Reducing
Internal
Waits
Nottingham University Hospitals
Liz Williamson- Deputy Programme Director
Scott Purser- Project Lead
What we plan to cover today
• The NUH improvement programme
• Why this was important
• Getting started
• Discovery
• Toolkit
• Rollout
• How we captured the benefits
• Developing the toolkit
• What the Future holds
• Reflections
Our hospitals
City Hospital: largely elective
& chronic care centre
(including cancer)
QMC: our emergency site
(Emergency Department &
trauma centre); Children’s
Hospital
Our vital statistics
• Turnover £755 million
• Circa 1,700 beds and 87 wards
• Over 13,000 staff & 1,200 volunteers
• 180,000 A&E attendances and 96,000 admissions
• 66,000 day cases and 24,000 elective operations
Our whole hospital improvement
programme is called “Better for You”
• Started in 2009/10, Better for
You is our most comprehensive
improvement programme
• It is a quality driven programme,
which releases financial savings
• Currently, 250+ projects across
the organisation, directly
involving 2000+ staff
• Change, which is caring, safe
and thoughtful
• The key feature is staff and
patient engagement
We developed the Better for You 5 Step
Process – where staff engagement is key
Set Up and Plan
Discovery
Design & Trial
Implementation
Embed
Engage with stakeholders & establish scope – Identify
potential benefits - Set up Team & Hub
Identifying the issues and problems to be solved from
every perspective – staff views, patient views, ‘business
data’
Testing Future state in a real environment – Agree Plan Do
Study Act – Assess whether trials deliver benefits
Controlled implementation &/or roll out of future state and
realisation of benefits identified
Ensure changes are sustainable – full handover into
operational environment – Knowing How We Are Doing
Why did we need to reduce patient
waits?
• Good quality care is helped by good patient flow
– Improvements to the Emergency Pathway relies on consistent ‘pull’
from the specialties
• To meet some of our formidable challenges (activity, £££)
– We needed to shrink our in-patient capacity (“more with less”?)
• We respect patient’s time and do not want to keep healthy people in
hospital
– We want patients to have a positive experience
– Some staff have learnt to accept/not challenge internal waits
• Research says hospital stays can create safety issues
• In-patient/hospital care is a scarce and expensive resource
Aim and Scope of the project
• Identify where and why waits occurred
– Identify opportunities to work differently and/or smarter
– Support directorate CIP plans
• Reducing LOS
• Reducing in-patient beds
• Reduce the number of waits by 5080%
• All adult wards
Point us in the
direction of
where the
opportunities for
improvement
might be
Discovery started with a 4 week data
collection of internal waits
The size of the problem
The opportunities for
improvement
What patients were
waiting for, where and for
how long
Extensive analysis of data
Identified a group of staff
to undertake data
collection as part of their
existing role
From this data, we found that ‘internal’
waits made up 40% of all waiting time
We found that every day, we
had on average:
•117
patients waiting for
Internal (average 117 patients per
Internal (average 117 patients per
day)
internally
provided
services
day)
• Average wait for internal
External
(average
services
= 487days
Average number of beds occupied
per day by 'waiters'
externally provided services
•Average wait for external
services = eight days
External
Internal (476 bed
Internal
External
days)
City
patients per day)
• 87 patients waiting for
Internal
QMC
0
20
40
60
80
100
Internal
City
50
QMC
40
External
34
72
120
12.0
60.0
10.0
50.0
8.0
40.0
6.0
30.0
4.0
20.0
2.0
10.0
0.0
0.0
Imaging
Echo
Angio
Specialty bed Psychiatric
bed (e.g. B50,
A23)
Specialty
review
Therapies
Family
decision
Beds (cumulative)
Beds
Top eight waits accounted for 50% of
bed occupied by patients ‘waiting’
Beds
Cumulative
Data analysis proved to be very
complex!
The data was analysed by specialty, wait and opportunity
We calculated baseline and stretch targets for bed
reductions
Clinical judgement
was used to
determine the ‘% of
time waiting’ that
could be ‘released’
Base target
for internal
waits
95 beds
Base target
for external
waits
118 beds
Stretch target
for all waits
279!!
