Transcript How to write an award-winning storyboard Dr Alan Willson

How to write an award-winning storyboard
Dr Alan Willson
Supporting NHS Wales to Deliver World Class Healthcare
Purpose of NHS Wales Awards
• Recognise achievement
• Provide learning material to support the
training and development of NHS staff
• Stimulate and encourage an evaluative
approach to implementing better ideas in
service delivery
Model for Improvement
The Judging Criteria
with examples from shortlisted storyboards
1. Storyboard Title
• Gynaecological Cancer Rehabilitation Scheme for the
Prevention of Lymphoedema and Incontinence
#86 Gynaecological Cancer Rehabilitation Scheme for the Prevention of Lymphoedema and
Incontinence
• Contact Card for Relatives Following Bereavement
#149 Contact Card for Relatives Following Bereavement
2. Brief Outline of Context
• Where this improvement work was
done
• What sort of unit/department
• Which staff/client groups were
involved
2. Brief Outline of Context
• This community service for disabled children and their families
is based in an NHS Trust Children’s Centre and brings together
specialist social workers, local authority occupational therapy
staff, a specialist teacher, care coordinators, community
learning disability nurses, special school nurses and Diana
nurses in an integrated team.
#0031 Developing a Children’s Integrated Disability Service (CIDS)
• A multi agency Task Team was established in 2000 to review
historical Day Care Services provided at Cam Cyntaf Day
Centre, Glanrhyd Hospital and Ty’r Ardd Social Care Day Centre
in the community. The client groups included 170 individuals
with severe and enduring mental health to those with mild to
moderate mental health problems.
#0152 Integrated mental Health Day Opportunities Service `
Continued
2. Brief Outline of Context
• AMBU Health Board is one of the largest in Wales employing
around 300 midwives. It serves a population of 600,000 with an
annual birth rate of about 6,380. The maternity services are
based in 3 separate sites and midwives provide care in a variety
of settings including consultant led units, midwife led birth
centres, the community and home.
#0114 Flexible Retirement – Everyone’s a Winner!
3. Brief Outline of Problem
• Statement of problem
• How they set out to tackle it
• How it affected patient/client care
3. Brief Outline of Problem
• Parent Education for pregnant women has traditionally been organised in
weekly sessions. Before the 1990’s it was during the day and only for
women. Midwives and Service Commissioners realised that the take-up for
the session was not optimum and that with many women now working,
holding the information programme in the day is not always convenient.
The drop out rate becomes high as the sessions progress and continuity of
midwife is not available depending on available rotas. Parent Education
has since been offered for couples in six weekly evening sessions and is
very popular, with demand outstripping supply, but again the drop out
rate is high.
#0160 Streamlining the Parent Education Programme – Bringing It into the 21st Century.
Continued
3. Brief Outline of Problem
• Pressure Ulcers cost the National Health Service £2.4 Billion a year
(Bennett et al 2004). Nice Guidelines have pointed out that Hospital audits
have shown hospitals to range between 10%-14% incidence of hospital
acquired Pressure Ulcers. Incidence rates within the Department have
shown to be at 4.2%. Target for the 1000 Lives campaign was to reduce
Pressure Ulcer Incidence by 50% per 1000 bed days.
#0106 Pressure Ulcer Prevention – Zero Tolerance
• The Sister and staff identified a problem in the provision of key services to
patients around: Electrocardiograph (ECG); Phlebotomy; Podiatry and
Therapies which was part time, nine to five, Monday to Friday, leaving a
significant gap in care for patients, the rest of the time. The above was
observed to significantly hamper patient’s progress and delay discharge
from hospital.
#0125 The Flexible and Sustainable Workforce
4. Assessment of Problem and
Analysis of its Causes
•
•
•
•
Quantified problem
Staff involvement
Assessment of the cause of the problem
Solutions/changes needed to make
improvements
4. Assessment of Problem and
Analysis of its Causes
• The group agreed to redo the audit by:
• Developing an audit tool to record the patients body temperature
through out the care pathway.
• To ensure consistency only one method of recording temperature
• Tympanic thermometers were the best method chosen by the team.
This audit identified that the problem started when the patient was
admitted to the Day Surgery unit, by the time they changed and walked to
the anaesthetic room 77% patients arrived hypothermic and transferred to
operating room hypothermic. Forced warm air blankets improved the
patients body temperature, but they still remained hypothermic when
transferred to recovery room 88% transferred from operating theatre to
recovery were hypothermic. The audit identified that the impact of
transferring patients from the ward to the anaesthetic room reflected on
the outcome of the patient’s recovery and discharge home.
