Q Exchange

How to achieve improvement with digital tools and new applications

To address the findings of an employee’s MBA dissertation (regarding ED) with consideration give to current and future digital applications and QI activity These findings have informed our project aim

Read comments 36

Proposal
2022

Meet the team

Also:

Stefania Schino, The Hill, OUH.

What is the challenge your project is going to address and how does it connect to the theme?

Timely emergency services have always been the jewel of the NHS crown, but for staff or patients, this is often not the case. Facing rising urgent care demand, 4-hour targets are missed by most organisations most of the time. Delays increase mortality (4,519 patients died as a result of crowding in 2020-2021, Royal College of Emergency Medicine review). Staff frustration leads to burnout and rota gaps lead to a vicious cycle of even poorer quality care.

The digital revolution should have reversed this, but the experience of front-line staff is that innovations such as Electronic Patient Records add barriers and bureaucracy. This leads to less efficient, less effective and no safer care. Industry experts recognise that this missed opportunity is because digital interventions are often rolled out to mimic current processes, rather than redesigning them. To overcome this missed opportunity will take a mindset shift driven by new insights.

What does your project aim to achieve?

Following an in-depth analysis of the MBA dissertation in which he outlines recommendations for the Emergency Department (ED) in Scarborough:

The overall goal of this project is the analysis of the most critical processes identified through the dissertation (with particular focus on patient triaging and onwards referral activities) and the benchmarking with OUH to generate specific recommendations for improvement in Scarborough and Oxford.

Data visualisation will play an important part of our solutions and recommendations.

Specific objectives:

· Definition of comparison metrics and peer groups (at Scarborough and OUH) for benchmarking and application of proven risk and reliability adjustments for benchmarking

· Benchmarking, the generation of scale for measuring the level of innovation (and innovative/efficient performance) of ED departments.

· Assessment of applicability of recommendations generated through the dissertation (in both environments?)

· Roadmap (guidance) for improvement in ED in Scarborough (baked by comparison with OUH) and other hospitals with same ED innovation rating.

How will the project be delivered?

Collaborating across two departments of very different digital maturity (in Oxford and Scarborough), we have a unique opportunity to test solutions from one organisation in the other. This application both ways will keep us grounded in digital as an enabler.

The quality improvement and digital teams will ground this in a sound methodology (the Model for Improvement) and support staff and organisational learning through the improvement journey.

1. To create a map of processes in ED to include IT systems, communication channels and patient flows.

2. Recruit clinical staff and patients to measure key processes in detail.

3. To redesign these including customer service, immersed in co-design.

4. Test out the solutions with iterative refinements in both participating organisations

We will work with the 162 members of the Urgent and Emergency Care SIG by inviting them to help mapping, for which their time will be rewarded with Hexitime credits. Five other SIGs have been approached.

How is your project going to share learning?

We will share our learning and progress during the duration of the project on a Hexitime campaign page, which will also enable engagement with the improvement community. We will also use a shared team space on Hexitime and several Q SIGs to host Action Learning Sets to include clinical and non clinical staff and patients.

As the setting for the project will be York and Scarborough Teaching Hospital and Oxford University Hospitals NHS Foundation Trusts. This will also allow us to produce generic conclusions and recommendations at the end of the project that could be used in every ED setting. This will be published in peer reviewed journals such as BMJ Open Quality.

As OUH is part of the Shelford Group of 10 university trusts, this gives the opportunity to share learning through an extensive and influential network

We will share all diagrams and process maps via Q SIGs and Blogs.

How you can contribute

Please add comments on this idea and include issues facing your A&E so we can share findings with you directly. Here are some of the issues identified:
ED as a gatekeeper to hospital services, ensure consistent practices and communication, reduce unnecessary admissions, peripheral areas (SAU, EAU, CAU, should match availability of ED, signposting of patients to services outside the hospital, and transfer of patients to specialist areas.
Offer to run some of our ALSs to help us to understand the challenges in different settings and clinical areas. Please comment.
Inform us of any previous activity/research in this area.
Share any ED process documentation you have.
Help identify key ED processes.
Share any detail of digital information boards that you use. This type of information board could play a part in our project.
Respond to our posts in the Q SIGs that we are members of.
Join our Action Learning Sets.

