“Honest disagreement is often a good sign of progress.” – Mahatma Gandhi
Our journey started at a meeting chaired by the Deputy Director of Operations (DDOP) for Unscheduled Care on 9th October 2014; whilst discussing (and mildly put – disagreeing on) the time patients waited for clinical assessments on our 36 bedded Acute Medical Unit (AMU) at Blackpool Teaching Hospital NHS Foundation Trust. This discussion (and ensuing difference of opinions) demonstrated that the group felt passionately about patients being seen in a timely manner and this highlighted the need to measure key quality indicators on AMU.
“We cannot solve our problems with the same thinking we used when we created them.” – Albert Einstein
From time immemorial, our AMU used a traditional white
board - a standard grid board with combinations of magnets/symbols, coloured
handwritten patient details and squiggles by clinicians representing clinical
reviews being completed. The white board was augmented by an A3 paper ‘take-sheet’
which the ‘call-taker’ used to record referral details of patients due to
arrive to AMU. The ‘call-taker’ was also required to transcribe the referral
details on the clerking proforma and then walk the length of AMU to deliver it
to the receptionist at front desk.
This process with its inherent inefficiencies,
duplication and risk of error ‘worked’ and had never been challenged before.
“When you need to innovate, you need collaboration.” - Marissa Mayer
December 2014 marked the beginning of a Clinical-Managerial partnership between the AMU Registrar and the Directorate Manager who had a common desire to improve existing process on AMU, but were unsure of the detail on how to do so.
This led the development team to map existing workflow,
draw up technical specifications for a new solution, and within three months
version 1 of the AMU Patient Tracker was created using SQL and C#.
This was then put through two months of user testing and refinement
based on staff feedback. Following this, the development team organised training
sessions for clerical, nursing and medical staff (coinciding with the junior
doctors’ rotation) leading up to the launch of AMU Patient Tracker in April
2015.
The omnipresent white board was wiped clean and the
chaotic take-sheet was retired on
“A journey of a thousand miles begins with a single
step.” - Lao
Tzu
•
Identification at referral of patients on critical medication
•
triage via R/A/G score based on NEWS within
15min of arrival for all patients
•
assessment of patients on AMU based on clinical priority
and wait times
•
responsible clinician and 'current status' of patient journey
highlighted at all times
•
automated warning indicators (e.g. barrier nursing (MRSA, C.diff,
ESBL)/research trial/vulnerable adult)
•
mandatory Expected Date of Discharge (EDD)
determined at senior review
•
mandatory primary and secondary screening for
VTE prophylaxis
•
mandatory dementia screening for patients aged
above 75 years
•
treatment escalation status (Amber care/
DNACPR) highlighted
•
facilitation of Pharmacy drug history and clinical
checks, as well as handover comments from pharmacists
“You have to dream before
your dreams can come true.” - A. P. J. Abdul Kalam
"Dreams are extremely important. You can't do it unless you can
imagine it." -George Lucas
As soon as the development team had deployed AMU Patient Tracker they
began to dream –“wouldn’t it be cool if, all the information collated during patients’
stay on AMU travelled with them to their specialty ward, and their digital
journey continued?”, this was accompanied by the dream of creating a safer and
smarter handover system (an audit of 402 paper-based medical on-call handover
tasks at our Trust in September-October 2014 found that only 3.23% of patients
handed over between on-call teams had a complete set of handover details as
specified by Royal College of Physicians Acute Care Toolkit 1 (2)).
In order to realise these dreams the team needed to
develop a system to cover all in-patient wards, link it to AMU Patient Tracker,
integrate it with other hospital systems, record meaningful clinical information
and provide relevant functionality to ward based clinical teams; with the aim
of improving patient safety and enhancing efficiencies on the wards.
“If everyone is moving forward together, then success takes care of itself.” – Henry Ford
By mid-July; the development team had linked up with a Consultant Geriatrician with a keen interest in medical education who wanted to improve the current process of doctors’ handover. The team also linked in with two nursing colleagues through the Trust’s Better Care Now Program’s agenda on the need to standardise the ward white boards and nursing handover.
“Without continual growth and progress, such words as improvement, achievement, and success have no meaning.” - Benjamin Franklin
In August 2015 the development team worked with the divisional analyst for Unscheduled Care, reviewed the data collated through AMU Patient Tracker and created a suite of automated reports based on SAM CQIs, these departmental reports which were first published in September, were the first of their kind to provide the Trust with detailed information on flow through AMU on a daily, weekly and monthly basis.
