East Ayrshire Community Hospital



Ayrshire and Arran

Ward 2

Ward 2 began implementing releasing time to care in January 2010.

8 months on, we have implemented the three foundation modules and built in sustainability. We have also completed the process modules to include medicines, handovers, meals, patient hygiene, and patient observations and ward rounds.

Graph

RTC Ward Report out

Ward 2 Progress within Releasing Time to Care

Sustainability

As shown above we have built in sustainability tools to include 10 point check list and encourage individual members of staff to keep these updated.

The nursing assistants have been greatly involved with meals and patient hygiene.

Example

Process mapping to improve patient meals

|Information – 19/05/10 |

|Time meal times |Get a good picture of the mealtimes over a week | |

|Patient surveys |Need to ask BAM if they have any information |Some more serous incidents reported |

|Complaints |regarding this |occasionally but not helpful to this |

| |Perhaps we could add this to our own surveys, being |exercise |

| |specific about service to get the information we | |

| |want | |

|Incident reports |No incident reports on meals |Will keep a log of minor incidents to |

| |Is this something we should think about? |ensure that improvements can be made |

|Food wastage |Most days wastage is quite low |This is better as plates are coming already|

| | |allocated to patients so we are able to |

| | |give patients the portions they have |

| | |requested |

|Best guidance food nutrition |

|Safe practice serving / |Kitchen supervisor raised concerns that plates might|Discussed concerns with staff |

|storing food |be sitting out too long and not warm enough for |Staff feel that meals are served approx 20 |

| |safety |minutes faster so that staff are then free |

| | |to assist all that need assistance and |

| | |identify any problems much sooner |

| | |Plates and patients are less likely to sit |

| | |unattended |

|MUST |Ensure correct use of red plate, food charts |This will continue to be monitored |

|Protected mealtime policy |Need to prioritise staff mealtimes to provide best |Meal times now to begin at 11:45 16:00 |

| |cover for patients |breakfast unchanged |

|Care plans / choices |n/a reports may help with identifying who requires |New reports not started by will be |

| |help and make every one more aware |introduced soon and monitored thereafter |

|Communication |Need to improve / coordinate discussions re RTC |Meeting arranged with preliminary flow |

| |module |chart drawn up and introduced |

| |No continuity at present, no real comparisons, no | |

| |real decisions | |

Too many suggestions not enough action.

Need to establish a co-ordinated routine to create a standard process.

Then try a flowchart to prepare patients and serve meals.

Suggest that senior staff may need to be more involved in this process to provide leadership and continuity.

• Keep communication flowing

• To ensure that action is taken and maintained

• To help establish a routine

19/05/2010

Progress now being made, important to continue with that communication is maintained between staff to ensure that the system is being monitored, improved and maintained.

[pic]

Meals Algorithm

Meals flow chart

Clear patients trolley tables of obstructions prior to meals

Clear corridors of obstruction

Assist mobile patients to table / dining area

Ensure bed patients are prepared for meals

Enforce protected mealtimes

Cutlery, salt & pepper is on table and patients room by domestic

A designated nurse to co-ordinate for patients who need assistance

Trolley arrives in ward

Meals arrive with patients names on them

Patients who need assistance, meals will be staggered

Designated nurse will check all patients’ progress

On completion of meals staff will check patients dietary intake and document if required

Patient’s menus

All menu cards will be completed prior to meals

Patients arriving on ward menu card will be sent to kitchen ASAP

|Challenges |Staff suggestions |Actions |

|Not enough staff at time to provide |Changing staff mealtime |Testing both these suggestions with a mealtime |

|assistance with feeding |Staggering assisted plates from |co-ordinator to improve communication |

| |start of mealtime | |

|Patients not prepared for dinner |Changing staff meal time to allow |Same as above |

|taking staff away to assist |for preparation prior to mealtime |Unable to carry this suggestion forward due to |

|preparation |If meals could be on a tray for |lack of resources |

| |easier distribution | |

|Rooms and tables not clean or set for |Again better prep prior to meals |As above |

|meals |Tables were in poor state and |New tables easier cleaned and prepared |

| |difficult to clean | |

|Unpredictable situations arising at |Senior staff could help out more |Senior staff aware that a situation has occurred |

|mealtimes that take staff away from |when required |Nursing staff to assist meals at end of medicine |

|serving meals | |round |

|Red plates food charts difficult to |All staff to be aware of red plates |Mealtime co-ordinator will collect information |

|keep tabs on |and feed back to |from staff to complete monitoring |

|Meals not ordered for patients who |Try to ensure that menu choices are |Could be part of the improved admission module |

|have been admitted |made on admission | |

|Disorganised at time |Flow chart may be helpful |Complete improvements and introduce chart |

|Meal distribution reviewed 13/07/10 |Patients with dementia / confusion |Meals served at tables will be served in |

| |getting mixed up with courses |individual courses |

| | |Meals served in rooms will be assessed |

| | |individually to determine if appropriate to serve |

| | |all courses together |

Releasing Time to Care

Time saved collecting items from store cupboard within Ward A

Evidence is required to highlight the significant saving which impacts on direct patient care.