#0008 Reducing Harm & Risks of Hypothermia to Surgical Patients Under General
Anaesthetic
Continued
4. Assessment of Problem and
Analysis of its Causes
•
We established that there were tremendous examples of positively evaluated work
supporting the most vulnerable in the community. Their main limitations however
were that:
• They were too small to have a critical mass of resource to meet user need
• They were too restrictive in terms of “exclusion criteria” to allow those in
need to access them
• They were too restrictive in terms of who could refer patients to the service
• They were often age or disease discriminatory
• Joined up working particularly with respect to integration with services
providing personal care provision were missing
• There was no clear line of horizontal accountability that crossed traditional
barriers, rather each component was accountable in a vertical manner through
different lines of management.
The combined skill mix of the interagency partners was integral to crossing these
barriers. A co-located integrated inter-disciplinary team sharing an electronic
patient record that could cross the interfaces of primary, secondary and
intermediate care were the principal components used to tackle these problems
to enhance patient care and satisfaction.
#0122 The C.E.L.T.I.C. Experience, An All-inclusive Seamless Intermediate Care Service
Continued
4. Assessment of Problem and
Analysis of its Causes
•
According to The Department of Health (DoH) (2000) 6 million people in the United
Kingdom suffer with urinary incontinence. The earlier local study highlighted the
reluctance to seek help for incontinence and with the increasing number of
referrals to the District Nursing service for incontinence assessment the idea of
setting up a clinic was conceived. Discussions then followed between the District
Nurse and Continence Advisor. The concept was presented to the head of District
Nursing and to General Practitioners from two rural practices. The proposal was
accepted and accommodation to run a clinic was secured at a GP Surgery. Plans
were then drawn up to take the venture forward.
#0084 Proactive Approach to Continence Care in a Rural Community
•
Up to 10% of patients are readmitted as emergencies within 3 months of their
initial acute admission because of further stone formation or stone migration. In
the UK, Metabolic assessment of urinary stone formers is rarely undertaken in the
form of urine, blood and stone analysis to identify those at risk of recurrent stone
disease despite this being part of the European and American Urological Guidelines.
No other Urological Centre in Wales currently runs a metabolic stone clinic.
#0077 The Metabolic Stone Clinic – Benchmark Prevention for High Risk Patients
5. Strategy for Change
• How the proposed change was
implemented
• Clear client or staff group described
• Explain how they disseminated the results
of analysis and plans for change to the
groups involved with/affected by the
planned change
• Include a timetable for change
5. Strategy for Change
• The Practice News Letter and Health Promotion board displayed in
the practice informed the practice population of problems
associated with urinary incontinence and the ease of access to the
clinic (March 2005). The GPs and practice staff were made aware
that the clinic would commence in July 2005, held on a monthly
basis and would accept male and female clients of any age group.
Develop protocol and referral forms for the clinic by July 2005.
Develop Audit Tool for use on an annual basis. Collate evidence to
support effectiveness of the clinic. Disseminate experience and
findings to colleagues at Carmarthenshire NHS Trust Professional
Group Meetings. Attend and present annual report at the GP
Professional Group meeting.
#0084 Proactive Approach to Continence Care in a Rural Community
5. Strategy for Change
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Formation of steering group consisting of Consultants, GPs, nurse advisors, modernisation
manager, Nurse directors from Trust and LHB and patient representatives [2005/6].
Appointment of chronic disease co-ordinator and 8 specialist nurses, 1 physiotherapist & 2
administrators[January 2006]
Co-ordination of “top up”, clinical assessment skills training for specialist nurses [March 2006]
Personalised visits to Carmarthenshire GP surgeries, secondary care medical and elderly care
teams, A&E, medical admission units, CCU/intensive care teams, district nursing teams and
newly appointed admission avoidance teams/services; informing them of the chronic disease
service [June 2006]
Identify link nurses in each GP surgery [October 2006].
Baseline review of medical emergency admission rates and QoF data [2005/2006]
Update needs analysis regarding current service and training needs in primary and secondary
care [October 06- Mar 07]
Produce evidence based diagnostic and treatment algorithms [June 2006]
Update Heart failure and Diabetic components of Carmarthenshire CHD & Diabetic “tool kits”,
designed to facilitate standardised management for CHD and Diabetic patients throughout
Carmarthenshire [November 2007].
