How to write an award-winning storyboard Dr Alan Willson

1. How to write an award-winning storyboard Dr Alan Willson

2. Purpose of NHS Wales Awards • Recognise achievement • Provide learning material to support the training and development of NHS staff • Stimulate and encourage an evaluative approach to implementing better ideas in service delivery

3. Model for Improvement

4. The Judging Criteria with examples from shortlisted storyboards

5. 1. Storyboard Title • Gynaecological Cancer Rehabilitation Scheme for the Prevention of Lymphoedema and Incontinence #86 Gynaecological Cancer Rehabilitation Scheme for the Prevention of Lymphoedema and Incontinence • Contact Card for Relatives Following Bereavement #149 Contact Card for Relatives Following Bereavement

6. 2. Brief Outline of Context • Where this improvement work was done • What sort of unit/department • Which staff/client groups were involved

7. 2. Brief Outline of Context • This community service for disabled children and their families is based in an NHS Trust Children’s Centre and brings together specialist social workers, local authority occupational therapy staff, a specialist teacher, care coordinators, community learning disability nurses, special school nurses and Diana nurses in an integrated team. #0031 Developing a Children’s Integrated Disability Service (CIDS) • A multi agency Task Team was established in 2000 to review historical Day Care Services provided at Cam Cyntaf Day Centre, Glanrhyd Hospital and Ty’r Ardd Social Care Day Centre in the community. The client groups included 170 individuals with severe and enduring mental health to those with mild to moderate mental health problems. #0152 Integrated mental Health Day Opportunities Service ` Continued

8. 2. Brief Outline of Context • AMBU Health Board is one of the largest in Wales employing around 300 midwives. It serves a population of 600,000 with an annual birth rate of about 6,380. The maternity services are based in 3 separate sites and midwives provide care in a variety of settings including consultant led units, midwife led birth centres, the community and home. #0114 Flexible Retirement – Everyone’s a Winner!

9. 3. Brief Outline of Problem • Statement of problem • How they set out to tackle it • How it affected patient/client care

10. 3. Brief Outline of Problem • Parent Education for pregnant women has traditionally been organised in weekly sessions. Before the 1990’s it was during the day and only for women. Midwives and Service Commissioners realised that the take-up for the session was not optimum and that with many women now working, holding the information programme in the day is not always convenient. The drop out rate becomes high as the sessions progress and continuity of midwife is not available depending on available rotas. Parent Education has since been offered for couples in six weekly evening sessions and is very popular, with demand outstripping supply, but again the drop out rate is high. #0160 Streamlining the Parent Education Programme – Bringing It into the 21st Century. Continued

11. 3. Brief Outline of Problem • Pressure Ulcers cost the National Health Service £2.4 Billion a year (Bennett et al 2004). Nice Guidelines have pointed out that Hospital audits have shown hospitals to range between 10%-14% incidence of hospital acquired Pressure Ulcers. Incidence rates within the Department have shown to be at 4.2%. Target for the 1000 Lives campaign was to reduce Pressure Ulcer Incidence by 50% per 1000 bed days. #0106 Pressure Ulcer Prevention – Zero Tolerance • The Sister and staff identified a problem in the provision of key services to patients around: Electrocardiograph (ECG); Phlebotomy; Podiatry and Therapies which was part time, nine to five, Monday to Friday, leaving a significant gap in care for patients, the rest of the time. The above was observed to significantly hamper patient’s progress and delay discharge from hospital. #0125 The Flexible and Sustainable Workforce

12. 4. Assessment of Problem and Analysis of its Causes • Quantified problem • Staff involvement • Assessment of the cause of the problem • Solutions/changes needed to make improvements