Plan timeline

1 Jun 2022	Visualise various aspect of Scarborough ED e.g. interfaces & patient flow.
1 Jul 2022	Obtain relevant documents e.g. SOPs, transfer and discharge criteria.- review.
1 Aug 2022	Compile list and start mapping key processes (work as done).
1 Oct 2022	Instigate improvement projects/focus groups to identify process improvements - QI tools
1 Dec 2022	Prepare interim report and Blogs on project progress. BMJ papers.
1 Feb 2023	Design ALSs for delivery locally and remotely in collaborating SIGs.
1 Sep 2023	Feedback from ALSs for PDCA cycles to identify process improvements.
3 Jan 2024	Publish process maps on WWW to share learning across EDs.
1 May 2024	Draft final report for feedback and recommendations for digital applications.

Comments

Thomas John Rose 22 Mar 2022

<a href="https://nhsproviders.org/training-events/digital-boards">Digital Boards</a> look like a good solution to providing up-to-date information to staff.</p>
Thomas John Rose 18 Mar 2022

I'm just reading up on this 2018 winning Q Exchange idea: https://q.health.org.uk/idea/2018/coordinating-care-for-emergency-department-frequent-attenders-networking-and-prevention/

I hope to learn from the outputs achieved.
Simon Dodds 13 Mar 2022

This looks like a very relevant and timely project. I've done quite a bit of mapping, measuring and simulation modelling of A&E systems in the past so would be happy to contribute lessons learned from that. The relationships between between patient flows, data flows, resource flows and decision flows in A&E is time critical and given the complexity of A&E departments flows some form of digital twin is now a realistic engineering option.
1. Thomas John Rose 13 Mar 2022
  
  Thanks Simon. I've attended your Flow course and well remember the advantages of flow management. Your critical review of some of our processes will be appreciated. A 'digital twin' is a great way of looking a options.
2. Hesham Abdalla 13 Mar 2022
  
  Thank you for your comment and that great offer of help, Simon.
  
  I have learned a little about Healthcare Systems Engineering and applied it in planned care settings, so would benefit from your experience in measuring, modeling, and simulation in this more complex context and will add it to our project plan.
Megan Morys-Carter 10 Mar 2022

Hi Tom, Good to see this laid out here. I think there are some interesting lessons that could be learned from comparing the two institutions. At Oxford, there are a group of Innovation Fellows who work in and around A&E who might be good people to connect into action learning sets and discussions.

It would be good to get a bit more clarity in the proposal on outcomes: what problems do you think you might be able to solve? I wonder if it's also worth explicitly drawing in patients more directly into the process mapping and observations. My (thankfully limited) experience of waiting around in A&E is that there's plenty of time for 'secret shopping' and observation so patients might have some very useful insights!
1. Thomas John Rose 13 Mar 2022
  
  Damian, I should have also said that National Standards will be used but a degree of co-design with Service Users will form part of the design process so some additional feature may be introduced.
2. Thomas John Rose 13 Mar 2022
  
  Damian, I only have the Service Principals the we designed as part of the 2nd Q Lab. These are for a back pain and mental illness Service. Some of these principals are not Service specific and some are relevant only to this Service. We will use the same design process though. Details of the 2nd Q Lab can be found on the Q Lab pages of the Q site. If you would like any more detail then let me know and also we will certainly keep you up-to-date with the Service principals that we design as part of this idea.
3. Damian Roland 13 Mar 2022
  
  HI Thomas - I note you are developing; "a set of A&E Service Principals" Do you have these or are these to be developed as part of this project? I'm interested in what these may be? I am presuming this will be distinct from national standards?
4. Thomas John Rose 11 Mar 2022
  
  Megan, Thanks for your comments. I agree with the value to both Oxford and Scarborough in some collaboration on this project. The idea of using ALS to facilitate discussion, I hope, will produce some interesting results. I will publish the MBA findings and the areas that are most relevant to the theme for this Q Exchange.
  
