Since a 2009 report identified an rise in death rates on the day new doctors start work, the duel issues of training and induction that affect both new and senior staff have come under close scrutiny. Anne Mawson and Lucy Reynolds explain how a University Hospitals Coventry and Warwickshire Trust programme has moved to address them.
The concept of a NHS “Black Wednesday” is now familiar to many staff, largely due to a controversial 2009 report - Early In-Hospital Mortality following Trainee Doctors’ First Day at Work - which identified an average 6 per cent increase in death rates on the first Wednesday in August every year – the day freshly qualified junior doctors arrive, en masse, on the wards.
The report reviewed data from 175 hospital trusts between 2000 and 2008 and, while it avoided pinning blame for the increased death rate directly on junior doctors, it highlighted a very real challenge for trusts – that of ensuring consistent patient safety and service delivery, in the face of mass staff changeover.
In addition to the headline issue of patient deaths, National Policy drivers also put onus on trusts to deliver rigorous induction training for their junior doctors, as part of obligatory NHS Litigation Authority standards.
Internally, trusts are also under pressure to coordinate induction across the hospital system, not only to ensure that junior doctors feel welcome and supported when they start, but also to enable other staff, such as senior nurses, to prepare for the increased demand on their own time and skills that inevitably occurs during changeover periods.
In response, University Hospitals of Coventry and Warwick Trust began its doctor in training review programme in late 2009, with the aim of improving induction and training processes for junior doctors in time for the August 2010 changeover.
Not only did this programme aim to sustain patient flow and safety during change-over, it also, for the first time, put the junior doctor at the centre of the change process.
Traditionally junior doctors have to repeat the same induction checks and processes for every four month rotation. UHCW’s work aims to standardise these processes, to avoid unnecessary process repetition, whilst building junior doctor confidence to treat and discharge patients.
The IMPaCT programme (improve, motivate, participate and create transformation) is one of the trust’s key vehicles to improve the quality and efficiency of the services it delivers through process and system redesign and cultural transformation.
Its overall aim is; “To meet the health needs of our patients by providing high quality, cost effective and efficient healthcare services, delivered by appropriately trained, skilled, motivated and happy staff.”
Its specific objectives are to:
- Add value to the healthcare experience for patients through improved patient safety and access;
- Optimise the efficiency, productivity and utilisation of resources to increase revenue, profitability and sustainable financial stability;
- Develop an effective and empowered workforce.
The programme adopts a variety of methodologies to realise its aims and objectives however, the fundamental philosophy on which the programme is built is that of lean working.
An important aspect of the programme is to facilitate a change in the overall culture of the organisation to one of continuous improvement where delivering improved high quality clinical services to our patients is regarded as an integral part of unlocking efficiency and productivity gains.
As part of this lean approach, UHCW’s doctor in training review programme has been developed, under the joint directorship of associate medical director Mair Edmunds and associate director of HR Donna Howard. This joint leadership reflects the crucial role that non-clinical staff, such as HR or IT staff, play in assuring patient quality and safety, by generating efficient hospital systems. Executive sponsorship was also provided by Ian Crich, chief human resources officer.
The engagement process
The first step in UHCW’s journey was to identify the current state with regard to junior doctor induction, and then to map out specific issues and improvement opportunities that would enable the trust to move towards a desired “future state”.
Lean mapping workshops were set up in October and November 2009, to bring all departments and teams involved in the changeover together, to review existing processes and focus on how the trust could make improvements.
Workshop attendees included the trust’s head of medical staffing, medical education manager, occupational health nurse and administration specialist, estates admin manager, switchboard manager, payroll manager and ICT support analyst, again reflecting the vital role of non-clinicians in achieving patient quality and safety.
The process of value stream mapping identified a wide number of issues within the system, such as: inaccuracy of contact details being captured; confusion around who leads on departmental induction, and whether different departments duplicate training content; uncertainty about the required content of e-induction and of mandatory and induction training; lack of synchronisation between different parts of the induction system.
In order to align the improvement process around common goals, these issues were categorised into specific programme objectives, so that the generalised ambition to improve junior doctor induction and training became reframed around five core concepts:
- Information sharing: between those departments involved in pre-employment and induction processes for junior doctors;
- Communications: better communication both between departments, and with junior doctors before induction;
- Induction: reviewing and improving trust induction, department induction and mandatory training provision for junior doctors
- Clinical safety: ensuring clinical and professional on-the-job training;
- Operational working: ensuring correct levels of staffing support are in place.
A detailed action plan was then developed for each theme and the following changes were implemented in time for the August 2010 induction process, resulting in the improvements outlined below.