Introduction of “Heart Save” heart failure training course [2006/7]
Introduction of “XPERT” diabetic patient training course [2006/7]
Development & introduction of integrated COPD care pathway [2006/7]
Introduction of “COPD” telehealth pilot [2007/8]
Develop standardised clerking and communication documentation for the service [January 2008]
Establish patient focus groups to evaluate and inform service development [November 2007]
Develop & test service satisfaction questionnaires
#0146 “Chronic Disease - Continuums of Care”
Continued
5. Strategy for Change
•
•
•
Medical staff are often resistant to change which is dictated to them but will often
support change when there is strong evidence of it’s benefit or previous personal
involvement with critical incidents. Nursing and Operating Department
Practitioners are heavily influenced by medical leadership so it was essential to
have medical support in all areas.
Time was spent talking to all members of the teams in small groups and answering
the queries before we embarked on implementation. Each consultant was also sent
written information at least a week prior to implementation. After a month’s pilot
(using the model for improvement and small steps of change) with the introduction
of the checklist in Llandough Hospital, we made minor changes and moved on to
main theatres at UHW starting the checklist in a new theatre each week. We
started with the most enthusiastic teams and then rolled out rapidly in order to get
round all the theatres. We planned to have the checklist in place in all surgical
theatres by August 2009 and to use the final six months to improve compliance and
focus on poor performing areas.
During the first six months other specialities such as radiology, podiatry,
dermatology and cardiology were contacted and encouraged to alter the checklist
for their clinical use but maintain the core standards set out by the NPSA. Their
ownership is important for sustainability of the project.
#0174 World Health Organisation (WHO) Surgical Safety Checklist – A Successful Strategy for
Implementation
6. Measurement of improvement
• Details of how the effects of the planned
changes were measured
6. Measurement of improvement
• Client evaluations, capturing both quantitative and qualitative information
are completed.
• Standardized outcome measures are used pre and post intervention
(SF36).
• Formal research is currently being undertaken by Cardiff University to
understand the effectiveness of the Programme
• Jobcentre Plus “tracking” of clients to measure return to work outcomes
(30% return to work)
• Postal survey to 500 discharged clients to measure customer satisfaction
(25% response rate to date)
• NLIAH Case Study of the effectiveness of the CMP Partnership Steering
Group
• The cost effectiveness of delivering the course compared to ‘one to one’
interventions has been analysed.
• Article published in OT News (October 2008)
#0132 Positive Partnership Working: The NHS and Jobcentre Plus Working Together to Support
Citizens living with Long Term Conditions to Return to Work.
Continued
6. Measurement of improvement
• Collated a directory of each GP link nurse, outlining their method of
systematic GP follow up
• Medical emergency admission rates from the Trust and QoF data from
each GP surgery was provided monthly to the LHB, and compared
quarterly against the previous years data
• Staff questionnaires issued to primary and secondary care, ascertained
their local management and training needs
• Evaluation questionnaire regarding the education programmes
• Patient focus groups and user satisfaction questionnaires
• Comparatives of quality of life scores [Minnesota QoL questionnaire]
• Comparatives in application of evidence based prescribing
• Referral waiting times for diagnostic echocardiograms
#0146 “Chronic Disease - Continuums of Care”
7. Effects of Changes
• Statement of the effects of the change
• How far these changes resolve the
problem that triggered the work
• How this improved patient/client care
• The problems encountered with the
process of changes or with the changes
7. Effects of Changes
•
Our first months data showed a compliance of between 60-70% and four months later this data
has improved to approximately 90% compliance at UHW main theatres.
Llandough Hospital data was not as good with as low as 15% compliance initially but after
focusing on the problem of surgical engagement this improved to approximately 80% four
months later.
Data for completion for all emergency procedures was not as good, initially only achieving
approximately 50% compliance initially. This has improved but we need to focus on emergencies
that are undertaken outside the designated CEPOD theatre (theatre 7).
