at least £5130 in a six weeks. In addition, further bed days were saved from fast-tracking investigations in this patient cohort and avoiding prolonged in-hospital stays. This unburdens the service and frees up beds to be used by patients who need in-hospital stays.

Lessons learnt:

Hot clinic, a next-day surgical assessment clinic, is a safe and effective method of managing a select group of general surgical patients acutely. It avoids unnecessary admissions to acute general surgical beds and results in significant cost savings.

Message for others:

We feel that our experience clearly demonstrates a useful model for admission avoidance in a select group of patients and a better use of resources. We hypothesise that a similar model can be used effectively across different specialties.

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Project Title:

A Standardised Patient Summary and Handover Proforma Can Improve Out-of-Hours Inpatient Care

Submitted by:

Amit Kaura, Hajeb Kamali, Simran Sinha, Cara Harris, Jarrod Richards, Seema Srivastava

Context:

The project was primarily undertaken by Foundation Programme doctors at Southmead Hospital, Bristol, UK.

Problem:

Foundation Programme doctors at North Bristol NHS Trust raised concerns about the quality of information handed over to out-of-hours medical and surgical teams. At present, out-of-hours doctors receive either verbal or written handover of specific tasks required for inpatients. However, key patient history and management details were inconsistently handed over. Similarly, summarised key medical information about all ward patients is rarely available, though many ad-hoc reviews are likely during out-of-hours service. This was due to the lack of a systematic or consistent method for patient handover, which was having an impact on the safety, effectiveness and efficiency of inpatient care delivered by out-of-hours medical and surgical teams.

Assessment of problem and analysis of its causes:

Doctors of all grades at North Bristol NHS Trust, from Foundation Programme doctors to consultants, were invited to focus group meetings for a discussion on methods of improving the handover process. A questionnaire was distributed to all Foundation Programme doctors to collect information on three key areas of effectiveness: 1. 2. 3.

Intervention:

A satisfaction score for the handover system being used. The time taken for the out-of-hours doctor to gain an accurate impression of the patients medical history. The percentage of occasions whereby out-of-hours jobs were performed by the Foundation Programme doctor without reviewing any medical records.

A quality improvement project was developed in order to create a standardised method of handover that would allow communication of clinically significant information in a timely and effective manner. A patient summary and handover proforma was created with the following headings: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

Bed Number Demographic Information Presenting Complaint and Diagnosis Co-morbidities Operations/Procedures  Current Issues Management Plan Discharge Plan and Social Issues Key Blood Results Further Notes, e.g. DNACPR status Out-of-Hours Jobs

Strategy for change:

Following approval from senior management, all doctors at North Bristol NHS Trust were informed of the pilot handover system via trust email. The initial rounds of data collection were carried out on a Care of the Elderly ward. The day based ward doctors electronically completed the patient summary and handover proforma and subsequently printed out hard copies for the out-of-hours doctors. The proforma was updated on a daily basis by the Care of the Elderly ward doctors.

Measurement of improvement:

The “Plan, Do, Study, Act” (PDSA) methodology was employed to assess the effectiveness of the newly implemented patient summary and handover proforma. Following each out-of-hours shift, the Foundation Programme doctor provided questionnaire feedback on the effectiveness of the proforma. Baseline measurements were taken from nineteen Foundation Programme doctors and feedback was received from seven Foundation Programme doctors for each PDSA cycle. As part of each cycle, amendments were made to the proforma to further develop and improve the outcomes measured.

Effects of change:

The newly devised patient summary and handover proforma achieved the following key results: • • •

Satisfaction score of handover system (1 = poor – 5 = excellent) Baseline: 2.47, PDSA Cycle Three: 4.37 Time taken for the out-of-hours doctor to gain an accurate impression of the patient admission Baseline: 13 minutes, PDSA Cycle Three: 6 minutes Percentage of occasions whereby out-of-hours jobs were performed without reviewing any patient medical records Baseline: 68%, PDSA cycle Three: 0%

Once established on the Care of the Elderly ward, it would take, on average, only six minutes to update the proforma on a daily basis. Having demonstrated the effectiveness of the proforma, fifteen out of the seventeen Foundation Programme doctors questioned were willing to implement the new proforma on their ward. Lessons learnt:

A standardised patient summary and handover proforma is a tool which can improve the safety, effectiveness and efficiency of care delivered by out-of-hours medical teams. Work is ongoing to implement this tool on other wards and integrate it with North Bristol NHS Trust IT systems. Having patient management system software for standardised data entry across all wards will enable trust wide improvements in the quality of out-of-hours patient care.

Message for others:

A standardised patient summary and handover proforma is a simple, inexpensive tool, which has proven to be effective in improving the quality of out-of-hours patient care. Implementing a similar tool at other NHS trusts without a formal handover process is strongly encouraged.

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Project Title:

ECG Labelling: At The Heart Of Patient Safety

Submitted by:

Laura Kettley , Rory Sharvill, Jonathon Wordsworth, William Rolls

Context:

The North Bristol Quality Improvement Programme is designed to encourage active involvement of junior doctors in identifying simple ways to eliminate patient harm and improve quality of care. This quality improvement project was designed to promote the documentation of ECGs; a common yet vital investigation, whose timely review and documentation are integral to maintaining safe practice. The project was undertaken within the medical admitting wards in North Bristol Trust over a period of four months.

Problem:

The project was instigated following two critical events within North Bristol Trust that resulted in severe patient harm. In both cases, poor ECG documentation was a major contributory factor. It was the aim of this improvement programme to avoid further adverse events by improving the labelling of ECGs.

Assessment of problem and analysis of its causes:

The minimum documentation on an ECG, as recommended by consultant opinion and the British Cardiology Society, should include: patient name, date of birth/hospital number, date and time of investigation, reviewer signature, name, bleep number and findings (either on ECG itself or in the notes). Initial data collection from fifty ECGs revealed universally poor documentation, with only 4% fulfilling the criteria.

Intervention:

Change was implemented through the development of a prompt sticker, designed to be kept with the ECG machine and placed on an ECG at the time of creation. The sticker design allowed space for the operator to fill in the patient’s demographic details, time and date of the ECG, plus space for reviewer to fill in their personal details and tick a box stating that their findings had been documented.

Strategy for change:

Implementing the sticker required the education of both the nursing staff and doctors. Education was achieved through discussing the changes at handover meetings, ward safety briefings, junior doctor teaching sessions, getting the ward consultants involved, placing posters and sending emails.

Measurement of improvement:

The impact of the sticker was evaluated across three ‘plan, do, study, act’ (PDSA) cycles. In each cycle, fifty ECGs were assessed for how many components of the documenting criteria were present. Where possible it was also noted what grade the reviewing doctor was. Our results revealed a modest improvement in the documentation of ECGs. Following the first PDSA cycle, the number of ECGs with a complete data set rose from 4% to 50%. However, on subsequent data collections, only 64% of ECGs had the sticker on and only 38% of those were fully labelled. Interestingly, the grade of doctor reviewing the ECG had a huge impact on the completion of documentation; 0% of those at Registrar grade had a fully completed data set, whilst foundation year doctors were the most compliant.

Effects of change:

The results obtained did reflect a positive change in encouraging the proper labelling of ECGs, however it was not as great as hoped. The greatest problem encountered was ensuring that all staff were aware of the prompt sticker and that motivation to continue its use was maintained over time despite staff turnover. The current popularity of using stickers and proformas as clinical tools may well have played a role in not achieving higher levels of complete documentation. “Not another sticker!’’ is something we’ll all of heard being uttered at least once. Increasing seniority and confidence in ECG reviewing capabilities may also account for the reason documentation levels decreased in those at Registrar level.

Lessons learnt:

The main learning point from this project was that implementing a change in order to avoid a rare event is often met with ambivalence and a loss of enthusiasm over time. The key to ensuring its success is regular education to maintain awareness. The choice of intervention is also very important, as over saturating your colleagues with paper work and stickers can be a barrier to change.

Message for others:

This project highlighted that improving patient care is something that everyone can achieve through recognising problem areas in our everyday work and taking small steps to counter them. Quality improvement is not with out its challenges however, and care must be taken to introduce a change that is flexible and innovative enough to be taken on with enthusiasm and maintained in the long run.

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Project Title:

Invasive procedures training in Foundation Year doctors

Submitted by:

David Lai and Lay-In Lim

Context:

We carried out this project in a foundation trust hospital in the North West which involved foundation year doctors attending an invasive procedure training course facilitated by consultants and registrars.

Problem:

We found that foundation doctors are performing invasive procedures at an early stage of their careers after being taught at the bedside by senior colleagues. We believe this compromises patient safety as the majority of foundation doctors do not receive formal teaching on invasive procedures before they actually perform the said procedures on real patients such as lumbar puncture, chest drain insertion and central line insertion.

Assessment of problem and analysis of its causes:

We have carried out an initial survey in two different foundation trusts, involving 71 foundation year doctors. Five questions were asked. 1. 2. 3. 4. 5.

Confidence in performing invasive procedures on a scale of 1 (not confident at all) to 5 (very confident): (Figure1) 58% were not confident at all in performing the procedures. 21% rated “2”. 14% rated “3”, 4% rated “4”. 3% failed to choose an option. 0% rated as being very confident. Formal training on mentioned invasive procedures: 77% declared having not received any formal training. 23% received formal training. Relevance in teaching programme: 97% agreed in the need to implement this teaching programme formally in the foundation curriculum. Previous experience with mentioned invasive procedures: 73% declared having never done any of these procedures before. 27% have done at least one of the mentioned procedures before Usage of mannequins 89% wanted to be taught formally with mannequins under a controlled environment before having real experience.

Intervention:

We organised an invasive procedures training course for Foundation Year doctors in one of the surveyed foundation trust hospitals. The course was facilitated by consultants and registrars employed by the hospital and comprised of teaching stations involving lumbar puncture, chest drain insertion and central line insertion through the use of mannequins. The event took place in the post-graduate centre of the hospital. Participants were divided into three groups and each group rotated through three stations, each lasting 50 minutes.

Strategy for change:

We approached the clinical skills unit staff to enquire about availability of mannequins suitable for these procedures. We discussed about this project and the results of the first survey with the consultants and registrars working in A&E and general medicine as well as consultant anaesthetists. We managed to secure a date where they would be available to run the course.

Measurement of improvement:

We then performed a second survey after the teaching course which 19 trainees attended. A confidence scale of 1 (not confident at all) to 5 (very confident) was used for questions 1 and 2. 1. 2. 3. 4. 5. 6.

68.4% reported as not confident at all prior to being taught; 21.1% rated “2”, 5.3% rated “3” and 5.3% rated “4”. 0% rated as being very confident. (Figure2) After the teaching course, 0% were not confident at all, 10.5% rated “2”, 26.3% rated “3”, 36.8% rated 4, 15.8% rated 5. (Figure3) 100% agreed the session was helpful. 100% agreed the session was necessary for foundation year doctors. 100% agreed this training course should be implemented in the foundation training curriculum. 78.9% agreed that other procedures besides the ones taught, should be added. Answers suggested included ascitic tap, ascitic drain, pleuritic tap, suprapubic catheterisation.

Effects of change:

We noted a significant improvement in the confidence of foundation year doctors after being taught in a standard way under controlled conditions. We strongly believe that a standardised method of teaching procedures will markedly reduce the incidence of mistakes or errors made during such procedures, thereby improving patient safety and health care. Mannequins were limited for various procedures and we thus had to limit the course to three procedures.  Following the successful outcome of this course, we are organising a similar course in the other surveyed foundation trust.

Lessons learnt:

We found that good organisational skills and perseverance are required in organising a teaching course. It was difficult to gather consultants and registrars to be available for teaching this course due to their clinical commitments. Therefore, communication through emails and liasing with post-graduate administrators was key to the successful running of this course. We would have included more diverse procedures to the teaching course to meet different needs. We would also hope to audit the confidence of the trainees at a later point in the future for these procedures.

Message for others:

We believe standard teaching methods lead to standard delivery of health care and patient safety. This will reduce the scope for mistakes or errors due to incompetency or lack of information.

Appendix: Page 57

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Project Title:

Thoracic surgery venous thromboembolism prevention audits – Simple strategies using a multi-disciplinary approach to improve compliance rates on a busy surgical ward.

Submitted by:

Conrad Lee, Amit Modi, Edwin Woo

Context:

This audit project was conducted by cardiothoracic doctors with involvement of a multi-disciplinary team at the department of Thoracic Surgery, University hospital, Southampton, UK.

Problem:

Venous thromboembolism (VTE) is a preventable complication in hospitalised patients. Vigilance in this area is particularly required in Thoracic surgery, as there is a large population of high risk patients particularly oncology cases. Robust adherence to VTE prevention guidelines is, therefore, a key priority to improve patient safety. However, compliance to VTE prevention policies remains a continual challenge and is often overlooked because of other clinical priorities Our initial audit conducted between August and October 2011 revealed a compliance rate of 66% to local Trust VTE prevention policies. Non-compliances were largely due to incomplete VTE risk assessments.

