Award Report – Implementation phase

Lead organisation: University College London Hospital (UCLH) NHS Foundation Trust

Partner organisations:

Clinical Operational Research Unit - University College London (CORU UCL)

Development areas/support needs identified:

Lean/process redesign methodology

Nursing and Midwifery Clinical Leadership plan developed by Chief Nurse

Date: July 2014

1. Introduction This section summarises background, local problem and specific aim(s) of the project (Answers the overarching question: why?) 1.1. Background knowledge and local problem

It was agreed that there was no need to add to this section as there has been no addition or change to the background to the project or a change of scope within it.

1.2. Intended improvement: aims and underlying theory of change

The following sections have been added:

Review of the role and responsibility of the ward sister vs clinical administrator and Ward Clerk roles

Development of a set of Customer Service workshops as part of the change management process

Development of Corporate Service Metrics to test PDSA cycles.

Development of a Corporate Service Improvement Team

Additions to the logic model are included in Appendix A.

1.3. Expected learning What in particular do you hope to learn? Describe the broader learning you aspire to take from the programme, beyond the specific questions your evaluation plan aims address (evaluation plans may look at a specific component of the project or at the project from a specific angle).

This section remains unchanged

2. Methods This section describes contextual issues, the intervention itself, the implementation and evaluation plans (Answers the overarching question: what will you do?) 2.1. Context

The diagnostic phase of the project was implemented in May 2013 where three Concierges joined the Ward Sisters Concierge Service. It was expected to last one year however it was noted that there may need to be a transition period up until the service is disbanded. The Service is subsequently being phased out with ward rounds ceasing on 30

th June 2014 with a

view that the service closes entirely on the 30th July 2014. The support from the corporate

areas and active input to the project has continued from the ‘Corporate Lead’s’. To date we have received 798 issues and have captured every interaction we make including emails, phone calls and face to face interactions and time these in our CRM system, we have also undertaken a root cause analysis of the issues and found that all 798 fall into one or more of 6 themes See Appendix B. In the next phase we will launch transformational service improvement projects that address the most time consuming and complex processes for Ward Sisters under the principle that if we can tackle these, the learning can then be developed into a Productive Corporate Service Tool and disseminated across the rest of the organization.

2.2. Risks

Scope creep: This has not proved to be particularly problematic; the scope has evolved in certain areas (e.g. undertaking review of sanitary conditions at a UCLH hospital to solve the issue and also to test the current process of undertaking maintenance and repair.) Other out of scope issues have been defined as significant to the ward sisters and therefore have been reviewed by the team. It was found that these out of scope issues also fell into the cultural themes or 6C’s that are described in the update for the Implementation phase. There have also been areas where it has seemed natural to align with existing projects to share learning

and promote a common purpose. A good example of this is the Making a Difference Together Campaign that focuses on patient and staff experience.

Ward Sister time may be released, but not convert into clinical leadership time: Activity follows have continued to be collected and key information is being fed into existing projects to develop our Clinical Leadership project, including a move to strengths based recruitment for Ward Sisters. The diagnostic phase has also outlined the need to expand this area of review into the role and expectations of ward sisters, vs clinical administrative staff as it has been highlighted that this is variable across the UCLH site. This will continue to be picked up in partnership with senior nursing colleagues. Disbanding the Concierge Service: The process of disbanding the Concierge Service is underway. We are supporting the Ward Sisters through this transition period as there had been some confusion due arising from a misconception that the project ended with the disbanding of the Concierge Service. We are holding a Service Improvement Roadshow in July 2014 to tie the findings from the Concierge Service to the next phase of the project to help sustain engagement with nursing colleagues.

2.3. Intervention

Describe the proposed intervention in sufficient details and initial plans for how the intervention will be implemented: how often; by whom; stakeholders involved; etc.

