Mid Cheshire Hospitals NHS Foundation Trust project team interview
Olivia Jagger, Clinical Fellow at The Faculty of Medical Leadership and Management, conducted interviews with the project leads from the Mid Cheshire Hospitals NHS Foundation Trust to provide insights into the HEE BTBC pilots and discuss some of the lessons learnt from their pilot project ‘Enhancing training and education in handover and supporting an electronic solution’.
Dr Shirley Hammersley, Consultant lead for the project is Clinical Lead in Acute Medicine and Emergency Department and a Royal College of Physicians Tutor.
Dr Richard Ellis, Trainee lead for the project is an ST4 Neurology trainee and a Clinical Leadership Fellow.
What were the main aims of the project?
Richard: Our aim was to improve clinical handover for patients out-of-hours through seamless information transfer and enhanced training and education, to ensure better continuity of care and improved patient safety. We introduced a highly structured, handover process supported by an innovative, electronic handover system. We increased consultant supervision at handover and including input into prioritisation and allocation of tasks for ward-based patients.
Shirley: The electronic handover system serves two purposes, it enabled us to look at handover across the whole hospital base, enabling staff to keep track of patients waiting to be seen and patients transferred to wards. It is also used to record the allocation and completion of clinical tasks. This supports trainees to prioritise tasks, reduces risks associated with paper-based handover and provides a clear audit trail.
What educational interventions and training were delivered to the trainees?
Richard: We introduced a validated handover training programme, which focused on what makes good clinical handover including accountability and ownership of patients and tasks, leadership, task prioritisation and time management. This met trainee’s curriculum requirements for communication, handover, team working and patient safety.
Shirley: We not only provided training about safe handover, but with greater senior input at handover we were able to build in ‘learning bites’, making each handover an educational experience.
How did you measure outcomes?
Richard: We measured many different outcomes, including task completion rates, out-of-hours discharge rates, length of stay data, critical incident analysis and staff feedback.
Shirley: HEE helped us to identify an academic partner through the University of Keele, Dr Daniel Monnery, who developed the training programme and evaluated the project. He videoed handovers to evaluate how the structure was being followed and analysed human factors. He also facilitated focus groups, which provided ongoing evaluation. This provided us with objective feedback from someone outside the hospital.
What has been the impact of this initiative on quality of patient care, safety and experience?
Richard: Since implementation, results demonstrate an improvement of 24.6 per cent (up from 58 per cent pre-pilot) in out-of-hours tasks being handed over and completed. There was a significant 10 per cent increase in out-of-hours discharge rates with no negative effects on length of stay. Critical incident analyses revealed a change in the types of critical incidents reported; moving from a mixture of human and systematic error to only human error.
Shirley: Whilst there were improvements measured, it was challenging to evaluate this project in isolation, because many factors potentially impacted the outcomes measured. However, there was a noted culture change, we managed to make care proactive and not reactive.
What feedback did you receive from trainees?
Richard: We held focus groups and used safety attitudes questionnaires with trainees throughout the project to gauge their opinions. Feedback throughout has been overwhelmingly positive. Any negative comments received have been constructive and used to improve the handover process.
Shirley: Trainees rated the hospital ‘excellent’ for patient safety on the National Training Survey and a Core Medical Trainee commenting on the handover system said ‘we don’t use it because we have to; we use it because we want to’.
What are the main leadership and management lessons learnt?
Richard: 1) Establish buy-in early, particularly with consultant colleagues. 2) Directly confront and challenge motivations behind reasons for inertia. 3) Choose influential champions within each key stakeholder group to drive change.
What organisational factors contributed to the success of the initiative?
Richard: We were fortunate to have the full backing of the trust board. The project was supported by the chief executive (CEO), medical director, cinical lead and divisional general manager. As a trainee-implemented project it was part of the Learning to Make a Difference Programme initiated by our Royal College of Physicians tutor, Dr Shirley Hammersley, and supported by the CEO. This level of support was fundamental to the project’s success.
I was able to take four months part-time out-of-programme to participate in the Mersey Clinical Leadership Fellowship which allowed me to dedicate time to the project as well as to develop myself as a medical leader.
What were the main challenges?
Shirley: There were many challenges with IT with lots of faults and errors to begin with. We initially ran the old system concurrently, but a year in we have completely switched over.
Richard: The biggest challenge was the change in culture required from a number of key stakeholders. In order for the project to be a success it required a change in the processes or behaviours of a diverse group of people from doctors in training to receptionists, from bed managers to consultants. We identified champions early on to help us to achieve our goals and with their help were about to build momentum and enact a wholesale culture change within the trust.
What has happened since the HEE BTBC project has finished?
Richard: One year after running the pilot the handover system, processes and training programme are completely embedded in medicine and are continually being improved.
Shirley: We are now in the process of expanding to general surgery and Trauma and Orthopaedics. Our next steps are to develop what more we can do with the system. With a move towards seven day services, data collected electronically about the type and number of jobs generated will be used to inform workforce planning. We are also using information collected to improve patient flow, by identifying what elements hold up patient discharge, for example waiting for discharge summaries or waiting for test results, and diverting resources accordingly to overcome these delays.
How might your project be adopted or the lessons learnt shared in other trusts?
Richard: We have presented our findings widely in local, regional, national and international forums and trainees rotating to other hospitals have taken the lessons learned and good practice cultures with them. As a result the practices established in our project are being adopted not just by other teams within the trust, but also in other hospitals.
Shirley: The electronic system we used doesn’t have to be implemented in the same way. Iit worked for us, but every hospital is different and whatever baseline IT system they have could be adjusted accordingly. The benefit of the electronic systems is that it enables us to audit handover. However, the real success of the project was culture change. Emphasis on the importance of handover and the role of senior support in supervising and facilitating handover is key to improving patient safety.
What was your experience of being part of the HEE BTBC programme?
Richard: The input from HEE from day one has been indispensable and I have learnt a lot about management and leadership as a result of working closely with them. It has opened my eyes to what can be achieved within the NHS to improve patient care and safety when provided with a supportive and open environment in which to make positive changes. I have since moved on to another trust and I have not just integrated the handover structures there, but have also taken steps to get involved on a number of management committees as the SpR representative in order to help drive positive change.
Shirley: Being involved in the HEE BTBC programme provided much more than just financial support. Writing the application for the programme and presenting our proposal at interview meant we thoroughly planned the project before we started. HEE also gave us great ideas and support, for example they recommended partnering with an academic organisation, which is where our partnership with Keele University arose. Being part of a formal structured process and meeting regularly kept us on track. The opportunity to meet with leads from other HEE BTBC projects and share ideas was invaluable. I will take many of these lessons learnt forward in future work.