  Following the good practice designed in the 2nd Q Lab, in which I took part, we are planning to produce a set of A&E Service Principals. This will require some co-production with patients and your idea for a ‘secret shopping’ technique seems to me to be a good way to approach this task. The Service Principals will work in conjunction with the process documentation and again the views of patients on their trial application can be sought.
Sam McIntyre 10 Mar 2022

I work with the Royal College of Emergency Medicine's Informatics and QI committees and may be able to help out.
1. Thomas John Rose 18 Mar 2022
  
  Fiona, Thanks for your comment. Our Idea page will be updated this weekend and will include more detail on the project. Word count limits limit the amount of information we can include. One thing is for sure though, we will be using RCEM standards and guidance in our project. Please ask a question here if you would like some specific detail.
2. Fiona Burton 18 Mar 2022
  
  Hi Thomas, the RCEM QI committee would love the opportunity to look at the project plan. The project sounds very promising!
3. Thomas John Rose 10 Mar 2022
  
  Sam, I've had a look at https://rcem.ac.uk/clinical-guidelines/ and this will be a great resource for our project.
4. Thomas John Rose 10 Mar 2022
  
  Sam, Thanks. We will soon be outlining our project plan and as a first step maybe you could comment on that. It will, I hope, show a logical flow but we may have missed a key step in the process that you can spot. Great offer of help from you.
Simon Noel 4 Mar 2022

This proposal offers an interesting opportunity to understand the comparative obstacles of implementing a system to assist patient flow in a digitally mature environment, versus a digitally immature setting. There will be a number of factors which will need to be explored regarding the generation of data and how the challenges of providing real-time data are to be met, both in manually keeping a board up to date via a direct manual process and where these data are drawn from other clinical systems and data may be naturally updated in near real time.
1. Thomas John Rose 4 Mar 2022
  
  Simon,
  
  Thanks. This could be a great opportunity to make that comparison. The learning from this for Scarborough and Oxford, plus the Q Community, would be unique and valuable. Transferring data from other clinical systems, i.e. IT systems, to a board, i.e. a Digital system, is a good example of a Digital application.
Hesham Abdalla 3 Mar 2022

This looks promising as I can see see great value in addressing an important workstream which routinely becomes clogged, leading to greater risk of harm to patients and burn out of staff.

Although digital solutions should be an enabler, frustratingly they can often contribute to greater delays and longer waiting times; Often this is caused by designing them around "work as imagined", rather that "work as done".

A focused piece of work mapping Emergency streams of staff, information and patients, would allow for better solutions.

Our digital and QI teams at Oxford University Hospitals would like to collaborate with you on this, offering a contrasting setting to Scarborough ED. This could make our shared learning more applicable to more contexts. I appreciate being included in the project team.
1. Thomas John Rose 4 Mar 2022
  
  Hesham,
  
  Thanks. I think that your comment about the importance of designing systems around "work as imagined", rather than "work as done" is so true. The initial aim of the idea is to do a focused piece of work mapping Emergency streams of staff, information and patients at Scarborough ED. Included in this will be interfaces with IT systems and data collection. This work will be process based. Collaboration with Oxford University Hospitals and the shared learning that this will enable will certainly add to the value of this idea. Work will eventually focus on a specific area of ED activity and comments on this idea will influence the final selection of that area.
2. Damian Roland 4 Mar 2022
  
  Thanks Hesham - going to chat to team and get back to you on how we make this work!
Damian Roland 3 Mar 2022

Sounds like the need to merge digital/electronic tools with QI processes and methodologies is vogue - our project follows a similar theme!

I'd be interested in what you mean by digital application. We are working with an machine learning tool, which I presume comes under the remit of a digital application. I'd be interested whether our projects could support/share information with each other.
1. Thomas John Rose 18 Mar 2022
  
  NHS Providers have the following definition for 'Digital':
  
  Definition of Digital: Applying the culture, processes, business models and technologies of the internet era to respond to people’s raised expectations.
  
  That fits for us.
2. Thomas John Rose 4 Mar 2022
  
  Damian,
  
  Thanks for you comment. I have commented on Digital vs IT systems below. Maybe the Q Exchange Team can provide a clear definition. I'm sure that if our ideas are successful then it would be a very good idea to share ideas and findings. I look forward to that.
Jo Scott 23 Feb 2022

Hi Thomas and Adam - it sounds like an interesting project. I don't know if it might be helpful to specify which aspects of the unfavourable audit findings regarding A&E this project will focus on? Are the digital applications seeking to enable change in a specific area? Who specifically do you want to engage in the co-production process, and action learning sets, and have you thought about the challenges to overcome relating to staff in engagement in this unpredictable and highly pressurised environment?

There is another idea I've just read that is focusing on alcohol-related frequent attenders of A&E - I wonder if you might find it useful to get in touch with them to share learning and ideas about improvement projects in an A&E setting? https://q.health.org.uk/idea/2022/alcohol-frequent-attender-nursing-community-team/

Best of luck with the idea!