During December 2013 work was undertaken to take stock of existing data from the project, and scope the Service Improvement Strategy for the remainder of the LSTL programme. It was found that each of the issues the Concierge service has received to date could be attributed to one of 6 areas, which are known as the 6C’s and projects have been scoped under each theme with the focus on delivery of release of ward sister time. Learning from these projects will be developed into a set of toolkits which will make up the Productive Corporate Service Tool.

Theme 1: Corporate Overlap Theme 2: Complex Processes Theme 3: Customer Service Theme 4: Communication Theme 5: Culture Theme 6: Commercial Contracts

The main workstreams of the LSTL service improvement strategy are outlined in Appendix C.

Alongside the fundamental issues established through the thematic analysis of the 6 themes, it has been recognised that the areas of complex process and corporate overlap (themes 1 and 2) represent the highest amount of wasted time for the end user. To address this LSTL project are proposing the following principle to be adopted for all new processes: Key Principle: “All processes should be mapped from the end user perspective and standardized to ensure the end user is only expected to complete one step. All other necessary steps should be proactively managed by Corporate Services” The LSTL project is proposing that this standard is implemented and tested through the LSTL project on the four areas of Corporate Overlap/Complex Process that represent the highest amount of wasted time and administrative burden before being rolled out across all end user facing processes, through the Productive Corporate Service Tool. There are four system wide processes as follow that when mapped from the end user ‘value stream’ result in overlap, waste and increased amount of time to navigate through the system, these projects will be underpinned by workshops that are created for the remaining 4 themes and are as follow:

Theme 1 & 2: Projects to address Corporate Overlap and Complex Processes

New Starter Processes

“New Starter Processes” begin after a line manager is notified by recruitment that a candidate has a start date, The baton then falls to the line manager who is responsible for ensuring that the candidate has everything they need to be ‘work ready’. This is a good example of where a Corporate process has not been designed from the perspective of the end user. The first issue we have found in navigating this on behalf of the Ward Sisters is establishing what processes we should follow. A review of available data through the issues the Concierge have captured and analysis of available information for managers has shown that we currently expect managers to potentially review 1,828 policy pages, 101 forms, 22 ICT systems, 214 webpages to establish each of the new starter processes, due to silo working, and lack of responsibility for ‘customer flow’. After the end user has established this information for each of the processes they are responsible for managing and navigating each process where each department who has requirements and standards, this process currently represents an average of 146 steps. We have found that learning is based around individual experience of a process as opposed to clear processes for the end user; these processes are perceived as frustrating due to the expectation on the end user to chase to push these through. These problems are replicated by the 2300 starters we have each year across the organisation. During the New Starter Processes project we will be testing the principle under the basis that this is one of our most complex processes, and learning from this project can be replicated in other areas of the organisation. “All processes should be mapped from the end user perspective and standardized to ensure the end user is only expected to complete one step. All other necessary steps should be proactively managed by Corporate Services”

Access to financial systems This represents a system that is based around a paper form, which is used to support five different processes. The forms are often lost which results in frustration, while this is a smaller scale project, it represents one of the most time consuming issues we have received on behalf of the Ward Sisters.

Procure 2 Pay

The value stream for the end user is “I need to procure items to be delivered to the ward”. This process overlaps four different corporate services and the Ward Sisters are responsible for navigating between each (See Appendix D). The Procurement department have been one of the most engaged and have already facilitated a co-location of front line helpdesk experts from across three functions, to up skill staff across the different specialisms (Accounts Payable, Procurement and Financial Systems). Whilst colocation has been the first step, we are working with the team to use PDSA cycles to test changes to how the customer flow through the service is managed. We have also translated the Trust ‘Patient Experience Workshops’ into a Corporate Customer Experience programme in partnership with the Making a Difference Together team which has been very well received. This will form a set of 4 workshops that support front line staff during the change process while we redesign processes. Knowledge is captured from these sessions to test the feelings and thoughts of the individuals who have participated.