Assessment of problem and analysis of its causes:

After discussions with surgical house officers, nursing staff and pharmacists working on the thoracic surgical ward, we found that there was a general lack of awareness related to poor compliance. Our unit lacked robust ‘safe-guards’ and MDT involvement to ensure VTE prevention is undertaken throughout hospital stay. Our house officers highlighted knowledge gaps relating to VTE prevention in specific groups of thoracic patients which were not covered in the Trust’s generic on-line VTE prevention modules. Poor accessibility to risk assessment forms was also identified.

Intervention:

To increase awareness of the problems identified, we circulated emails with our findings and recommendations to our doctors, nursing staff and pharmacists, as well as the Trusts’ clinical effectiveness team. We provided specific guidance and information for VTE prevention in thoracic surgical patients at our local departmental induction.  To improve the consistency of VTE risk assessment, the assessment forms are now stapled to drug charts with admission document packs.  To ensure VTE prevention is undertaken for all patients throughout their hospital stay, our nurses are now involved in checking for any outstanding VTE assessment and prophylaxis each morning. A VTE tick box was introduced to handover sheets to allow a quick overview of any outstanding issues regarding VTE prevention, to be raised on our daily ward round in a timely manner. 

Strategy for change:

The audit was presented at the Monthly Thoracic surgery departmental MDT meeting to where plans for changes and responsibilities for the action plans were discussed. Priorities for the implementation of each strategy were set.

A formal audit report including data analysis and meeting discussion was distributed via email to Thoracic department consultants, registrars, ward managers, pharmacists and the Trust’s clinical effectiveness team.

Auditors liaised with the ward managers and the clinical teams and discussed the logistics of implementing the changes.

We discussed the specific knowledge gaps regarding VTE prevention in thoracic patients with our registrars, and agreed on several guidance points to be included at the next local induction for house officers.

An educational lecture was given by the auditor to the department’s doctors and nurses to raise awareness of the problem and to encourage a multi-disciplinary approach.

Changes were implemented over a 2 month period and the proposed actions were re-audited at set dates by the auditors.

Measurement of improvement:

Using prospective data collection from patient notes and drug charts, we re-audited our compliance rate in December 2011. A second reaudit was conducted in January 2012 to review the sustainability of changes made to compliance rate.

Effects of change:

Our re-audit in December 2011 showed a raise in compliance rate from 66% to 87.5% (p=0.0137). Further re-audit in January 2012 showed compliance rate of 90.5%. In addition, the rate of missed doses of chemoprophylaxis has reduced from 4.8% to 0%. These results showed that our strategies have made a sustainable change in our service. Our staff has become more vigilant in ensuring VTE preventions are undertaken for each patient.

Lessons learnt:

Compliance to VTE prevention polices can be challenging on busy wards. Our audit has identified that poor compliance can be a result of simple daily issues that are overlooked easily, yet amendable by simple measures. Simple and affordable strategies such as education, raising awareness, increasing accessibility and sharing ownership via a multidisciplinary approach can improve compliance rates to VTE prevention policies

Message for others:

As highlighted from our audit project, there are many simple issues we face daily on busy wards that hinder the provision of best practice. Many of these issues are not corrected, because we lack the awareness or sometimes, even choose to ignore them. These problems can actually be easily resolved to make a huge positive impact on our service provision. We should encourage the frontline staff across all disciplines to work together in audit projects and identify such gaps.

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Prize Winner Casebook 2012


Project Title:

Development of post-graduate education in improving the safety of pleural procedures

Submitted by:

Olivia Lucey

Context:

The British Thoracic Society set out new guidelines stipulating the use of ultrasound for all pleural procedures with effusions. To reflect these changes, the respiratory department at the Royal Sussex County Hospital (RSCH) developed a pleural pathway service which aims to treat patients requiring procedures as outpatients, preventing unnecessary hospital admissions and providing doctors with training opportunities. Patients are treated in the Acute Medical Unit (AMU). Education interventions were directed at all grades of doctor and held either in the post-graduate centre or on AMU.

Problem:

The main obstacle to both the pleural pathway and procedures undertaken on inpatient medical wards is the lack of trained personnel to perform safe procedures. Currently only two respiratory consultants have level 1 competency in thoracic ultrasound. This limits patient flow through the pathway. Patients requiring drains on medical wards or medical takes should be referred to the respiratory team for intervention but due to lack of trained staff these drains may be delayed causing unnecessary or prolonged hospital admissions, with greater risk to the patient.

Assessment of problem and analysis of its causes:

I interviewed the two pleural lead physicians in order to identify obstacles to the development of the patient pathway and generate ideas for improving trainee competence in ultrasound. I analysed data from a questionnaire targeting doctors at all levels to assess experience and proficiency of pleural procedures including the use of thoracic ultrasound. I was able to confirm the need for development of postgraduate training in thoracic ultrasound through these two analyses.

Intervention:

With the support of the two pleural lead physicians, I used a multifaceted approach to delivering appropriate education initiatives to improve the quality and safety of pleural procedures required for patients with effusions. We delivered a pilot thoracic ultrasound course including the background theoretical and practical knowledge required. I helped provide targeted teaching sessions for foundation year doctors in the management of patients with drains to improve patient experience and reduce hospital stay. These interventions were evaluated using feedback forms and a pre and post intervention knowledge test. I also created a pleural procedures rota to ensure distribution of supervised opportunities for trainees and a logbook to record competency and progress.

Strategy for change:

Having gathered the necessary evidence for the need to develop post-graduate education in this area, I attended meetings with key staff (including the consultants, AMU coordinator and matron and respiratory nurses) to ensure the initiatives were appropriate and encouraged. Following the proposed one-day thoracic ultrasound course in May 2012, we plan to disseminate the results of the survey and multiple teaching sessions. We intend to continue delivering courses to future cohorts of doctors and continually improve the teaching technique.

Measurement of improvement:

I collated feedback from all teaching sessions delivered. The pilot thoracic ultrasound course was evaluated by looking carefully at feedback given by attendees and discussion with the two consultants. Data from the questionnaires helped to guide further interventions as it displayed a need for trainees to learn thoracic ultrasound and demonstrated a complete lack of experience in most cases despite its use being advised by BTS. Grounded theory was used to analyse the interview data. The full one-day thoracic ultrasound course has not yet happened, but its effect will be evaluated using a questionnaire.

Effects of change:

We have started the process of incorporating thoracic ultrasound into the post-graduate curriculum by formalising a rota, impressing on trainees that it is a required skill and encouraging them to take training opportunities. Clearly we cannot expect to immediately impact on patient care through education as it is an ongoing process, however two respiratory registrars are now at Level 1 competency and can contribute to the running of the pleural pathway. A lack of communication regarding pleural work between the radiology and respiratory departments was identified as an obstacle.

Lessons learnt:

Using education to empower individuals to contribute to improving patient care is achievable and measurable. However, there are difficulties with how quickly a patient benefits due to the length of time it takes to become competent and the relatively short periods of time a doctor is in a rotation. I also learnt how understanding organisational context is key to implementing meaningful changes. Next time, I would aim to target doctors at the start of their rotations to ensure they attain competency quickly.

Message for others:

Education is a tangible and effective medium through which to improve patient care. I hope that through generating opportunities for doctors in training to become more knowledgeable and competent in thoracic ultrasound, the complication rate of pleural procedures will decrease over time.

Casebook 2012

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Project Title:

“Learning Together”: Joint Paediatric training clinics for Paediatric Registrars and GP Registrars in a Primary Care setting

Submitted by:

Chloe Macaulay

Context:

We developed these clinics within the London School of Paediatrics and the London School of General Practice. Development involved discusisons with different groups involved - GPs, GP trainees, Paediatric Consultants and trainees.

Problem:

Our current general paediatric postgraduate training curricula and programmes are focused on training paediatricians almost exclusively in, and for, today’s predominantly hospital-based system. Looking more widely at the government’s health reforms and the future direction of healthcare, in the medium and long-term many general paediatricians are likely to be spending at least some of their time working within a primary care ‘out-of-hospital’ setting (RCPCH 2011). Despite the high number of children coming into their surgeries, many GPs have little or no experience of paediatrics as part of their professional training. This means that, technical competence notwithstanding, many GPs lack the confidence to assess and treat children effectively, something that comes from specialist training and experience.” (Kennedy 2010). RCPCH data (RCPCH 2007) suggests that only 50-60% of GPs, in many parts of the country, have had any formal paediatric / child health training. Facing the Future (RCPCH 2011) states that there are currently 10,000 GP trainees in the UK and that less than 25% of them will undertake any paediatric placement during their training.

Assessment of problem and analysis of its causes:

We carried out an audit of London Paediatric trainees . 95% said they would appreciate some training in an out of hospital setting. Anecdotally, many GP trainees expresed an interest in doing some more Paediatric Training.

Intervention:

A joint registrar-led clinic is arranged every week or fortnight in a primary care setting. This clinic will be run by a senior Paediatric Trainee and a GP Registrar. The clinic will be jointly supervised by a named Paediatric consultant and a GP trainer. Children seen will be a mixture of “walk-ins” from that morning (‘true” primary care), secondary referrals from other GPs in the practice that might otherwise be referred to hospital, and follow up of long term conditions eg review of asthma management.

Strategy for change:

We developed a proposal for the clinics and approached the Heads of both the London School of Paediatrics and the London School of General Practice. After several meetings and reworkings of the proposal we are currently in a pre-pilot phase (trying the clinics out in two settings). We are in the process of allocating practices and hospital sites for a larger pilot from September involving GP ST4 trainees.

Measurement of improvement:

Evaluation will involve written reflection and focus groups exploring the benefits and leraning for individual trainees. We also plan to ask families for their views of the clinics. Additional outcomes are referral patterns for the GP trainees involved.

Effects of change:

We do not yet know the effects of these new clinics. Anticipated benefits include acquisition of knowledge and skills, and different perpectives. Anticipated benefits also include closer links and collaborative working between primary and secondary care resulting in better integrated care for children.

Lessons learnt:

It is very slow process. You need to involve your stakeholders early.

Message for others:

If you have an idea, you can make it happen. In this case, the difference was made by the support and enthusiasm of the two Heads of Schools.

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Casebook 2012


Project Title:

Electronic handover system for out of hours service in a busy district general hospital

Submitted by:

Sharon Man, Chrysostomos Tornari, Gary Sharp

Context:

The improvement project was started in Newham University Hospital (NUH) by members of the Junior Doctor Committee (JDC) in 2011 and is undergoing further development.

Problem:

Handover of ward patients to the medical on call team at NUH has traditionally been carried out in a meeting using handover sheets in paper format. We think that this format makes it difficult for the on call team to organize and prioritize tasks on the basis of patients’ clinical need. This may impact on patient safety as a result of delay in ordering and chasing of some diagnostic tests that require prompt action. Furthermore, updating handover sheets wastes time and resources as new information must be handwritten or photocopied. We propose that an electronic handover system that can be accessed through the hospital’s intranet can help improve doctors’ efficiency and stress levels while on call, enabling them to complete more tasks for patient care and to carry out medical review of ward patients more promptly.

Assessment of problem and analysis of its causes:

The problem was identified by doctors who attended the hospital’s Junior Doctor Forum meeting and the JDC agreed to act upon this. To quantify the problem we have designed and distributed questionnaires to measure junior doctors’ perception on the current handover system with regards to its efficiency, stress levels while on call and their perception of its impact on patient safety.

Intervention:

The JDC worked together with the IT department to design an electronic handover template which features data entry fields including patient demographics, diagnoses and active problems along with separate fields for actions required from doctors at different grades. Such actions include reviewing blood tests that have been requested by the day team (see illustration). Once these fields are completed by the day teams, an electronic patient list can be generated and sorted according to the doctor’s grade, task priority and deadline. The patient list can be updated with new problems and saved continuously so that all members of the on call team can share and act on the updated information promptly.

Strategy for change:

Discussions were held between relevant stakeholders and the JDC to plan a strategy for implementation of the electronic handover system. The Clinical Director and Departmental Leads for Medicine agreed with the proposal and IT personnel agreed to programme and upload the handover template designed by the JDC to the hospital’s intranet. The proposed timetable for change is over one month for all doctors to try the new electronic handover system, feedback on any problems encountered and for us to collect data on their perception of the new system. We plan for the electronic handover system to replace the current system if our data shows the former improves doctors’ perception on handover efficiency and patient safety.

Measurement of improvement:

We intend to perform statistical analysis of data collected from the questionnaires sent out to doctors to compare their perception on the medical handover system before and after implementation of the electronic handover system.

Effects of change:

Due to unforeseen circumstances, this project is currently ongoing in the data collection phase. We encountered problems initially in translating our idea of a handover template to an electronic format due to a lack of continuity of IT staff working on this project with us. When our proposed template was ready to go online it was temporarily suspended as it coincided with members of the JDC rotating to other hospital placements and NUH’s imminent merger with two other trusts. The project was resumed when ex-members of the JDC established contact with the current year group of doctors in NUH.

