Planning advice April 2015 National Breaking the Cycle Initiative

Background to the Week Social movement is crucial, it starts with: 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 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 re- calibrate the system

The compelling story

  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   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. If you had 1000 days left to live how many would you chose to spend in hospital? The compelling story - continued

Hospital is NOT a place of safety for people who are medically stable Dr Richard Genever - Chesterfield Royal Hospital NHS Foundation Trust

MondayTuesday WedsThursdayFridaySaturdaySunday Midnight Midday 3-day LOS difference between 9am and 9pm admissions The compelling story – continued - time of admission is important Source – NW Resource Utilisation Management Team 2014

4-day LOS difference between 9am and 9pm admissions Age >75 years The compelling story – continued - time of admission is important more so for older patients Source – NW Resource Utilisation Management Team 2014

Commitments for the week – why are we doing this ? 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 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? 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 A control room is needed in each trust to help co-ordinate and over see the week ECIST can help – call or 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.

Silver Command Front line teams and Ward Liaison officers can ask for instant support to help resolve problems in real time Local Structure – how does it work? Dr Richard Genever - Chesterfield Royal Hospital NHS Foundation Trust

Examples of measures you could use 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…. 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 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 – if you have a query that isn’t covered, you can and someone will contact you directly