The development team met with the AMU clinical team on 16th
September and discussed changes based on clinical requirements and developer
insights with the vision to create version 2 of AMU Patient Tracker. Some of
these changes were-
·
frailty screening at the point of referral
·
objective criteria for NEWS based triage
·
flexible clerking options to facilitate clinical
reviews by the AMU team in AE
·
display of critical clinical pathway indicators (i.e.
AKI, Sepsis, Pneumonia, etc.)
·
functionality to highlight if a bed were
unavailable (e.g. awaiting a clean)
With ‘winter pressures’ fast approaching, the feature of
flexible clerking (i.e. clinical assessments of medical patients in AE waiting
for a bed on AMU) went live on 27th October, and the other features
constituting AMU Patient Tracker Version 2 went live on 12th January
2016.
On 6th November 2015, at the Trust’s annual Celebrating
Success awards, the AMU Patient Tracker Team (development team and clinical
team) were announced as runners up in the Innovation/Service Improvement award
category.
Having begun the dream of continuing the digital tracking of
patients’ journey in June earlier in the year, the development team had been
working with the two nurses from Scheduled and Unscheduled care divisions and had
now completed the technical specifications and process mapping for Ward
Tracker. They were now ready to take the next big step, and on 15th
December the team met with the Scheduled and Unscheduled Care DDOPs, and were
given the green light to pilot Ward Tracker on the Short Stay Ward.
The development team with the addition of two nursing
colleagues, and the Emergency and Acute Medicine Directorate Support Manager
(new in post) from here on are referred to as the Ward Tracker team.
After a further couple of months of application development Ward
Tracker pilot on the Short Stay Ward began on 16th March 2016 and
the traditional white board was replaced with a digital touch screen.
This was followed by a four month period of fine tuning, observation
and review of Ward Tracker which ‘pulled’ information from AMU Patient Tracker,
incorporated warning indicators tailored to an inpatient ward setting, included
nursing assessment summaries, status of therapist referrals and pharmacy
reviews, treatment plan and discharge readiness summaries, as well as being
integrated with specialty e-referrals, diagnostic results and patient documents
stored in the Clinical Hub (an in-house developed clinical portal).
“Creativity is bound up in
our ability to find new ways around old problems.” - Martin Seligman
The AMU team under the guidance of their Directorate Manager and
AMU’s new Head of Department had been part of the Ambulatory Emergency Care
Network and were keen to streamline the care of ambulatory patients. In June
2016 , the development team were involved with this initiative and developed an
automated AMB score(3) calculator to
identify patients appropriate for ambulatory care, and extended AMU Patient Tracker functionality to cover the
Ambulatory care footprint; as well as creating process to track patients who required
follow up in Ambulatory clinic.
AMU’s neighbours on the Surgical Assessment Unit (SAU) had
also asked the development team if they could have the same functionality as
AMU Patient Tracker with additional features to distinguish patients under the
care of the different surgical teams. SAU Tracker went live end of July 2016.
The pilot on Short Stay ward had demonstrable benefits
relating to reduction in length of stay, reduction in stress related staff
sickness, and a reduction in the top 5 patient safety category reported
incidents and the Ward Tracker team felt the time was right to spread to other
inpatient wards.
Though the digital application was ready, there was still
the need for the hardware (digital screens and IPads) to enable its use on the
wards. On 26th July 2016, the Ward Tracker team with executive
sponsorship from the Medical Director made a case to hospital charitable funds
and were successful in their bid of £109,000 for – 32 digital screens, 32 blue-tooth
keyboards and 99 IPads.
Over the next two months the Ward Tracker team met on a
weekly basis, liaised with the IT department, Estates team and ward based clinical
teams, to formulate a ‘roll-out’ project plan which entailed IT hardware
installation, Trust wide communications, staff training (including user
guides), system admin to set up user accounts, development tweaks to include
Red/Green day methodology for board rounds (4), with a planned
launch date of 3rd October 2016.
“Fortune favors the bold.” – Virgil
Though the 3rd October planned launch date was
not achieved, Ward Tracker went live across 29 wards in a phased approach over
16 working days commencing from 18th October 2016, finishing on 8th
November. The traditional white boards from these wards were either repurposed
or put in storage. The Ward Tracker team continued to meet for an hour every
Thursday afternoon for the next month to review staff feedback and resolve any
issues that had been highlighted.
