Greater Manchester Mental Health Foundation Trust Best Care Every Day: Perfect Week Events
The Healthier Patient Pathways Transformation Programme was introduced in June 2021 to deliver improved systems, approaches and outcomes in relation to GMMH capacity, bed management and patient flow. Five workstreams were identified to drive a reduction in Out-of-Area (OAP) patients, improve ward efficiency and to identify a standardised way of working across the Trust.
Under the first Workstream- Best Care Everyday, Perfect Week events launched in June and concluded in September. The Perfect Week aims to deliver a gold standard patient experience by focusing on quality and patient flow. The underpinning principle of the Perfect Week is that every minute of a patient’s life is precious. By providing best care every day, timely resolution of challenges and optimising staff skills and time, the key outcomes are to improve patient flow, create bed capacity and ultimately reduce OAPs and length of stay.
A 3 week analysis was completed across different areas of the Trust, mainly focusing on the Patient Flow Service’s ability to control patient movement, whilst also monitoring key care indicators in the patient journey that add to an effective and efficient ward. Meridian identified a potential improvement across the services which will see the length of stay reduce by up to 20% and additional resources (inc. bank & agency) be reduced, for equivalent volumes. This would result in the achievement of the zero reportable out of area placement target, as well as potentially a further reduction in some of the contracted acute bed capacity. Expressed in financial terms, this equates to a minimum annualised value of £1,885,000(spot purchased bed capacity 2020-’21), but by adding improvements in PICU and some of the contracted acute beds, more likely close to £4 million–the weekly minimum improvement value is projected at £36,250 after the points of installation.
- Reduction in the Waiting List Initiatives
- A matching of demand with capacity resulting in the reduction of PAs required for the current demand
- Greater management control
- A refined booking process
- Management devolved to the correct levels using specifically developed KPIs.
Each Division participated in two planning workshops prior to the actual Perfect Week that outlined the programme goals, the Bronze, Silver and Gold approach to escalation with each division identifying a lead who would support flow via established escalation routes.
Key tools such as the Sit-Rep and the Discharge Countdown Tool, assisting with the review of the front door pressure, allocation and escalation of actions and review of barriers to discharge were agreed. During the workshops colleagues were introduced to the Lean Approach and participated in the identification of key change ideas from pre-admission to discharge, to be taken forward during the Perfect Week using QI methodology.
Senior leaders and clinical colleagues from both inpatient, urgent care and community services, alongside key stakeholders such as Commissioners, colleagues from Acute Hospitals, Adult Social Care and other local services participated in the planning workshops and daily Bronze, Silver and Gold meetings. The approach and progress of the Perfect Week was also reviewed at weekly Lead Consultant meetings. The overarching programme goals of the Perfect Week:
Specific discharge targets were set for each Division, with a vision to have zero reportable OAPs during the perfect week and an attempt to repatriate OAPs wherever possible depending on bed capacity. The baseline period for setting a weekly discharge target was February- April 2021, taking into account the average weekly CCG Admissions for each locality (including OAPs) and adding 5% on top (introducing a stretch target) for each Division to cater for optimal flow:
Although Central Manchester did not have a specific bed base leading to the Perfect Week, it was agreed in consultation with the Heads of Operations to split Park House wards to North and Central Manchester.
The Improve patient experience, ensuring that each day is value adding for the patient Improve staff wellbeing and motivation Create sustainable flow across our inpatient units Reduce Length of Stay and deliver 0 Out of Area Placements (OAPs) by the end of Sept 21 3 above targets for North and Central Manchester were calculated on bed base. Following completion of their Perfect Week, discharge targets were re-set based on admissions by GP postcode.
During the Perfect Week Divisions were monitoring the following key metrics relating to Patient Flow:
During the planning events, colleagues were invited to think about the perfect ‘Gold Standard’ patient experience that provides maximum patient support and significantly enhances patient flow and identify key change that could make a difference. Under four working groups (first contact, admission to inpatient ward, inpatient care episode and discharge pathway) a total of 42 changes ideas were generated across all Divisions.
Most of the ideas were tested during the Perfect Week following a Plan-So-Study-Act cycle approach and certain ideas requiring longer term planning were saved for consideration in the future. Key themes from the change ideas were:
In order to replicate the benefits of escalation procedures through the Bronze, Silver, Gold Meetings, an Escalation Process Flowchart was created to be tested by Divisions following the completion of the Perfect Week.
