The Trust’s RPIW programme commenced in December 2016, so far five have been completed across the two sites, four at Cumberland Infirmary and one at West Cumberland Hospital.
The headline summary from all of the RPIWs
- Increased involvement of patients and relatives in their care.
- Improved safety (e.g. pressure care, medication, equipment).
- Freeing up time to care; the potential time savings from the RPIWs equates to 37,800 hours a year or £572,670 (band 5/6).
- Saving money; a redistribution of equipment directly from the RPIWs has saved in excess of £10,000 and reductions in the cost of care, primarily from the success in reducing pressure ulcers, could save the trust in excess of £750,000.
- Improved patient experience e.g. Larch A/B have had their highest ever patient satisfaction ratings since the RPIW.
- Improved flow of patients and information across wards and departments.
- Reduced waste through improved workplace organisation and standardisation of care plans and other paperwork.
- Improved team working to save time, improve patient experience and building relationships both within the Trust and with our partners elsewhere in the health and social care system.
- Increased staff morale, engagement and empowerment; improvement is becoming part of the culture.
Maple B/C/D – 28th November – 2nd December 2016
Focus: Improved Discharge
The primary focus of the Maple B/C/D was on improving discharge and one of the main reasons discharges were being held up was that staff simply did not have time to complete all the tasks required. The RPIW focussed on saving time for staff and this in turn led to efforts being directed towards gathering evidence to show how reorganising the ward and repurposing rooms would enable this.
This resulted in the creation of a single clean utility, a multi-purpose treatment room, a specialist nurse office, a staff resource room, and a much improved MDT office for doctors and AHPs. Not only did this create a time saving but also ensured the ward conformed to Trust policy on storage of liquids and controlled drugs.
Further time was saved through a streamlining of the MDT board round to increase focus on the discharge process and involve colleagues from external agencies to help overcome difficulties with setting up and restarting care packages and continuing rehabilitation etc. The team also worked with Community Hospitals in order to redesign the ‘handover’ form in order to stop photocopying of patients notes and release time to care.
An Improvement culture is now firmly established on Maple ward with all staff expected to bring an idea to discuss at their appraisals and the creation of a walking, talking ‘Maple Marsden’ to increase staff knowledge and enable better training for students.
All of this has contributed to the length of stay on the ward being reduced.
Ward 4 – 13th – 16th February 2017
Focus: Pressure Area Care
The focus for Ward 4 was on freeing up time for the staff to be able to make improvements in pressure area care; to this end a rationalisation of paperwork alone saved up to 25 hours a day. A 5S of ward areas, including the top up, not only saved time but also money with well over £3,000 of equipment redistributed to other wards and a review of ordering and stock levels potentially saving £2,700 per complete top up.
There were however innovations around pressure care itself with the introduction of carer prompt cards and a new patient information leaflet to raise awareness and the realisation that perhaps patients haven’t had their positions altered as often as required led to the introduction of a behind the bed clock to indicate when the next movement was due.
The formerly underutilised day room has a new lease of life with staff being identified to lead activities such as cake decorating or flower arranging, an improved level of MDT working with both Occupational and Physio therapists undertaking group activities; and the purchasing of a ‘Renaissance Rehab’ system to help with patient activities and rehabilitation.
All of this has led to a more than 95% reduction in hospital acquired pressure ulcers on Ward 4 which, if replicated across the trust, could lead to a financial saving in excess of £750,000.
Larch A/B – 3rd – 7th April 2017
Focus: Patient Flow
Along with the targets set by the sponsors the workshop team had a vision; they wanted to make the patient the focus of all their actions and developed an ‘Always Bedside’ approach. Completing all stages of an admission at bedside reduced the overall time spent by 70% but increased the time spent during the process with the patient by 40%. Bedside handover, in which nurses discuss care with the patient (and in the evening relatives), has led to improved patient contact and the ward’s highest ever level of patient satisfaction.
A new HCA led transfer process with no paper SBAR has resulted in the process taking 70% less time, saving 12.5 hours of nursing time a day. A refined discharge process including the provision of a dedicated TTO cupboard and computer for pharmacy staff has resulted in a process that at its longest could take 6 hours being reduced to 26 minutes at best and regularly within an hour of decision to discharge.