Estates and Facilities maintenance and minor works

This project will address the issues that we have received most frequently into the Concierge service. The Trust is currently launching an Estates and Facilities Strategy that the LSTL project has actively participated in the research and shared learning. This strategy will be launched in August 2014, at which point the maintenance and minor works review projects will be scoped. We have found that there is variation across the organisation as to the extent in which ward sisters are responsible for estates and facilities processes. This has prompted a review of the role and responsibilities of the ward sister to standardise this across the site, the responsibility for these improvements will be owned by senior nursing teams.

Theme 3: Customer Service Improvement Project

We have found departments are often not proactive in there instructions to end users and written and verbal correspondence is often viewed as unhelpful and Corporate Service front line staff do not recognise end users as ‘customers’ of their services.

One of the 2014/15 Trust Objectives is to deliver high quality patient experience and customer service excellence by developing standards for patient experience (as customers). Whist it is recognised that this should be the primary focus, the LSTL project is working alongside the Making a Difference Together Campaign (MADTC), to develop Corporate Service customer experience programmes, that maps the tools used in the patient experience programme to customers of Corporate Services. Elements of this programme are currently being trailed in the Procurement team and have been received positively.

Theme 4: Communication Service Improvement Project

We have found that each Corporate Webpage is completely different, and varies in the quality of information provided. The information provided is not mapped out in a consistent way and much of the information is out of date. Information needs to be framed on what the user is trying to do, rather than what each department does which represents a fundamental change in the way information is traditionally presented. Users often navigate for information once, and where this is not easily accessible lose confidence in the webpages and resort to helpdesks or ‘helpful people’ within the organisation. The LSTL project is looking review how information is displayed and searched for on the Intranet and put together pages that bring together process from the user perspective, that are proactive in the information they provide.

Theme 5: Culture Service Improvement Project

End users feel that the onus is very much on them to navigate Corporate Processes particularly in areas of overlap. Corporate Departments often implement VIP processes as opposed to contingency processes where there are problems in the system, due to breakdown in understanding of customer flow, this results in variance in customer experience and an overreliance on single ‘helpful people’ who in turn become swamped with requests. In addition, end users are expected to visit departments for sign off and collection of items which represents wasted time for the end user. We have shared learning with other organisations such as Guy’s and St Thomas’s Hospital who have picked up on a similar issues, which they have built on by trialling a service that brings Corporate Services to the customer which has resulted in members of staff being more pro-active, and have already experienced a decrease in helpdesk calls, and customers that are more skilled in navigating systems. LSTL are planning to launch a ‘Customer Flow’ project which will capture changes to Corporate Processes and the resultant effect on Ward Sister time. The principle of building in mystery shopping and ‘system walks’ from the eyes of the end user will also be tested as part of the PDSA cycles that are implemented as part of the service improvement projects.

Theme 6: Commercial Contracts Service Improvement Project

We have found that third party contracts work to differing standards and processes and communication structure appear to be set up for Corporate Services, as opposed to the end users. One of the root causes of this is that third party contractors are often not included as part of the team, with lack of two way communication and alignment to the Trust standard and values for Customer Service. There is often no clear escalation route in these areas and different standards for contact with departments that are not clear to the end user, the provision of service and responsibility of the Ward Sisters is also variable across site. While it is recognised that contracts can be difficult to negotiate, it is proposed that a set of principles that are developed to be included at the point of retendering and new contract negotiation to ensure that processes follow the same standards, and that services are aligned with the values and provide the same level of service that is expected from UCLH Corporate Services. We will build on existing examples of where a third party partnership works well, such as our Pulse Bank team and disseminate best practice across other teams.

2.4. Embed and Spread

The Service Improvement Strategy will focus on the implementation of PDSA cycles to test the success of proposed local interventions through each of the three strands. PDSA cycles will be coupled with the use of After Action Reviews (AAR’s) for both positive and negative experiences within corporate processes to gather learning so that a ‘best practice’ package of modules and toolkits can be developed into a Productive Corporate Services Tool, see Appendix E.