Internal = 149
External = 130
If every wait on
every day is
included
Also includes estimations
for wards not included
(NB assessment wards,
maternity)
We needed a message which created
shared drive for (the need for) change
• Patient safety is paramount
• Financial imperative to reduce costs
An in-patient wait is a wasted resource
and
exposes patients to unnecessary risk
We took the decision early on that we
needed to ‘do something’ across the
trust and at pace
• Set up a Steering Group – initially
chaired by the Deputy CEO/DoN
• Key involvement – Medical Director,
senior nurses
• Early involvement with other
improvement projects (imaging, heart
services)
14
We created a ‘toolkit’ of actions which would
help us reduce internal waits
Status
at a
glance
Daily
board
round
Escalation
process
The toolkit
included:
• key principles of each of
the 4 components
• ‘how to’ section
• glossary of terms
Problem
solving and
resolving
waits
Daily Board Round is at the
heart of the process
How to set up.......................and lead a daily boardround
Identify a time for
board round (eg 8am,
9am etc)
Identify essential MDT
members who need to
attend daily board rounds
Inform essential MDT
members of their roles
and responsibilities when
participating
Set a date to commence
board rounds and invite
essential MDT members
The identified lead for board round
begins discussions by asking for
each patient:
What is the patient waiting for
today to progress their care?
Has the referral been made?
When do we anticipate the
patient will be medically stable?
What is the predicted discharge
date?
Identify patients who are:
Sick
Being discharged
Waiting for tests and
diagnostics
Status at a Glance
At the time we had a mix of electronic and manual
white boards - we had to standardise the layout
Who is
Who is
medically
stable?
Is the patient
medically stable/fit
(y/n) i.e. do they
need an acute
medical bed
Expected date the
patient will no longer
require an acute hospital
bed. This should be
reviewed daily by
medical teams and
should not incorporate
any delays/waits
Medically stable
y/n
Predicted medically
stable date
Name
Consultant
Nurse
R1
Ann Other
AA1
Jenny
X
R2
Jean Smith
AA1
Jenny
y
R3
And so on….
BB2
Jenny
y
R4
CC3
Jenny
y
R5
AA1
Jenny
y
R6
CC3
Jenny
n
B1
AA1
Jane
n
B2
AA1
Jane
y
B3
CC3
Jane
n
Bed
ready for
discharge?
What are
patients
waiting
for?
05-Jan
02-Jan
01-Jan
03-Jan
Date patient is expected
to actually be discharged.
For most patients this
should be the same as
This should be since
the medically fit date but admission to hospital
for some e.g. patients
waiting Lings Bar, it may
be different
Predicted Discharge DateLOS (since admission) Destination
06-Jan
3
1
2
3
B5
B6
CC3
BB2
AA1
Jane
Jane
Jane
H
H
Waiting for (incl date/time of ref)
TTO
Social worker
Occ Therap
Physio
24 hour tape (4.1.10 9am)
TTO
Needed
Needed
Needed
Ultrasound (4.1.10)
TTO
Complete
Complete
NH
OT assessment (referred 5.1.10)
TTO
H
Social services assessment (4.1.10)
TTO
Internediate Care (2.1.10)
TTO
02-Jan
4
CITY
03-Jan
1
H
02-Jan
B4
Please list all the things that the patient is waiting for and the date
referred. Codes/suitable abbreviations should be used if your board is Optional column headings
in a public area
H
Jenny31/12/08 0815
Complete
Jenny31/12/08 0815
Complete
Jane 31/12/08 0830
Complete
Jane 31/12/08 0830
09-Jan
1
H
01-Jan
3
H
TTO
Complete
Needed
Complete
03-Jan
3
H
TTO
03-Jan
4
NH
TTO
02-Jan
3
H
TTO
04-Jan
2
H
TTO
02-Jan
1
H
TTO
01-Jan
3
CITY
TTO
03-Jan
3
H
TTO
Jane 31/12/08 0830
Jane 31/12/08 0830
n
BB2
Sarah
y
BB2
Sarah
y
G3
CC3
Sarah
n
G4
AA1
Sarah
y
SR1
CC3
Jenny
n
SR2
BB2
Jane
y
10-Jan
2
H
Jane 31/12/08 0830
Jane 31/12/08 0830
n
G2
Jenny31/12/08 0815
Jenny31/12/08 0815
Referred
y
G1
Jenny31/12/08 0815
Jenny31/12/08 0815
Referred
TTO
TTO
Updated by (date, time,
initials)
Complete
Referred
Needed
Complete
Complete
Complete
Needed
Sarah 31/12/08 0830
Sarah 31/12/08 0830
Sarah 31/12/08 0830
Sarah 31/12/08 0830
Complete
Jenny31/12/08 0815
Jane 31/12/08 0830
06-Jan
1
H
Problem Solving
Identifying waits at board round
• encouraged the MDT/ward staff to be pro-active in resolving
waits themselves, at an earlier stage
• gathered on-going data on the top waits
• enabled us to focus improvement efforts in the right areas
Examples of some of the waits identified at board round
A CT scan requested
yesterday at 10am
and not done by
10am today
Waiting more than 24
hours to move to
another ward/specialty
Waiting for a
decision to progress
the patient’s journey
from a senior
decision maker
An investigation that is
only undertaken on a
Wednesday and
today is Friday
Waiting more than 24
hours for a review
from another specialty
after referral
Waiting for TTO’s to
be prescribed
Therapy assessment
more than 24 hours
after referral
Referrals made on
Friday but not done
until Monday (due to
a 5 day service)
Escalation Process for wards
Aimed to get the right people involved at the
right time – not too early, but not too late!
