Day Two Core Training May 2015
This… Is… Jeopardy!
RT2C Jeopardy Factors for Evidence of Productive Basic Wild Card Benefits Ward House Principles Success
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Final Jeopardy
Knowing How You Are Doing cont…
The measures dashboard
Additional Measures - length of stay - ward cost per spell
Knowing How We are Doing (KHWD) Module • Understand what is happening now • Display measures on a board • Use meetings on performance to drive improvement • Regularly update information
From a test site……. Safety crosses
Trend Over Time
How will you display your data?
How will you display your data?
Visualisation and the 3 second rule
Once you have measures on your board… • Arrange specific meetings at the KHWD board • Make them useful and informative
• Set the standard for the meeting • Highlight successes
An example of a meeting around the performance board……
Activity Follow
What is an Activity Follow? • It is a one hour detailed recording of activities a member of the nursing staff undertakes • It captures the task at hand and the location where it is performed • These pieces of information are recorded every minute during the hour
Why do an Activity Follow? To be able to understand what: • Activities are being undertaken by the staff on the ward • Find out how much time your staff are spending on direct patient care • Where these activities are taking place • To find out what may be impinging on these activities, i.e. interruptions etc.
Tools required to do an Activity Follow • A3 clip board • watch with second hand or digital display
• pedometer • pencil and rubber (and a spare) • activity follow sheet (A3)
Getting Started: Activity Follow
Gathering Gathering Gathering Space information for information information general onDirect intended comments on on location activity task GatheringArea information to calculate Area on tono. calculate and and analyse type of activity interruption Care totals Time
Activity Follow Exercise Do an activity follow by watching the video clip and observe the nurse carry out her activities You may not be able to work out the location on the ward but try if you can
To help you, the nurses intended task is to redo a wound dressing
What it should look like: an example
Calculating direct care time • Count the number of dots in the direct care (DC) time area • Write the total in the DC total column
• Divide the DC total figure by 60 and then multiply by 100 • This figure is your % of time spent on direct care
What else does the Activity Follow tell me? • • • • •
High discussion total? High administration total? High motion total? Large number of interruptions? Where was the nurse actually working on the ward? • The intended task tally
Direct Care Time Totaliser • Use the totaliser spreadsheet to summarise the activity follow sheets • Fill in the orange section with information from the follow sheets • The green section will automatically add up and calculate the direct care time for the period you are assessing
Activity Follow Totaliser
Direct Care Audit
Direct Care Audit Activity types e.g. direct patient Activity Study Sheet contact, clinical 9 meetings etc.
Date
Zone / Area
Activity description
Start time
Observer
Role
Signature
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5 10 15 20 25 30 35 40 45 50 55
0
Paid hours on duty
Hours of Shift
Person
Hour start: 0
Collect it on A3 paper then transfer to the collation and analysis tool
Time intervals of 5 minutes
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5 10 15 20 25 30 35 40 45 50 55
0
12
5 10 15 20 25 30 35 40 45 50 55
0
13
5 10 15 20 25 30 35 40 45 50 55
0
TOTAL hh:mm
5 10 15 20 25 30 35 40 45 50 55
0
5
10
15
20
25
30
35
40
45
50
55
Grand Total
Direct Patient Contact
0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00
0:00
Clinical Meeting
0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00
0:00
Clinical Administration
0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00
0:00
General Administration
0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00
0:00
Non Clinical meeting
0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00
0:00
Telephone contact
0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00
0:00
CPD/ give or receive training
0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00
0:00
Relative/Carer Contact
0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00
0:00
Clinical/medical audit
0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00
0:00
Breaks
0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00
0:00
0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00
0:00
0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00 0:00
0:00
Actively waiting for patient Waiting for/Looking for/Collecting 0
TOTAL
0
5 10 15 20 25 30 35 40 45 50 55 0
0
0
0
0
0
0
0
0
0
0
0 0
Inpatients may choose just one team, rather than whole ward.