At the 2016 annual Celebrating Success awards on 25th
November, the Ward Tracker Team was announced as winners of the Non-Clinical
Team of the Year award.
Ward Tracker provided a platform to capture all inpatients
with their associated demographic, current location (pulled from our PAS) along
with ‘live’ clinical details. This enabled the creation of an Acute Care
Toolkit 1(2) compliant e-handover module
with pre-populated details of patient demographics, location (ward and bed
number), clinical background, current diagnosis, responsible consultant and
treatment escalation status. The e-handover module only required the handover
provider to specify the handover task detail, select a Patient Risk Assessment Score
(2), and determine the minimum level of competence required to complete
the task.
This module allowed for tasks to be escalated with change in
patient status, enabled on-call teams to sort tasks according to their ward
areas, rota based roles, clinical and time priority, and provided for a
standardised, transparent and auditable handover solution which was accessible
from any hospital computer.
The launch of e-Handover module of Ward Tracker for on-call medical
doctors coincided with the junior doctors commencing their 4 month clinical
rotation in the first week of December, and in order to embed this new process;
a member the Ward Tracker team attended every 09:00 and 21:00 medical handover
for the next two weeks leading up to Christmas 2016.
An audit of 349 medical on-call handover tasks using
e-handover (December 2016 to February 2017) found that 95.13% of patients
handed over between on-call teams had a complete set of handover details compared
to 3.23% in the previous paper based audit in 2014, using the RCP Toolkit 1
handover standards.
Thus, over the course of two years, the dream of tracking
patients’ journey through their hospital stay from referral to discharge,
standardising nursing handover, replacing the traditional white boards with
standardised digital screens accessible from any location, and the dream a
safer and smarter on-call handover had now been achieved for an engaged
workforce, supported by charitable funds with executive backing, as a
‘black-op’ (i.e. outside of any Trust planned strategic activity) by a small
team (with no official status), who were committed to improving patient safety
and enhancing organisational efficiency.
“The greatest value of a picture is when it
forces us to notice what we never expected to see.”-John Tukey
“The value of an idea lies in the using of
it.”-Thomas A. Edison
During the
first couple of months of early 2017, the Ward Tracker team worked closely with
the Divisional Analyst for Unscheduled care who created an automated report on
board round activity. Through this report clinical and operational teams were
now able to review reasons for delays i.e. ‘red days’ in patients’ journeys at
a ward level at the click of a button – this live information had never been
available to the organisation before and sparked the beginning of thoughts and
conversations on how information recorded in Ward Tracker could influence
operational decisions.
"To stay ahead, you
must have your next idea waiting in the wings."- Rosabeth Moss Kanter
With feedback from engaging with staff as well as the Ward
Tracker team’s innovative ideas, the focus now was to build on the foundations
that had been laid - to further improve patient safety and organisational
efficiency with the next phase of Ward Tracker developments.
Though up till now the ‘black-ops’ approach had been
successful, the team recognised the need to formalise a development plan and
agreed that in order to sustain progress additional resources were required
(i.e. an additional Health Informatics developer and a clinical lead for Ward
Tracker).
In order to make a case for additional resource, the AMU
Registrar and the Directorate Manager worked on a business case for the next
phase of Ward Tracker developments. This business case; with the executive
backing of the Medical Director was presented to Trust Management Team on 30th
March and agreement was reached to support the required £30K investment for a
two year period.
In April 2017, the development team liaised with Pathology
service and the clinical team on AMU to embed an auto-alert for patients with
Acute Kidney Injury (AKI) within AMU Tracker. This auto-alert provided a visual
prompt for the clinical team to recognise and commence a digital AKI pathway.
The e-Handover module of Ward Tracker for on-call medical doctors
was also replicated for other specialities (Surgery, Cardiology and ENT) in
early May.
“Leadership is not about a
title or a designation. It's about impact, influence and inspiration. Impact
involves getting results, influence is about spreading the passion you have for
your work, and you have to inspire team-mates and customers.” - Robin S. Sharma
In May, the Clinical-Managerial partnership of the AMU
registrar and the Directorate Manager were shortlisted out of 90 nation-wide
applications; for the Sir Peter Carr Award alongside four other teams from Essex,
Derby, Leeds and Bradford (5). Also, on 21st June, the
team’s work on eHandover was awarded first prize at the Trust’s Quality
Improvement Awards.