Lessons learnt:

We have learnt that leadership and continuity of stakeholders in carrying out a project is extremely vital for its success. We would probably avoid introducing a project during periods of staff changeover and would collect objective measures of improvement earlier on in the process.

Message for others:

Junior doctors often have great ideas on healthcare improvement but may encounter many barriers. We have learnt that doctors need to organize themselves as a group and involve other stakeholders to plan a strategy together with a clear timeline in order to overcome some of these barriers. Importantly, there needs to be strong leadership, determination and persistence within the group to follow through an idea from its conception to implementation. Establishing contact and sharing ongoing projects with incoming doctors when rotating on to new placements is paramount in ensuring the survival of patient care improvement projects and preventing good ideas from being ‘lost’ in the system.

Appendix: Page 58

Casebook 2012

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Project Title:

Improving the quality of weekend handover amongst surgical firms at Frenchay Hospital, North Bristol Trust

Submitted by:

Izzie Mark

Context:

The project required involvement of all junior doctors working on the four surgical firms at Frenchay Hospital between November 2010 and April 2011.

Problem:

It was noted that weekend handover in General Surgery at Frenchay Hospital needed improvement. Anecdotally, there had been occasions when important tasks were not performed or recorded by the on-call weekend staff, which had impacted negatively on patient care.

Assessment of problem and analysis of its causes:

To assess the extent of the problem, two different methods were employed. Firstly, each Monday the notes of all patients handed-over the previous Friday were audited to measure how many of the requested tasks had been undertaken. A score was assigned to show the percentage of jobs completed, giving equal weight to a range of activities (blood requests, reviews or other ward tasks). The average baseline score for the first 5 weeks, prior to effecting any changes, was 67.4%. Secondly, all junior doctors completed a questionnaire, assessing their satisfaction with the weekend handover system. It scored an average of 39%. Doctors were also invited to suggest areas for improvement. Two possibilities were identified: to change an unpopular and inadequate weekend sticker and to provide a consistent handover sheet, which hitherto varied in format (paper/Microsoft Excel/ Microsoft Word).

Intervention:

Through the course of four PDSA (plan-do-study-act) cycles, the format of the sticker was modified. After each change, another questionnaire was circulated to all doctors, requesting their satisfaction with the modified sticker and asking for improvement suggestions. Changes were implemented as a result of this feedback. In a fifth PDSA cycle, the patient lists for all surgical firms were converted to a common Microsoft Excel format, capable of being copied and pasted into a weekend handover sheet. This reduced the potential for mistakes and loss of information in the handover process. 

Strategy for change:

We ensured that the surgical secretaries printed handover stickers every Thursday. The secretaries were sent a new sticker design each Thursday morning to ensure the modified sticker was available by Friday. Regular communication was maintained with the secretarial staff to keep them informed about on-going proposals, feedback and developing results. All junior doctors using the handover system were involved. To ensure their continued engagement with and adherence to the project, they were briefed regarding its objectives, results and progress, not only orally but also through several power-point presentations. Changes were implemented over a period of 6 weeks, although an audit of the completion rate of weekend jobs requested was maintained for a total period of 14 weeks (including baseline scores). This gave sufficient time, after the modifications implementation, to assess whether effective changes had been maintained.

Measurement of improvement:

We developed a scoring system to assess the extent of the problem. The average baseline score for the first 5 weeks, prior to effecting any changes, was 67.4%. The scoring system was continued and recorded weekly. Results can be seen in the graph attached.

Effects of change:

Through the course of 5 PDSA cycles, the average baseline score (indicating the percentage of requested jobs completed over the weekend) improved from 64.7% to 84.4%. The questionnaire completed by all surgical doctors demonstrated that the new system was universally more popular than its predecessor. The average satisfaction score with the system improved from 37% to 68% and it was reported that the revised procedure saved junior doctors a significant amount of time and reduced the likelihood of errors jeopardising patient care.

Lessons learnt:

As a group of foundation doctors, working on a quality improvement project gave us the opportunity to identify an area of weakness and thereafter effect changes which improved efficiency and the quality of outcomes. This was very empowering. On future projects, I will try to involve more senior supervisors earlier in the process. Close support and involvement at consultant level would guarantee that the implemented changes were sustained after the current cohort of junior doctors were rotated from their surgical firms.

Message for others:

This project demonstrated that through relatively small and simple changes in practice, junior doctors achieved a significant improvement in clinical outcomes. The number of requested tasks completed over the weekend was successfully increased. We developed a handover system which saved doctors’ time and reduced the likelihood of error, thereby improving the level, quality and safety of patient care at weekends.

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Prize Winner

Appendix: Page 58

Casebook 2012


Project Title:

Transforming young people’s experience in hospital – empowering children and students through play

Submitted by:

Claire Elizabeth Matthews

Context:

The project is at King’s College Hospital (KCH) and utilizes the energy, drive and youthfulness of the King’s College London (KCL) students to engage children in the peadiatric department of the hospital whilst providing learning opportunities for future healthcare professionals in communication, child interaction and multidisciplinary teamwork.

Problem:

All too often children’s experiences of hospital are dominated by imposed restrictions, prescriptive care and isolation. Without autonomy, children’s experiences are often dictated by those who care for them. This project aims to empower children in hospital though child-led play, without incurring expense or requiring additional staff.

Assessment of problem and analysis of its causes:

At KCH, the ratio of play specialists to paediatric beds was 1:23 and there was no cover in A&E. The team was overstretched and facing budget cuts. A survey of paediatric patients’ experiences revealed that only 34% felt they had been involved in decisions on the wards and in the A&E this reduced to 12%. Child-led play is one of the few outlets for children to express autonomy, build self-esteem and escape to normality.

Intervention:

The KCH Student Play Team project was created in conjunction with the KCL Paediatric Society and the KCH play specialists. The project engages 130 students from all backgrounds, disciplines and years who volunteer on a fortnightly rota. Every weekday evening (6-8) and Sat/Sun morning (10-12) and afternoon (3-5) a team of 6 students from nursing, midwifery, physiotherapy and medicine courses play with young patients and their siblings on the wards and in A&E. Students are equipped with ‘Bob the Builder’ style play tool-belts that include all the play essentials in addition to their imaginations. The advantage of utilizing health care students is that they already have hospital ID’s, enhanced CRB’s and occupational health clearance.

Strategy for change:

After a go ahead from hospital managers in November 2011, we won a £700 student union grant for capital cost and began recruiting and training 132 health care students so they were on the wards by Christmas. To ensure minimal running costs, I used training days to demonstrate to students how their creativity can be their most powerful play tool. We ran activities where each team of 6 students were given an item commonly found on the ward and they then had 10 minutes to create as many games or activities with that item as possible. Nappy bags became wigs for a puppet show, paper plates became wheels that transformed a child’s bed into a Ferrari and the FA cup final was re-enacted with plastic spoon players sellotaped to fingers and a teabag for a ball! This imaginative thinking created an inexpensive way of turning the A&E waiting room and evenings and weekends on the wards into an adventure.

Measurement of improvement:

In March 2012 a survey was sent out to 100 students, families and children, to collect feedback from all involved in the project. The Student Play Team provide 425 hours of voluntary service a month and bring smiles and laughter to an average of 64 children a week. This is all whilst developing the communication skills of the universities students. I am also calculating the social return on investment (SROI value) for the project.

Effects of change:

The results of the survey showed and that patient satisfaction improved by 68%, perceived waiting times in the A&E reduced by 52% and students confidence increased by 93%. The programme saw ten times the amount of dedicated 1-1 child-led play time in the hospital, increasing children’s autonomy and improving families experiences.

Lessons learnt:

Due to the success, expectations have now been set by staff and children alike and I am worried about times when we will have fewer students able to help such as during exams and holidays. To overcome this, we are introducing a flexible rota system for these times whereby we ask students to sign up for two shifts a month. I think it is important to encourage students to stay in the programme for at least a year to help with the training of the new intake of volunteers in September. I therefore spoke to the hospital management who agreed to sign certificates of appreciation for any student who regularly volunteered with the team for a year.

Message for others:

Students are an untapped resource grateful of hospital based learning experiences and recognition. Hospitals can maximise on students energy, drive and youthfulness to engage children in hospital whilst providing learning opportunities for future healthcare professionals in communication, child interaction and multidisciplinary teamwork. Since launching the King’s Student Play Team we have already been invited to Sydney, Melbourne and Argentina to set up similar schemes there.

Casebook 2012

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Prize Winner 39


Project Title:

Management of Paediatric Nephrology Unit External Referrals and Telephone Consultations for Immediate Advice: Trainee-Led Service Improvement Project

Submitted by:

Susan Minson, Rachel Shute, Helen Jones, Daljit Hothi, Rukshana Shroff

Context:

This paediatrics trainee-led service improvement project was completed at Great Ormond Street Hospital for Children in the paediatric nephrology department. We conducted a project to improve the communication and documentation of telephone calls between our team and our colleagues at other hospitals, and between our team and patients and their families.

Problem:

A significant bulk of the registrar’s workload is spent dealing with telephone calls from parents, community teams and paediatricians working at DGHs. In our paediatric nephrology department we wanted to improve the management of such calls. The current practice was suffering from poor continuity of documentation, especially in cases where multiple calls about a single child had taken place, and poor handover within our internal team.

Assessment of problem and analysis of its causes:

We formally audited our current practice over a 2 week period to assess the volume, type and frequency of calls and review the documentation of new and repeat telephone consultations on the same child. Our starting audit of telephone consultations showed that the majority of calls (70%) were from paediatric teams at other hospitals and over the 2 week period multiple calls were registered on the same patients.  Overall documentation was poor, limited and in many instances (60% of follow-up calls) previous clinical information and advice given was not available for subsequent calls.

Intervention:

We felt that improving the continuity of documentation was key to improving our service. We needed a clear method of documentation with an agreed handover process to ensure the information was available when needed. Following the audit we worked with the medical team and clerical staff to create a proforma for collecting clinical data and a filing system to improve continuity of documentation between registrar shifts. We consulted all members of the clinical team including doctors and nursing staff and also clerical staff. The porforma was used to collate information from other trusts and parents and was then handed over between the registrars to ensure information was to hand when receiving calls.

Strategy for change:

We worked with the consultants and managers in our department to agree to pilot the change. The proforma and filing system were then introduced for a 6-week trial period and the process of managing outside calls was re-audited by the same registrar team.

Measurement of improvement:

After introducing the new proforma we re-audited external calls over a 2 week period and found clearer documentation and significantly reduced instances (<5%) where previous telephone consultation notes were not available.

Effects of change:

The introduction of the proforma and handover system had a number of benefits for trainees, for colleagues at other centres and importantly for our patients and their families. The workload burden of outside calls to trainees was significantly more manageable and the registrars benefitted from improved training via better follow-through of patients over time. The improved documentation also benefitted our colleagues at other centres, improving efficiency as there was less need for them to repeat clinical information. Patients and their families benefitted too as telephone consultations were more easily filed in their notes. 

Lessons learnt:

We describe a simple trainee-led service improvement project that produced a positive result to the way telephone calls were managed in our centre. We achieved successful change by ensuring all members of the clinical team contributed to and were invested in achieving a positive outcome.

Message for others:

We achieved successful change by ensuing all members of the clinical team contributed to and were invested in achieving a positive outcome. We introduced a relatively small change, which would be easily achievable in a six month post which improved our training and also the service we provided to our patients and their families. Small scale service improvement projects are easily achievable by trainees and can result in substantial improvements to the quality of training and service provided.

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Casebook 2012


Project Title:

Audit of the management of elective caesarean sections and introduction of enhanced recovery in obstetric settings for the first time in the country

Submitted by:

Sameena muzaffar

Context:

Audit performed in maternity unit at Royal Hampshire County Hospital, Winchester.

Problem:

A retrospective note review audit of 40 patients having recently undergone elective caesarean section was performed. We found that 6% of our patients have major degree of anaemia (Hb <9g/l) and 15% had minor degree of anaemia (Hb <10.5 g/l) at the time of surgery. 9% of our women had poor pain control. Majority of our patients (99%) had catheters taken out and mobilised the next day after elective Caesarean section. Only 29 % of patients were discharged before within 48 hrs of surgery. Majority of women (51%) were discharged between 48 and 72 hrs after surgery. Women had no medical input between 48-72 hrs of their stay. Again, majority of our patients (83%) had no review by operating surgeon or an obstetrician in the postoperative period. The results of our Audit project very clearly show the scope of improvement and it can be achieved by introduction of enhanced recovery for our patients.

Assessment of problem and analysis of its causes:

A retrospective audit of management of elective caesarean sections in the unit was conducted. As many key stakeholders as possible were identified and invited to 2 meetings where the results from the audit were discussed, entire patient journey was mapped out and suggestions of improvements and solutions to problems were gathered. This information from the audit findings and meetings formed the basis of our proposed new patient pathway and the identification of service improvements.