At present is takes 3 minutes to walk from one end of the ward to the other to collect items from the store cupboard which is required for direct patient care.

To access another area which could be utilised as storage space takes 30 seconds.

Cost to convert the cupboard - £600

A nurse tracking her movements visited the existing store area approximately 40 times during a 12 hour shift. (See diagram)

Converted store cupboard would impact on the patient care time saved as follows:

| | | |

|Period of Time 12hour shift |Time saved |Time saved |

| |Minutes |Hours |

|Day |120 | 2 |

|Week |840 |14 |

|Month |25200 |420 |

|Year |302400 |5040 |

| | | |

The results are based on tracking movement and completing a waste walk.

Therefore the amount of time saved would be the equivalent to 420 shifts per year.

5040 hours saving per year for direct patient care.

This is calculated on an approximation as staff and patient’s needs vary on a day to day basis, however it is clear that the converted cupboard at a cost of £600 would still save time and money to deliver direct patient care.

3 minutes

30 seconds

[pic]

Waste Walk completed by Allison Wood, RTC Facilitator

Releasing Time to Care – Admission / Discharge Process

We have completed this module by identifying some of the main problems within the ward associated with the admission / discharge process in order to improve these services.

We did this by looking at each process individually and asking all staff to identify any problems.

We also compiled a questionnaire for both the admission and discharge process and these were completed by patients.

All information was gathered together and solutions to the problems were discussed with staff.

To ensure that these services are improved a 10 point check list will be completed at intervals and an audit tool was compiled and will be completed every 4 weeks.

Releasing Time to Care – Admission Process

|Problem |Aim |Action |

|Care plans |All relevant care plans to be completed |New patient profile booklet to be |

| |on admission and planned with patient |implemented in ward, care to be discussed |

| | |with patient |

|Property disclaimer |Property disclaimer to be signed |Admitting nurse to get patient to sign |

| | |property disclaimer if possible |

|Transfers |Patients transferred to have transfer |Nurse taking handover for patients being |

| |letter and letter for GP |transferred to ask for transfer letter, |

| |Warfarin / insulin to be prescribed for |Doctors letter and Warfarin / insulin to |

| |day of transfer |be prescribed prior to transfer |

|Staff unclear about admissions / |Admissions / transfers to be clear |Patient status at a glance board now in |

|transfers | |use making admissions / transfer clear |

|Estimated discharge date (EDD) |Estimated discharge date to be given by |Nurse to ask GP for estimated discharge |

| |GP on admission |date on admission and to be documented |

Releasing Time to Care – Discharge Process

|Problem |Aim |Action |

|Discharge process |All discharge sheets to be completed |Discharge sheets commenced on admission |

| | |GP to give estimated discharge date |

| | |All trained staff to complete |

|Transport issues |Correct transport arranged for discharge |Patients to be assessed by nurse |

| | |arranging discharge for 1 man or 2 man |

| | |ambulance taking into consideration, |

| | |steps etc at home, consider relatives |

| | |taking belongings and zimmer home |

|Discharge prescriptions |Discharge prescriptions to be delivered to|Dr Watt discharges to be arranged for pm |

| |ward in time for discharge |to allow time for prescription to be |

| | |delivered to ward |

| | |Medications to be checked with patient |

| | |and copies distributed appropriately |

| | |All GP practices to be delivered to ward |

| | |and medications to be checked |

|Estimated discharge date (EDD) |Patients to be discharge within estimated |Reasons why to be given if not within |

| |discharge date |estimated discharge date |

|Filing |Notes to be filed appropriately |Dr Watt patients, nursing notes should be|

| | |filed into notes |

| | |GP patients nursing notes should be filed|

| | |in cabinet and GP notes returned to |

| | |practices |

Releasing Time to Care – Syringe Drivers

We carry out these nursing procedures to ensure that the administration and preparation of drugs given via syringe driver is completed effectively and accurately ensuring safe patient care.