13. 4. Assessment of Problem and Analysis of its Causes • The group agreed to redo the audit by: • Developing an audit tool to record the patients body temperature through out the care pathway. • To ensure consistency only one method of recording temperature • Tympanic thermometers were the best method chosen by the team. This audit identified that the problem started when the patient was admitted to the Day Surgery unit, by the time they changed and walked to the anaesthetic room 77% patients arrived hypothermic and transferred to operating room hypothermic. Forced warm air blankets improved the patients body temperature, but they still remained hypothermic when transferred to recovery room 88% transferred from operating theatre to recovery were hypothermic. The audit identified that the impact of transferring patients from the ward to the anaesthetic room reflected on the outcome of the patient’s recovery and discharge home. #0008 Reducing Harm & Risks of Hypothermia to Surgical Patients Under General Anaesthetic Continued

14. 4. Assessment of Problem and Analysis of its Causes • We established that there were tremendous examples of positively evaluated work supporting the most vulnerable in the community. Their main limitations however were that: • They were too small to have a critical mass of resource to meet user need • They were too restrictive in terms of “exclusion criteria” to allow those in need to access them • They were too restrictive in terms of who could refer patients to the service • They were often age or disease discriminatory • Joined up working particularly with respect to integration with services providing personal care provision were missing • There was no clear line of horizontal accountability that crossed traditional barriers, rather each component was accountable in a vertical manner through different lines of management. The combined skill mix of the interagency partners was integral to crossing these barriers. A co-located integrated inter-disciplinary team sharing an electronic patient record that could cross the interfaces of primary, secondary and intermediate care were the principal components used to tackle these problems to enhance patient care and satisfaction. #0122 The C.E.L.T.I.C. Experience, An All-inclusive Seamless Intermediate Care Service Continued

15. 4. Assessment of Problem and Analysis of its Causes • According to The Department of Health (DoH) (2000) 6 million people in the United Kingdom suffer with urinary incontinence. The earlier local study highlighted the reluctance to seek help for incontinence and with the increasing number of referrals to the District Nursing service for incontinence assessment the idea of setting up a clinic was conceived. Discussions then followed between the District Nurse and Continence Advisor. The concept was presented to the head of District Nursing and to General Practitioners from two rural practices. The proposal was accepted and accommodation to run a clinic was secured at a GP Surgery. Plans were then drawn up to take the venture forward. #0084 Proactive Approach to Continence Care in a Rural Community • Up to 10% of patients are readmitted as emergencies within 3 months of their initial acute admission because of further stone formation or stone migration. In the UK, Metabolic assessment of urinary stone formers is rarely undertaken in the form of urine, blood and stone analysis to identify those at risk of recurrent stone disease despite this being part of the European and American Urological Guidelines. No other Urological Centre in Wales currently runs a metabolic stone clinic. #0077 The Metabolic Stone Clinic – Benchmark Prevention for High Risk Patients

16. 5. Strategy for Change • How the proposed change was implemented • Clear client or staff group described • Explain how they disseminated the results of analysis and plans for change to the groups involved with/affected by the planned change • Include a timetable for change

17. 5. Strategy for Change • The Practice News Letter and Health Promotion board displayed in the practice informed the practice population of problems associated with urinary incontinence and the ease of access to the clinic (March 2005). The GPs and practice staff were made aware that the clinic would commence in July 2005, held on a monthly basis and would accept male and female clients of any age group. Develop protocol and referral forms for the clinic by July 2005. Develop Audit Tool for use on an annual basis. Collate evidence to support effectiveness of the clinic. Disseminate experience and findings to colleagues at Carmarthenshire NHS Trust Professional Group Meetings. Attend and present annual report at the GP Professional Group meeting. #0084 Proactive Approach to Continence Care in a Rural Community