2.5. Management of the Project

The project board has been impacted by the resignation of the Workforce Director and the change of working hours for the Chief Nurse, both project sponsors. The Workforce Director post has been successfully covered by Jeremy Over, which has provided consistency from a project lead perspective, however the Senior Nurse presence is still under review and there has been a transition between project managers due to the departure of Jacki Parker in February 2014. It is proposed that the project will report into existing forums such as the Deputy Chief Executive’s Corporate Directors meetings, and through the Resource Management Board who are responsible for back office systems and processes. Whilst this is a change from the initial governance structure, there will be additional benefits through this senior level Trust wide engagement, and potential to disseminate learning through these forums. The decision to make these changes to the Governance Structure will be agreed in July 2014. We will also review the structure of the project and workstream teams as we move into the Service Improvement and Embed and Spread phases of the project.

2.6. Measurement plan Outline: chosen measures and how these relate to the overall theory; what systems you will use; frequency of data collection and data reporting; baseline data.

The baseline data was set by the March 2013 Ward Sister Activity Log and subsequent surveys have been undertaken according to plan on a quarterly basis. A review of metrics has been undertaken and additional metrics have been identified for evaluation. These include staff based measures such as staff turnover and retention rates, completion rates for surveys and audits deemed to be clinical leadership such as patient survey and compliance on key patient safety measures. We will also monitor patient experience metrics captured via the Trust’s Making a Difference Together Campaign, and data captured from a routine staff vitality questionnaire.

2.7. Evaluation plan

Strand one: Concierge Model

Due to the complexity of the Corporate Services, metrics will be established on a department by department basis, in order to track changes through the course of the project. The project

will also propose a standard set of metrics to be captured across all Corporate Services. This will be a key part of the work undertaken during the service improvement stages of the project. The examples provided in the original delivery plan will be captured as overarching metrics across each of the Corporate Services. We will also track time release through these metrics, and check whether any time released is reflected in the results of the Ward Sisters activity follows.

Corporate Satisfaction Measures:

Corporate Satisfaction Measures will be developed as part of the Service Improvement phase and embedded and spread of the project and will include both quantitative and qualitative metrics. Customer acceptance tests (mystery shopping) will be developed and applied across all processes that are subject to intervention from the LSTL project; this will then be embedded as a form of continual quality check and rolled out as part of the Productive Corporate Services tool.

Strand Two: Corporate Improvements/Increased Clinical Leadership

We have encountered issues in ward sisters completing the activity survey as the completion rate dropped to less than 50%. To address this, the method of distribution was revised (via the matrons), the survey was reformatted to make it more portable and easy to complete. We have also recruited a group of third year Nursing Students to complete the activity follows through shadowing of the ward sisters. The first set of data using the volunteers will be collected in July 2014 and will be used as a validation of data already received with regards to its validity. We will also interview the students to capture knowledge on perceived clinical leadership tasks vs actual clinical leadership tasks.

It is recognised that a potential barrier to the activity follows is the element that corporate processes are not often completed in continuous blocks of time. The little and often approach is difficult to capture as the perception of time is often much less when compared to actual time spent. We will validate and test this through time release captured through review and transformation of processes during the service improvement phase of the project.

Group I metrics have been difficult to establish because of the low rate of harms. The safety thermometer shows no trend as this is a snapshot audit and directly dependent on the case mix at the time (e.g. a case mix with higher need will have a greater rate of harms but that case mix may change by the next audit), in addition the harms may occur after the snapshot occurs and this will therefore not be a true reflection of the risk and care on the ward.

Clinical Leadership: The project team is in discussion with senior nurses regarding the development of the process of professional development and is offering feedback from the project regarding observations about the complexity of the role of the ward sister, succession planning and professional development. It is recognised that there are also links with the strengths based recruitment project for ward sisters across UCL Partners, and this is being reviewed in July 2014.

