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Improvement and Transformation
Process Improvement
TTO and Discharge Summary Process Review
Nick Holding
Head of Improvement and Transformation
Summary
• Overall TTO lead time reduced by 67% (3hours)
• Patient TTO delays reduced by on average 10 hours per day (1 ward)
• Potential release of approx. 300 hours per day of bed usage time, across inpatient areas (USC & SC)
• Earlier discharge time
• Care Groups identified TTO and Discharge Summary
process as area of focus, following Breaking the Cycle week
• Ward 27 identified as pilot area
• Collected real time current state data
• Working with operational teams, ran a number of improvement events to test ideas using PDSA cycles over 3 months
Improvement and Transformation
What is the problem we are trying to solve?
Improvement & Transformation Team formed to focus on a key improvement for the Trust
Breaking the Cycle week identified TTOs and Discharge Summary as priority
Identified Ward 27 (RSH) as pilot ward to test ideas and experiments
Ward and Pharmacy teams fully engaged as key stakeholders
6 month project timescale to carry out deep understanding of current state, and using PDSA cycles, identify potential new ways of working
Aim to reduce turnaround time of TTO by half
Improvement and Transformation
“We believe that a high number of discharges are delayed due to the process of producing TTOs and discharge summaries”
Improvement Methodology
Provide current state information to stakeholders
Ideas for improvement generated by teams
Scientific method used to prove or disprove hypothesis
Using Plan, Do , Study, Act (PDSA) cycles, experiment and measure improvement activity
Review, adapt and retest ideas
Encourage continuous improvement through many small local changes
Support teams to make improvement by providing advice, guidance and facilitative resource
Start small, think big
Improvement and Transformation
Project Plan and Timeline
Improvement and Transformation
Milestone
Activity
Communications and Engagement
Impacts on project
Phase 1 – Current state understanding
Phase 2 – Report findings and identify opportunities for improvement. Test ideas using first PDSA cycle
Phase 3 – Review experiments and plan for follow up based on findings
Phase 4 – Test follow up experiments to identify all improvement opportunities
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NovemberOctoberSeptemberAugust December January
Complete process follows and direct
observations1
Complete systems data capture for process analysis 2
Analyse all data and measurements 3
Create Current State Value Stream Map
Sense check with
stakeholders
Prepare first Kaizen Event including identifying
activity
Kaizen Event #1 4
Report baseline findings
Analyse data and measurements from
Kaizen #15
Prepare 2nd Kaizen Event including next steps activity (PDSA)
Report PDSA cycle findings
Kaizen Event #2 6
Final report and recommendations
8
Week 1 ALT,
Seattle
Week 2 ALTALT Coursework & Team Training
Supporting KPO Lead, and early value stream work
Supporting USC Urgent Care Recovery Projects
Analyse data and measurements from
Kaizen #27
Feedback PDSA cycle findings
to stakeholders
1:1 updates with stakeholders, patient representative etc. Develop links and networks. Comms messages
Improvement and Transformation
01:27 01:0000:4901:10
Total average time taken to process patient’s TTO
=266 minutes
4.4 hours
The time between the
patient being
medically fit for
discharge & TTO
requested
Time between TTO
requested &
preparation started in
pharmacy
Time between
preparation completed
& prescription ready in
pharmacy
Time between
prescription ready in
pharmacy & arriving
on ward
Source. Sema, eScript, Pharmacy dept docs & direct observation
• Followed process over 2 week period • Tracked 50 patients journeys • Average total process (TTO turnaround) lead time =
4hrs 40 mins
What is the current state?
Current State Value Stream Map
Improvement and Transformation
Summary
4 main areas where delays occur 1. Ordering TTOs
a. Multiple information hand-offs between staff b. Batching of work
2. TTOs waiting to be picked a. Impacted by Out Patient prescriptions b. Ward priorities based on reactive urgency
3. Delivery of TTOs to ward a. 3 methods of delivery used b. Slowest method used in most cases c. Delivery system designed to be efficient for us, not patient d. Up to 3 hour delay for delivery (if last on list and just missed
delivery run)
4. Discharge Summary production a. Collation b. Completion c. Printing/Sign-off
Improvement and Transformation
Focus Areas
Ordering TTOs – Multiple handoffs of information and batching often
results in delays to producing TTO order.