5 10 15 20 25 30 35 40 45 50 55 0
0
0
0
0
0
0
0
0
0
0
0
0
5 10 15 20 25 30 35 40 45 50 55
0
0
0
0
0
0
0
0
0
0
0
0
0
5 10 15 20 25 30 35 40 45 50 55
0
0
0
0
0
0
0
0
0
0
0
0 0
5 10 15 20 25 30 35 40 45 50 55 0
0
0
0
0
0
0
0
0
0
0
0
5
10
15
20
25
30
35
40
45
50
55
On the day of the audit Count and record: occupied beds at 12 noon and midnight total attendances for the time period (e.g. outpatients) total patients during the day (e.g. Day Hospital)
Identify collection point for forms at the end of the audit
Calculating direct care time • count the number of dots in the direct care (DC) time area • write the total in the DC total column • divide the DC total figure by 60 and then multiply by 100 • this figure is your % of time spent on direct care.
The Observer • impartial • not one of the staff taking part in the audit • available to answer queries
• to check periodically that the audit is being completed accurately • require a detailed role description
• could be the site lead, unit manager, colleague from another department
Well Organised Ward
What is the Well Organised Ward (WOW)?
The Well Organised Ward is an approach to simplify your workplace and reduce waste by having everything in the right place at the right time, ready for use The modules covers how to use the 5S process
Why do it? • Increase „direct care time‟ • The ward will look and feel better • Decrease mistakes & errors • Easier to work
• Reduce risk
Prepare • Introduce the WOW module / 5S Game
• Involve the wider team as they use the areas in the ward • Communicate - Build confidence
• Review the waste walk – pictures or video the area (and main process) • Get everyone talking about the ward environment
What is 5S?
5 steps that help to create an ideal workplace by organising, cleaning and reducing waste
Not just another ‘good tidy up’ It is about having a ward where: • Things are left ready for the next person • The process for doing this is agreed and understood by everyone on the ward • Changes are maintained and become second nature • Everyone understands why things are done the way they are done • There is always the option to review and further improve
The 5 s process 1. 2. 3. 4. 5.
sort set shine standardise sustain
5S Game The “Numbers Game” is an exercise that illustrates the power of 5s.
The game consist of 7 quick rounds. You must not look at the sheets until instructed and must finish when time is up
© NHS Institute for Innovation and Improvement
Sort if possible remove everything from the area use an inventory sheet to record everything in the area, note quantities put items that have been removed in the designated area
Visual Management
Visual management: 3 second rule
Well Organised Ward
Before and after 5S process in ward sluice
Before and after 5S process in ward store cupboard
Well organised ward and visual management
Communication
Pre-WOW
Post-WOW
WOW- The Patient Kitchen
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WOW- The Clean Utility Room
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Time Benefit Quantification for Kitchen and Clean Utility WOW ~Linen Carts 152.48 hrs of Nursing time saved each year, $4,077 saved per annum ~Kitchen Remodel 252.25 hrs of Nursing time saved each year, $11,901 saved per annum
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WOW - Supply Room Pre-WOW …
WOW!
“It’s amazing. You can find things so much easier. It’s much less frustrating because everything’s in colour-coded bins – and we save money ordering less supplies because of it.” -Staff Nurse 62
PROBLEM
Weights are not documented during the first week of every month
WHY?
Chair scale is broken
Ramp scale is difficult to access and creates a safety issue
WHY?
Not maintained/old equipment
Soaker tub is in the way
WHY?
Unclear where it came from/who to ask
Always been like that
SOLUTION Purchase new equipment
Move ramp scale out of the room into user friendly space
Do we all see the same thing?
Tool: Fresh eyes What ideas and approaches would someone else who is not associated with the issue bring?