|Problem |Aim |Action |

|Disruptions during preparation |To reduce interruptions |Close treatment room door wear purple |

| | |aprons |

|Ensure all equipment is clean and in |To provide working syringe drivers |Regular checks of equipment |

|working order | | |

|Ensure all staff are up to date and |To ensure all staff are trained in |Attending appropriate study days / yearly |

|competent in use of syringe drivers |preparing syringe drivers |updates within unit |

|Ordering the correct medication and |To ensure adequate medication and |Cupboard to be checked regularly and be |

|dilutent for syringe preparation |dilutent available |restocked when required |

|Medical Kardex and syringe chart not |To ensure medication Kardex and syringe |To ensure GP has prescribed medication on |

|completed or filled in correctly |chart prescribe correctly |Kardex and completed syringe chart |

| | |appropriately. Hourly checks by nursing |

| | |staff |

|Lighting within room not appropriate for |To provide effective lighting |To ensure bedside lights are in working |

|checking hourly | |order. Report on safety brief |

Releasing Time to Care – Wound Management

We carry out these procedures to provide a safe and effective management in the healing of all wounds to provide optimum care for patients.

|Problem |Aim |Action |

|Fragile areas being treated |Early detection and information passed on to |Care plan and treatment regime |

|conservatively for inappropriate time |appropriate nurses |completed and reviewed on |

|before care plan put in place | |appropriate time scale |

|Different nurses changing treatment to |To ensure same treatment carried out for |Ensure nursing staff follow care |

|same wound management |appropriate time scale |plans avoiding inappropriate |

| | |changes. Advice from link nurse |

|Delay in referring to specialist nurses |Early referral to tissue viability nurses |Follow advice given by tissue |

| | |viability nurse on wound care |

|Inappropriate wound dressings |Attend study days for wound management and |Discuss with ward manager quality |

| |dressing care. Discuss care with link nurse |and cost of product and their |

| | |effectiveness |

|Satisfactory Waterlow scores may still be|Use observation to assess along with numerical|Provide pressure relieving equipment|

|at risk of pressure wounds |scores | |

|Irregular dressing changes |Ensure documentation is completed and record |Document in handover sheet and pass |

| |when dressings due changed |on at report |

Releasing Time to Care – Obtaining Specimens

We carry out these procedures for diagnostic information to allow GPs to prescribe appropriate treatment.

|Problems identified |Suggested solution |Action taken |

|Inadequate or insufficient information|Ensure all personal details are documented in |Staff made aware of correct information |

|on forms |patients profile for staff to refer to | |

| |Highlight information required to staff completing | |

| |forms | |

|Incorrect blood bottles put out |Make sure poster for correct bottles is visible |Poster is on wall and on blood trolley |

| | |Ensure staff check |

|Not having MRSA packs made up |Have a pack made up for each empty bed ready for |Packs now made up prior to admission |

| |admission | |

|Not passed on that MRSA screen has |Complete form in patient profile |This procedure has now been adopted |

|been carried out |Document on handover | |

|Results not followed up |Document on handover sheet when results are available|Staff made aware of importance of keeping |

| |Ensure GPs are informed of results as soon as |username and passwords up to date |

| |possible |Results checked daily |

|Investigation sheet not being |New documentation stating investigation and result |Ensure all staff use same documentation |

|completed | |Speak to ward sister about new documentation |

|Patient removing bedpan when sample is|Ensure patient is aware a specimen is needed and |Staff and patient aware of the need to recover |

|required |explain why |specimen |

| |Encourage and assist patient to use toilet | |

Improving patient safety and reliability

Example

Releasing Time to Care – Medicine Module

|Issues identified |Causes |Actions |

|Interruptions |Drugs not on trolley |Trolley will be cleaned and restocked each night |

| | |Stock should be replaced from ward stock or |

| | |emergency drug room |

| | |Any drugs not available will be ordered from |

| | |pharmacy, message left in trolley to confirm |

|Interruption |Patients asking for assistance |Patients advised to use buzzer for nurse |

| | |assistance to ensure nurse administering drugs is |

| | |not interrupted |

|Interruption |Other staff |Staff administering drugs will trial purple aprons|

| | |All staff aware not to disturb staff when wearing |

| | |purple aprons |

| | |Notices on display to alert external staff and |

| | |visitors |

| | |Another allocated staff member will hold all keys |

| | |while medicine round ongoing |

|Interruption |Phone calls / enquiries |Staff administering drugs will not take calls |

| | |during this time |

| | |Nursing assistants or other staff will take |

| | |message or advise best time to call |

| | |Currently trying to review ward information |

| | |leaflet to advise best times to phone and visit |

| | | |

|Interruption |No glass / drink available in room |Discussed with house keeping staff, water jugs |

| | |will not be removed from rooms until medicine |

| | |round completed |

Questionnaires were distributed to all involved in medicine administration. Interruptions (various causes) were identified as a major issue.