Intervention:

A pathway was designed to check patients Hb in advance of surgery, to facilitate the administration of intravenous iron infusions, if indicated. Post natal analgesia bundle was created by the anesthetic team and maternity pharmacist on the computer based prescribing programme to ensure all women have adequate post operative analgesia prescribed. An enhanced recovery pathway was written and disseminated between all team members. The following changes were made to encourage enhanced recovery after the elective Caesarean section a) catheter removal was brought forward to midnight of the day of surgery b) intravenous fluids are stopped as soon as possible d) women is encouraged to sit in the chairs or at the dining tables to eat meals. These changes are delivered by the post natal staff. Daily medical review has been introduced and helps in early detection of complications, establish fitness for discharge and provide an opportunity for de-brief and further information for patients. New patient information leaflets have been designed and introduced for LSCS.They include advice on a)what the woman herself can do to optimise her health prior to operation b) what to expect post operatively c)discharge advice. To involve patients further in their own care they are asked to complete patient diaries.

Strategy for change:

The change was introduced by the introduction of generic elements of enhanced recovery for elective caesarean section patients. The following people were identified as key champions in their area and agreed to be directly involve in the delivery of the project: Michael Heard consultant obstetrics and gynaecology; Martyn Pitman consultant obstetrics and gynaecology; Susannah Foster consultant anaesthetist; Derinell Haikney band 7 midwife for ANC; Lyndsay Cotton band 7 midwife for PNW; Terri Kemp band 7 midwife for labour ward; Stephaine Goodwin midwifery matron; Sharron Hurrell practice development midwife; Semeena Muzaffar SPR obstetrics and gynaecology; Emma Torbé SHA Service Improvement Fellow ; The project was discussed and approved by the chair of the patient safety committee. We also won a prize of £5000 towards our project from South Central SHA. It took two months to plan and implement change, educate staff and design patient information leaflet and diaries. The staff was educating about the plans for change by face to face teachings in labour ward forums,doctors weekly teaching sessions, and at midwifery handovers. Posters and emails were also used for staff education. Enhanced recovery pathway was launched on 1st of Feb 2012 and all elective sections in our unit are on enhanced recovery pathway. Re-audit had already shown the changes and positive effects of our enhanced recover project. The results will be discussed in the clinical governance meetings.

Measurement of improvement:

A re-audit of the first 30 patients on Enhanced Recovery Pathway was done The results showed the improvement in Preop-optimization of Hb, decrease in variance in analgesia, early catheter removal and mobilization and early discharge. Improvement in postoperative medical input was shown in the results of the audit. Collection of patient satisfaction data has shown improvement in patient involvement, patient information and patient satisfaction after introduction of Enhanced Recovery in our Unit

Effects of change:

The project improved the quality of care by 1. 2. 3. 4. 5. 6.

Reducing anaemia in patients pre and post operative, reducing thromboembolic risk through early mobilisation, reduced dehydration optimised Hb and reduced PPH risk. Reducing hospital acquired infections Reducing post operative pain by standardising analgesia prescribing Early detection of complications as a result of daily medical review Reductions in variances of care as a result of standardising pathways of care Increased patient involvement in their care by introduction of patient information leaflet and patient diaries

Lessons learnt:

Few things about the patient journey were highlighted by patients in the patient dairies. Patients representatives should have been invited in initial share holders meeting to see the journey from patients point of view. Consider more patient involvement next time.

Message for others:

There is a great scope for Enhanced Recovery in Obstetric settings and it makes significant improvement in quality of care and patient satisfaction.

* Casebook 2012

Prize Winner 41


Project Title:

‘iTreat’: A hospital linked iPhone application to streamline Junior Doctor clinical activities, save time and improve patient care

Submitted by:

Karl Payne

Context:

This improvement project was undertaken within the United Lincolnshire Hospitals (ULH) NHS Trust, at the Lincoln County and Boston Pilgrim Hospital sites. The project involved the postgraduate education department and all of medicine, surgery and microbiology. The project was aimed at junior doctors, using a group of Foundation Year 1 (FY1) and Foundation Year 2 (FY2) doctors.

Problem:

From personal experience and discussion amongst colleagues and collaborators, it was identified that there was a need to streamline the access to clinical information and ULH Trust disease management protocols for junior doctors. It was felt that too often decisions were being made not referring to appropriate sources/protocols and that time wasted waiting for access to ward desktop computers was impacting upon the working activities of junior doctors, and ultimately the quality of patient care.

Assessment of problem and analysis of its causes:

To assess the problem we undertook a preliminary baseline survey; to discover how junior doctors accessed information, and the levels of smartphone ownership and medical app usage within this group. Our initial data pointed towards a frustration with the current system, a high level of smartphone ownership and usage during clinical activities, and more importantly a clear intention to endorse a hospital linked smartphone app.

Intervention:

As an intervention we designed and produced an iPhone app specific to the ULH Trust, given the name ‘iTreat’. The authors did not create any new ULH Trust protocols, but sought to package already approved documents into an easy to access and navigate format, available on a smartphone and in the pockets of all junior doctors. Sections were created to include: a) a direct RSS feed from the ULH Postgraduate department, b) the ULH Trust antibiotic formulary, c) ULH Trust approved disease management protocols from 12 medical/ surgical specialties, d) a ‘favourites’ section to store commonly referred to app pages, and e) a hospital extension number phonebook (figure 1 in Appendix).

Strategy for change:

To trial this intervention it was decided to run a formal research study as a means to fully evaluate the impact and any required alterations to the iTreat app. A study protocol was constructed and NHS Research Ethics Committee approval obtained. Study methodology was a pre-test post-test design; participants were recruited from FY1 and FY2 doctor groups working within the NHS Trust; eligible to participate within the study if they owned an iPhone.

Measurement of improvement:

Data capture used a mixed methods approach of pre and post-study questionnaires and semi-structured interviews. 39 Foundation doctors enrolled onto the study; the iTreat app was distributed via the Apple appstore and made available during a 4 month trial period.

Effects of change:

Quantitative (questionnaire) data is available for presentation: Pre-test data reported participants spending, on average, over 30 minutes per day searching for ULH Trust guidelines, finding these ‘often’ difficult to locate. The majority of participants described time wasted accessing guidelines as having a ‘minor’ to ‘moderate’ negative impact upon patient care. Post-test data reported the app was felt to be ‘easy’ to use, with ‘good’ aesthetic properties. The antibiotic and disease management protocols were described as the most useful app sections. The majority of participants felt that the app saved them time during clinical activities, with over half of participants stating a ‘moderate’ positive impact upon patient care. The main encountered problem within this project was the opinion of participants as being perceived as unprofessional while using the app on hospital wards. This theme is currently being explored in ongoing qualitative (interview) data collection.

Lessons learnt:

Message for others:

Several learning points, and areas for further research have been identified from our work: •

Junior doctors show a clear desire to endorse smartphone technology, and we provide evidence for the benefits of its implementation.

What junior doctors want is full hospital handheld technology integration. Being able to view patient clinical data remotely with access to access to hospital files such as work rota’s. This level of integration requires further monetary investment and a change in Information computer technology (ICT) strategy.

Similar future projects need to involve all levels of trainees; both at Core trainee and Specialist trainee level, as the findings from our junior cohort can only be partly extrapolated to these groups.

“Hospital linked smartphone apps can assist the working activities of junior doctors, saving time with the perceived follow on effect of an improvement in the quality of patient care” As the NHS continues on its quest to computerise hospital clinical records, we highlight smartphone technology as one avenue of ICT improvement to positively impact upon the health care system.

Appendix: Page 58

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Casebook 2012


Project Title:

Improving Care for Severely Injured Children within Wessex

Submitted by:

Kate Pryde

Context:

Whole system improvement project carried out within the Wessex Region. There was engagement with all stakeholders in the complex multidisciplinary journey of the severely injured child including pre-hospital staff, emergency departments, intensive care, paediatrics, surgeons, orthopaedics, plastic surgery, pharmacy and rehabilitation.

Problem:

Trauma is the leading cause of death in children >1 year. Trauma outcomes in the UK are significantly poorer than comparable developed countries with 20% increased mortality rate. The UK is currently setting up trauma systems to try and improve outcomes for both adults and children. The NHS Clinical Advisory Group (CAG) for Children with Major Trauma produced recommendations in 2011 to advise on the development of strategic activities to support recommended standards of care for children with major trauma. The Wessex region wasn’t meeting these standards, delivering sub optimal care to the severely injured children in the region and this project focused on implementing the CAG guidelines within the region, with particular reference to the processing of severely injured children within the trauma units and their secondary transfer.

Assessment of problem and analysis of its causes:

• • • • • •

Intervention:

Audit of processing in trauma units revealed many sub optimal standards: Lack of consultant lead trauma care for children Lack of paediatricians within the trauma team Prolonged time to initial CT (mean 129 minutes, standard = <30minutes) Additional studies showed that staff were not aware of the relevant pathways and protocols to be followed for trauma and where to find them. These data were presented to the various stakeholders in various forums and the results discussed to try and elicit the reasons behind this.

The problem was multi factorial and part of an incredibly complex system so required multiple interventions with different groups of professionals. They have included: • • • • • •

Creation of children’s trauma teams within trusts Agreement of recommended method of anaesthesia of severely injured children with the Emergency Department Agreement of pathway for obtaining appropriate timely imaging in severely injured children Creation of time critical transfer patient pathways and checklist for staff Creation of folder of guidelines for Children’s Major Trauma Creation and delivery of education package for the whole children’s trauma team, learning and working together in simulation to improve the care they give to patients. This involved skills and human factors training as well as simulation.

Strategy for change:

The changes were implemented locally through working with the different teams involved. Regional we worked with the Trauma Unit leads through The Wessex Trauma Network and paediatric critical care lead for each trust through the paediatric critical care forum. These were both over 6 month periods.

Measurement of improvement:

• • • •

Effects of change:

• • •

The project is not yet complete and differences to patient care are not yet possible to measure with the system “going live” next week, April 2nd. Quantitative process measures such as time to critical interventions – anaesthesia, CT scan have more than halved as measured by serial simulations and real cases. Qualitatively teams now work better together with clear leadership and followership. Through real time simulations of cases with the whole team, simulation time to CT in one trust has been bought down from 77 to 26 minutes. The changes are yet to be fully implemented and so effects have not been fully assessed. The novel teaching and education packages, using whole team approach, which have begun have had excellent feedback which has inspired regional hospitals to take responsibility and ownership of their continued multidisciplinary education by running training days. The result is a cultural change within each hospital working towards high quality team based trauma care. Sustainability is built upon local ownership of the change. Broader impact is expected, as improvements in systems of care for injured children are applicable to seriously ill children.

Lessons learnt:

Building of relationships is key to ensuring lasting improvement occurs. This takes time and can easily be seen as a waste of time when as clinicians we are used to always being busy doing. Time planning, thinking and building relationships is crucial and must be built into your project plan.

Message for others:

• • •

Invest time in building relationships with those crucial to ensuring the change happens. Identify your early adopters and early majority (Rogers 1962) to shift the change earlier and create a critical mass. As a leader of change you will constantly come up against brick walls and you have to be prepared to wipe off the dust and get going again. This project has resulted in whole system change driven from the grass roots upwards, rather than top down. It will resonate for years and improve care for hundreds of children.

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Project Title:

Patient Safety First - Empowering Junior Doctors to Improve Care for Patients

Submitted by:

Kate Pryde, Julia Harris

Context:

Improving the quality of patient care through safer practice is a priority for the NHS. In recent years there has been increasing recognition of the untapped potential in junior medical staff to not only identify some of the major problems within hospitals but also their ability to tackle them. Over the past 2 years within Wessex, we have developed a patient safety programme that all core trainees (ST1) attend, regardless of speciality. The purpose of the programme is to get trainees to engage with patient safety through examining their own practice, to identify its flaws and then give them experience of influencing others to change care.

Problem:

Junior doctors are an untapped resource in improving patient care. At the coal face they have the ability to see what could be improved but often lack the skills and knowledges of how to go about implementing change.

Assessment of problem and analysis of its causes:

Junior doctors receive little or no training in patient safety or quality improvement methodology in training.

Intervention:

The program consists of a one-day course with trainees then undertaking a project of their own choice back in their own clinical practice. The morning of the training day is devoted to teaching sessions on various elements of patient safety, including human factors, using examples from industry to illustrate and draw parallels. A session introduces delegates to one improvement tool: using PDSA cycles. In the afternoon participants break into specialty groups and explore the risks in their specialty. Participants are required to identify a project from their own practice, either individually or in groups. They then return to the work place and carry out the project using the PDSA cycle methodology. The projects are mentored by Patient Safety Champions (senior trainees or consultants from relevant speciality). Towards the end of the academic year a one day Trainee Patient Safety conference gives the opportunity for all the projects to be presented to peers, safety champions, safety leads from trusts, chief executives and the SHA medical team. Keynote speakers from the field of Patient Safety make this an informative and enjoyable day. 

Strategy for change:

The Dean made the training day compulsory for all ST1 trainees, with a number of training days over the year to ensure everyone could attend. Ensuring sustainability a train the trainer approach has been adopted with some schools now able to offer their own training day.

