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The Clock was Ticking………………
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• Private Haematology/Oncology Day Hospital • Over 19,000 presentations per annum
• Over 600 Apheresis procedures per annum
• Average 75 patients/day
• 27 treatment areas
• Pharmacy on-site
• Co-located with the Mater Private Hospital
• Practice Management - 12 VMO’s• Over 33,000 consults per annum
Icon Cancer Care South Brisbane
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Picture this…………………..
• Nurse Manager only
• Nurse allocated to 6 patients/8 hour shift
• Nurse Workloads – fight for chairs
• No extra staff to fall back on
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The way it was…………….
• Add on patients and treatments
• Staff very stressed, negative, unhappy
• Anxious and frustrated Patients
• Long Wait Times – sometimes >2 hours
• Offsite pharmacy supplier
• Lack of allied health support
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We looked old and tired…………
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Booking Scheduler
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Daily nurses allocation list
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It wasn’t all bad news………..
• Dedicated, committed staff
• Providing excellent nursing care
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How to make the change happen….
John Kotter’s 8 steps to Lead Change
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‘Waiting over an hour to start
treatments’
‘Waiting to see doctor
about tests’
‘Nearly 2 hours waiting time. ’
‘Running behind for whatever
reason and your appointment gets put back, you get anxious
and nervous, and it is prolonged’
Patient Survey Results‘Expectations around wait times were met’ = 42%
‘A less pleasant experience being wait time’ = 34%
1. Create Urgency • Patient – Feedback cards / Satisfaction Surveys• Staff – Satisfaction Surveys / Staff Turnover Rate > 50%• Implementation of CHARM
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2. Form a Powerful Coalition • Focus Group - representatives from all groups on site• Consumer Representation
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3. Create a Vision for Change
• “Exceptional Cancer Care for Everyone”• Realistic Targets• Safety of the Patient
4. Communicate the Vision
• Engage staff in the process and solutions• Communication, Communication, Communication• Listen, Listen, Listen• Staff needed to believe it!
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Suellen video
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3. Create a Vision for Change
• “Exceptional Cancer Care for Everyone”• Realistic Targets• Safety of the Patient
4. Communicate the Vision
• Engage staff in the process and solutions• Communication, Communication, Communication• Listen, Listen, Listen• Staff needed to believe it!
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5. Empower Action
Introduction to team nursing…• Clinic zoned into areas
• Staff allocated to areas from roster
• Each team includes a Team leader
• Each RN responsible for 2/3 chairs
• Team Leader supported by Clinical Nurse Consultant with regular ‘HUDDLES’
Results
• Patients always aware of who is responsible for their care
• Nurse had patients visible to them at all times and supported by others
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17 18
Time7am
7.30am
8am
8.30am
9am
9.30am N7
10am
10.30am
11am
11.30am
12pm
12.30pm
1pm
1.30pm
2pm
2.30pm
3pm
3.30pm
4pm
4.30pm
5pm
5.30pm
6pm
6.30pm
7pm
7.30pm
8am - 6.30pm (10hr) : 1 staff (Team Leader)
7am - 3.30pm (8hr) : 5 staff (one Team Leader) 9am - 7.30pm (10hr) : 1 staff (Team Leader)
7am - 5.30pm (10hr): 3 staff (one Team LEader) 10am - 6.30pm (8hr) : 1 staff
8am - 4.30pm (8hr) : 1 staff 11am - 7.30pm (8hr) : 2 Staff
7am - 5.30pm (N 11)
7am - 3.30pm (N12 & T/L)
8am - 4.30pm (N13)
11am - 7.30pm (N14)
21 2613Treatment Area
16 19 20 211211109876P1543
Nurs
e 13Nu
rse
9 &
10
Fast Chairs
Nurs
e 11
Nurs
e 11
Nurs
e 11
22 23 24 25
Add
on ch
air -
NO
BOOK
INGS
Nurse 4
Nurse 3
7am - 5.30pm (N5)
7am - 3.30pm (N6)
9am - 7.30pm (N7 & T/L)
10am - 6.30pm (N8)
7am - 3.30pm
(N9)
7am - 3.30pm (N
10)
7am - 5.30pm (N1)
7am - 3.30pm (N2)
8am - 6.30pm (N4 - T/L)
11am - 7.30pm (N3 - cover
lunch & end of shift)
Nurs
e 13
Nurs
e 13
Nurs
e 12
Nurs
e 12
Nurs
e 14
Nurs
e 14
Nurs
e 1
Nurs
e 1
Nurs
e 1
N7
Nurs
e 8
Nurs
e 8
Nurse3
Nurs
e 6
Nurs
e 6
Nurs
e 6
Nurse 7
Nurs
e 5
Nurs
e 5
Nurs
e 5
Nurse 14
Nurs
e 2
Nurs
e 2
Nurs
e 2
Roster Requirements
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Team Leader Role
