Storyboard Entry Form 2014
Main author: John Frankish (Co-author: Julie Poole, Hiro Tanaka,
Gordon Gillespie, Elaine Fling, Claire Kellaway, Suzanne Jones,
Alison Legge, Vicki Williams, Terence Watkins)
Email: John Frankish
Telephone: 01633 431734
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1. Storyboard title: a clear concise title which describes the work
Team time to improve the pathway for patients admitted with a hip
fracture at Royal Gwent Hospital (RGH)
2. Brief outline of context: where this improvement work was done;
what sort of unit/department; what staff/client groups were involved
This work has been carried out from December 2010 to date in the
Trauma & Orthopaedic Directorate at RGH consisting the multi-disciplinary
clinical team working across the pathway. The team includes:
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Consultant surgeons
Consultant anaesthetist
Consultant geriatrician
Ward sisters
Physiotherapy
Occupational therapy
A&E representation as required
ABCi improvement coach
3. Brief outline of problem: statement of problem; how you set out to
tackle it; how it affected patient/client care
Meeting the needs of frail elderly patients requires timely and effective coordination across Ambulance, A&E, nursing, theatres, anaesthetics, care
of the elderly, physiotherapy, occupational therapy and rehabilitation
services linking through to community based services for those people
who are able to return home.
In 2010 there were anecdotal reports that the service at RGH was not
effective or efficient. Analysis showed that patients were waiting for up to
4 days on average for a theatre slot. The service was not able to state
how it was performing in comparison to other units in Wales or the UK.
There was no co-ordinated approach to improving the care. There was no
understanding of the patient experience or how this might contribute to
improving care. A report had been received that suggested risk adjusted
mortality rates were high although discounted due to methodological
problems in its production. The unit was not achieving standards of care
in the ‘Blue Book’ that sets professional standards for hip fracture in the
UK (1) or the all-Wales Hip Fracture Pathway (2).
The Scheduled Care Division therefore commissioned an improvement
intervention with four key objectives:
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2.
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To
To
To
To
reduce mortality
improve time to theatre
reduce length of stay
release bed resources
4. Assessment of problem and analysis of its causes: quantified
problem; staff involvement; assessment of the cause of problem;
solutions/changes needed to make improvements
An initial analysis identified a key problem as a lack of a coherent engaged
team. The service was not coming together on a multidisciplinary basis to
discuss and build solutions. Although clinicians would come together in the
day to fire fight they never met as a team to reflect on the service. The
monthly Directorate meetings did not have the capacity to achieve the
level of detail required.
There was little or no effective data being used to allow a baseline to be
understood and to support understanding of problems.
5. Strategy for change: how the proposed change was implemented;
clear client or staff group described; explain how you disseminated the
results of the analysis and plans for change to the groups involved
with/affected by the planned change; include a timetable for change
A fortnightly team meeting of the MDT was established to start to work
through the pathway to analyse and resolve problems. The meetings
were and are held in a seminar room adjacent to one of the wards.
The pathway was divided into segments. Issues in each segment were
identified through brain storming and actions implemented and monitored
in the team meetings.
Some of the key changes made were:
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Development and implementation of ward boards (‘Plan for Every
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Patient’)to support effective planning and communication of actions
to meet individual patient need
Development and implementation of a ‘Theatre Plan for Every
Patient’ Board initially located in the seminar room but
subsequently moved to the Theatre rest room
A focus on the need for priority of hip fracture patients using a
simple priority poster next to the Theatre Planning Board –
previously there was no clear prioritisation
A patient information booklet
Data collection using the national hip fracture database (NHFD)
undertaken by Advanced Nurse Practitioners
To focus all patients with hip fracture on one ward (February 2012)
where possible.
Subsequently the work of the group was reformed around a four part
clinical bundle to look at key standards with effective measures in March
2012. This work commenced with a workshop that pulled together the
trauma teams from both RGH and Nevill Hall Hospital and has led to the
development of a similar Trauma Operational Team meeting to discuss
and iron out issues at NHH.
The teams continue to meet together regularly. A third learning set is
planned for March 2014 which will include patient representation for the
first time building towards co-production.
6. Measurement of improvement: details of how the effects of the
planned changes were measured
Initial measurement was undertaken using coded data from the Patient
Administration System (PAS). The time taken to start data entry using
the National Hip Fracture audit requires the service to still use coded data
to look at the baseline but does now allow the service to look at ongoing
issues. In January 2014 ABCi created a VBA tool in excel that allows Hip
Fracture Database information to be imported and displayed in run charts
automatically.
7. Effects of changes: statement of the effects of the change; how far
these changes resolve the problem that triggered the work; how this
improved patient/client care; the problems encountered with the process
of changes or with the changes
Our run charts (below) show us that there has been a clear and sustained
improvement in time to theatre. The focus on priority has halved the time
to theatre. NHFD 2013 audit shows however that we are still a poor
performer nationally. While the team can be pleased with the
improvement to date this is creating a renewed engagement to deliver
further improvement.
Although time to theatre improved by 2 days there was no decrease in
overall length of stay. An unexpected consequence of having patients
through theatre 2 days earlier has been a correlative improvement in
home discharge. NHFD Audit 2013 reveals that RGH is the 4th best out of
180 hospital in the UK for getting patients home. RGH data quality at 30
days is also one of the best in the UK.
NHFD also shows that the unit’s mortality rate is comparable to other
units in the UK and is not an exception.
8. Lessons learnt: statement of lessons learnt from the work; what
would be done differently next time
Carving out and maintaining team time to make improvement work
business as usual is essential component to service improvement.
Investment in effective measurement and sharing of data in team
meetings repays its effort allowing the team to analyse its issues and
celebrate its success.
The use of regular learning sets as part of business as usual may be a
useful reward in itself and an opportunity to spread learning across teams
in different locations.
The opportunity of regular team meetings with time outs provides an
opportunity for us to bring patients into co-production on a sustainable
basis. The team is working with the kings Fund to see what this would
look like and this will be the centre of the next learning set.
9. Message for others: statement of the main message you would like
to convey to others, based on the experience described
Multidisciplinary clinical team time focussed on understanding and
resolving operational issues in the patient pathway is a crucial aspect of
service improvement and needs to be a part of business as usual.
The NHS Wales Awards are organised by the 1000 Lives
Improvement Service in Public Health Wales.
www.1000livesi.wales.nhs.uk
References
1. British Orthopaedic Association 2007 The Care of Patients with
Fragility Fracture ("Blue Book")
2. All Wales Fractured Hip Programme
(http://howis.wales.nhs.uk/sites3/page.cfm?orgid=608&pid=30979)
3. National Hip Fracture Database National report 2013
(http://www.nhfd.co.uk/20/hipfractureR.nsf/0/CA920122A244F2ED80
2579C900553993/$file/NHFD%20Report%202013.pdf?OpenElement)
Graphs
RGH 30 day Mortality – from NHFD 2013
No. patients