Wait occurs
Resolved by
ward staff
Key role for
matrons
Wait occurs
frequently
Resolved by
ward staff
Ward staff
inform matron
of theme
Wait occurs
Ward staff
unable to
resolve
Ward staff
inform matron
of theme
Wait occurs
Ward staff
unable to
resolve
Ward staff
inform matron
of theme
Matron informs
Clinical Lead
during daily
meeting
Issue taken to
internal waits
steering group
for investigation
Matron
resolves
Matron unable
to resolve
Matron
informs
clinical lead
during daily
meeting
Feedback loop at all stages of the process
Clinical lead
resolves or takes to
internal waits
steering group
We planned a comprehensive rollout
across 60 wards – took a team of 8
people 4 months to complete
1 week preparation with
B4Y project lead, Matrons,
Clinical Lead and Head of
Service for each directorate
2 weeks intensive support
per ward within directorate
from B4Y team member
(supported by B4Y project
lead)
2 weeks light touch to all
wards within the directorate
from B4Y project lead. B4Y
team members move to
next directorate
B4Y project lead remains
named contact for
directorate until end of
rollout
Training Team – from Better for you and Productive Ward
Mostly senior nurses – plus an OT!
1-2 hours per day
We designed a daily manual checklist to
capture data on process steps and waits
Recorded daily and submitted
at the end of each week - one
form for each ward
Process measures
•Board round undertaken
•Senior decision maker present
•LOS graph plotted
•Waits escalated
•Cause of waits review undertaken
+ details of waits
 Hugely time consuming to collect and
analyse (but crucial)
 After 6 months, these forms were
individualised for each ward, based on
their top waits
Every week we reported the total number of
internal waits (in patient-days) and the average
number of pt-days per form/ward
Bed reduction
programme
commenced
96 beds
We created a dashboard for every ward
ward, which updates automatically
What was achieved during Phase 1
Implement
Toolkit
on all medical
and surgical
adult wards
Reduce the number
of internal wait
Patient days by
50% (min); 80% (max)
All adult wards (n=56)
implemented the toolkit
Other benefits:
• Reduction in
Internal waits reduced from
750 (July 2010) to
260 (October 2011) = 66% reduction
Reduce LOS
to support
closure of
95 beds
96 beds closed were during
March/April 2011 across
both campuses
Reduce
outliers to
zero
Reduced from a high of
120 during February 2011
to around 15-20 in October 2011
number of
inappropriate
cardiology
Investigations
(24 hour tapes
for in-pts)
• Enhanced patient
experience through
fewer unnecessary
waits
Impact on top 4 waits...
Imaging
Imaging
Cardiology
Cardiology
Dropped
Droppedfrom
from baseline
baselineof
of 172
172
inMarch
March to
to an
an
in
averageof
ofaround
around90
90
average
Reduced
Reducedfrom
fromaabaseline
baselineof
of112
112
inMarch
March to
to an
an average
average of
of
in
around 40
40
around
Ward processes
Specialty Bed
Reduced from a baseline of
128 in March to an
average of around 25
Reduced from a baseline
of 100 in March to an
average of around 35
There were Better for you projects running
concurrently in Imaging and Cardiology – this was
crucial in being able to affect changes in these
complex areas
Successes from the Services
Imaging: % of in-patient ultrasound scans completed
within 24hrs of request
Before:
60%
After:
98.8%
Cardiology: % of in-patient ECHOs completed within
24hrs of request
Before: 58%
After:
98%
How staff felt about the project...
You have won me
over!
I didn’t think it would
make a difference
but it has!