2.8. Economic evaluation plan Describe your plans for economic evaluation, how the return on investment will be defined. Please consider the return on investment from both the project and the health economy perspectives.

This section remains unchanged 3. Communication and engagement plan

High-level timetable and arrangements for implementing and managing the stakeholder engagement strategy. Regular updates have been provided via weekly emails to ward sisters and reinforced by face to face updates from the Concierge team via the weekly ward rounds. An event was held in April 2014 with members of Corporate Service teams to draw together action plans for the next stage of the project. A showcase event will be held on the 24

th July 2014 before the Ward Sisters Forum

to “tell the story” of the project to date and the next steps. We are also creating infographics to help to articulate the problems diagnosed through the Concierge and proposed next steps. These will be launched in July 2014

The initial expectation of the length of time to undertake improvements was very quick, with many of the improvements expected to be solved in the first few months. We have found that these issues are of course more complex, ingrained and difficult to solve and this makes communication complicated. Where we have explained the complexity and vision for the next stages of the project, the proposals have been described as ‘inspirational’ and as marking the beginning of a transformation in the amount of time spent on corporate processes.

4. Sustainability strategy

Describe your plans for holding onto the gains and build the work into ‘business as usual’ within the project’s boundaries. By addressing the most time consuming and complex processes for Ward Sisters we will have developed a best practice approach where the learning captured during this service transformation can be replicated across other less complex areas of Corporate Services. We intend to propose and develop a Corporate Service Improvement team who are responsible for delivering the Productive Corporate Service Tool during the embed and spread stages of the project. This is designed to be an internal service improvement resource that captures and retains knowledge in order to continually improve services, rather than a reliance on external contractors for this support. The LSTL project is seen as has a good reputation and unique expertise that is actively sought in areas where there is overlap.

5. Spread and engagement strategy

UCLH has engaged lean experts KM&T to undertake a scoping exercise to develop a 5 year transformational roadmap for the Trust, this work has recognised the importance of the work of the LSTL project and deemed ‘Liberating All’ as being one of the top level priorities under this roadmap. Whilst the LSTL project and Transformational Roadmap are separate the LSTL project will operate in alignment with these projects and is seen as the first step that will influence the rest of this strategic vision through its embed and spread principles. Within the scope of the LSTL Project will be to embed the key principle to reduce and standardise the number of end user touch points in order to deliver a release of time to Ward Sisters in areas that will ‘Liberate All”. Where the transformation roadmap dictates potential for further leaning of services, this will then take place at minimal impact to the end user, as there will already be minimal touch points. This is illustrated in the diagrams in Appendix E for the Procure to Pay workstream.

6. High-level timetable

Indicate only key milestones and deliverables.

See Appendix F

7. Learning and development plan High-level timetable and arrangements for implementing and managing the project team learning needs and the strategy set up to keep own theories under scrutiny / challenge and capture current thinking or way of doing things / uncover blind spots. There is no change to this section

8. Key learning from set up phase

This update has been included alongside the context and planned interventions section for the next stages of the project.

9. Early findings Describe how and why the initial plan is evolving, and the most important lessons learned from this evolution, particularly the effects of internal feedback from tests of change. Summarise the most important successes and difficulties in implementing intervention components and main changes observed in care delivery and clinical outcomes; consider unexpected results. Explore possible reasons for differences between observed and expected outcomes. (Answers the overarching question: what are you discovering?) In addition to the findings described in the context section we have also found the following:

We are anticipating that the original equation with regards the release of Ward Sister time may be more complex than initially proposed:

Total Ward Sister time – time release from Corporate Processes = Increased Clinical Leadership time + improvements to patient care

It is recognised that many of our ward sisters are currently working more than the required 37.5 hours per week, and we acknowledge that any time release may result in benefits to work life balance. We are currently reviewing literature to establish the best metrics to monitor improvements in this area. In addition we are also reviewing the support available from senior clinical leaders to ensure that our Ward Sisters are capable of fulfilling a 75% clinical leadership role. This links well with our new strengths based recruitment programme that underpins the Clinical Leadership Development work that the Trust is undertaking.