Measurement of improvement:

In 2009-10 there were 7 training events and 146 trainees went through the programme with 13 oral and 13 poster presentations at the conference. In 2011, the Wessex Postgraduate Dean made attendance at the one-day course compulsory and 276 trainees went through the programme with 90 projects being completed. At the conference in July, there were 15 oral and 75 poster presentations. Since September 2011 a further 180 trainees have attended the training day and are in clinical practice working on projects to improve patient safety locally. In addition, a parallel programme has helped to develop the expertise of the 24 Patient Safety Champions in each specialty.

Effects of change:

Projects were grouped into the areas of: Handover; Drugs; Equipment; Patient care & General Patient Safety. One group introduced clear labelling on the front of syringe drivers in ITU to reduce risk of potentially giving bolus of the wrong drug. Another re-worked an existing chest drain documentation sheet to include vital information such as patient names, indication for insertions, signs of infection. Groups utilized things that were already happening to improve care – lists of outliers that were previously only circulated to juniors at weekends are now given daily reducing risk of a patient not getting a timely review. Discharge processes were altered to reduce the number of patients who failed to get their follow investigations or appointments booked. Patient safety information boards were introduced to raise the profile of departmental risk management activity including highlighting SIRI’s, relevant audits and top 3 risks. Many were multi disciplinary in nature, sustainable and crucially all were at little or no cost, which is vital in this flat cash environment. Trainee were encouraged to reflect on how care was delivered in previous posts to share good practice as well as come up with innovative ideas to solve local problems. Trainees have presented locally to Trusts, nationally at Specialty meetings and internationally at the International Patient Safety Forum. 

Lessons learnt:

The challenge now is how to ensure this fantastic work is sustainable. How can best practice be spread across individual hospitals and across the region – reducing variation and raising quality to give our patients better care? We need to ensure senior Trust managers including chief executives are aware and engaged with the work to catalyse these improvements.

Message for others:

Junior doctors can make significant improvements to quality and safety of patient care in a small amount of time with no money.

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Casebook 2012


Project Title:

Re-Auditing Compliance With The Best Practice Tariff For Fragility Hip Fractures

Submitted by:

Emma Radford, Ross Fawdington, Dia Giebaly, Alastair Marsh

Context:

The project was conducted in the Trauma and Orthopaedic department at Russells Hall Hospital (District General Hospital, Dudley).

Problem:

Neck of Femur (NOF) fractures contribute significantly to morbidity and mortality in elderly people. Historically, patients with NOF fractures have not always received high quality care on orthopaedic wards, owing to the complex medical and social problems that coexist in this patient group. Shortcomings have been recognised nationally, and in 2008, Lord Darzi published High Quality Care for All, identifying hip fractures as an area of poor performance. To address this, the DOH introduced the Best Practice Tariff (BPT) for hip fractures in April 2010. This is a set of recommendations that incentivise Trusts to deliver better quality care. The BPT recommendations are (a) time to surgery within 36 hours, and (b) involvement of an ortho-geriatrician, (including assessment by a geriatrician within 72 hours of admission). My team and I were keen to ensure that we were providing high quality care in line with these recommendations. We conducted an audit to assess our compliance with these recommendations and to identify areas for improvement.

Assessment of problem and analysis of its causes:

We conducted an initial audit cycle between 1st April and 30th June 2010. We assessed the proportion of patients with NOF fractures that had met the BPT criteria. Data collection was conducted by junior doctors, supervised by the orthopaedic registrar and consultant. The Ward Manager accessed data on our behalf from the National Hip Fracture Database. Where patients had not met the BPT criteria, we reviewed their medical notes and theatre records to establish the reasons why (e.g. medically unfit for theatre within 36 hours). The DOH recognises that 85-90% of patients will not be fit for surgery within 36 hours. However, 100% of patients should be assessed by an orthogeriatrician within 72 hours of admission. We used these percentages as our audit ‘standards’. We identified 109 eligible patients, with only 53% meeting all BPT criteria. 20% were not seen by an Ortho-Geriatrician within 72 hours of admission, 18% were not operated within 36 hours of admission, 4% breached both criteria and 5% had incomplete data.

Intervention:

We made the following recommendations: 1. 2. 3. 4.

Calculating the surgery breach time on admission and stating it on the trauma operating list. This list is distributed each morning to surgeons, wards and theatre staff to ensure all team members are aware of the breach time. Starting data collection immediately on admission to ensure accurate recording for BPT audit and to ensure information is uploaded accurately on to the National Hip Fracture Database. Placing NOF patients early on trauma operating lists to avoid acquired list delays leading to cancellation. Changing the Medical Ward Round frequency to; Monday AM, Wednesday (any time) and Friday PM. This avoids any time period greater than 72 hours elapsing.

Strategy for change:

We presented our audit findings and recommendations in the daily trauma meetings, attended by the surgical team, as well as specialist hip fracture nurses (who could disseminate the information to the wider nursing team). We updated the anaesthetists and theatre staff about the ‘breach time’ which had been added to the trauma theatre lists. We held a meeting with the ortho-geriatric consultant and negotiated a system of ward rounds that would prevent breaches of more than 72 hours. We allowed a six month period before reauditing.

Measurement of improvement:

The re-audit was conducted between 1st January and 31st March 2011. This identified 120 eligible patients, with 81% meeting the BPT criteria. 3% were not seen by an Ortho-Geriatrician within 72 hours of admission, 12% were not operated within 36 hours of admission and 4% breached both criteria. By reviewing medical notes, we discovered that all patients not seen by an Ortho-Geriatrician within 72 hours were initially managed as ‘outliers’. All 19 patients that breached the target ‘surgery within 36 hours’, were not fit for surgery within this period.

Effects of change:

We have demonstrated that our simple recommendations for improved management of patients with NOF fractures have enabled improved compliance with the BPT. We have improved from 53% compliance to 81%; significantly closer to the Department of Health target of 85-90%. Since the BPT is an enhanced tariff price for the treatment of a NOF fracture, we have also been able to demonstrate a financial gain for the trust. (See uploaded poster for calculation). We have earned the hospital an extra £14,685 for this 3-month audit period.

Lessons learnt:

This audit project has demonstrated that the introduction of relatively simple measures can have a significant impact on improving patient care. However, to make such changes successfully, we must ensure that all MDT members are ‘on board’. In future, in addition to conducting meetings with team members, I would also consider sending written information to act as a resource for the team to refer to. 

Message for others:

We have demonstrated that the care of patients with NOF fractures has improved at Russells Hall Hospital, resulting in financial gain for the Trust which can be re-invested to provide further improvements to patient care.

Casebook 2012

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Project Title:

Oral Fluids in Older People : Are we Getting it Right?

Submitted by:

Rishi Rallan, Ananya Vashisht, Rita Mildner

Context:

We report on an audit project conducted in a district general hospital. The project was initiated following a Care Quality Commission (CQC) report in 2011 which found failing standards in dignity and nutrition for elderly patients. The audit was initially conducted by two foundation doctors and a consultant, but since the results of the audit, we have actively involved several members of senior nursing staff, hospital managers and doctors to ensure a positive outcome for our patients.

Problem:

Water is an essential daily requirement and older patients in particular are more susceptible to insufficient oral fluid intake. During admission to hospital it is important to ensure, that as well as managing the acute illness, patients oral fluid requirements are being met. Our aim was to assess whether older patients at our hospital were receiving sufficient oral fluids and if not, to propose changes for improvement.

Assessment of problem and analysis of its causes:

The nationwide impact of the CQC reports regarding the problem with oral fluid intake for hospitalised patients, prompted us to perform a retrospective study looking at patient records in our hospital. We randomly selected 100 patients over the age of 65 years from the inpatient wards. Patients who were dying, on intravenous (IV) fluids or non-oral feeding were excluded yielding 67 patients who were analysed. The documentation showed that a significant proportion of patients were not being weighed. Patients’ fluid intake was poorly recorded, including those ‘at risk’ who were identified by ‘red jugs.’ Furthermore, doctors were not reviewing fluid status regularly and in some cases, patients’ renal function declined possibly as a result of the above.

Intervention:

We reiterated that all patients were to be weighed and all fluids taken recorded on one fluid chart. Doctors and nurses are to document a specific target volume of intake based on an agreed fluid matrix, on the fluid chart. The fluid chart is to be reviewed regularly as part of the doctors’ ward round and the nursing handover. The current fluid chart is being modified to pull together all the required information about oral fluid intake, as well as preventing any ambiguity by avoiding duplication. We also clarified the indication for ‘red jugs’, and have ensured that all staff are aware of their use, notably for patients who are unable to administer their own fluids and are not aware of the need for fluids.

Strategy for change:

Since our audit findings, there have been regular meetings and tutorials for healthcare professionals on the importance of oral fluids. These have generated debate on ways to tackle the issue of patients’ poor oral fluid intake. Education and improvement in patient safety is a continual process, hence we have created a sustainable way to promote education which is not affected by staff changing posts. A group of five doctors and senior nurses have been assigned to specific wards where they perform weekly spot checks and provide one to one discussions with nurses and doctors in charge of patients when short-falls are identified. Similarly, good practice is recognised and praised. This not only ensures immediate patient safety, but frequent checks also ensure that the standards are maintained.

Measurement of improvement:

‘Spot checks’ are currently being undertaken, and initial indications are that there have been improvements week on week and plans to re-audit in the week 9th-13th April are underway. We aim to present findings at local and regional meetings.

Effects of change:

Subsequent actions post CQC reports resulted in the trust being compliant with regards to oral fluid requirements. Up to now our spot checks have shown an improvement in documentation, with almost all patients being weighed. Weaker areas highlighted from the spot checks are instantly fed back to the nurses and doctors concerned and we are noting improvements on a weekly basis.

Lessons learnt:

Our audit has demonstrated that there is the need to improve documentation of oral fluid intake in order to optimise patient care and safety, and that as health care professionals we all need to take responsibility for this. Future plans will be to re-audit this topic in a variety of hospitals, aiming to ensure that basic fluid requirements for patients, is no longer under scrutiny.

Message for others:

Dealing with patients involves not only specific medical or surgical management, but a holistic approach to their care; and this involves each and every one of us actively participating in ensuring that all patients have at least the basic fluid requirements they deserve.

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Casebook 2012


Project Title:

The Paediatric Observation Priority Score: A trainee led culture change exercise

Submitted by:

Damian Roland, Gareth Lewis and Ffion Davies

Context:

This project was delivered in a busy childrens’ emergency department which sees over 34000 children per year.

Problem:

It is important initial assessment of children presenting to urgent care providers is of high quality. However it is well reported that key observational and physiological features are not documented by staff. The NPSA, NICE and CEMACH have all recommended improved governance around the assessment of acutely unwell children. Audits of initial assessments locally highlighted extreme variability in the frequency of core measurements. Additional comments on the appearance of the child were often missing and discharge observations not performed. 

Assessment of problem and analysis of its causes:

Case reviews highlighted that staff education, time pressures and inflexibility of paperwork were common problems. Discussion within and between nursing groups, junior doctors and consultants revealed that generally the quality of assessment was good but at times of peak demand and reduced senior cover there were risks that potentially unwell children would be missed. It was also felt that significant numbers of very well children were being admitted unnecessarily, especially overnight, by junior staff.

Intervention:

The intervention took place in two phases: The first involved the production of a specific assessment tool for use in children. This was based on previously published work and then revised with senior clincians. It was vital that the tool engaged all staff and they had ownership of it. Therefore for the first six months the tool was used in conjunction with normal assessment methods and revised according to nursing and junior medical staff feedback. Once the tool had universal approval this was embedded into departmental paperwork. This was vital to ensure uptake of the intervention and reduce duplication of effort. The resulting POPS tool is attached. The key aim of the second phase was to educate all staff to ensure a complete POPS was performed on all medically unwell children presenting to the department.

Strategy for change:

The strategy: 1. Marketing Campaign. This involved promotions such as “Are you top of the POPS?”. These interventions had minimal impact as posters and global e-mails were ignored. 2. Targeted Group teaching. Nursing and Medical staff were briefed during short teaching sessions during handover. These produced small increases which failed to be sustained. 3. Individual Teaching. With the aid of the department practice nurse bespoke but short on-the-shop-floor teaching was given to nursing staff about POPS. Staff who completed a paper based assessment were rewarded with a metallic POPS badge to wear. The prospect of getting a ‘badge’ seemed to promote competition and awareness amongst staff and assessment rates improved.  4. Seeing action on feedback. The project lead regularly obtained feedback and delivered responses directly to and from individual staff. Those who contributed and received information in this way had almost 100% completion rates. 

Measurement of improvement:

1. 2. 3.

Effects of change:

Behaviour – A sustained increase in the documentation of a complete set of observations on children presenting with illness was seen from 30-40% (2010) up to 80-90% (2011) Function - In a review of 942 cases prioritisation and admission rates increased with increasing POPS. No child with a POPS of 0 was found to have a serious bacterial illness. Outcomes - Despite an increase in overall presentations to the department (3.7%) since the introduction of POPS there has been overall reduction in the number of admissions (-11.2%). There have been no incident forms involving its use. 