Theme 1: Information sharing
To improve information sharing between departments, a shared drive was set up, enabling all involved in the pre-employment or induction process to access one centralised set of information.
This shared drive ensured that all departments had timely and consistent access to information during pre-employment checks (e.g. Criminal Record Bureau and occupational health checks).
Theme 2: Communications
To ensure consistency of communication, one new, standardised starter form was developed and sent to all new starters. In addition, starter information was loaded onto a shared drive in advance of the changeover period, to allow car parking passes, occupational health clearance, log-in and systems access to be set up in advance of day one in the trust.
This approach to pre-loading information and issuing consistent communication forms ensured that from over 200 new starters, over two days of induction, less than 30 were classified as “rapid starters” (compared to over 100 on a traditional intake).
A rapid starter is somebody who requires all the usual pre-induction processes (e.g. IT access) to be undertaken on the day of induction. Before induction is complete, the new registrant cannot access clinical systems to request tests or review results, and cannot access wards (without their security badge), which is a big issue if they are carrying the arrest bleep. By ensuring full induction before day one, these service bottlenecks were significantly reduced.
Theme 3: Induction
Significant changes to the induction process were made. The pre-employment checking process was streamlined, by reducing it to one process instead of 20, and by moving as many of the induction processes as possible prior to the actual start date. Information sharing reduced the amount of correspondence the doctors were receiving in advance of day one, and for the first time welcome packs were given out at induction. These packs contained car parking permits where required, and ICT network and pre-loaded systems access details. The coordination of induction processes prior to day one also meant that only 65 identity-card photos had to be taken on the day in 2010, compared with over 200 in 2009.
A new localised bleep distribution system was also implemented, with ownership being taken within individual specialties. This provided assurance that all new junior doctors had bleeps from day one. In addition, the return of bleep registers to switchboard ensured that an accurate list of bleep allocations could be maintained and overseen.
UHCW’s e-Induction system was also re-launched, to incorporate several additional theoretical aspects of mandatory training content. A strong result was seen in this area, with 94 per cent of new starters fully or partially completing phase 1 of e-induction prior to actual induction, and thus allowing utilisation of clinical systems from day one on the ward.
In addition to those completing phase 1 of e-induction, an additional 17.8 per cent fully completed and 80.9 per cent partially completed phase 2 e-induction. Importantly, the re-development of the e-induction system also enabled UHCW to deliver and record mandatory training for doctors, independent of their start date on the wards, and thus to meet NHS Litigation Authority requirements.
One further modification was developed with regard to specialty inductions. For the first time, induction content was reviewed for each specialty, to avoid duplication or gaps, and dedicated specialty induction leads were identified. This meant that new starters were collected from the clinical sciences building (where induction training takes place) by the specialty lead, and enabled a register of speciality induction to be kept, with starters’ attendance being recorded on the OLM system.
Theme 4 & 5: Patient safety and operational working
For the first time, information and communications technology floorwalkers were introduced in August 2010, providing practical, on-hand help to junior doctors if they were experiencing IT difficulties. In terms of patient safety and flow, this significantly improved practice.
Research shows that discharge rates typically decline following change over, as junior doctors tend towards admitting patients, rather than discharging them. Consultation in UHCW identified that this was often due to IT-related issues, as much as lack of confidence in diagnosis skills. At UHCW, discharge is done electronically. This means that if a junior doctor has made a decision to discharge, but is unable to navigate the IT system, the patient will still be admitted. By enabling responsive IT support, patient flow and discharge can be maintained.
In addition, patient safety information was provided at induction and throughout the e-induction process, so that all new starters were informed of key safety agendas. For instance, Hospital at Night is a dedicated programme designed to ensure consistent levels of support are provided out-of-hours (typically, staff shortages are experienced during weekend and evening shifts). A system has been introduced at UHCW, to ensure that any jobs that come in overnight are allocated to the appropriate staff ensuring optimum efficiency when it is most needed.
For instance, rather than junior doctors being tasked with taking bloods, this is now allocated to nursing staff, freeing up valuable junior doctor hours. In August, all new starters were made aware of this system, so that they understood how it worked, and could ensure smooth transition from day one.
The changes implemented for August 2010 helped to streamline the rotation and induction process for junior doctors, minimising the impact of such a large scale changeover on the operational working of the trust. In August 2009, the hospital virtually came to a stand still during change over, as new junior doctors, lacking confidence in assessing and discharging patients, generated high numbers of admissions, blocking patient through-flow.