The usual 5S of the ward resulted in more than £2,000 of equipment being returned to stores or redistributed to other areas and rationalising and remodelling the way paperwork is stored and distributed has saved further time and money.
Overall the time saved from changes implemented during and after the RPIW week mean the MDT saved on the ward could be as high as 14,200 a year. Recognition of the improvement work was widespread with articles appearing in ‘Emergency Nurse’ magazine and on the Nursing Standard and NHS Improvement websites.
Accident & Emergency – 25th – 29th October 2017
Focus: Patient Flow
The focus on flow initially fell on the triage process which had the potential to greatly help further down the line. The addition of an HCA to the process in order to better facilitate early investigations has relieved the pressure on staff further along the patient journey and when a doctor is available to be ‘front of house’ it has vastly increased the throughput of walk in, walk out patients.
The ‘Always Cubicle’ approach has increased patient contact while reducing the time taken to clerk patients into the unit. It will mean greater utilisation of IT equipment within the cubicles and provide greater reassurance to often very anxious patients.
Work on the layout of the ward has resulted in agreement to create a paediatric triage area to increase privacy and dignity, a ‘revamp of resus’ with the help of the pharmacy team has made the unit better compliant with processes around preparation and storage of medication as well as saving lots of time that was used up by daily checks of rarely used equipment.
After discussions with the Trauma & Orthopaedic team there is now a vastly improved pathway for T&O patients, especially those on a fractured neck of femur pathway who could potentially now be in a bed on Maple B/D within 46 minutes. The A&E team will now hold regular meetings with both the T&O and surgical teams to better improve the patient journey. In another example of improved team working NWAS has agreed to give the department another touchscreen to better help with their work in the area.
Finally, the team have introduced a patient information card to help patients understand and be more involved in their care. It is hoped that this will help with managing expectations and keeping patients better informed. The 30/60/90 day process is ongoing for A&E and will be completed in February 2018.
Elm B – 30th October – 3rd December 2017
Focus: Falls and Medication.
The creation of a ring fenced ‘Stroke Assessment Cubicle’ was a key aim for the workshop team and ward staff in general. It will ensure a greater percentage of patients go through the correct stroke pathway which not only means they will have much improved outcomes but also means the trust will benefit from Best Practice Tariff and reduced length of stay.
A PEP (Patient Engagement Programme) Talk is being trialled on the ward to encourage greater involvements of patients in their own care and rehabilitation as well as enabling better organisation for staff, saving time and promoting greater MDT working. Created with input from a Consultant Neuropsychologist from CPFT it highlights, along with closer working with the Early Supported Stroke Discharge (ESSD) team, the benefits to the patient and both organisations of working more closely.
The team rationalised the paper work on the ward and have refined the discharge checklist to make it more user friendly and so it can be used as the framework for discharge and will better highlight the patients’ needs for the ESSD team who will make regular visits to the ward to better facilitate a smoother discharge for patients.
The team worked hard on the ward environment with a 5S of various areas improving general tidiness and also feeding in to work around reconfiguring room use to enable a new centralised clean utility which will greatly help with medication issues and also overstocking. This work also aims to provide another quiet area for rehabilitation in order to better allow patients to discuss things such as low mood; and a governance and improvement hub for staff who currently have no quiet area to undertake mandatory training.
Overall more than 4,200 hours of potential time savings have been identified but it is as yet too early to ascertain whether the changes have succeeded in reducing falls and medication issues over a longer term.
CLIC are committed to continuing to support RPIWs and other improvement training in NCUH. The core CLIC team of Stephen Singleton, Karen Morrell and Rachael Davies will be available to oversee the workshops. Nick Jackson, Sarah Linnard, Gill Long and Jayne Edwards having been developed to support and lead delivery and the CSI team at CPFT are also supporting RPIWs. Key NCUH staff have become improvement champions as a result of RPIWs and bespoke Cumbria Production System training the list includes but is not limited to Emily Dixon, Debbie Evans and Rachel Eastham (Ward Managers), Christine Musgrave and Claire Barlow (Matrons), Helen May (In-patient Physio Lead) & Georgia Wright and Liz Klein (Heads of Nursing). Sue Gallagher (CCG lay representative and patient representative) has been a key member of the RPIWs.