The project has demonstrated a shift in staff attitude in regard to the assessment of children and positive outcomes for patients as noted in measurements of improvement. There are still ongoing barriers to obtaining 100% completion rates. These generally occur when staff not trained in its use are performing assessments.

Lessons learnt:

There was a distinct advantage in the project being conceived and delivered by a junior doctor. Communication between other doctors and nursing staff was without any hierarchical overtone and feedback could be (and was) brutely honest. This enabled reactive and proactive change to occur. However senior team approval was very useful in aiding dissemination and although some marketing strategies failed others were very successful!

Message for others:

Systems to improve the assessment of high risk patient groups are of obvious benefit. However it must be remembered that it can be an extremely challenging and a long term endeavor to shift ‘norms’ in clinical practice. A sustained effort ensuring that ALL staff feel they have something to contribute and demonstrating the results of their feedback is vital.

Casebook 2012

*

Prize Winner

Appendix: Page 59

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Project Title:

Implementation of an evidence based treatment pathway for forearm buckle fractures in children.

Submitted by:

Rachel Rowlands

Context:

This project was implemented in a children’s emergency department of a tertiary hospital (34,000+ attendances/ yr). The user groups were hospital staff including doctors, nurses, emergency nurse practitioners and play specialists.

Problem:

Best evidence shows buckle fractures in children can be treated in simple splints with no follow up as opposed to plaster of paris (POP) casts with fracture clinic review. Implementation into health care systems has been sporadic but would decrease returns to hospital, maximise healthcare resources and improve parent’s productivity while reducing their costs.

Assessment of problem and analysis of its causes:

Previously all children with distal forearm buckle fractures were placed in a POP and referred for orthopaedic follow up. Implementation of an evidence-based approach required• acknowledgement of the problem • development of a safe alternative pathway • stakeholder (patients and staff) confidence in the new system.

Intervention:

The project lead, a paediatric emergency medicine trainee, designed a bespoke pathway. This underwent many adaptations in response to user feedback and is attached as a separate file. Staff utilised the proforma for any patient with a potential buckle fracture. Following the flow chart a decision was made that the child was suitable for a splint and discharge with no further follow up. These patients were given clear written advice and told to wear the splint for 3 weeks. The orthopaedic team reviewed x-rays of all splint patients at their daily meeting. This safety net ensured splints were not being applied inappropriately. Parents received the contact number of fracture clinic to report any concerns.

Strategy for change:

Implementation followed a stepwise process: • Adapting an evidence-based pathway to local practice. • Orthopaedic collaboration to ensure engagement and safety net. • Focused sessions to educate medical and nursing staff on appropriate splint usage and fitting. • Ensuring availability of pathway and advice sheets in hard copy and via the local intranet.  • Set up a thorough and robust audit process reacting promptly to concerns or problems via a PDSA approach Department handover meetings were used to raise awareness and disseminate information. Project awareness commenced in December 2010 with implementation in January 2011.

Measurement of improvement:

Measurements were made in three areas: • Length of time in the department prior (2009-2010) and after (2011) intervention: Mean time from presentation to discharge in 2009-10 142.2 mins (n=1512;SD 51.2). Mean time from presentation to discharge in 2011 127.8 mins (n=801;SD 51.4). This difference was significant (p<0.001) . The same period showed no significant difference in time for compound wrist or ankle fractures. • Fracture clinic appointments saved following implementation: 440  • Critical incidents or complaints: No critical incidents or formal complaints as a result of the implementation. A handful of patients (less than 10) have returned for additional pain relief or change of splint size.  • Patients recalled by the orthopaedic team.  Three recalls re-assessing the degree of angulation but no significant changes to management as a result of these. 

Effects of change:

The time difference appears small in the context of the four hour target but is significant, especially during peak periods in the department. It equates to the time required to place a POP on a child, demonstrating face validity and the fact the pathway does not increase time by being complex to interpret. Parental satisfaction has not been measured in a formal sense but the absence of negative feedback suggests this approach is acceptable to parents. Patient care has been improved by removing the need for follow up reducing pressure on parental resources and time. Departmental workload is reduced freeing time for other clinical commitments and potentially improved patient care.

Lessons learnt:

Initial barriers were: • Agreement on the format and structure of the pathway. Although the pathway itself was not questioned the exact terminology used was debated. Increasing the use of pictures showing the types of facture improved user engagement and understanding. • Orthopaedic endorsement was fundamental to success. Their concerns centered on the potential inappropriate splinting of fractures by junior staff. By demonstrating the ease of use of the proforma and the large net savings, especially on orthopaedic time, approval was obtained.

Message for others:

Not all systems in medicine can be rectified or improved by the use of proforma but pictorial descriptions can promote change. We hope other units will look at their own practice in relation to the management of buckle fractures and also in other areas where a dedicated pathway proforma could be implemented. We encourage others to test the proforma widely and seek early endorsement from all stakeholders, especially those who may not be managing the patients directly. This project demonstrates trainees can implement wide scale long lasting change.

Appendix: Page 60

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Casebook 2012


Project Title:

Enabling Doctors in Quality Improvement and Patient Safety (EQuIP)

Submitted by:

Jane Runnacles

Context:

A quality improvement educational programme, EQuIP (Enabling Doctors for Quality Improvement and Patient Safety), has been designed for Doctors in Postgraduate Training (DrPGT) at Great Ormond Street Hospital. The aim is to equip DrPGTs with skills to complete improvement projects supporting the Trust’s patient safety objective of “zero harm”.

Problem:

Medical training continues to fail to prepare graduates for the real world where continual improvement is required to deliver a high quality service with “zero harm”, excellent outcomes and good patient experience at a lower cost. This has an impact upon patient care since research suggests junior doctors are crucial in improving systems of care (Health Foundation, 2011), and are the future NHS leaders.

Assessment of problem and analysis of its causes:

Evidence was gathered to show that DrPGTs have little experience of quality improvement projects to address patient safety issues and would require mentoring support for projects to be successful. DrPGTs rarely have the opportunity to develop leadership skills by implementing changes in their department, yet they are in the best position, as frontline staff, to see where patient safety issues lie and to work on feasible solutions with the multi-professional team. The London Deanery recognises this with their “Beyond Audit” initiative, to which EQuIP has been aligned. For improvement to be effective and sustainable DrPGTs require senior support throughout a Quality Improvement (QI) project, alongside an educational programme (Health Foundation, 2011). Changes at this micro-system level with effective clinical leadership are important for changes in the wider system.

Intervention:

EQuIP aims to remedy the traditional approach of clinical audit by exposing DrPGTs to improvement methodology, alongside mentoring with senior clinicians and managers to enable them to complete high quality projects within their department. The target in this first year is to train 40 DrPGTs at the Trust, of whom 5 are identified to deliver workshops within their department to train other DrPGTs and frontline clinical staff. The intended outcome is to change the way DrPGTs view healthcare by becoming quality “champions” for their department, thus improving their attitudes to patient safety and the science of improvement. This programme is essential to prepare for the demands of the NHS in the future. EQuIP was planned after scoping the experiences of other improvement education programmes. It was designed so all DrPGTs at the Trust participate in a one hour (level 1) workshop to understand the importance of quality improvement to address patient safety concerns, delivered in departmental teaching slots and monthly pan-hospital lunchtime forums. DrPGTs apply competitively for level 2 training, a 6 month rotational programme consisting of 2 full day workshops on patient safety and improvement methodology a month apart, with project surgeries facilitated by Improvement Managers for guidance on their project. Level 2 participants are allocated a senior clinician for at least 3 coaching meetings and an Improvement Manager for mentoring and shared learning. More senior DrPGTs have the opportunity to progress to level 3 training, over a 9-12 month period. This incorporates paired learning with general managers, access to executive leaders for coaching, opportunities to attend board and management meetings and patient safety walk-arounds. This programme differs from others in that it aims to build capacity with the DrPGT being the catalyst for change while being trained and crucial for change in the future.

Strategy for change:

As the newly appointed Darzi leadership fellow at the Trust, I run level 1 workshops in every clinical department and at Trust induction to emphasise the importance of leading a QI project and sign-posting to the level 2/3 programme for support with this. The Trust transformation team was keen to engage with DrPGTs to address the national QIPP agenda and find solutions to local patient safety issues. Therefore the improvement managers from this team were involved to run project surgeries with the Associate medical director for patient safety, and to support DrPGTs in their clinical units. In the first month of the programme, senior clinicians from every clinical unit were appointed as clinical improvement leads and could therefore be engaged with teaching on study days and coaching. The programme has been running for 6months and now DrPGTs from the initial cohort are acting as departmental “champions” and running level 1 workshops themselves.

Measurement of improvement:

Over the last 6 months, 20 level 1 workshops have been held across different departments. Workshops and study days have been evaluated using questionnaires and have been continuously improved. So far 31 DrPGTs have joined the level 2 programme, and 4 already on the level 3 programme. Interest in EQuIP has been observed in every department; clinicians and improvement managers are recommending DrPGTs for EQuIP, and projects are recognised at management board level. Four have presented their work at a London Deanery conference, and two have recently discussed their projects at successful consultant interview, with excellent feedback. Preand post- programme questionnaires were designed to help measure this change in organisational culture, combining a patient safety attitudes questionnaire and a validated leadership questionnaire. Results have shown little prior knowledge of improvement for patient safety and no experience of working collaboratively with managers to implement change. The post-programme survey results are pending. 

Effects of change:

Plans for sustainability and spread have been incorporated in the design of this EQuIP programme and involve engagement of clinicians and managers from the outset. EQuIP participants are delivering workshops in their own departments, and in time will be in more senior positions at other hospitals where they can disseminate their learning. The Trust board is committed to the delivery of EQuIP and it fits directly with Trust initiatives, therefore in time it will become an integral part of patient safety initiatives. Our experience will help inform the design of a regional programme, with a train the trainers approach.

Lessons learnt:

Time is a challenge so it is important to tailor such a programme to ensure DrPGTs have support to complete projects through high level involvement of managers and senior clinicians. Since DrPGTs rotate through their post every 6-12, I would design the programme to start soon after induction next year. Mentoring and project surgeries provided by improvement experts are crucial to the success of individual projects, and access to these should be as flexible as possible. Project surgeries were not a compulsory part of the programme initially but two of the first cohort did not complete their projects because they had wasted time due to lack of input. Participants benefit from the opportunity to present the progress of their project to their peers and experts to receive tailored feedback. Experience of working collaboratively with an NHS manager on their project can help develop a better understanding of each other’s roles.

Message for others:

Small scale QI projects co-ordinated by doctors in postgraduate training can have a substantial impact on patient safety and systems of care. It is important that an educational programme provides adequate mentoring support and progress feedback, alongside practical QI methodology, for projects to be successful.

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Project Title:

A simple intervention to assist common anaesthetic prescribing for the new anaesthetists and recovery staff

Submitted by:

William Shippam, James Jackson, Justin Kirk-Baley and Ashok Raj

Background:

New anaesthetic trainees are exposed to multiple unfamiliar drugs from the first day of their training. The potential for drug errors is high with devastating effects. It has been shown that using an easy to carry drug card reference improves the quality of antibiotic prescribing in a paediatric population [1]. We propose that implementing a similar card for common anaesthetic drugs would improve prescribing practice.

Objective:

Evaluate the requirement and implementation of a prescription tool to improve efficiency and patient safety when prescribing common and emergency anaesthetic drugs.

Intervention:

A reference card with common and emergency anaesthetic drug doses, which can be inserted into a hospital identification badge holder for quick reference. These cards were distributed to anaesthetic trainees and recovery staff at Royal Surrey County Hospital.

Design:

Survey of anaesthetic trainees and recovery staff who commonly prescribe or administer hypnotics, muscle relaxants, analgesics, antibiotics, anti-emetics or emergency drugs. The survey elicited the staffâ&#x20AC;&#x2122;s experience and confidence of prescribing these drugs and their use of existing reference tools, such as the British National Formulae or smartphone applications. As an objective measurement a paediatric scenario assessed the staffsâ&#x20AC;&#x2122; ability to calculate five different drug doses (oral morphine, cefuroxime, dantrolene, thiopentone and atracurium) under timed conditions. The survey was completed before and after the introduction of the reference card. The Wilcoxon Signed-Rank Test was used to test the significance of the data.

Main outcome measures:

Timing and accuracy to calculate five drug doses out of a score of 5, before and after introduction of the reference card. Proportion of those surveyed who would find a prescription tool beneficial to aid their clinical practice.

Results:

In a survey of 17 people (10 anaesthetists and 7 recovery staff) only 24% felt confident to prescribe drugs for adults and children without using a source of reference. 76% regularly use a source of reference to check drug doses and 88% felt that a credit card-sized reference tool would be beneficial. The mean scores to correctly calculate five drug doses before and after card introduction were 2.5/5 and 4.7/5 respectively (p<0.0007). The mean scores for only the anaesthetic trainees were 2.6/5 and 4.6/5 respectively (p<0.0083). No one correctly calculated all five drug doses pre-intervention. The mean time to complete the assessment before and after card introduction was 275 seconds and 131 seconds respectively (p<0.0008). The mean time for only the anaesthetic trainees was 151 seconds and 87 seconds respectively (p<0.0195).