As part of the 6th Acute Medicine Awareness day on
22nd June, the team hosted a visit from the then President of The
Society for Acute Medicine (SAM), Dr Mark Holland and the Past President Dr
Philip Dyer. The purpose of this visit was to share and showcase the AMU
Tracker, eHandover, board rounds and the ability to generate Society for Acute
Medicine Benchmarking Audit (SAMBA) at the click of a button – themes which had
generated interest within the Acute Medicine fraternity when the team had
presented some of their work at previous SAM conferences in Cardiff (May’17), Edinburgh
(September’16) and Belfast (May’16). On the back of this visit from SAM, the
development team were invited to share and present their journey at the SAM
conference in Birmingham on 11th-12th September(6).
The development team also facilitated visits from Healthier
Lancashire and South Cumbria Change Programme (STP) on 27th June and
the Emergency Care Improvement Programme (ECIP) on 21st July; to share the lessons learnt from the
journey so far and gain from their specialist insights.
“Data are just summaries of thousands of
stories – tell a few of those stories to help make the data meaningful.” - Chip & Dan Heath
“The goal is to turn data into information, and
information into insight.” - Carly Fiorina
The development team were bolstered by the addition of an
addition developer (realised from Ward Tracker phase 2 business case) who joined
the team in August 2017, with this came additional development capacity and new
ideas, and the team began work on the to
be called ‘Acute Care Map’ (ACM) - a system to provide all Ward Tracker users with
a map and list view of the hospital from a ‘Trust Board to patient on the ward
level’, with the ability to dissect and analyse real time information recorded
on Ward Tracker by division, directorate, ward, consultant and patient group;
whilst highlighting nursing/medical intensity needs, clinical pathways, stranded
patients, reasons for internal and external delays including Delayed Transfers
of Care (DToC) as well as medical outliers.
The Acute Care Map also provided a platform for interactive
reports on red day themes emerging from the board round module of Ward Tracker,
as well as an interactive Key Performance Indicator (KPI) dashboard for
stranded patients, DToCs, medical outliers, board round compliance and pre-noon
discharges. This application was launched in the first week of November to mark
the first anniversary of Ward Tracker with the aim to provide one version of
the truth of real time state of play within the organisation.
Alongside the Acute Care Map the team had commenced work on
a new eDischarge system to replace the existing Sharepoint based system. The
new system was integrated with Ward Tracker to facilitate auto-population of information
already collated within Ward Tracker, with links to diagnostic results too.
Following a 2 week pilot the new eDischarge system was launched trust wide on 4th
December.
"No one can
whistle a symphony. It takes a whole orchestra to play it." - H.E. Luccock
With the Trust Executive team bought in to the Acute Care
Map tool, a three month formal engagement piece of work was commissioned and
commenced mid-November. This £7600 business case facilitated an addition of a
business change facilitator to the team and allowed for backfill for members of
the Health Informatics team to engage with ward managers and nursing staff with
the aim to demonstrate the functionality of ACM, emphasise its reliance on the
timeliness and quality of information recorded on Ward Tracker and to capture feedback
from staff on ACM and Ward Tracker.
As part of this engagement, a ‘call to action’ event for
nurses was organised by the Director of Nursing on 8th December, the
engagement team carried out 60 visits to 36 wards and met with 128 members of
staff. This was supported by the IT department who visited all ward areas to
resolve any outstanding issues with Wi-Fi, screens and IPads. The engagement
team also met with the Patient Influence Panel on 13th December to
gain their thoughts on the development work being undertaken. The results of
this engagement piece were presented at the Better Care Now meeting on 27th
February.
Alongside this engagement work, the development team
automated the process of identification of medical outliers, stranded patients
and DToC patients (previously the ward manager was required to manually create
daily lists and fax them to the respective directorate managers who collated
all the lists for publishing). Automation of these processes saved approximately
109 hours of nursing time per week.
The development team further grew with the addition of a new
health informatics developer in January 2018 and commenced the development of
integrated referrals for Physiotherapists and Occupational therapists as well
as a Mortality app (Learning from Deaths) aimed to streamline the process of
screening and structured judgement reviews for patients who die during their
hospital stay.
‘Sometimes you need to press
pause to let everything sink in.’ - Sebastian Vettel
‘Pause today and notice
something you have worked hard on and recognize yourself for it. Acknowledge your
effort.’ - Kristin Armstrong
Though development
work continued; the pace slowed as March 2018 was a time to pause, reflect and
take stock of where things were at.
