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Clinical-Management Pairing & Enhancing the Elective Caesarean Section List Neil Davies & Okiemute Emanuwa, Medway Foundation Trust Background The challenges of management clinician relationships are well documented. There is increasing evidence that improved doctor/manager relationships are associated with successful service improvement and superior patient outcomes. Lord Darzi’s 2008 Next Stage Review, underlines the need for partnerships in clinical and non-clinical leadership to enable quality improvement. In 2011, as part of a wider clinical leadership programme, the Kent Surrey and Sussex (KSS) Deanery and the NHS Management Training Scheme launched a pilot project to develop leadership skills of early career doctors and non-clinical management. This initiative paired graduate management trainees with Foundation Year 2 (FY2) doctor to undertake a joint project that will further their learning of leadership skills. Objectives: •Support understanding in respective value to the •Realising benefits of collaboration and role modelling organisation; within their organisations; •Achieving specific learning objectives around •Encourage collaborative learning at early stage in leadership and management; career; Approach Elective Caesarean Section Sessions at Medway NHS FT Stakeholders Project Drivers FY2 Doctor Interest/ experience/ skills/ relationships Management Graduate Clinical Area Anaesthetics 1.Process mapping concurrent processes Specific Issue At Medway Maritime Hospital, a service improvement focus Start Time interest and experience. Obstetricians Anecdotal evidence from staff indicated unnecessary Patient safety issues/ inefficiencies/ staff morale Theatre staff & practitioners Obstetric Theatres was identified in Obstetric Theatres as an area of mutual Obstetric Theatres Medway Maritime Hospital Midwifery Phase 1 2. Stakeholder mapping 3. Facilitate a ‘bottom-up’ approach Nursing staff variation and delay in session start-up time for elective KSS and NHS Institute Phase 2 caesarean sections. Help improve elective C-section sessions Obstetrics)theatres:)barriers)to)starting)Elective)sessions)on)time) Dear colleague, Communication & We’re a small team looking at how we can ensure elective sessions start on time in a safe and reliable way. We are currently looking at 2 ways to measure this: Patient in theatre at 08.45am & Patient ready for procedure (Anaesthesia complete) at 9am. The sessions are often late in starting for a variety of reasons. In tackling this issue together with the teams across the delivery suite, this project will: · Engagement · · · · Measure start times daily and discussing with the teams to understand why we start late Identify those critical barriers to starting on time Work as a team to address those issues Feedback to the Trust about external factors to gain support for changes Ensure we can support the planning and preparation on the day of surgery and before As the December Team of the Month award shows, the wider trust recognises the great work going on in Obs Theatres and wider maternity services. Your experiences and opinions are vital to its ongoing success. Qualitative & Quantitative Analysis and Results We would be grateful if you could take the time to consider what factors you think prevent sessions starting on time. We are very interested to hear your constructive suggestions for improvement. Attached is a simple form that can be emailed back to us, or printed and posted back to “Neil Davies, PMO, Level 1”. It is important that this work takes into account the opinions and feedback of all colleagues within your teams. We are always very happy to hear your ideas or thoughts and don’t hesitate to get in touch. We will be working up in the delivery suite throughout the week, so please come over, say hello and tell us what you think. Between September and December 2011: Quantifying the issue Data Collection The mean delay in session start of key stakeholders; time for elective caesarean section Self report questionnaires across service area; lists was 38 minutes per day. Best wishes, Neil Davies (ext 8939), [email protected]) Dr Kiemu Emanuwa ([email protected]) Structured interviews Name (optional)…………………………… Issues% affecting% ability% to% start% lists% on%time% % Obs%&%Gynae% related% issues% Details% Date:…………………….. Ideas% /% Proposals% % Hospital% related,% but% external%to% Obs%&%Gynae% % Personal% issues,% e.g.% other% commitments,% contractual% issues,% etc.% % Any% other% issues% Please&email&to&[email protected],&or&post&to&“Neil% Davies,% PMO,% Level% 1”.!! Prospective survey and “5 Whys” analysis of late starts. Resource equivalent of 1300 nursing hours in one year. Session procedure distribution and Delay in session start time, Sept to Dec Consistent delay in start up & large variation in procedure/turn around times Causes of delay Identifying the problem Initial prospective study indicated prima Causes of delays: All Procedures Waiting for surgeon facie predominantly Waiting for midwife due to availability of Diagnostic required midwives Patient complications delays and 14 12 10 8 6 4 2 0 120% 100% 80% 60% 40% 20% 0% obstetricians at session Causes for delay: Surgeon delay root Causes for delay: Midwife delay cause as attending multiple medical productivity and quality improvement projects have been launched (e.g. cell salvage, scheduling), complementing work on session start up time. staff, particularly Organic Change engagement strategy, has led to a wider focus in the service area. A number of additional patients, and difficulties for Continuous evaluation and improvement Monitoring improvement, development of toolkit to handover to permanent staff. performance. The initial analysis, along with the cross-professional stakeholder midwives to Recommendations formalised Disseminated trough communication channels, primarily at multiple small group meetings The joint clinical-management involvement has already contributed to improved analysis revealed issues such Phase 3 Conclusions start up. Further Analysis and consultation with key stakeholders The ‘bottom-up’ approach to communication and data collection has increased awareness around of delays across all professional groups, challenging cultural norms and coinciding with an afternoon cover. initial improvement in start up times. Elective Obs Procedure timings Apr-May 2011 19:00 18:30 18:00 17:30 17:00 16:30 16:00 15:30 15:00 14:30 14:00 13:30 13:00 12:30 12:00 11:30 11:00 10:30 10:00 09:30 09:00 08:30 Time arrived Patient Arrival Time Anaesthetic application Operation time 10-May-12 09-May-12 08-May-12 07-May-12 06-May-12 05-May-12 04-May-12 03-May-12 02-May-12 30-Apr-12 01-May-12 29-Apr-12 28-Apr-12 27-Apr-12 26-Apr-12 25-Apr-12 24-Apr-12 23-Apr-12 22-Apr-12 21-Apr-12 20-Apr-12 19-Apr-12 18-Apr-12 17-Apr-12 16-Apr-12 15-Apr-12 14-Apr-12 13-Apr-12 12-Apr-12 11-Apr-12 10-Apr-12 09-Apr-12 08-Apr-12 07-Apr-12 06-Apr-12 05-Apr-12 04-Apr-12 03-Apr-12 02-Apr-12 08:00 Time to exit theatre Session procedure distribution April-May 2012; comparative statistical process chart Sept 11 & Apr 12 April/May performance data evidences a small incremental improvement in delay reduction (8min knife to skin) and less variation in procedure distribution. Change can be in part attributed to increased focus on session start up through communication and engagement of theatre staff. Delivering Continuous Improvement •Disseminate and display results & raise awareness of pathways and timings •Continue engagement of key stakeholders and deliver further service recommendations. •Maintain prospective data collection, finalise toolkit for handover to enable continuous improvement. • Extending management-doctor pairing relationships across the trust through audit partnerships.