We also plan to introduce a set of standard Corporate Service measures to track release of time that we can attribute into time released for Clinical Leadership. This will enable us to effectively monitor whether this time release results in an increase to Clinical Leadership as expected.

One of the most powerful findings has been through the power of acting a critical friend on existing projects. This has been tested on the recent Finance and Procurement project, and has influenced the proposal to create a Corporate Service Improvement team. Subsequently the LSTL project is seen as having a good reputation and unique expertise that is actively sought in areas where there is overlap.

While data has proved powerful in articulating the true extent of the problems experienced by Ward Sisters and other end users, it has also proved daunting for some services. For example when articulating the 6C’s we initially developed a series of examples, however this was not accepted and was confusing for departments. We have now developed these by posing the 6C’s as a set of challenging questions that can be asked before implementing Corporate Processes as a sense check, See Appendix B this has now been well received and will become part of the Productive Corporate Services Tool.

We have experienced a number of ‘side effects’ that have tested the original theory of change proposed in the initial project plan. Originally we expected that we would be able to pinpoint precise areas for service improvement within departmental processes through the Concierge ‘diagnosis phase’ of the project. We have subsequently found the underlying cause of the problem through taking an overview of Corporate services. This has not only allowed us to pinpoint the six themes that are common across all services, but also helped us to establish how far the complexity of interdepartmental relationships has been underestimated. These hand offs and areas of overlap between services are what result in the most time consuming issues for Ward Sisters.

The next ‘Service Improvement’ and ‘Embed and Spread’ Phases of the project will tackle these areas of complex corporate overlap and interdepartmental relationships, and in doing so the common issues and resultant time attributed to these corporate processes will be released across all levels and areas of the organization which is a far wider spread than originally anticipated. The benefit of this is that the Productive Corporate Service package we will develop will be applicable to wider audience.

Appendix A: Logic Model

Appendix B: The 6 Themes

Appendix C: Service Improvement Phase July 2014 – June 2015: Figure 1: Project Overview

Appendix D: Procure to Pay project

Appendix E: Embed and Spread Phase June 2015 – November 2015

Appendix F: High Level Timetable for projects to address Theme 1 & 2 (Complex Processes/Corporate Overlap)

New Starter Processes (NSP) 2014 2015

J J A S O N D J F M A M J J A S O N

I

Project Team and Governance

Vision, Strategy and Plan

Scoping of development of existing e-systems

Development of Corporate Service KPI's

Mapping of system from end user perspective

II

Internal system wide mapping of process

Process redesign incorporating Lean

III

Development of existing e-systems

Solution development - coordination of NSP

Incorporation of 6C Toolkit

Communication and customer engagement

Implementation of PDSA cycles

IV Lessons learned to Productive Tool

Procure 2 Pay 2014 2015

J J A S O N D J F M A M J J A S O N

I

Project Team and Governance

Vision, Strategy and Plan

Development of Corporate Service KPI's

Team Development: PDSA Cycles using Customer Service Toolkit

II

Internal system wide mapping of process

Mapping of system from end user perspective

Process redesign incorporating Lean

Implementation of PDSA cycles

III

CRM specification and solution development

Incorporation of 6C Toolkit

Communication and customer engagement

Implementation of PDSA cycles

IV Lessons learned to Productive Tool

Access to Financial Systems/ Authorised Signatory Process 2014 2015

J J A S O N D J F M A M J J A S O N

I Project Team and Governance

Vision, Strategy and Plan

II

System wide mapping of process

Mapping of system from end user perspective

Process redesign incorporating Lean

Solution Development

III Lessons learned to Productive Tool