– Currently, Pharmacist resource is shared between wards
– Some anecdotal information suggested that high number of TTOs were for meds which patient were already on. This has been tested and it applies approx. 10% of TTOs
Improvement and Transformation
01:27 01:0000:4901:10
Total average time taken to process patient’s TTO
=266 minutes
4.4 hours
Focus Areas
TTOs waiting to be picked – TTO order displayed on Pharmacy order screen waiting
to be picked
– Prioritised over other ward drug orders (non-TTO)
– Outpatients prescriptions prioritised inpatients
Improvement and Transformation
01:27 01:0000:4901:10
Total average time taken to process patient’s TTO
=266 minutes
4.4 hours
morning afternoon
Outpatient activity highest in
morning, affecting ability to provide
inpatient TTOs early
Focus Areas
Delivery of TTOs to ward – Slowest method used most often (courier)
– Delivery system designed to be efficient for us, not patient
– Up to 3 hour delay for delivery
(if last on list and just
missed delivery run)
– Findings show that at
times meds on ward,
but staff aren’t aware
Improvement and Transformation
Results
Mean turnaround time reduced from 4hr 40mins to 1hr 33mins Reduction of 3hrs per patient 67% reduction
100 patient journeys measured Improvements and ideas generated and tested by those who do the work
TTO Turnaround Times
Improvement and Transformation
Tested Pharmacist
effect on Ward Round
‘Runner’ used to
deliver TTO to wards
Re-tested previous actions
Introduced 2 productions
lines (OPD and Inpatient) into
Pharmacy
Individual patients
1hr 33mins
4hr 40mins
Source. Sema, eScript, Pharmacy dept docs & direct observation
Baseline (pre-Kaizen) 1st Kaizen Event 2nd Kaizen Event
Mean turnaround time
Improvement and Transformation
Where the gains were made
Pharmacist presence on ward round each day
Additional benefits identified Supports improvement in MDT
involvement at Ward Round More responsive to medication
queries and reviews
OPD prescriptions often impact of production of inpatient TTO
2 production lines established to focus on OPD and inpatients separately
Stimulated process improvement within dispensary
Assistant Technical Officer (‘runner’) established to support real time delivery of medication to ward
Established consistent drop off point on ward
Updated PSAG to show TTO on ward
66% reduction
80% reduction
75% reduction
1hr 27mins
29mins
1hr 10mins
19mins
60mins
14mins
Source. Sema, eScript, Pharmacy dept docs & direct observation
Kaizen Plan
Improvement and Transformation
Improvement opportunities which have been overcome by experiments, identified by teams
Kaizen Plan shows improvement activity
Takes current state
value stream map and highlights what has been achieved
Shows which
opportunities remain for further activity
Future state map
generated from this
Future State Value Stream Map
Improvement and Transformation
Lead time down from 293 mins to 115 mins
Process value
adding time increased from 6% to 17%
Much of process is
back office, therefore non-value adding to patient
However, is
necessary non-value adding activity
Other Qualitative observations
Ward Improved communication between doctors, nurses and
pharmacists
Immediate response to queries between teams
Less time spent by nurses looking for TTO on ward
Ward clerk spending less time chasing TTO (phone calls)
Ward staff not needing to collect TTO from Pharmacy
PSAG TTO flag update gave reporting and tracking capability
Pharmacy Pharmacists contribution to ward round, capturing issues
early and responding to changes
Less phone calls into Pharmacy chasing TTO
Reduced queues for Outpatient prescriptions
Dispensary teams engaged in process improvement and workplace reorganisation
‘Runner’ provided tracking system to enable improvements in TTO location
Improvement and Transformation
Benefits realisation Quality Patients not waiting in hospital unnecessarily, enabling them to get home earlier
Reduced risks associated with being in hospital
Bed utilisation improved leading to better quality of care for patients who need admitting
Service Reduced delays in discharge by 3 hours per patient
Release of approx. 300 hours per day of bed usage time, across inpatient areas (USC & SC)
Improve compliance with earlier discharge time (pre 1pm from 9% up to 19%)
Additional 3 patient (on test ward) discharged daily before 1pm
Workforce Assignment of tasks to appropriate roles releases staff time in other areas
Staff satisfaction improved as delays to patients are reduced
Job satisfaction regarding delivery of pharmacy dispensary service
Cost Potential reduced overtime spend in pharmacy dispensary
Potential reduction in ED breaches
Improvement and Transformation
Recommendations These recommendations are mainly for RSH where the project was based, however some will apply to PRH
Short term Introduce Assistant Technical Officer (‘Runner’) into Pharmacy with clear job specification
Establish and maintain 2 (possibly 3) production streams in pharmacy dispensing
Establish daily management of non-urgent prescriptions in pharmacy dispensing
Re-establish co-ordinator role within pharmacy dispensing to oversee process flow
Train additional ‘checkers’ to improve ratios in dispensary, avoiding bottleneck
Ensure all C.O.Ws are operational and in use on Ward Rounds
Medium Term Review allocation of ward based Pharmacists to support daily ward round attendance
Carry out 5s review of dispensary work area to improve process flow
Encourage culture of continuous improvement by supporting dispensary teams to make changes to work area and process
Review frequency of nurse presence on Ward Rounds
Longer Term Establish satellite pharmacy in Chemotherapy Day Unit to support improvements in supply
Carry out full analysis of daily demand against resource allocation. Establish daily and hourly Takt time, and allocate resource accordingly
Improvement and Transformation