18. 5. Strategy for Change • Formation of steering group consisting of Consultants, GPs, nurse advisors, modernisation manager, Nurse directors from Trust and LHB and patient representatives [2005/6]. • Appointment of chronic disease co-ordinator and 8 specialist nurses, 1 physiotherapist & 2 administrators[January 2006] • Co-ordination of “top up”, clinical assessment skills training for specialist nurses [March 2006] • Personalised visits to Carmarthenshire GP surgeries, secondary care medical and elderly care teams, A&E, medical admission units, CCU/intensive care teams, district nursing teams and newly appointed admission avoidance teams/services; informing them of the chronic disease service [June 2006] • Identify link nurses in each GP surgery [October 2006]. • Baseline review of medical emergency admission rates and QoF data [2005/2006] • Update needs analysis regarding current service and training needs in primary and secondary care [October 06- Mar 07] • Produce evidence based diagnostic and treatment algorithms [June 2006] • Update Heart failure and Diabetic components of Carmarthenshire CHD & Diabetic “tool kits”, designed to facilitate standardised management for CHD and Diabetic patients throughout Carmarthenshire [November 2007]. • Introduction of “Heart Save” heart failure training course [2006/7] • Introduction of “XPERT” diabetic patient training course [2006/7] • Development & introduction of integrated COPD care pathway [2006/7] • Introduction of “COPD” telehealth pilot [2007/8] • Develop standardised clerking and communication documentation for the service [January 2008] • Establish patient focus groups to evaluate and inform service development [November 2007] • Develop & test service satisfaction questionnaires #0146 “Chronic Disease - Continuums of Care” Continued

19. 5. Strategy for Change • Medical staff are often resistant to change which is dictated to them but will often support change when there is strong evidence of it’s benefit or previous personal involvement with critical incidents. Nursing and Operating Department Practitioners are heavily influenced by medical leadership so it was essential to have medical support in all areas. • Time was spent talking to all members of the teams in small groups and answering the queries before we embarked on implementation. Each consultant was also sent written information at least a week prior to implementation. After a month’s pilot (using the model for improvement and small steps of change) with the introduction of the checklist in Llandough Hospital, we made minor changes and moved on to main theatres at UHW starting the checklist in a new theatre each week. We started with the most enthusiastic teams and then rolled out rapidly in order to get round all the theatres. We planned to have the checklist in place in all surgical theatres by August 2009 and to use the final six months to improve compliance and focus on poor performing areas. • During the first six months other specialities such as radiology, podiatry, dermatology and cardiology were contacted and encouraged to alter the checklist for their clinical use but maintain the core standards set out by the NPSA. Their ownership is important for sustainability of the project. #0174 World Health Organisation (WHO) Surgical Safety Checklist – A Successful Strategy for Implementation

20. 6. Measurement of improvement • Details of how the effects of the planned changes were measured

21. 6. Measurement of improvement • Client evaluations, capturing both quantitative and qualitative information are completed. • Standardized outcome measures are used pre and post intervention (SF36). • Formal research is currently being undertaken by Cardiff University to understand the effectiveness of the Programme • Jobcentre Plus “tracking” of clients to measure return to work outcomes (30% return to work) • Postal survey to 500 discharged clients to measure customer satisfaction (25% response rate to date) • NLIAH Case Study of the effectiveness of the CMP Partnership Steering Group • The cost effectiveness of delivering the course compared to ‘one to one’ interventions has been analysed. • Article published in OT News (October 2008) #0132 Positive Partnership Working: The NHS and Jobcentre Plus Working Together to Support Citizens living with Long Term Conditions to Return to Work. Continued

22. 6. Measurement of improvement • Collated a directory of each GP link nurse, outlining their method of systematic GP follow up • Medical emergency admission rates from the Trust and QoF data from each GP surgery was provided monthly to the LHB, and compared quarterly against the previous years data • Staff questionnaires issued to primary and secondary care, ascertained their local management and training needs • Evaluation questionnaire regarding the education programmes • Patient focus groups and user satisfaction questionnaires • Comparatives of quality of life scores [Minnesota QoL questionnaire] • Comparatives in application of evidence based prescribing • Referral waiting times for diagnostic echocardiograms #0146 “Chronic Disease - Continuums of Care”

23. 7. Effects of Changes • Statement of the effects of the change • How far these changes resolve the problem that triggered the work • How this improved patient/client care • The problems encountered with the process of changes or with the changes