Staff agreed to trial use of purple aprons:

• Information leaflets provided for patients and relatives

• Posters put in place to inform all staff

• Staff wear purple aprons during medicine round

• Interruptions documented for audit purposes

Comparison

|Before | |After |

|Time taken |45 minutes | |Time taken |55 minutes |

|Number of patients |12 | |Number of patients |12 |

|Interruptions |15 | |Number of interruptions |6 |

4 – Drugs not available on trolley

1 – Nurse asked for keys

2 – No water available in room

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Conclusion

Although the second round appeared to take longer, nurse experience and the number of drugs administered may have contributed to this.

Overall the number of interruptions was greatly reduced by using purple aprons and thereby reducing the risk of drug errors. This would also demonstrate that more time was spent on direct patient care.

Nursing staff generally felt that the purple aprons were of benefit and will continue to reinforce their use in conjunction with the other changes.

Improvements will be monitored by regular audit.

CQI’S

Majority of reports been showing compliance of 95% or above for a consecutive 4 months or more.

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Measures Board

[pic]

Improving Patient Experience You Said / We Did

[pic]

Example of patient feedback board

Patient Quotes

Staff are very friendly.

Meals are very enjoyable.

This ward is a goldmine.

Friendliness of staff care received was excellent.

Could not ask for anything better or ask for better nurses

Complaints

No complaints from April 2009 – March 2010 recorded from commencement of RTC in January 2010

Processes to improve direct Care Time

On commencement of the Releasing Time to Care programme,

Having carried out activity follows our direct care time was 26%.

As a team we have used other tools to evidence utilising our time more effectively and introducing small changes within the ward environment

E.g. utilising disposable medicines cups rather than plastic which has saved:

10 minutes per medicine round

40 minutes per shift

280 minutes per week

We are now in the process of revisiting the activity follow to ascertain the amount of direct patient care delivered, with these small adaptations in place.

Staff PDP/Clinical Supervision

There is a clinical supervision policy in use within Ayrshire and Arran, at present this has not been rolled out in all areas. Training to commence in January 2011.

PDP compliance within Ward 2 is 100% at present.

Staff Feedback on Releasing Time to Care

Staff have been keen to become involved with Releasing time to care.

They have put a lot of time and effort into making it work within the clinical area, however due to the lack of funding for the conversion of the store cupboard it has been noted that some staff are disillusioned with the project.

|Releasing Time to Care |Ward: |

|Staff Questionnaire |Designation: |

|  |  |

|1. Has Well Organised Ward helped in your daily work? |100% |

|2. Has Patient Status at a Glance board made it easier to access patient information? |60% |

|3. Has the patient feedback board Knowing How We Are Doing affected how you deliver |60% |

|care? | |

|4. Have you found the patient feedback a positive experience? |60% |

|5. Has the introduction of Releasing Time to Care made handover/ reports less time |20% |

|consuming? | |

|6. Have the reports given a more accurate account of the patient care to be delivered?|100% |

|7. Overall have you found your involvement in RTC to be a good experience? |60% |

|8. Do you feel you are delivering more direct patient care? |20% |

|9. Would you recommend RTC to colleagues working in other areas? |60% |

|Overall data for Ward 2 |60% |

Staff Comments on RTC

|Releasing Time to Care |Staff Comments |

|Staff Questionnaire | |

|  |  |

|1. Has Well Organised Ward helped in your daily work? |Helpful that equipment can be found ready for |

| |use .Organised cupboards mean supplies are |

| |easily found |

|2. Has Patient Status at a Glance board made it easier to access patient information? |Easy to access information without reading |

| |through notes |

|3. Has the patient feedback board Knowing How We Are Doing affected how you deliver |This can vary due to workload |

|care? | |

|4. Have you found the patient feedback a positive experience? |Better to know quickly about any problems |

|5. Has the introduction of Releasing Time to Care made handover/ reports less time |Has not saved time but the introduction of |

|consuming? |reports for Nursing assistants has improved |

| |the service |

|6. Have the reports given a more accurate account of the patient care to be delivered?|This can vary due to workload |

|7. Overall have you found your involvement in RTC to be a good experience? |Due to daily workload I had less input |

|8. Do you feel you are delivering more direct patient care? |I would still like more time to provide hands |

| |on care |

|9. Would you recommend RTC to colleagues working in other areas? |I still don't know |

| |Not sure how it will impact in the long term |

| | |

Conclusion

To date Ward 2 is carrying out more activity follows to demonstrate to staff the true effect of RTC and the direct patient care time. We are also utilising the productive community toolkit to further make sustainable change within the clinical area.

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