Learning To See – Why Use Observation? • See things that are obvious to someone outside the system • Helps you to find out what people really do and how they carry out their work • Inspires new ideas • Helps redefine the problem or challenge you are working on
Learning To See (cont.) • • • • •
People do not always do what they say they do People do not always do what they think they do People do not always do what you think they do People can not always tell you what they need Things are not always what they seem
Adapted from IDEO
“If you want to find out about water, don’t ask a fish.” Chinese proverb
Creating Focus in Observation • • • •
Watch the video What did you see/observe Make some brief notes We are going to talk about these observations
Fresh Eyes Video
Creating Focus in Observation (cont.) • Become the character indicated on your card o Mother with child o Transport improvement person o Elderly person o Health improvement person o Information designer o Tourist • Watch the film again • Make some brief notes • We are going to talk about what we learned in character
Read this Text Out Loud:
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Patient Status At a Glance
Introduction • Nursing staff are often interrupted • People ask questions about patients o where is the patient? o which nurse is caring for the patient? o who is the Consultant? o which patients have been referred to OT? o are the take home drugs ordered or ready? o are there any delays to patient‟s discharge?
What is PSAG?
Visual management of patient information - updated regularly - seen „at a glance‟ - used effectively
What it covers How to determine the best use of patient boards on the ward by answering these questions: • what information should be on the board? • what is the board used for? • who should update the information? • when should the board be updated? • what confidentiality issues are there and how will they be dealt with?
10 Point checklist - baseline 1. 2. 3. 4.
The patient board is in a position central to staff It is used in shift handovers and discharge management Bed boards have information helpful to the patient Information on bed boards feeds easily into patient status board 5. Patient confidentiality issues have been addressed 6. Staff know where information on the board comes from 7. Frequency of updates and who does it is agreed 8. The board is always up to date 9. All users can quickly understand patient status by reviewing the board 10.Regular and random audits are carried out on how complete and up to date the board is, and whether it is used for its designated purpose
Mocking up you patient status board
Copyright © NHS Institute For Innovation & Improvement 2010
Create PSAG board – involve your whole team
Use of magnets
Board key
Less is more
Address confidentiality issues
Use of symbols Copyright © NHS Institute For Innovation & Improvement 2010
What does ‘good’ look like?
Take a look at some of the boards that other wards have created…..
Patient Status At a Glance: Instant Information & Scheduling Enhancing visual management to reduce interruptions and to improve scheduling
Before
•Patient Status •Next Actions •Waiting for… •Ready to go
After
PSAG board used in handovers:
Chelsea & Westminster’s David Erskine Ward - Patient Status At A Glance board
A PSAG board
This is an example of a PSAG board from a team at a Family Centre The board is used during handover and can be moved from room to room as required.
Solent Healthcare – Children & Family Services
RH PSAG (Discharge) Board
LGH: 24 hour Interruption Counter • Day Shift – 110 Interruptions to patient care in twelve hours Nurse walked 10.8 miles
• Night Shift – 48 Interruptions to patient care in twelve hours Nurse walked 7.71 miles
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LGH: Interruption Countermeasures Individual Patient White Boards Purpose: ~ Decrease the number of unnecessary interruptions to Nursing staff related to frequently asked questions from patients and their families. ~ It is a tool for the patient to remember key information that is pertinent to them (Date, Nurse, Doctor etc.).
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How does ‘good’ feel? “I can plan the day for the ward staff using the colour codes to indicate which patients are going home or are delayed.” (ward sister) “ “It really does make a difference and I feel that I’m not
interrupting the nurses because its all there in black and white… in the form of a blue square” (physio)
Group discussion: How would we use the PSAG? 10 point checklist: 1. The patient board is in a position central to staff 2. It is used in shift handovers and discharge management 3. Bed boards have information helpful to the patient 4. Information on bed boards feeds easily into patient status board 5. Patient confidentiality issues have been addressed 6. Staff know where information on the board comes from 7. Frequency of updates and who does it is agreed 8. The board is always up to date 9. All users can quickly understand patient status by reviewing the board 10.Regular and random audits are carried out on how complete and up to date the board is, and whether it is used for its designated purpose
Reflections on Day Two…
Look ahead to Day Three