The purpose of the flowchart is to provide a structure escalation process to ensure that any barriers are addressed promptly, avoiding unnecessary delays. Following the completion of Perfect Week events, a ‘Change Package’ based on the key themes has been developed and will be introduced to all Divisions for monitoring and implementation via weekly Sustainment meetings. Furthermore, as part of the Care Process Excellence Workstream, key change ideas are incorporated in the Admission, Treatment and Discharge Standards following consultation with front line staff, clinicians and senior leaders.
Following the completion of all the ‘Perfect Week’ events, the responsibility for patient flow is now allocated to the Divisions, allowing the Patient Flow Service to plan more proactively. There is a greater focus on determining value adding actions such as utilising the Discharge Countdown Tool to improve the knowledge of patient barriers.
The ‘Daily/Weekly Operating Report’ measures the variance in discharge performance of all Divisions against the agreed target with the goal of creating capacity. A bi-weekly meeting with the Heads of Operations chaired by Associate Directors allow for effective follow up on the rationale behind variances and support is offered where needed.
The table below demonstrates performance against the baseline and discharge targets for each Division:
Improvements were also noted on A&E conversion rates during the Perfect Week compared to the week before, highlighting that joint working during the Perfect Week facilitated identifying least restrictive alternatives to admission:
In regards to Length of Stay (Discharged) a comparison is made between the baseline period (Feb-Apr 21) and the last three months (Jun-Aug 21). Although the data below mainly suggest a decrease in Length of Stay, it is expected that for the next few months, monthly averages will increase as a result of discharging patients with extensive Length of Stay:
Key achievements for each Division are outlined below:
The Perfect Week was an excellent opportunity to strengthen system wide collaboration and highlighted that every minute of a patient’s journey from point of admission should add value towards a safe and timely discharge. It also emphasised the requirement for shared responsibility regarding patient flow and the importance of understanding admission pressures and increased focus on finding the least restrictive alternatives to admission. Furthermore, the Trust has developed a Perfect Week formula for sustaining and delivering patient flow going forwards. Divisions reflected on their Perfect Week and key learnings are summarised below:
Divisions were asked to gather feedback from patient, carer and staff perspective on the Perfect Week. Below are some quotes taken from the Patient Service User Feedback Surveys, but also from direct conversations with our patients and carers:
GMMH staff found the overall experience very productive and rewarding; teamwork, collaboration with external partners, overcoming barriers and working on solutions were some of the key highlights. Some staff also voiced their confusion about what was expected of them prior to the Perfect Week events and the need for more time to plan ahead.
Positive feedback was also received from our wider partners:
Sustaining the changes implemented during the Perfect Week events has been a key priority from the beginning of this programme and one of the biggest challenges. Sustaining positive outcomes from the Perfect Week will also be supported from work undertaken through the other HPP Workstreams. Following the NHS Sustainability Model, work around the 10 factors relating to process, staff and organisational issues is under continuous development. A consultation session with Trust Innovation Group from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, an exemplar leader in QI in Mental Health, supported the use of the NHS Sustainability Model in order to sustain and spread positive changes.
The Sustainability Model, suggests closely working with the following 10 factors in order to sustain change:
Sustaining the changes implemented during the Perfect Week events has been a key priority from the beginning of this programme and one of the biggest challenges. Sustaining positive outcomes from the Perfect Week will also be supported from work undertaken through the other HPP Workstreams. Following the NHS Sustainability Model, work around the 10 factors relating to process, staff and organisational issues is under continuous development. A consultation session with Trust Innovation Group from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, an exemplar leader in QI in Mental Health, supported the use of the NHS Sustainability Model in order to sustain and spread positive changes. The Sustainability Model, suggests closely working with the following 10 factors in order to sustain change:
The Perfect Week provided an opportunity to trial new ideas and also learn about the challenges that affect patient flow. It also demonstrated how bringing people together and engaging with the wider system can achieve great things. An overall increase of 26.8% on discharges against the baseline period and an 83% reduction on reportable OAPs was achieved across the Trust. Sustainability is key in maintaining positive changes on patient flow and Divisions are closely collaborating with the Healthier Patient Pathways Group, Business Intelligence and IM&T in order to provide a robust framework for continuation of successful outcomes.
The GMMH COVID Recovery Board are asked to note the outcome of this very successful project, and support, where required the next steps, associated with sustaining the gains from the GMMH Perfect Week and outcomes and potential development of further ‘mini perfect events’ that help to sustain patient flow, excellence in care and support and further the Trust’s improvement.