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In August 2012, we reviewed our elective surgery admission process for Children from a child’s perspective. This was a huge project involving managers, consultants, anesthetists, nurses, ward team, operating theater team etc. There were several work streams and team leading on various aspects of the project.

Project Details:

”I am having an operation!” – A child’s eye view to improve our Paediatric surgical inpatient pathway

 Summary:

We took the child’s perspective of the steps in our surgical inpatient pathway, from “Decision to admit” in clinic, through treatment to discharge. We engaged with stakeholders and gathered patient/parent feedback to guide improvements. Opportunities for realigning pathways to benefit the child, operational processes and systems were identified along with strengthening team working. Pilot implementation was trialled in a week-long hands-on event. Solutions were monitored and evaluated, modified where necessary and then rolled out across children’s inpatient elective surgery. Now our patients/parents get much better information, benefit from more nursing care and go home much sooner while our staff are happier.

Project Background:

The key reason and evidence for initiating the work came from listening to the children and their parents as they travelled through their care journey. By identifying all the key unnecessary steps and delays as perceived by the child and strengthening the added value moments such as increased time with their individual nurses and doctors the programme organically took root.

Additionally, an architectural redesign project for the Children’s Services is underway, destined for realisation in 2015, and we were keen to ensure that the new building would be designed to best suit the needs of children and parents.

Analysis of admission and discharge times indicated delays at both ends of the process for parents/ patients, and length of stay data compounded these findings to stimulate the need for generating a sense of urgency with staff in executing these parts of the process. This analysis combined with patient/staff feedback immediately catalysed our staff to quickly come together and agree to improve this service for the benefit of our patients and their parents.

Project Aims:

The overarching aim of the project was distilled by the team into a rallying cry of – “no delays, zero harm, every time!” and this drove the team forwards during the project. The instilling the mantra of putting ourselves in the place of the child meant we consistently took the patient’s perspective as the project progressed.

Our Aims were both quantifiable and qualitative. Both types of change would be measured as closely as possible to demonstrate the impact of the project as the changes took effect.

Output measures included average discharge times occurring earlier in the day, contributing to an overall reduction in length of stay for patients. In addition, organisational and process issues led to patients being cancelled on the day of surgery, and this was a key focus for improvement.

Qualitative measures included the patient experience in using the pathway, rendered quantitative by means of effecting a reduction of patient/parent complaints related to this service. Staff experience of delivering the pathway should be positively influenced, measured through means of a specific staff satisfaction survey centred on this process. We also aimed to improve services by releasing nurses’ time to care.

Our key focus was to declare our ambition to the parents and explain the improvements that were expected at each step of the patient’s journey so that enhanced clinical pathway became a contract between the family and the team providing all aspects of care.

Process:

St George’s Healthcare NHS Trust and GE Healthcare Performance Solutions formed a partnership to methodically drive this project forward.

We created a project team to guide this project through to fruition, with senior representation from management, nursing and surgical functions which produced a clear project charter including the scope, methodology, metrics and team requirements.

Stakeholder interviews were conducted with staff delivering the pathway and surveys of patients/parents and staff and data analyses were carried out to establish baseline levels prior to implementation of changes. Staff were trained in waste elimination and rapid change management, attended a two day workshop to explore the pathway, its issues, opportunities and created an agreed action plan with timescales and responsibilities for implementation.

All staff got a chance to air their views, solve problems and develop new approaches. Staff were released from core responsibilities for five days to enable the implementation of the improvements, to monitor their effectiveness and adapt the solutions as necessary.

Through the process of training the large multi speciality staff cohort turned into a true cross speciality team who believed that they could, would and did overcome all boundaries.

The impacts of these improvements were recorded by staff, and presentations of progress made to executives, including our CEO and stakeholders from across the Trust, both at the end of the initial five implementation days, and then after 30, 60 and 90 days.

Our approach

 Over a three month period, we;

  • immediately formed a true cross specialty team that engaged with stakeholders across staff groups, gathered patient/parent feedback and system data to guide improvements
  • Trained the team in rapid improvement methodologies
  • Held a two day workshop to identify waste and opportunities to realign the pathway to benefit the child and meet current demands.
  • Released staff from core responsibilities for five days to implement actions
  • Tracked improvements through data analysis to sustain these for the future

Outcomes:

The main outcomes are directly related to the original aims of the project – children wait less, spend more time with their nurse and go home sooner.

Number of patients who get a date of surgery on the day of their outpatient appointment or the day after increased from 42% to 82%, reducing parental anxiety

  • Changes in pre-op assessment reduced costs by over £550 per month
  • 30% reduction in average length of stay, from 85 hours to 58 hours
  • 18% more elective patients treated per week
  • Aligned teams and functions to common goals in children’s surgery, leading to closer cooperation and improved team-working

Ultimately, this project has aligned multiple teams and staff groups with a common set of goals in children’s surgery and has led to closer cooperation and improved team-working across surgical specialties. Problems arising are being resolved at a more local level in a more timely fashion, and those appropriate for escalation are being raised and addressed earlier. Front line staff now have the confidence to proactively address known issues and rapidly improve these for the benefit of our patients.