•
•
#0174 World Health Organisation (WHO) Surgical Safety Checklist – A Successful Strategy for Implementation
Continued
WHO Checklist Compliance - UHW Elective Dec 09
Checklist Completion (UHW ElectiveJuly to September 2009)
Checklist Completion (UHL Elective July-Sept 09)
100.0%
200
95.0%
363
350
105.0%
100.0%
95.0%
190
90.0%
90.0%
350
140
142
135
131
30.3%
138
35.0%
30.0%
109
96
100
100
90.0%
88.7%
80
25.0%
86
10.0%
THEATRE TWO
45.0%
150
135
25.0%
19.0%
15.0%
10.0%
5.0%
0
7
0
75.0%
THEATRE EIGHT
THEATRE
ELEVEN
THEATRE FIVE
THEATRE FOUR
WHO Checklist Compliance - UHL Elective Dec 09
THEATRE NINE
THEATRE ONE
THEATRE SIX
THEATRE TEN
THEATRE THREE
THEATRE TWO
TRAUMA
THEATRE
Checklist Completion (UHW Emergency July-Sept 09)
WHO Checklist Compliance - (UHW Emergency Dec 09)
300
60.0%
140
267
94.8%
120.0%
52.3%
127
50.0%
90.0%
138
250
80.0%
76.1%
78
80
71
61
77
50.0%
70
67
60
Percentage
WHO
Checklist
Complete
30.8%
30.0%
28.6%
150
30.0%
24.5%
110
100
20.0%
17.6%
100.0%
100.0%
100.0%
100.0%
80.0%
72.4%
80
66.7%
66.7%
11.8%
66.7%
63.8%
60.0%
59.4%
60
50.0%
50.0%
40.0%
Percentage WHO Checklist Complete
40
32
50
10.0%
7.7%
30.0%
20.0%
ORTHO FOUR
ORTHO ONE
Locations
ORTHO SIX
ORTHO THREE
ORTHO TWO
RED THEATRE
YELLOW
THEATRE
11
5
3
Location
EA
T
E
O
TW
EA
TR
TH
A
TR
AU
M
EM
ER
G
EN
RE
E
TH
TR
E
TH
EA
SIX
TR
E
TR
E
TH
EA
TH
EA
SE
TR
E
TH
EA
TH
EA
TR
E
N
O
N
IN
E
VE
N
E
R
E
FO
U
TR
E
TH
EA
TR
E
EN
FIV
TR
E
TH
EA
EIG
HT
EL
EV
TR
E
TR
E
TH
EA
TH
EA
Locations
1
RE
1
3
2
RE
EA
T
TH
CY
G
EN
TH
EA
RE
1
5
3
1
EM
ER
G
EN
CY
TH
EA
T
RE
EA
T
TH
CY
G
EN
ER
ER
3
2
TH
4
3
0
CY
0.0%
EM
THEATRE TWO
20
0.0%
1
EM
13
6
THEATRE THREE
THEATRE SIX
THEATRE ONE
0.0%
3
THEATRE TEN
0.0%
2
2
THEATRE SEVEN
THEATRE NINE
7
THEATRE FOUR
THEATRE FIVE
17
O
D
ORTHO FIVE
13
CE
P
BLUE THEATRE GREEN THEATRE GYNAE THEATRE
0.0%
1
TRAUMA THEATRE
0.0%
17
THEATRE EIGHT
10.0%
0
EMERGENCY THEATRE 3
20
0
EMERGENCY THEATRE 2
20.0%
THEATRE ELEVEN
12
40
Total Patients
100.0%
98
100
Total no of pts
40.0%
58
40.0%
33.3%
33.3%
EMERGENCY THEATRE 1
Sessions
60.0%
88
Percentage Compliance
98
89
197
200
70.0%
No. Of Lists
71.4%
68.1%
Sessions
80.6%
100.0%
0.0%
Percentage Compliance
82.1%
78.9%
Percentage Completed
100.0%
Total
Patients
74.2%
100
50.0%
120
85.1%
120
0.0%
Location
100.0%
87.1%
20.0%
15.8%
50
Locations
88.5%
Total no of pts
Percentage WHO Checklist Complete
30.0%
100
20
160
35.0%
80.0%
Location
140
40.0%
32.9%
40
39
40
50.0%
154
85.0%
0.0%
TRAUMA THEATRE
THEATRE THREE
THEATRE TEN
THEATRE SIX
THEATRE ONE
THEATRE NINE
THEATRE FOUR
THEATRE FIVE
THEATRE ELEVEN
THEATRE EIGHT
163
166
31.4%
47
45
60.0%
55.0%
46.8%
122
52
50
65.0%
182
172
57
60
15.0%
5.0%
70.0%
184
173
67
85.7%
62
20.0%
65
92.1%
90.0%
50
0
92.5%
RED THEATRE
150
93.0%
92.5%
YELLOW THEATRE
40.0%
Percentage WHO Checklist Complete
93.3%
120
ORTHO TWO
162
Total no of pts
54.8%
53.8%
ORTHO THREE
45.0%
75.0%
200
ORTHO SIX
50.0%
Percentage
WHO
Checklist
Complete
ORTHO ONE
200
95.0%
94.9%
58.8%
58.5%
ORTHO FOUR
55.0%
80.0%
220
60.7%
ORTHO FIVE
60.0%
52.1%
96.2%
140
63.0%
GYNAE THEATRE
58.5%
85.0%
250
BLUE THEATRE
No. of Lists
65.0%
250
160
Percentage Compliance
70.0%
66.7%
Total
Patients
GREEN THEATRE
75.0%
69.2%
100.0%
No. of Lists
72.5%
69.5%
100.0%
Sessions
72.9%
300
295
300
80.0%
76.3%
Percentage Completed
77.1%
180
85.0%
81.4%
Percentage Completed
400
Percentage
WHO
Checklist
Complete
7. Effects of Changes
•
•
•
•
•
•
•
•
•
Results from the trial of using the Forced warm air
gowns. On admission 60% patients arrived hypothermic
and forced warm air gowns were immediately applied.
