Herding Cats alias Leadership Liz Smith Advanced Nurse

“Herding Cats” alias Leadership Liz Smith Advanced Nurse Practitioner, Cardiac Services, Cardiorespiratory and Critical Care, Great Ormond Street Hospital, London, UK, December 2014, PCICS Conference Miami December 2014 S

S Not sure where to start S Challenge their environment – care pathways S CICU expanding boundaries S Data will be increasingly important Situation S CICU needs to be aware of care beyond

Cardiac Services - GOSH Preadmission x Cardiac Intensive Care + emergencies Optimize High Dependency & Ward D I S C H A R G E

Cardiac Surgical Volume Nov 2014 Apr-Nov 2014/15 Cardiac bypasses 50 384 Non-Bypass 11 100 ECMO 2 15 Bridging to transplant 0 12 Heart and / or Lung Transplants 2 17 Tracheal Surgery 1 12 Thoracic - major 7 89 Apr-Nov 2013/14

Fast track Congenital Heart Surgical Program ( n ~ 18 % ) Pre admission Day of surgery CICU Ward & follow up Fast track integrated care pathway Child & family receive ongoing holistic care Cardiac Nurse Practitioner Led Pre surgical assessment < 3/12 Advanced Nurse Practitioner Family prep / Information Arrive day of surgery Pre-surgical checks / assessment Cardiac nurse practitioner team First on surgical list Short stay CICU, rapid deintensification Moved to HDU same day De-intensify to Ward area Education of family home Appropriate follow up support

Fast Track – time value 100 % Before 2006 100 % After 2006 Ward HDU D I S C H A R G E CICU Ward HDU CICU Days 1 2 3 4 5 1 2 D a 3 y s D I S C H A R G E 4

Family & Child preparation Fast Track surgery, is it enough ? Vanessa Garside , NP, MSc 2012 Question % yes % no or other Comments Better /as expected experience 93 % 7% Improved by 17 % Local teams informed of admission 20 % 81 % Improvement project Needed to make an unplanned call 23 % 77 % Wound care Pain control General reassurance Adequate follow up support 88 % 13 % All receive 24 hr follow up call with ongoing assessment

Vision of Project S Optimizing patient flow & streamlining the patient journey S Agree processes where clinical staff, families and children can manage their expectations of the system & service provided S External Drivers – financial pressures on the National Health Service, ongoing review of National Children’s Congenital Heart Services and the opening of a new Children’s Cardiac unit

Background

The Quality & Productivity Challenge ty li ua Q Keep Quality at the core – Quality Improvement tools & process Effectiveness Ref : Department of Health ( 2007 ) High Quality Care for All, Darzi, White Paper, DOH

The Friday Meeting Cardiorespiratory & Critical Care Mortality, Morbidity, Outcomes 5 th December 2014 Best Outcomes @ Lowest Cost Satisfied Families Constant focus on innovation Training Centre of Choice Deep Collaboration Teams Transparency Next>

Assessment

• Leadership styles and theories • YOU will all know a Leader who inspires • Aim - meet a shared, achievable, measureable goal • Impact on patient care s t e c Fa • • ce n e l ip g & si h s r tenin thy es ork e r d u t r s Lea skills, li trust wonal struc teamw & r , n t e y o t c i t n x e ica resp st & e armo n u h m ce & s tru e t m o o C fiden use prom – n Co iency ces to grity e c ate l u Leaders appointed Effi influen ent, int em e g o s t a t U Multi-professional meetings, an nge y w a h s C regular basis using Quality Improvement ar Tools her n t o o i Vis racter elf ! Agreement at each stage ! ha thy s C Key actions/ outcomes from each session now K Documentation & progress reports Escalations - Divisional Management Team

Tree Diagram CNP / CLN follow up calls, documentation lead caseload, clinical baselines Rapid discharge & follow up Standardise education across clinical areas, standardise documentation across areas, start education preadmission clinical baseline agreed Daycare education & discharge CICU prep for discharge to the ward 2 Plan Process Journey Structure or W p u k Gro Discharge rounds, EDD, Standard education & Documentation follow from Day Care. Booking investigations early ECHO CXR m ea r t s ork it s. a w s i o l h f t with patient ing Standard documentation, z i m opti l na: doctor Communication : nurse, iority w o i s s pr – nurse : fe doctor, consultant : rregistrar, o e r tu i-p ed c tneeded l u r u across clinical areas t s M agre & ers f b m briefings e o m t m i Standard n Planning process a m l documentation ie a a e i t t i l Pat. Pre planning & iprep, h in ona nursing t i d! SBARD, s r w s a e y l f o handover b o on b i- pr favora t l s u M eam red t a l p l Education of families A com Discharge medication standardised ey n r u o j Internal transfer CICU to ward area Ward area predicted discharge date Planning discharge : timing, time of day, hospital help minimal EDD, staff & families Whiteboard, electronic systems EDD, discharge area Coordinate discharge across Areas Discharge rounds