• Team Leaders allocated to each area• Leadership role• Coordinates care• No direct care for a period of 4hrs/day• Communicates to Clinical Nurse Consultant and Doctor• Participates in ‘huddles’ with Clinical Nurse Consultant
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Huddles
• 10am and 1pm with CNC and all Team Leaders
• Alerts to potential chair waits
• Identifies pressure on staff ie breaks and overtime
• Allows CNC to visualise clinic as a whole to enable decisions on:
* Potential add ons
* Delays in chairs (hospital transfers/unwell pts)
* Ability to swap patients or release staff to other teams
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Team Shift Time Name Chair Allocation Handover toMiddle Section
T/L:
(Closes @ 6.30pm)
7am – 4.30pm (N1) 1, 2, 3
6.45am – 3.15pm (N2) 4, 5 & P1
8am – 6.30pm (N4) T/L & from 5pm 1, 2 & 3
1.30 pm – 7.30pm (N3) Help & from 3pm 4, 5 & PR1
Front Section
T/L:
(Closes @ 7.30pm)
7am – 3.30pm (N5) 6, 7, 8
6.45am – 3.15pm (N6) 9, 10, 11
9am – 7.30pm (N7) 12 & 13 until 10am – then T/L
10am – 6.30pm (N8) 12 & 13
9am – 5.30pm Float & Help
Fast Area &
Add On
(Closes @ 3.30pm)
7am – 3.30pm (N9) 16 & 17
7am – 3.30pm (N10) 18 - & Help
West Wing
T/L:
(Closes @ 5.30pm)
6.45am – 5.15pm (N11) 22, 23 & 24 until 11am
7am – 3.30pm (N12) 19, 20, 21
8am – 4.30pm (N13) 25 & 26
11am – 7.30pm (N14) 22, 23, 24
Daily Staff Allocation
HUDDLES IN NURSES STATION @ 10am & 1pm
ALL TEAM LEADERS MUST ATTEND
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Scheduling Appointments
• Accuracy of length of appointments• Discussed current issues
• Reviewed data: • Correct time allocated: 36%
• Too much time allocated: 22%
• Not enough time allocated: 42%
ARRIVED SCH TIME TREATMENT TOTAL CARE TIME
11/10/2016 6:47 206 240
11/10/2016 6:49 361 180
11/10/2016 6:51 210 240
11/10/2016 6:51 196 180
11/10/2016 6:53 147 90
11/10/2016 7:04 247 240
11/10/2016 7:05 308 180
11/10/2016 7:10 85 180
11/10/2016 7:20 140 210
11/10/2016 7:23 278 180
11/10/2016 7:28 167 120
11/10/2016 7:29 183 180
11/10/2016 7:35 474 270
11/10/2016 7:50 74 60
11/10/2016 7:50 146 240
11/10/2016 7:58 173 180
11/10/2016 8:02 183 180
11/10/2016 8:16 123 210
11/10/2016 8:22 245 240
11/10/2016 8:23 101 150
11/10/2016 8:27 174 180
11/10/2016 8:30 350 360
11/10/2016 8:34 235 180
11/10/2016 8:51 143 150
11/10/2016 8:52 226 150
11/10/2016 8:53 204 60
11/10/2016 9:11 57 60
11/10/2016 9:11 245 120
11/10/2016 9:16 28 30
11/10/2016 10:01 215 240
11/10/2016 10:02 335 300
11/10/2016 10:03 22 60
11/10/2016 10:03 427 60
11/10/2016 10:18 145 150
11/10/2016 10:20 126 180
11/10/2016 10:21 185 180
11/10/2016 10:25 175 180
11/10/2016 10:32 220 180
11/10/2016 10:36 309 240
11/10/2016 10:36 215 240
11/10/2016 10:40 389 180
11/10/2016 10:57 223 120
11/10/2016 10:58 261 270
11/10/2016 11:01 86 30
11/10/2016 11:04 301 90
Results• Nurse involvement in planning• Nurse’s predicting future appointments• Add on’s – discussions with Doctor’s • Unwell patients
October 2016 - Sample of Appointment Time Data
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CHARM
• Scheduler Patient allocated to chair not nurse
Visual display of where pts are and how long they will be in chair Aids with add on procedures
• Pathways VMO’s order the patient pathways
Pharmacy responsible for chasing orders in advance
Allows add on products by VMO’s at any time
Easy understanding of patients treatment plan/diagnosis
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CHARM Test Screen
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“DO NOT BOOK” Chair• 1 chair that is not allocated any patients
• Managed by Clinical Nurse Consultant
• Utilised when other chairs become under pressure
Fast Chairs• Open from 7am – 3.30pm
• 30 minute procedures
• 1RN and 1EN
• Treatments/ Procedure: include: Access device care – flush/dressings Venesections S/C and IM administrations, Short IV chemo administration
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6. Create Quick Wins
References:2016 Data Taken from Total Care2017 Data Taken from CHARM – Appointment Time V’s Actual Start Time
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Cost Savings – Nursing Overtime
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Renovations
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Patient and Staff Video
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7. Build on the Change & Make it Stick
• Onsite Pharmacy – mixing on site
• Bone Marrow Clinic
• Pathology the day before
Where to from here…..
**Consolidate, Promote, Consistency!!
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This could not have been done without them….