All patients transferred from the day Surgery were
normothermic and the temperature was maintained until
the patient was fully recovered and discharged. This had
an impact on the outcome of the patient’s recovery:
Length of stay reduced in recovery
Analgesia – reduced to oral on the ward
Reduced readmissions (improving pain control, nausea
etc)
Discharge time reduced from 8pm to 2pm
Patient satisfaction – (10 day post operative phone call.)
Infection control – single use
Easy access to limbs- Velcro
The group agreed that the best way forward was to
introduce across Powys operating theatre, no cloth
gowns are used for any patients under going surgery. We
are continuously auditing to ensure that patient
temperature is maintained. We may have had a saving of
£240 per month, but most important we reduced harm
and saved lives.
#0008 Reducing Harm & Risks of Hypothermia to Surgical Patients Under General
Anaesthetic
8. Lessons learnt
• Statement of lessons learnt from the
work
• What would be done differently next time
8. Lessons learnt
• The team has met certain challenges along their journey, which with
determination and robust planning these were overcome.
• These have included staff shortages, but through innovative planning all
areas were able to send their staff for education and training.
• There is no doubt that a recognised forum that met regularly to make
decisions was important.
• Being able to accept failures, address them and move on was also
essential in maintaining the momentum of change.
• Start small but aim big.
• Capture the enthusiasm of the frontline staff as well as the patients and
their carers. There is no better way of improving morale than through
successful initiatives driven by the staff themselves.
#0106 Pressure Ulcer Prevention – Zero Tolerance
Continued
8. Lessons learnt
• Strong involvement and support from the MDT is essential.
• Patients have numerous appointments during a cancer diagnosis, try to
coordinate with other members of the team or check appointments on the
IPM system.
• Not all suspected gynaecology cancers are actually diagnosed with cancer,
27% enrolled on the scheme were eventually cancer free. This decreased
activity is enabling the service to embark on a skin cancer lymphoedema
prevention scheme as well.
• Increasing capacity demands on the lymphoedema service the 6 week
scheme could be condensed into one morning or afternoon session.
• With the Welsh Assembly Government Lymphoedema Strategy being
published in December 2009 and prevention being one of the key aims this
scheme could be replicated throughout Wales.
#86 Gynaecological Cancer Rehabilitation Scheme for the Prevention of Lymphoedema and
Incontinence
9. Message for Others
• Statement of the main message they
would like to convey to others, based on
the experience described
9. Message for Others
•
•
•
Creating a specialised service within existing resources can reduce
demands on services a whole.
Clients who have been chaotic and presented with high levels of risk can
be active participants in their care and have a positive impact on their
peers.
Working with high risk can be done without worry when decisions are
supported by management and made as a group.
#0183 Taith – The Therapeutic Day Service
•
•
Improving service delivery in the NHS is not always about additional
financial investment, it needs the team to have the conviction to critique
their own service, be open-minded enough to change and be effective
motivators and communicators.
There is a wealth of specialist skill mix within the NHS and don’t be afraid
to benchmark new ideas that work outside the UK and above all- enjoy
what you do.
#0077 The Metabolic Stone Clinic – Benchmark Prevention for High Risk Patients
Common Problems
• Not ready to submit
• Section creep – between the 9 criteria