Tally Data & Pareto Charts – frequency of issues Data collated on reasons of delays in Patient Flow Examp Data c le 1 ollatio Medica n & wo tion eg rk stre ams Orderin IV to or g Medi a l frusim cations Standa to take ide rdizing h medica Examp tions a ome at admis le 2 t discha sion Earlier rge structu re Eg bas ic life s d educational up pl Standa rd infor port, deterior an for familie a s, from mation stream CICU to fami ting child, fet lined lies thr al diag ough o nosis u t t he jour Challen Proact ney ges ov ive Ca er agre Was th re Path ement ere any ways o f “ All my what st nationa an l p Challen atients are d standard or e dard care wa videnc if ges ov e base s ! er data ferent , “ ? collecti on acc uracy Reasons for delay

Aim statement Cha To reduce over a 6 month period the hospital length of stay ll Nurs enges : e • N s colleaheart disease by removing by 5% in children with congenital u g • Q rse led ues too disc of kservice ualit quality Cha inefficiencies and improving harg up the provision, y llen o o f e as ptim care chal ges Med s i leng z e r i i e c n p s m a s c g a es: m l h t meanwhile ensuring each child is discharged a e i c i e • S l ent i when i duca nt ex afety olleague ned : • Re dren n tion perie each • Q c s s o o t n r f a r e area ce & ding ready patie ndar main medically ualit di d nt y • e scha for f d co s co of ca The amil u n r r g r l c e d e es & erne • C wou be u ies & wou d re read ld be omm ld re nder : miss d unic ion ation uced pe comprom threat rform betw ised a een team nce indi cato s for rs disc harg es S

Recommendations

Work streams : Role out across all clinical areas Communication- daily meetings Documentation- electronic Data collection – Outcomes Team Presentations at weekly divisional meetings

Frustrations Time commitments & deadlines As project extended every ones commitment waivered However once back on track – renewed energy

eams t & s Wins : e c tion ur c o e s l l e r o c r ents e a t m a p d o l r e a • Oth v l & regu vice de r l e a s m r e o d i • F orkers alongs w , t r s o e l p o patient p r u e w s h e , t g f N n o i • ledge y, nurs w c o a n k m r s a team eg ph e h t al team n n i o i e s s s a e f ti- pro l • Incre y u m s s ce acro n pathwa e d i f n S Physically observable process, real co d e s a e r • Inc time data S Empower team “ new experience, action work streams “ , education to prevent loss of knowledge & process S Management measurement systems & reporting systems S Test improvement cycle S Reward success

CICU HDU Expanding boundaries of CICU, challenging the boundaries of CICU eg Ongoing clinical assessment Support packages – BIG data “New facets “ of parenting for families with complex care packages Paradigm shift of CICU to HDU, HDU to the ward & ward / HDU to the community regarding complexity of care CICU = Community HDU CICU WARD Community Care in CICU is equal to Community care for single ventricle & other shunt physiology Robust monitoring program

Bear Ward Discharges < Midday Baseline Formal Discharge Team Nursing Discharge Ta Performance indicator controversial

Learning Outcomes S 6 learning points

• Quality improvement Methodology • Emotional intelligence • Teams speak for themselves & be empowered • Time is needed to process & digest change developments • The long term effect on the team is often forgotten once the goal is achieved

Even when the plans are going well, some individuals may not be on board or have different agendas Does it matter ? Topical Innovation Early Adopters Champions ( 5 - 15 % ) Early Majority Late Majority Norm Laggards Never adopters

“ Don’t give in on The Vision “ You know your team better than anyone The dogs from the cats ! A team needs diversity & a wide skill base for success The Team is working hard to contribute to the goal & recognition of a job well done from the Leader !

What ever happens do not resort to physical or emotional anger !

• There will always be someone who is good at the job • Be patient, seek them out, advertise • They may not be who you think they are ! • Keep an open mind, Leadership is full of surprises & challenges

Once you have found them : • Encourage • Support • Empower • Reward • They maybe the change manager you are looking for • Remember the change manager does not have to have all the knowledge , they can reply on the team to inform and Leader to direct decisions & visions

Thank you for your attention “ No cats or humans were harmed in the making of this presentation “ Liz. smith@gosh. nhs. uk Thank you to : • Vicky Bank – Data & Outcomes Manager, Cardiorespiratory & Critical Care Services • Advanced Nurse Practitioner Team – Childrens’ Cardiac services • Cardiac Nurse Specialist Team – Childrens’ Cardiac services • Dr Alessandro Giardini – Lead Consultant Cardiology • Dr Cho Ng – Lead Consultant CICU