Dr Harpreet Sood (Associate
Chief Clinical Information Officer, NHS England) and Dr Indra Joshi (Digital Health
and AI Clinical Lead, NHS England) visited Blackpool on 13th March for the team to share their
journey and showcase their in-house developments.
In April, the
development team were announced as joint winners with the team from
Gateshead Health NHS Foundation Trust for the first Beautiful Information
healthcare innovation prize (7) and were also shortlisted for the HSJ Value awards for the
category: the use of information technology to drive value in clinical services.
‘All growth depends upon activity. There is no
development physically or intellectually without effort, and effort means
work.’ – Calvin Coolidge
Working with
physiotherapy and occupation therapy colleagues, the team launched the new
Physio/OT referral system in the first week of April 2018. This system was
integrated with Ward Tracker and prepopulated most of the referral details;
requiring ward based nursing teams only to select the patient and reason for
referral. The system allowed therapy teams to better manage their case load by
specific clinical pathways. With an average of 1934 therapy referrals (Physio
and OT) per month, the new referral system is projected to save approximately
1160 hours of nursing time per year.
In May the development team, liaised with a Urology
Consultant and created a Urology stent register which linked to the e-discharge
system and facilitated follow up for patients requiring urological stent
replacement or removal. The team also commenced work on other developments
relating streamlining the referral process for requesting OGDs (Oesophageal-Gastro-Duodenoscopy),
as well as creating clinical databases for Rheumatology and Pleural services –
including clinical/procedural noting and recording patient outcomes.
‘I see my path, but I don't
know where it leads. Not knowing where I'm going is what inspires me to travel
it.’- Rosalia de Castro
Moving forward the vision is to continue to build on and
revise our in-house developed systems to stream line process and increase
patient safety, and over the next couple of years we hope to collaborate with
our Electronic Health Record (EHR) supplier to embed our in-house systems
within the EHR.
We aspire to use the clinical information recorded in our
apps to keep patients informed of what’s wrong with them, what they are waiting
for whilst in hospital and when they are likely to go home. We aspire to spread
the use of our systems with primary care and community teams with the aim to
optimise patient care in a more cohesive manner, covering acute and long-term
patient care.
We aim to create a platform for healthcare professionals to use
measurement for improvement tools and adopt QI (quality improvement)
methodology to log, share and map their QI projects against the Key Indicator
dashboard.
Also, with the vast amount of clinical information being
recorded we aim to adopt a ‘machine learning’ approach to create predictive
models for length of stay and patient outcomes with links to operational
escalation protocols and planning tools.
‘Your focus
determines your reality’-Qui-Gon Jinn - Episode I - The Phantom
Menace
In just over three and a half years we have come a long way
- graduating from a hand written white board; to a stand-alone excel
spreadsheet on a single ward; to an in-house developed system across all adult
inpatient wards (excluding maternity), which is integrated with diagnostic,
patient document and referral systems, and captures patients’ journeys through
their entire in-patient stay, whilst facilitating standardised handover,
automation of daily reports, streamlining of therapy referrals as well as a real
time dissectible map/list view of the organisation linked to key measurements
aimed to improve patient care and organisational efficiencies.
We have moved from a small black-ops project team to a
formally recognised programme of work with symbiotic relationships with
clinical, operational and project management teams.
Inclusive leadership, a collaborative approach and shared
values of trust, selflessness, focus, perseverance and hard work have brought
us to where we are now. The aim of enhancing patient safety and improving
efficiencies has remained the focus of our endeavours, the journey has been
challenging, and clinical engagement with executive sponsorship and trust have
been key to what has been achieved so far.
We are grateful to all the teams (internal and external) and
colleagues (past and present) who have supported, challenged and encouraged us
on our journey of endless brainstorming, constructive debates, thoughtful
process mapping, tireless software development, inspiring networking, painstaking
testing and passionate measurement for improvement ; without whom none of this
would have been possible.
‘Look up at the stars and
not down at your feet. Try to make sense of what you see, and wonder about what
makes the universe exist. Be curious.’- Stephen Hawking
…our journey continues…
References
(2)
https://www.rcplondon.ac.uk/guidelines-policy/acute-care-toolkit-1-handover
(3)
Adapted from: Ala L, Mack J, Shaw R et al.
Selecting ambulatory emergency care (AEC) patients from the medical emergency
in-take: the derivation and validation of the Amb score. Clin Med 2012;12:423.
(5)
https://improvement.nhs.uk/news-alerts/sir-peter-carr-award-runners/
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