Conclusions:

The drug reference card is an effective tool to improve prescribing efficiency and safety in anaesthetic trainees and recovery staff. The drug card is statistically significant at improving the score to correctly calculate five drug doses and at reducing the time taken for these calculations. A credit card-sized drug reference tool is not only desirable but also easy to access. This concept could also be applied to other disciplines of medicine.

References:

1. South M, Royle J, Starr M. A simple intervention to improve hospital antibiotic prescribing. The medical journal of Australia. 2003

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Casebook 2012


Project Title:

Alignment of Junior Doctors in Quality Improvement

Submitted by:

Eleanor Soo

Problem:

At the heart of quality improvement strategies is the alignment of employees in adopting strategic supportive behaviours (1). Historically the success of quality improvement initiatives in healthcare is limited (2, 3). This is in part due to the lack of engagement of frontline healthcare workers, in particular doctors, who are considered critical to successful implementation of such programmes (4). ‘Management’ is considered a role restricted to those in designated leadership or management positions, and usually undertaken when doctors have reached Consultant level. As a result junior doctors, especially those at the start of their career, are customarily not involved. However, junior doctors are identified as an important group who could effectively contribute to quality improvement (5). This study examined the alignment of junior doctors with a quality improvement initiative and sought to identify any gaps in the quality improvement process. The results informed how participation of this professional group could be enhanced.

Assessment of problem and analysis of its causes:

Junior doctors were surveyed at a Trust undertaking an organisation wide ward based quality improvement programme (WBQIP). The questionnaire used scaled responses to quantitatively assess awareness and attitudes to the initiative, and their wider opinion of quality improvement responsibilities. Awareness of the Trust’s (WBQIP) was reported in 42%. However, none of the junior doctors had particpated or given their opinion to other healthcare professionals undertaking one of the numerous WBQIP projects. Their opinion was split between agreement (44%) and ambivalence (56%) regarding their formal inclusion in the programme. The vast majority (>85%) recognised and welcomed their professional responsibility to contribute to improving healthcare, and that all grades of healthcare professionals and managers should be doing so. The survey also found 42% had ideas on how patient care could be improved, but less than 10% felt they knew how to action their suggestions. The level of junior doctors’ awareness and involvement of the Trust wide initiative was surprisingly low, given the ward-based nature of the programme. Secondly, although they recognised their professional responsibility to contribute to raising the quality of care, there was a lack of opportunity and systems in place to harness their potential efforts. In summary, the results demonstrate misalignment of junior doctors with the Trust’s QIP.

Intervention:

A formal, structured, junior doctor quality improvement programme, based on best practice, was implemented. The programme involving all Foundation Year 1 doctors was underpinned by an action learning approach, and used simple and easily implemented quality tools taught and used in a just-in-time basis. Importantly the projects were chosen by junior doctors themselves and focused on the challenging issues they felt were most significant to their clinical practice. This principal of junior doctors identifying and selecting projects was a key element in getting their ‘buy-in’ and ownership.

Measurement of improvement:

A pre and post-programme survey was carried out. The results demonstrated a significant improvement in junior doctors’ quality improvement knowledge, skills and attitudes. The ‘learning-by-doing’ process also produced valuable learning points, for example “simple ideas can have real impacts on patient care”, and many were found to be recognised components of the Medical Leadership Competency Framework.

Effects of change:

Each of the six projects demonstrated the size and effect of their chosen challenge, and five successfully implemented their solution. All projects were presented to Trust Executives, at a regional meeting, and two presented nationally. One project secured has funding for their solution to be rolled out across the organisation. The programme also created an important communication channel with staff leading the Trust’s WBQIP. The programme is currently running for a second year.

Lessons learnt:

This study validates a belief junior doctors are an unharnessed resource when it comes to quality improvement. The lack of systems and processes in place to engage this professional group is a barrier to their involvement. Addressing this gap, by creating a formal programme, has successfully shown what junior doctors can achieve. Furthermore, this scheme demonstrates one strategy by which an organisation can align frontline staff in quality improvement work.

References:

1. 2. 3. 4. 5.

Boswell, WR., Boudreau, JW. (2001). How leading companies create, measure and achieve strategic results through “line of sight”. Management Decision 39(10), pp 851-859. Nwabueze, U. (2001). The implementation of TQM for the NHS manager. Total Quality Management, 12(5), pp 657-675. McNulty, T., Ferlie, E. (2004). Process Transformation: Limitations to Radical Organizational Change within Public Service Organizations. Organization Studies, 25(8), pp 1389-1412. Caldwell, C., Brexler, J., Gillem, T. (2005). Engaging Physicians in Lean Six Sigma. Quality Progress, 38(11), pp42-46 Department of Health. (2009) A junior Doctor’s Guide to the NHS.

Casebook 2012

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Prize Winner 51


Project Title:

A new electronic booking system for St. Maryâ&#x20AC;&#x2122;s Paediatric Short Stay Unit.

Submitted by:

Celia St.John-Green, Oluteye Ayooluwatunde

Context:

The paediatric short stay unit (PSSU) at St. Maryâ&#x20AC;&#x2122;s hospital is a small area with 9 beds and two treatment rooms, and is run by a small team of weekly changing doctors and nurses. It functions as a short stay ward as well as accommodating day-case admissions, specialist reviews and shorter attendances for nurse led procedures and IV drug administration.

Problem:

Referring patients to PSSU is an organizational challenge, which was not being adequately met through an inflexible and messy paperbased filing system. It was plagued by inappropriate or incomplete referrals, which left the ward disorganized and meant patients often waited a long time to be seen. Inadequate clinical details risked lowering the standards of patients care.

Assessment of problem and analysis of its causes:

We started by process-mapping the different patient pathways to capture who refers to PSSU, from where, and what care those patients receive. We highlighted the wide variety in patients, referral locations and care requirements. We hypothesized that the unfamiliarity of referrers with the structure of the ward day meant that without guidance it was difficult to refer appropriately and provide adequate information. We also noted the lack of an official feedback system to contact referrers or notify them of mistakes. We had discussions with key stakeholders from consultants and ward clerks to nurses, and these highlighted the difficulty in access (need to walk to PSSU/ring a ward member) meaning that families could not immediately be given their appointment time. In addition the set number of booking slots could not be adjusted to suit fluctuating staff levels. Finally the poor records of which children were booked to attend PSSU made coding problematic, potentially impacting upon hospital funding.

Intervention:

I worked with IT to create an online, remotely accessible outlook based calendar that updates in real time and can be viewed by all via their work email 24 hours a day. Regular slots repeat weekly and can be added to or removed by those with editing access to suit staffing levels. We worked with and adjusted existing definitions of different types of bookings, and generated a template of information required to refer a child for each. These definitions and information templates are incorporated into the calendar, prompting the referrer to complete the required information as they book the child in. We worked with the paediatric clinical assistant so that she could include monitoring, updating and adding new staff members to the calendar into her job role, thus ensuring the system remains a sustainable one.

Strategy for change:

The view that change was needed was unanimous and interest stimulated by our initial information gathering was high. Leading up to the launch date there were posters, reminder emails and discussions in departmental meetings. We changed from paper to electronic booking on the 18th February. In the first few weeks the paediatric clinical assistant and I were available to answer questions and solve problems.

Measurement of improvement:

I undertook a retrospective audit showing that appointments are now being altered to fit staffing levels on a weekly basis, but that the use of available slots has improved in some areas but decreased in others. The number of bookings with a complete referral has increased dramatically from 23% to 75%. In addition there is a subjectively reported increase in efficiency and organization on PSSU. This feedback was gathered by formal and informal discussions which have also highlighted the convenience of using the calendar, but that giving feedback to the referrer is still not being facilitated if they have failed to type in their name or contact details. We feel that being able to book mutually convenient times with more information available to the doctors and shorter waits due to improved organization will ensure the patient experience on PSSU is improved by this intervention. We need to continue to consider the cause of the number of unfilled appointments.

Lessons learnt & message for others:

The main learning is around communication. Seeking people out in person is invariably preferable to impersonal and easily ignored emails. I discovered that getting others affected by the problem interested and enthused generates a greater variety of ideas and solutions than individuals can alone, and in addition people are more inclined to back ideas to which they feel they have contributed. During calendar creation differences in opinion over editing access were at times hotly debated. It was re-enforced that as a junior member of a team acting as a middleman is considerably less effective than acting as a facilitator to get conversations rolling and thereby create a commonly acceptable outcome.

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Casebook 2012


Project Title:

Read to Lead: Creating an Accessible Forum for Leadership

Submitted by:

Emmie Stewart-Parker

Context:

Brighton and Sussex University Hospitals is an innovative Trust undergoing major redevelopment in the form of the ‘3Ts’ project: Teaching, Trauma and Tertiary care. Facilities are being expanded and the main site transformed to accommodate these. During this exciting time the concept of clinical leadership is particularly pertinent to harness the opportunities arising from this drive and to create sustainable changes for optimal service provision.

Problem:

Clinical leadership is an integral part of modern healthcare. This is evidenced by the GMC launching guidance on Leadership and Management and its incorporation into training. Furthermore, The Faculty for Medical Leadership and Management has recently launched, along with groups such as ‘The Network’ to champion leadership. Despite this raising of profile, anecdotal evidence suggests that an understanding of the concept of clinical leadership is generally poor.

Assessment of problem and analysis of its causes:

With the current political climate and healthcare reform plans, healthcare professionals do not necessarily feel empowered to implement ideas, and experience resistance to change.

Intervention:

We set up a monthly, Trust-wide, leadership event to raise the profile of leadership, inform and empower healthcare professionals to enhance their daily practice. The event was advertised trust-wide and attendance was encouraged from all professions at all grades. Each month a different, stand-alone, theme pertinent to leadership is explored for one hour in the evening. Recognising clinical and personal commitments, sessions are stand-alone, improving accessibility and encouraging participation. The title of the event, ‘Read to Lead’, describes the programme: a magazine-style article is circulated to attendees in the week before the event. Articles are taken from non-typical sources for healthcare audiences, including the Harvard Business Review and The New Yorker and are not necessarily set in the healthcare environment. Mainstream media provides less threatening, accessible, reading for those who may not regularly attend a journal club. It also enables a richer discussion of the themes during the session as comparison is drawn with other industries, introducing novel approaches to problems. Following an introduction to the theme, the event opens with a short film presenting further issues. These have been taken from feature films or lectures from prominent speakers in the political and business worlds, often outside the UK.

Strategy for change:

The deliberately informal format of the event creates a platform for debate. Through discussion provoked by the film and article, ideas for change are also shared and adaptation for the Trust considered. Senior members of the Trust board have attended, who can then feedback discussion points to the Chief Executive. Important ideas raised are recorded and circulated to attendees following the event to pursue. Some participants bring their own strategies to the event to discuss, adapt and gain support on realizing these. Interventions are discussed at both departmental and Trust-wide levels.

Measurement of improvement:

We record attendance at events and have attracted a wide range of professionals within the trust, including those from medicine, nursing, pharmacy, physiotherapy and management. The events attract an average of 30 attendees, reflecting the demand for such a forum and the multidisciplinary, multi-professional nature further emphasizes the relevance to all services and service providers. Feedback is sought via email and feedback forms and adjustments made. The event has become well recognized by the Trust and has been commended by the chief executive, with endorsements from other senior Trust officials. Healthcare professionals from other local Trusts have also become aware of the event and have requested to attend. These individuals have expressed an interest in taking the programme to their own Trusts.

Effects of change:

The Trust board has expressed interest in developing discussion points further. Read to Lead was set up and led by academic FY2s in Clinical Leadership and Medical Education, with the support of the Trust leadership champions. As trainees rotate through the academic post, they take responsibility for organizing and advertising events. As interest has grown, the next step is to extend locally throughout KSS deanery, harnessing the enthusiasm of others to roll-out the event using our package of resources. 

Lessons learnt:

There is a real interest in and need for access to leadership activities and forums. As enthusiasm is rife, it is important to give individuals an opportunity to express their ideas in a non-hierarchical, non-hostile, and even fun, environment. This will help empower individuals and form the dynamic, multiprofessional, multidisciplinary alliances needed to bring about change.

Message for others:

Leadership is an exciting, growing field. Simple interventions, such as bring together motivated healthcare professionals and managers to discuss ideas can be an extremely powerful tool.

Casebook 2012

53


Project Title:

Improvements in handover and documentation of a busy on-call service at a regional neurosurgical unit, with the use of a computerised database

Submitted by:

Adam Williams

Context:

A UK tertiary neurosurgical service serving a population of over one million is co-ordinated by 6 registrars overseen by the consultant body. In the current climate of shortened shifts, compromised team working and more frequent handovers, accuracy of transfer information is vital. A paper-based on-call system was assessed against a clinically-based electronic alternative.  