24. 7. Effects of Changes • Our first months data showed a compliance of between 60-70% and four months later this data has improved to approximately 90% compliance at UHW main theatres. • Llandough Hospital data was not as good with as low as 15% compliance initially but after focusing on the problem of surgical engagement this improved to approximately 80% four months later. • Data for completion for all emergency procedures was not as good, initially only achieving approximately 50% compliance initially. This has improved but we need to focus on emergencies that are undertaken outside the designated CEPOD theatre (theatre 7). #0174 World Health Organisation (WHO) Surgical Safety Checklist – A Successful Strategy for Implementation Continued

25. 7. Effects of Changes • Results from the trial of using the Forced warm air gowns. On admission 60% patients arrived hypothermic and forced warm air gowns were immediately applied. All patients transferred from the day Surgery were normothermic and the temperature was maintained until the patient was fully recovered and discharged. This had an impact on the outcome of the patient’s recovery: • Length of stay reduced in recovery • Analgesia – reduced to oral on the ward • Reduced readmissions (improving pain control, nausea etc) • Discharge time reduced from 8pm to 2pm • Patient satisfaction – (10 day post operative phone call.) • Infection control – single use • Easy access to limbs- Velcro • The group agreed that the best way forward was to introduce across Powys operating theatre, no cloth gowns are used for any patients under going surgery. We are continuously auditing to ensure that patient temperature is maintained. We may have had a saving of £240 per month, but most important we reduced harm and saved lives. #0008 Reducing Harm & Risks of Hypothermia to Surgical Patients Under General Anaesthetic

26. 8. Lessons learnt • Statement of lessons learnt from the work • What would be done differently next time

27. 8. Lessons learnt • The team has met certain challenges along their journey, which with determination and robust planning these were overcome. • These have included staff shortages, but through innovative planning all areas were able to send their staff for education and training. • There is no doubt that a recognised forum that met regularly to make decisions was important. • Being able to accept failures, address them and move on was also essential in maintaining the momentum of change. • Start small but aim big. • Capture the enthusiasm of the frontline staff as well as the patients and their carers. There is no better way of improving morale than through successful initiatives driven by the staff themselves. #0106 Pressure Ulcer Prevention – Zero Tolerance Continued

28. 8. Lessons learnt • Strong involvement and support from the MDT is essential. • Patients have numerous appointments during a cancer diagnosis, try to coordinate with other members of the team or check appointments on the IPM system. • Not all suspected gynaecology cancers are actually diagnosed with cancer, 27% enrolled on the scheme were eventually cancer free. This decreased activity is enabling the service to embark on a skin cancer lymphoedema prevention scheme as well. • Increasing capacity demands on the lymphoedema service the 6 week scheme could be condensed into one morning or afternoon session. • With the Welsh Assembly Government Lymphoedema Strategy being published in December 2009 and prevention being one of the key aims this scheme could be replicated throughout Wales. #86 Gynaecological Cancer Rehabilitation Scheme for the Prevention of Lymphoedema and Incontinence

29. 9. Message for Others • Statement of the main message they would like to convey to others, based on the experience described

30. 9. Message for Others • Creating a specialised service within existing resources can reduce demands on services a whole. • Clients who have been chaotic and presented with high levels of risk can be active participants in their care and have a positive impact on their peers. • Working with high risk can be done without worry when decisions are supported by management and made as a group. #0183 Taith – The Therapeutic Day Service • Improving service delivery in the NHS is not always about additional financial investment, it needs the team to have the conviction to critique their own service, be open-minded enough to change and be effective motivators and communicators. • There is a wealth of specialist skill mix within the NHS and don’t be afraid to benchmark new ideas that work outside the UK and above all- enjoy what you do. #0077 The Metabolic Stone Clinic – Benchmark Prevention for High Risk Patients

31. Common Problems • Not ready to submit • Section creep – between the 9 criteria