Royal Bolton Hospital introduced “patient gateways” to improve its respiratory pathway, with great success. Brian Bradley and colleagues explain how they did it.

Royal Bolton Hospital Foundation Trust has one of the busiest emergency departments in the North West. At times the urgent care surge of activity is difficult to cope with safely and in a timely manner. This has a significant impact on patient outcomes and staff morale.

In early 2009 a detailed analysis of the urgent care demand found that:

  • 6 per cent of all patients attending the emergency department are respiratory related;
  • 78 per cent of respiratory related hospital spells are emergencies;
  • 21 per cent of all deaths in Bolton are related to respiratory disease.

Using this analysis as a basis and with a significant desire among clinical leaders in the respiratory department to improve care, it was decided to focus improvement efforts on this key pathway “value stream” as an essential part of the urgent care transformation drive.

When this initiative began, the respiratory service was considered locally to be a good service but it still faced many challenges. These included excess mortality (a hospital standardised mortality ratio of 118), excess length of stay (average length of stay was 8.9 days), a readmission rate of 9.5 per cent, problems with inconsistent quality of care and relatively low morale.

The service included:

  • two inpatient wards;
  • specialist nurses for asthma, chronic obstructive pulmonary disease, lung cancer, tuberculosis and long term oxygen therapy;
  • nurse led clinics;
  • pulmonary rehab;
  • hospital at home service;
  • outpatient services;
  • teaching commitments for medical students.

The trust has been pioneering the use of lean in healthcare since 2005 through the Bolton Improving Care System. It has had significant success, particularly across the respiratory pathway.

This time, we liaised with ThedaCare Health in Wisconsin in the US over the “one decision flow” method, which is linked to lean principles for improving care. These are now known locally as patient gateways.

Patient gateways is an all-encompassing concept associated with agreed time out for the team to monitor and progress patient care and treatment to ensure a safe and timely discharge. The underpinning principle of patient gateways is one decision flow, which means having the right team members and the right information present at the right time to add value to the patient’s journey. They do this by making decisions as a team, agreeing and assigning actions and in this way reducing delays in the patient journey.

Understanding value

When the initiative began the respiratory service functioned in a traditional way. Four out of the five consultants could all have ward rounds on the same day. This batching of workload led to pressure on wards for both junior medical and nursing staff and resulted in waste such as:

  • management plans not being fully carried out from one ward round to next;
  • some investigations being missed or delayed;
  • low staff morale affecting working relationships.

Working in such traditional ways also meant patients were only seen on ward round days. This approach was less patient focused, often leading to lack of continuity in care, and at times extended periods where new patients were not seen by a consultant for up to four days. The result was dissatisfaction from both patients and staff.

The focus of the work was to support high quality safe care, leading to improved patient flow through reduced length of stay, reduced mortality and contributing to improved flow in the emergency department.

Frank discussions and engagement work with the lead respiratory consultant before the work began identified that the team would be taking a risk in the development and implementation of the patient gateways concept, as there was no guarantee of its success.

Over the next 18 months, current ways of working and practices were examined in detail, using lean tools such as mapping, activity analysis, Ohno’s circle (for observing processes), and staff discussions.

The open and secure environment gave staff the opportunity to challenge in a supportive way, and remove waste and unnecessary steps that did not add value. This helped to develop an improvement culture.

The team was supported by committed clinical leaders: Michaela Bowden, respiratory nurse specialist; Sue Hart, matron; and consultants Brian Bradley and David Allen, who supported the development of standard work for the respiratory services, removing variation, duplication, delays and error by implementing the key features of a “lean cell” (see diagram, top of page).

Key features of the cell are 6S (sort, scrub, straighten, safety, standardise and sustain), visual management, flow, pull and standard work.

The team leaders promoted honest and at times difficult discussions, always bringing the team back to their prime purpose – the patient. This significantly increased multidisciplinary working. This was done using the lean process of Nemawashi (preparing the way for an idea), rapid improvement events and rapid experiments and allowed the much needed time for teams to work through their concerns and issues to gain consensus.

The initial 12 months focused on the two inpatient wards and the implementation of patient gateways created enthusiasm for further improvements.

By April 2010, improvement work was continuing with the specialist nurses as they developed their lean cells in order to improve flow in their work and patient care. Outpatient redesign is in progress as is model lifespan pathway collaborative work with GPs.

Improvements on trial

During and after rapid improvement events, improvement actions were trialled via a series of rapid experiments and then fully implemented. Changes included:

  • all consultants’ job plans reworked and agreed allowing the implementation of daily senior review;
  • dedicated consultants per ward for a two week period, with full implementation on both wards in September 2009;
  • daily morning ward rounds;
  • daily multidisciplinary board rounds – leading to “one decision flow”;
  • recently introduced 4pm board round on Fridays for decisions regarding weekend discharges;
  • specialist nurses moved from traditional disease based allocation to seeing all respiratory patients across the organisation, helping to implement the lean concept of “pull” for respiratory patients;
  • specialist nurses moved to providing a seven day service.

The outcomes of this work have included step change results in mortality, length of stay (see graph, top of page), throughput and staff involvement and patient satisfaction. From a safety perspective this is significant, the standardised mortality rate has reduced from 118 to 91, and actual deaths fell by 10-20 per cent.

The need to escalate patients to higher level intensive care unit care from the respiratory inpatient wards has reduced by 34 per cent, helping the ICU reduce its bed occupancy to ensure that facilities are always safe and available to those in need via the emergency department.

The focus on one decision flow has had a huge impact on errors, delays in discharge paperwork, therapy assessments and prescriptions. Action following changing patient observations has significantly reduced.

The nursing and junior doctor teams on the wards have changed the way they work on the ward, for example medication rounds take place at different times of the day, it is clear every day who is doing what to ensure a decision to act is taken and the patient moves on in their journey without delay.

The reduction in delayed decisions, together with a redesigned respiratory specialist nursing service, has reduced both the variation and duration of length of stay from 8.9 to 6.9 days, allowing the teams to see over 25 per cent more patients per year and reducing their need to out-lie patients on other wards to zero.

Together with similar work in other specialties, this has contributed to the trust gradually reconfiguring its bed stock and move out of a dispersed old ward area on the site. At the same time readmissions also fell from 9.5 per cent to 8.5 per cent. 

Patients were involved in all the improvement activity. One commented: “I have been a patient here for the past 30 years, care has always been good. But the changes now on the ward are marvellous, you see a consultant every day, you know what is going on, and can action things sooner if necessary.”

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Royal Bolton improving care system