Being able to see how
long patients have been
in hospital is a real eye
opener
I can now tell my patients
what’s going to happen
next and when we’re
planning for them to go
home
We have tried to improve our
communication as a team for a
while now - a daily board round
has given us the ability to progress
this
Reducing Internal Waits
The Future
At the end of Phase 2 (18 months on)
• We had evidence that reported waits had
reduced by a further 20% (NB using a more
robust SPC approach now!)
• Evidence that the culture of accepting waits as
unavoidable was no longer the ‘norm’
• Most wards had a board round, but..
– Not all had a senior decision-maker
– Role of matrons had become less visible
– We weren’t identifying enough of the remaining waits
• We really wanted a better KHWD approach
A new Data Analyst brought a new set of skills to
our analysis, expanding use of SPC charts
We needed to be able to more accurately detect
‘process change’ and not react to normal variation
Moving into Phase 3, our aim was
Eradicate unnecessary waits to:
• improve patient experience and safety
• ensure our patients have the smoothest journey
possible through our hospitals and services
• improve capacity/flow
Some of the main changes in the third phase
include
 Waits of < 1 day (including TTOs)
 Increase service responsibility for ‘pull’
 Re-focus board rounds
Status at
a glance
Safety &
flow
round
Escalation
process
Problem
solving and
resolving
waits
During spring 2012, we realised we had ‘plateaued’
– so we re-design the toolkit and re-launched it
We have refocused the board round on
Safety & Flow
Nurse
Nurse in charge
• Overnight events
• EWS & pain control
• Outstanding investigations or
delays
• Falls assessment /Braden and
grade
• Facilitate board round and update
Horizon
• Ensure unexpectedly poorly & unreviewed are discussed first
• Agree who is responsible for
actions
• Ensure identified waits are
escalated/resolved
Senior Decision Maker
• Delegate Dr to review
unexpectedly poorly /unreviewed
patients
• Review all requested investigations
• Is patient progressing as planned?
• Review PDD & MS
• Ensure correct consultant is
allocated to patient
Therapy team
Doctors
• Identify patients who require input
• Identify and report any delays to
assessment/input
• Identify which patients need to be
seen first
• Check investigations on Notis
• Identify which patients require ETTO’s commencing
• VTE assessment required
Board
Round
The toolkit was re-developed using an approach
developed by lead cardiologist and his ward team
S
ICK pts
Patient needs to be seen by
a senior decision-maker
now – deteriorating,
overnight/ un-reviewed
admission
H
OME pts
Today’s
discharges
O
ther pts
All other
patients
LAN
Incoming patients
and outliers from
our ward
Weekend Plans
Do our patients have a plan of care
which is known to all key individuals?
“How do we know we
have run a successful
Safety and Flow
Board Round?”
P
Is everyone aware of what actions are
required to deliver each plan of care?
Is all the information about each
patients correct, including the
consultant?
On Friday is there a plan for the
weekend including nurse facilitated
discharge?
Have waits been identified?
Who is responsible to for resolving
them?
Could any outstanding
investigations/tests be done as an
outpatient?
S
a
f
e
t
y
&
f
l
o
w
We have improved and expanded data
analysis
By Directorate
By Ward
By Service
Imaging and cardiology waits have (more
than) halved - but are still the biggest
cause of waits
Our Current Challenges!
• Reduce the number of internal waits by a
further 20% in six months
• Harness the opportunities of our new
electronic bed management system
• Waits measured in hours not days
• Escalation plans for the top 5 services
• Electronic data collection
• Integrate Internal Waits ‘processes’ to
daily capacity/flow meetings
Some reflections
(or “what we would do
differently if we could”!)
It was (and is) tough
To get started......
To create the drive for change.....
To get enough of the ‘right’ people
involved and actually helping.....
Getting the cultural change from the
bottom up.....
But it has made a huge
difference
• It’s part of ‘our’ language now
• Board rounds are an accepted part of
everyday life (doesn’t mean they always happen
though!)
• Some wards have taken to the concept
well and easily, others.........
• Most of our services have responded very
positively and pro-actively to reducing
waiting times
What would we do differently?
• Get matrons much more actively involved
from the start
– Including training & rollout
• Get better and quicker feedback for wards
regarding their performance
• More medical staff involvement throughout
• Integrate into everyday systems more
quickly
• Manage poor performers more robustly
• Early involvement from services – creating
the pull
Questions?
Thoughts?
Comments?
Liz Williamson: liz.williamson@nuh.nhs.uk
Scott Purser: scott.purser@nuh.nhs.uk
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