Nick Hulme, Director of Operations

Helen Crick, Emergency Services Programme Manager

Jeremy Tozer, General Manager for Radiology Services

Claire O’Brien, Head of Admissions and Discharge

To ensure ‘no patient stays in hospital one night longer than they have to’; From Nov 2003 to Sept 2004, to increase the percentage of patients being turned around within 4 hours in Accident & Emergency (A&E), to improve access to CT scanning from a range of 2 hours to 8 days, to same day, and to reduce the LOS of emergency medical patients by one day.

• To increase  the percentage of patients being turned around within 4 hours from 85 percent  to 96 percent
• To improve access to CT scanning for Inpatients from average of 11 days for routine inpatients to same day, or next morning if non urgent referral after 8pm 
• To decrease the average LOS by 1 day

• Implemented streaming in A&E, creating minor and major steam on attendance, and providing a see and treat model, with dedicated workforce to maintain flow of minor patients
• Trialed ‘pit stop’ model for majors patients, ensuring rapid assessment within 30 mins of patients’ arrival, to facilitate decision to discharge or treat.  This is facilitated by senior member of the medical team
• Trialed surgical navigator in A&E, to quickly assess surgical attendees, and provide specialist opinion to surgeons
• Re-organised orthopedic ward flow, providing an immediate trauma ward, an elective ward, and rehab area, to facilitate flow of patients, providing appropriate skills to patients
• Trialed a new role of patient pathway co-coordinator
• Implemented pathology protocols to ensure only appropriate tests are requested and performed
• Produced escalation policy to alert senior team members and request support, if patients are nearing 4 hours in the A&E department
• Developed and implemented role of CT helper
• Developed in house IV training for IV administration for radiographers
• Separated room used for IV cannulation to ensure
• Insertion of cannula’s for administration of IV contrast by radiographers rather than radiologists
• IV contrast administered by radiologists rather than radiographers
• Changed rota’s and matched staff capacity to demand in emergency pathway
• Changed working patterns to enable radiologist available to report on scan up to 8pm
• Future planning to develop radiology workforce by training radiology assistants to cannulate
• Implementation of PACS and voice recognition in Nov 2004 to facilitate speedier diagnostic testing in the emergency pathway 
• Trialed care coordinator role in ward environment
• Developed multi-disciplinary training to enhance discharge skills and developing roles and responsibilities towards patients
• Provided patients with estimated date of discharge
• Provided patients and carers with information about generic patient journey
• Changed focus of bed management staff from beds, to whole system capacity management, including personnel resources for departments, on a daily basis
• Developed electronic decision tree to identify acute and sub acute patients in the care of the elderly pathway to ensure patients are receiving the right care in the right place at the right time by the right person

• Once is never enough!
• Use PDSA methodology to encourage staff to trial something that would otherwise appear unmanageable
• Be flexible – change often doesn’t go to plan
• Communication is key to everything!
• Involve all stakeholders
• Discover the real problems with process mapping – this is a real eye opener for staff who often just understand their part in the process, mapping helps people appreciate the whole system
• Ensure buy in from key people with responsibility and accountability, i.e. the manager of the department, this is crucial to ensuring new processes and ways of working are integrated into the day to day working and ensure sustainability
• Use the skills and knowledge of other staff within the trust
• Collate appropriate information to enable progress to be monitored and shared

Sarah Johnston, Head of Service Improvement, Ashford and St
Peters NHS Trust
sarah.johnston@asph.nhs.uk

[Storyboard presentation at IHI's National Forum, December 2004]