By marked contrast, trust data presented to UHCW’s executive management group shows that, in 2010 the number of medical and A&E discharges was sustained across August, with a significant increase in discharge volume also witnessed between the same period for 2010 and 2011 (see graph 1, attached).
In addition to sustaining patient flow, the trust also avoided a rise in mortality during August 2010, as well as avoiding the rise in ‘Medical and A&E Admissions with length of stay <72 hours’ that was seen in August 2008 and 2009 (see graph 2, attached).
UHCW’s success in stabilising length of stay, mortality and discharge rates during August 2010 all highlight that, by focusing the induction process on patient safety, and making it clinically-focused, patient flow can be successfully maintained during change over.
The review and evaluation work undertaken following the August 2010 induction has allowed further work streams to be identified, which are now undergoing development to enable the improvement process to continue:
With support from the ICT team, UHCW is developing a database allowing read and write access for clinical directors, educational leads and speciality induction leads. We have also developed a standard operating procedure, which provides a set of detailed written instructions to ensure induction and training are carried out uniformly across the trust, year upon year (in place since November).
Work is currently underway to gather feedback from doctors and other key stakeholders regarding additional areas for improvement. This communication process will be maintained, to ensure opportunities for further improvement are captured and acted upon.
A process is being developed to enable training completion statistics to be communicated to clinical directors and speciality induction leads. All new junior doctors have to complete mandatory training. Under the new system, once they have done so, a report will be sent to the clinical director, showing whether the junior doctor has or hasn’t completed the required training, and how they scored. This will enable performance monitoring and management of new junior doctors on a very personalised level, enabling specific issues to be escalated or addressed.
Work will also continue, to implement a training passport scheme, in conjunction with South Warwickshire Foundation Trust, and George Eliot Hospital Trust. At present, junior doctors have to repeat standardised national training courses each time they move between Trusts. To address this frustrating repetition, the training passport will show which training the junior doctor has already undertaken, so that he or she will not be required to repeat it after each rotation, with the exception of site-specific information.
In addition, the trust will continue to participate in the SHA’s wider induction programme development process, with the intention of creating a standardised induction package across all 44 West Midlands trusts. This will mean that junior doctors will be able to undertake induction once, at the beginning of rotation, and then will not be required to repeat it again.
Patient safety and operational working
Additional work is underway to ensure floorwalkers are available for all large junior doctor rotations (August, December, February and April) to support operational areas. This will ensure that junior doctors are able to access clinical systems easily, and will receive instant assistance if they have any IT-related problems.
In order to ensure the changes introduced in August are sustained and embedded in the longer term, a quarterly junior doctor review group has been set up. This group, which includes representatives of all departments involved in the pre-employment and induction processes for doctors in training, will ensure processes, procedures and systems continue to be adapted and improved based on a continual feedback loop.
UHCW has undergone a significant process of improvement since August 2009, and has generated learning along the way, which will enable other trusts to improve their junior doctor induction and training processes.
Key lessons from this process include:
1) Nominate a clinical and non-clinical lead to work in partnership:
This gave us access to a wide range of departments, and enabled us to gain multi-stakeholder buy in to the improvements required. It also generated understanding of current and ideal processes from a broad range of professional perspectives, highlighting the vital role contribution that non-clinicians make to patient quality and safety. The success of the junior doctors programme has led to further partnerships been clinical and non-clinical lead. For instance, the trust is currently undertaking a Medical Revalidation Programme, under the shared leadership of Donna Howard and divisional medical director Abdullah Shehu.
2) Develop a clear brief, and plan your approach:
We set out our strategy in a project initiation document, which was signed off through ELT and communicated through our executive briefing group. We then followed a planned methodology, which included lean techniques, clearly defined workstreams and regular reporting to the executive briefing group to ensure divisions were aware of project progress, and felt able to challenge practice across a number of areas over which they did not have direct line management.
It is recommended that a planned approach is adopted in relation to the identification, development, sign-off and tracking of projects of this nature. This will ensure key corporate projects are understood by all parties and are prioritised and coordinated to avoid overloading Divisions with a series of separate changes in a short period of time.
3) Keep stakeholders engaged and informed:
Since outcomes from this programme have impacted on all specialities and divisions, regular reports have been provided to the executive briefing group. In addition, separate communications have been sent to clinical directors and educations leads with updates about actions to be undertaken. Despite best efforts from the project leads, levels of engagement from different areas have been inconsistent, and have impacted on project delivery. It is therefore recommended that future projects of this nature have an allocated executive sponsor in order to ensure issues around lack of engagement can be tackled and resolved.