Jo
1. Thomas John Rose 28 Feb 2022
  
  Jo, Co-production will initially involve the Trusts QI and Digital teams and hopefully any proposed Service design changes will be reviewed by a representative patient group. Issues raised from the research findings could be discussed with staff using ALS maybe on-line to keep it out of the working environment.
2. Thomas John Rose 24 Feb 2022
  
  Thanks for your comments Jo. I will not be able to answer all your questions in one post but I'll start with the first. We have created a matrix mapping the research finding with the elements of the Q Exchange theme. Those findings that map most closely to the theme are the ones that will get the most attention. Word count has prevented use from including the matrix but we will publish it through another channel. Maybe a relevant Q SIG. Initial activity will be around improving current digital applications by better use of their features. Additional digital needs will be identified but at this stage implementation will not be possible within budget. One of the key areas of digital improvement is in communication, a topic that came up often in the research. A reply to the co-production and other questions to follow
Thomas Rollinson 23 Feb 2022

Sounds like a great idea, do you have an idea of the data you will collect and will you aim to implement any of the solutions identified during this project?
1. Thomas John Rose 24 Feb 2022
  
  Thomas, Thanks for you comment. Lots of data has already been collected during the MBA Project research. Yes solutions, when identified, will be tested using PDCA cycles and if results are positive then full implementation will be the next step. Positive results will be confirmed via further data collection on a process by process basis during the PDCA cycles. Ideally that data collection will be automated through existing digital application but new applications will be investigated.
Thomas John Rose 17 Feb 2022

If you 'Like' our idea you will get a notification when the idea is up-dated. We will up-date our Idea as a result of your 'comments' where necessary.
Kevin Minier 16 Feb 2022

Wonderful. How do you envisage ensuring that the patient/service user and informal carer perspective is central to the co-production of these new services?
1. Thomas John Rose 17 Feb 2022
  
  There are two aspects to Service design. These are the first is to design a Service that is effective and efficient. Part of this is to identify diagnosis and treatment strategies to be used. These decisions will influence many other features of the Service, particularly the working processes. Once these aspects have been designed the second aspect of Service design can be addressed. That is Customer Service. Customer Service design is undertaken using, in part, different design tools and people skills than that of other aspects of the design.
  
  Both aspects of the Service design should be given equal importance and that will be the case in this proposed project. Some of the findings of the MBA dissertation finding address Customer Service and these will certainly be fully addressed during the project. As we have said below we do hope to be able to publish the list of findings. Please consider joining the Service Design SIG to learn more about customer service design aspects in Service design.
Evelyn Prodger 15 Feb 2022

Sounds like a really interesting project.

It would be good to understand what the MBA findings were to know how they link to the planned work.

Would also be good to understand if this would be applicable to other clinical areas.
1. Thomas John Rose 21 Mar 2022
  
  Thomas, to add a bit more clarity around IT vs digital, how about IT collects the data and digital displays it. We think that digital display boards around ED will play a part in improving communication i.e. live situation reporting.
2. Thomas John Rose 28 Feb 2022
  
  Thank you for your comments Thomas. If you Google IT vs Digital you get 13.5m hits in less than 1 sec. A simple deference is that IT is a PC system and Digital is done on your phone. Another is that IT crunches the numbers and Digital displays the results. One thing is for sure though, you need to get your IT right first. Once key processes have been mapped ALSs will be used to identify issues and options for mitigation. This activity will be undertaken using digital technology - that's the display of the process maps and the ALSs. I'll add more detail to the idea text above.
3. Thomas Weijburg 28 Feb 2022
  
  Hello, I agree with Evelyn's comments, and feel that the idea could be slight;y more specific in scale and scope. On the one hand it feels fairly wide in terms of planned activities, whilst on the other hand I think more clarity around IT vs digital would be useful. I'd also be keen to get better understanding how ALS will be used to support future learning.
4. Thomas John Rose 15 Feb 2022
  
  Evelyn, Thanks for your comment. We have constructed a matrix document that cross references the MBA dissertation findings with key elements of the Q Exchange theme. Unfortunately we are unable to upload the document on the Exchange site this year. I will find some way of publishing the matrix and let you know when it is up.
  
  In terms of usefulness to other clinical areas I think that that will be the case. We will develop tools that allow users to link digital features of IT systems to the processes that depend on these features for their efficient operation. These tools will identify elements of the IT system that make its use difficult and therefore stressful to the user. I'm sure that that is not an unusual scenario.