Problem:

The existing paper-based referral and discharge documentation was inadequate to satisfy the rigours of modern practice. Entries were not always easily legible or complete, and rapid review of entries was difficult. The study aimed to optimise the accuracy, accessibility and completeness of handover of information to the multiple consultants responsible for on-going care of patients, often being cared for in satellite hospitals.

Assessment of problem and analysis of its causes:

We defined key criteria for each referred patient that were important to document and hand on. These criteria were then audited against the existing paper-based system. The criteria included date and time of referral, identifiers on the referring hospital and doctor, referred patient, history, examination findings and imaging results, as well as Consultant observations and decisions. Legibility was also deemed to be important.

Intervention:

Without any specialist IT input, a computer database was created using Microsoft Access 2005, including a form to aid the input of the above data.  This form included compulsory data entry fields of critical information; others fields were optional to facilitate ease of use.  The database was fully searchable and Access reports were designed to output the data as summarised printable sheet encompassing the entire shift’s referral cohort.  Further Access options were designed with filters to allow certain sub-specialist Consultants (such as complex spine) to better manage the follow-up of their patients.  The database was appropriately encrypted and password protected, stored on a secure hospital server with remote access available from all PC terminals. It was authorised by the hospital Data Protection Officer before activating.

Strategy for change:

The Registrar who proposed and designed the database utilised and refined it in use for three months to ensure functionality and ease of use. Subsequently, the remaining Registrars were provided with passwords and appropriate training and used the system for three months. The outcome was audited against the criteria selected.

Measurement of improvement:

50 consecutive entries from November to December 2010 using the previous paper-based system were audited by an independent data analyst. The data points were recorded as present or absent. Legibility was also assessed, and the entry was deemed illegible if more than three words were not decipherable by a medically-trained independent observer. 500 entries from the database between May and June 2011 were also audited against the same criteria.

Effects of change:

As shown in the attached bar-chart, all the criteria that we assessed showed improvement in completion when the computerised database was used. Furthermore, the database produced very high rates of completion, with 8 of the 16 criteria enjoying 100% completion rates in the 500 assessed entries, whereas not a single criteria was 100% complete in the paper-based system.   The database has subsequently been refined to allow for elegant output of handover sheets for both single day on-calls and weekends.  In addition, power data analysis tools have been written to allow us to audit aspects of the referral cohort such as by referring hospital, by pathology or by time of referral.  These facilities have been used by the directorate to help direct costings and rota management, and also by those involved with the development of Derriford into a major trauma centre.

Lessons learnt:

The audit demonstrated a significant improvement in the quality and completeness of documentation at a busy on-call regional neurosurgical unit. Handover information was both improved, and made easily accessible from anywhere within the hospital. Despite involving time- consuming construction, the database did not require specialist IT input. Further enhancements might include the incorporation of an online referral form to streamline the basic data acquisition, and the use of a wifi enabled tablet PC to improve flexibility.

Message for others:

We have demonstrated that use of a clinical database significantly reduces the likelihood of compromising patient care by failings in hand-over of information. Essential patient information is collated,recorded and transferred with high levels of consistency,accuracy and accessibility.  Furthermore, significant system improvements are possible in busy clinical environments without either delay or recourse to specialist and expensive outside advice.

54

Casebook 2012


Project Title:

Developing an Interim INR Monitoring Service

Submitted by:

Ruth Wood, Stacey Calvert, Helen Yarranton, Sheena Patel

Context:

This project was undertaken on the Acute Assessment Unit (AAU) at Chelsea and Westminster Hospital (CWH), a large London teaching hospital. The team consisted of AAU nurses, AAU and Haematology doctors, the Anticoagulant Nurse Specialist and the Anticoagulant Pharmacist.

Problem:

CWH has a nurse-led Anticoagulant Clinic, but due to a limited availability of ‘new patient appointments’, patients may have to wait. In the interim period patients attend AAU for an INR test and receive warfarin dosing advice from the on-call doctor. The responsible doctor often would not know who had attended for an INR check, what each patient’s target INR was or the dosing history. Frequently an outof-date telephone number meant the patient could not be contacted. Furthermore, warfarin dosing advice was often non-compliant with Trust Anticoagulation Guidelines. Patients newly started on warfarin were at risk of over- or under-anticoagulation and this posed a threat to quality of care and patient safety.

Assessment of problem and analysis of its causes:

An initial audit was performed to quantify the problem. Multidisciplinary meetings were held regularly to discuss possible improvements. The process was mapped out and areas of weakness identified. We followed a ‘PDSA’ approach. Our agreed priorities were:

Intervention:

We implemented two sets of interventions. Firstly: 1. A yellow folder was introduced onto AAU to keep a record of each patient’s INR and warfarin doses 2. The haematology junior doctors took over warfarin dosing from the on-call team 3. Patients were asked to attend AAU before midday so the INR result was back before the end of the working day

1. 2. 3.

Secondly: 1. 2. 3. 4. 5.

To improve adherence to Trust Anticoagulation Guidelines To improve documentation of warfarin dosing advice To ensure doctors responsible for dosing warfarin had the information required to do this safely

A paper appointments diary was introduced onto AAU A joint referral form was produced for Anticoagulant clinic and the Interim INR Monitoring Service (IIMS) A new guideline was written and published on hospital intranet A patient information leaflet was created An electronic template was produced on the Lastword® computer system for recording warfarin dosing advice

Strategy for change:

Three audits and two sets of interventions were implemented over a year. Initial work was performed by a Haematology F2 and later continued by a Haematology F1. All work was overseen by a Consultant and regular multidisciplinary meetings were held throughout. Progress was reviewed monthly by the Venous Thrombosis and Thromboprophylaxis Committee. Audit results were presented to AAU staff and junior doctors. Changes implemented were publicised with emails, poster flowcharts and presentations.

Measurement of improvement:

Each audit collected data over one month, initially prospectively, and later retrospectively. (The introduction of a referral form allowed for retrospective data collection.) Patients were identified for inclusion from the appointment diary, referral forms and hospital thrombosis register. Information was obtained from these sources and the Lastword® computer system. Outcomes measured included: 1. Adherence of warfarin dosing to the hospital guidelines 2. Documentation of warfarin dosing advice 3. Information available to the responsible doctor 4. Waiting times for Anticoagulant Clinic

Effects of change:

Our key results were: 1. Adherence to Trust Anticoagulation Guidelines increased between each successive audit cycle. (Initially 0% of patients were prescribed all warfarin doses in accordance with the guidelines, compared to 74% in the third audit). 2. The percentage of patients with all warfarin doses documented improved from 13% in the first audit to 91% in the third. 3. Information available to the doctor responsible improved in three of the four categories measured. 4. The mean waiting time for Anticoagulant Clinic increased from 10.1 days to 19.5 days. Problems encountered: 1. Junior doctors were initially reluctant to complete the referral form. 2. An electronic appointments system was abandoned as it over-complicated the referral process

Lessons learnt:

• • •

Message for others:

Involvement of the multi-disciplinary team was key to implementing our interventions successfully. More timely communication between the two junior doctors involved at different stages of the project would have saved time and avoided duplication of work. Trialling our electronic appointments system on junior doctors prior to implementation would have indicated earlier that this was not a suitable system.

By formalising an existing practice we have significantly improved quality of care and patient safety. Our solution was cost-effective; our only expenses were an A4 ringbinder and the cost of printing the patient information leaflets. A long-term solution is still required, however, as in essence we have simply created another clinic. The observation of a lengthening waiting time for Anticoagulant Clinic has strengthened a business case for employment of a second Anticoagulant Nurse. This would free-up junior doctors’ time for other clinical tasks.

Casebook 2012

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Prize Winner

Appendix: Page 60

55


Appendix Prescription and Wearing of TEDS in Surgical Inpatients at the Royal Devon and Exeter Hospital

Faxing is so 90s - Introducing an electronic system for inpatient inter-specialty referral in a district general hospital (Musgrove Park Hospital, Taunton) Flow diagram  of  Old  and  New  referral  systems,  with  data  supporLng  effect  of  change   Decision  to  make   referral/seek  opinion.  

Decision to  make  referral/ seek  opinion.  

‘Red Top’  paper  not   available  on  ward  

Locate “RED  TOP”   paper   Often illegible Easily accessible and paper free

Open web  from  on   intranet  

Locate WORKING  fax   machine  

Only 1 fax machine between 5 surgical wards. Some machines broken AND Faxing is so 90’s!

Find correct  fax   number  and  send  

No complete list of fax numbers even with switchboard. Often numbers old/ wrong

Fax free, faster, more secure, safer and more reliable.

Certainty that referral is received and ease of audit

Type form  and  click  send  

Copy automaLcally  sent   to  personal  email  and   audit    

Involves another phone call

Check that  red  top  has   been  received  with   appropriate  secretary  

Often not received and must be resent resulting in delay in patient review

Await acLon  

Shorter waiting time. Easier access by consultants who can plan time more efficiently and see patients earlier

Await acLon  

Shorter and more reliable process

Lengthy and unreliable process

Hand write  form  

Chart comparing  Lme  taken  to  send  Faxed  and  Electronic  referrals.   12  

Time (minutes)  

10 8   6  

Sending Time   Wri:ng  Time  

4 2   0   Faxed  

56

Electronic

Casebook 2012


The Overnight ENT box

Invasive procedures training in Foundation Year doctors

Casebook 2012

Â

57


Electronic handover system for out of hours service in a busy district general hospital

Improving the quality of weekend handover amongst surgical firms at Frenchay Hospital, North Bristol Trust

‘iTreat’: A hospital linked iPhone application to streamline Junior Doctor clinical activities, save time and improve patient care Figure 1: Screen shots of the iTreat app being viewed on an iPhone. Screen shot taken of each app section as shown by highlighted bottom row tab button.

58

Casebook 2012


The Paediatric Observation Priority Score: A trainee led culture change exercise

Weight (kg)

ED nursing:

Children

Date OBs

Time

use 24h clock

Score

Sats Allergies:

Nurse

Name and ID

Breathing

Nameband on patient: ☐ (tick when done)

Presenting complaint AVPU

Gut Feeling

Single-sentence summary if at all possible

Other

Pain

Time

0

1

2

3

4

5

6

7

8

9

10

Pulse

Analgesia declined in spite of reassurance and good explanation of the benefits Analgesia pre-hospital: Further analgesia required and given. Repeat score due at:

0

1

2

Planned interventions

3

4

Time and ID when done.

(circle those required)

5

6

7

8

9

10

Good communication:

Fluid Challenge Urine Dip X-ray FBC U&E NPT Cannula ECG

Time

Action and

If yes Name: Base:

‘A’ form needed? NBM or other diet restrictions? Is the child old enough to understand what is happening with them?

Resp Rate Temp

documentation required for any ticks in highlighted left column below

Does the patient have a social worker?

Oxygen

□ □ □

☐Y

☐N

☐Y

☐N

☐Y

☐N

Total Score Priority

BP

Glucose ☐N

☐Y CRT

Peak Flow

Other:

GCS E V M Sum

Pupils R

L

SIZE

REACT

POPS © Roland/Davies . March 2010 . Version 3.0

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59


Implementation of an evidence based treatment pathway for forearm buckle fractures in children.

DISTAL FOREARM BUCKLE FRACTURE PATHWAY LATERAL x-ray showing DORSAL BUCKLE of distal radius

N

Greenstick # Unsuitable for splint POP and fracture clinic follow up

Is the volar cortex intact? Y Is the buckle distal? (Distal 1/3 vs proximal 2/3)

Proximal # POP and fracture clinic follow up

N splint

Y Can you see significant DORSAL angulation? (>15° angulation of metaphysis to shaft) If unsure- check with a senior doctor

Splint

POP

Y

N Now look at AP x-ray

Y

Is the ULNA normal? OR Does the ULNA have a buckle fracture?

Y

N

Discuss with ED senior and refer to orthopaedic registrar for further management if necessary

Discharge with splint and NO FOLLOW UP Give and read through advice sheet with family Splint day and night for 3 weeks This is an ED Guideline- please consult a senior doctor if you’re unsure a child is suitable for splint treatment.

Developing an Interim INR Monitoring Service

Results: significant  improvement  in   adherence  to  warfarin  guidelines   %  paCents    with  adhert  warfarin  dosing    

100% 90%   80%  

57%

60%

Audit 1   Audit  2  

50% 40%  

40%

Audit 3  

30% 20%   10%   0%  

0%

Days 1  –  4  (loading)  

60

74%

73%

70%

5%

Day 4  onwards    (post-­‐loading)  

Casebook 2012


This Casebook is also available online: www.the-network.org.uk

Casebook 2012

61


Connect with us: Facebook: The Network NWNN Twitter: @thenetwork001 LinkedIn: The Network NWNN

Contact us: Email: thenetwork.org.uk@gmail.com Web: www.the-network.org.uk

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Casebook 2012

The Network Casebook  

Collection of quality improvement initiatives from trainee and junior health care professionals

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