National Breaking the Cycle Initiative
Planning advice
April 2015
Background to the Week
Social movement is
crucial, it starts with:
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A compelling story
A commitment
A structure
A strategy
A set of measured
actions and outcomes
Social movement – 6 characteristics
An example – creating a buzz
Dr Richard Genever - Chesterfield Royal Hospital NHS Foundation Trust
A compelling story…about patients
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High numbers of outliers hospitals – associated with patient risk
Crowded emergency departments – associated with patient risk
Increasing emergency admissions – frail older patients
High and sustained levels of escalation across the system
High levels of acute hospital bed occupancy
Patient experience, quality and safety – patients defaulting to the
acute trust / ED
• There feels like there is a need to try something different , to recalibrate the system
The compelling story
The compelling story - continued
 48% of people over 85 die within one year of hospital
admission
Imminence of death among hospital inpatients: Prevalent cohort study
David Clark, Matthew Armstrong, Ananda Allan, Fiona Graham, Andrew Carnon and Christopher Isles, published online 17 March 2014 Palliat Med
If you had 1000 days left to
live how many would you
chose to spend in
hospital?
 10 days in a hospital bed (acute or community) leads to the
equivalent of 10 years ageing in the muscles of people over
80
Gill et al (2004). studied the association between bed rest and functional decline over 18 months. They found a relationship between the amount of
time spent in bed rest and the magnitude of functional decline in instrumental activities of daily living, mobility, physical activity, and social activity.
Kortebein P, Symons TB, Ferrando A, et al. Functional impact of 10 days of bed rest in healthy older adults. J Gerontol A Biol Sci Med Sci.
2008;63:1076–1081.
Dr Richard Genever - Chesterfield Royal Hospital NHS Foundation Trust
The compelling story – continued - time of admission is important
Sunday
Midnight
Midday
Saturday
Midnight
Midday
Midnight
Midday
Thursday Friday
Midnight
Midday
Weds
Midnight
Midday
Tuesday
Midnight
Midday
Monday
3-day LOS difference between 9am and 9pm admissions
Source – NW Resource Utilisation Management Team 2014
The compelling story – continued - time of admission is
important more so for older patients
Age >75 years
4-day LOS difference between 9am and 9pm admissions
Source – NW Resource Utilisation Management Team 2014
Commitments for the week – why are we doing this ?
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To urgently ‘recalibrate / reboot’ the system
To improve patient experience, safety, quality and flow
throughout the trust
To reduce overall bed occupancy – eradicate outliers
To accelerate and improve discharge processes
To engage staff and improve the working environment
To reduce high escalation levels
Above all – to create social movement, frontline
engagement, a ‘buzz’. To see and feel what ‘good looks
like’
To use the week to accelerate and embed known good
practice – (e.g. the consistent use of the SAFER patient
flow bundle)
Examples of commitments others made when ‘breaking the
cycle’…..
• Cancel all non urgent meetings and
reduce email traffic
• Consultants stand down non clinical
SPAs
• There will be two senior reviews a day on
every ward every day
• Increased visibility of senior staff
• Deployment of Liaison Officers to wards
• Introduction of Internal Professional
Standards
• Move to a ‘go and see’ approach (rather
than office based)
• Permission from executives for front line
staff to get on and do things that prevent
patient delays (no matter how small)
Structure - how will it work?
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Clear leadership and management
structures should be planned and in
place in each trust from day one, so
every delay / problem can be dealt with
promptly
There need to be daily measures so
there is no doubt how every
organisation is doing in delivering their
commitments
There should be daily wash-up
meetings to understand lessons learnt
and next steps
Everyone must be encouraged to listen,
learn and share their experiences
Staff should be thanked daily for their
input
Local Structure
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A control room is needed in each trust to help
co-ordinate and over see the week
ECIST can help – call or email your questions
and comments; attend the surgeries and
webinars
Deploy a ‘ward liaison officer’ on each ward to
help resolve problems, no matter how small,
without delay.
Senior trust leads need to be available to help
resolve any problems that can’t be sorted out at
ward level.
The executive team should meet daily to review
progress and ‘go and see’ frontline teams
during the week.
Local Structure – how does it work?
Silver Command
Front line teams and
Ward Liaison officers can
ask for instant support to
help resolve problems in
real time
Dr Richard Genever - Chesterfield Royal Hospital NHS Foundation Trust
Examples of measures you could use
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Number of empty beds at 8am
% patients discharged before midday
Time of first patient transfers from
assessment units
Expected date of discharge – do your
patients know it?
Discharges – plan v actual
Patient moves for non-clinical reasons
Ambulatory emergency care %
Outliers
Compliance with the SAFER patient flow
bundle
SAFER
Patient Flow Bundle
The patient flow bundle is similar to a clinical care bundle. It is a combined
set of simple rules for adult inpatient wards to improve patient flow and
prevent unnecessary waiting for patients.
If we routinely undertake all the elements of the SAFER patient flow bundle
we will improve the journey our patient’s experience when they are
admitted to our hospital.
The Patient Flow Bundle - SAFER
S - Senior Review: all patients will have a consultant review before midday.
A - All patients will have an Expected Discharge Date (that patients are made aware
of) based on the medically fit for discharge status agreed by clinical teams.
F - Flow of patients will commence at the earlier opportunity (by 10am) from
assessment units to inpatient wards. Wards (that routinely have patients transferred
from assessment units) are expected to ‘pull’ the first (and correct) patient to their
ward before 10am.
E – Early discharge: a third of our patients will be discharged from base inpatient
wards before midday. TTOs (medication to take home) for planned discharges should
be prescribed and with pharmacy by 3pm the day prior to discharge wherever possible
to do so.
R – Review: a weekly, systematic review of patients with extended lengths of stay
(e.g. > 14 days) to identify the issues and actions required to facilitate discharge. This
will be led by clinical leaders supported by operational managers who will help
remove constraints that lead to unnecessary patient delays.
And Finally….
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Planning – a simple implementation plan is required. Getting everyone on board
is more important than anything else.
Communication +++. Use every method. Staff engagement is key. The perfect
week is all about social movement, ‘the buzz’ of doing the right thing without
delay
Commitment – from all system leaders and organisations involved
Measurement – the numbers and stories
Evaluation – seek out the lessons to inform future plans
Wrap up event at the end of the week led by the senior team – praise and
thanks, share stores, share results and commit to next steps
Further information can be found
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Website………………… It includes:
• National Breaking the Cycle guidance and tips
• National Breaking the Cycle checklist for
senior teams
• Frequently asked questions
• Presentations from trusts that have
undertaken weeks previously
• Additional practical information
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Email – if you have a query that isn’t covered, you
can email perfect.week@nhs.net and someone
will contact you directly