Improved Outcomes in Prevention and Early Diagnosis

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Simon Rattenbury
Head of Laboratory Service
Microbiology
Seven Day Services supporting
Improved Outcomes in Prevention
and Early Diagnosis - Presentation from seven day services in diagnostics event on 4 March 2013 #7dayDiagnostics

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Improved Outcomes in Prevention and Early Diagnosis

  1. 1. Simon Rattenbury Head of Laboratory Service Microbiology Seven Day Services supporting Improved Outcomes in Prevention and Early Diagnosis 4th March The Royal NationalThe Royal Free Throat, Nose andHospital Ear Hospital
  2. 2. RFH Founded in 1828 Royal Charter 1837 Clinical Instruction for Women The Royal NationalThe Royal Free Throat, Nose andHospital Ear Hospital
  3. 3. • ~600 beds Reduced from 1200.• 700,000 patients a year from all over the world.• Employ around 4,600 people and have a turnover of about £450m.• Major A&E.• All branches of surgery and medicine The Royal National The Royal Free Throat, Nose and Hospital Ear Hospital
  4. 4. What am I Going to Cover• Scientists / Pathology & its Role• What was the need & why consider 24/7?• What was the clinical need?• The outline planning of the 24/7 case?• What the key points/take home message?• What did it deliver / measure success today? (time, Money, efficiency etc) The Royal National The Royal Free Throat, Nose and Hospital Ear Hospital
  5. 5. Why 24/7 Why Microbiology• Patients arent ill 9 to 5: – Better patient outcomes – Fit with patients care pathways – Antibiotic Stewardship – The new system of working was developed over several years. It involved changes to staff roles, training and contractual arrangements and was a major restructuring exercise The Royal National The Royal Free Throat, Nose and Hospital Ear Hospital
  6. 6. The 63 heroes who saved our son: Revealed in the heart- tugging story of a critically ill baby and the astonishing army of NHS staff needed to save one lifeTo save one life: 7 doctors, 9 consultants, 18 nurses, 5support staff, 22 scientists, 1 professor and 1 receptionist The Royal National The Royal Free Throat, Nose and6 Hospital Ear Hospital
  7. 7. Pathology Challenge• Organise services around the patient/users, – not disciplines, staff groups, hospital labs• Transform structures and practices Reduce variability Provide evidence of progress• No change is not an option• Take ownership and drive the agenda The Royal National The Royal Free Throat, Nose and Hospital Ear Hospital
  8. 8. Delivering “end- Vision of 24/7 to-end” Pathology Service Pathology Services enabling better NHS care Better patient outcomes Transforming the & commitment to a existing path quality 24/7 operating model Providing quality Increasing productivity services at PATIENT & delivering continuous competitive prices improvement Providing a A Department Developing Providing an Service for the employees are proud scientific & clinical integrated service Future to be part of knowledge end to end Innovation R&D Target Markets: Core pathology services in chosen geographies The Royal NationalThe Royal Free Throat, Nose andHospital Ear Hospital Specialist reference services nationally & internationally
  9. 9. Improvement Cycle UserPathology Service Satisfaction Improvement Pathology Modernisation The Royal National The Royal Free Throat, Nose and Hospital Ear Hospital
  10. 10. Current Service Provision Departments philosophyMolecular Rapid Microbiology• Chlamydia/GC• TB Patient• MRSA• Enteric Panel Real time• 16s RNA sequencing• Fungal 18ITs Sequencing• Typical & Atypical respiratory• C difficile toxin• MALDI ToF The Royal National The Royal Free Throat, Nose and Hospital Ear Hospital
  11. 11. The Past• Staff turnover………..high• Staff cover at weekend and out of hours was on a voluntary rather than a contractual basis.• Reliance on high cost locum staff and high turnover meant the training and staff experience was variable and at times services had to be withdrawn due to lack of staff available to perform the work The Royal National The Royal Free Throat, Nose and Hospital Ear Hospital
  12. 12. The Past• 2000 all new contracts were changed to 24/7 working including bank holidays• Staff titles were changed to ‘Health Care Scientists’ in an attempt to remove glass ceilings and introduce equality and to gain greater job satisfaction The Royal National The Royal Free Throat, Nose and Hospital Ear Hospital
  13. 13. The Past• Two on call systems were in operation (routine and High Secure Pathology Unit) plus additional staffing for – Blood cultures – MRSA – C difficile – Resistant Gram negative screening• Shift Rota was complex and time consuming• Required at least 2 .5 days to prepare but was not EWTD compliant The Royal National The Royal Free Throat, Nose and Hospital Ear Hospital
  14. 14. The Past• 2004 Introduction of more support grades and Health Care Scientists• Band re-profile 6 to 5• AP• MLA• No A&C grades The Royal National The Royal Free Throat, Nose and Hospital Ear Hospital
  15. 15. Staff grade 07/08 08/09 2011/138 6 5 57 BS 10 13 87 CS 6 4 46 BS 15 13 145 BS 0 0 34 AP 2 2 63 MLA 1 1 22 MLA 2 8 8A&C 4 3 3 0A&C 2 2 0 0Totals 50 49 47 The Royal National The Royal Free Throat, Nose and Hospital Ear Hospital
  16. 16. Workload & StaffingYear 06/07 07/08 08/09 11/12 12/13approxWorkload 250,000 300,000 350,000 500,000 600,000Staffing 50 50 49 47 47 The Royal National The Royal Free Throat, Nose and Hospital Ear Hospital
  17. 17. Introduction of 24/7• Major change• Negative and some positive impacts on staff• Time, effort and strong communication to work through the issues with staff.• Major concern for staff was reduction in pay; managed by providing pay protection for up to one year, variable lengths The Royal National The Royal Free Throat, Nose and Hospital Ear Hospital
  18. 18. Introduction of 24/7• The benefits to staff – self roster – working hours 37.5hrs – Improved staff safety.• New ways of working and career development – new roles to emerge e.g. the associate practitioner role.• Continuity of staffing – Provide better quality services and reduce the pressures that had previously been experienced The Royal National The Royal Free Throat, Nose and Hospital Ear Hospital
  19. 19. Introduction of 24/7• Addition of three bands 5• Gradual introduction of band 4 to be trained as Associate Practitioners.• Budget – Funding for pay protection was required Overall the remaining staffing changes were managed within the existing budget by re-profiling the skill mix. The Royal National The Royal Free Throat, Nose and Hospital Ear Hospital
  20. 20. Challenges• Unions• Consultation• Committee• Staff questions• HR A4C pay rates• Reserve lists• Multidisciplinary HSPU training• Three monthly and weekly rota• Went live 1st Aug 2009 The Royal National The Royal Free Throat, Nose and Hospital Ear Hospital
  21. 21. Challenges• Terms and conditions• Working practices - consultants• - technical• Culture - professional• - Management » - “siteism”• Corporate identity• Changing job roles• Ownership / territory• Takeover mentality• Disaffected staff The Royal National The Royal Free Throat, Nose and Hospital Ear Hospital
  22. 22. Staff View WORKING CONDITIONS RECRUITMENT AND RETENTION A4C/KSF INDUCTION STAFF CPD FOCUS TRAINING HEALTH AND SAFETY LOW SICKNESS RATES The Royal NationalThe Royal Free Throat, Nose andHospital Ear Hospital
  23. 23. What’s Needed• Management Support• Resources• Team Building• Organisational / Personal Development• Vision / Plan• Leadership• Resolve• Time• Stability• Communication The Royal National The Royal Free Throat, Nose and Hospital Ear Hospital
  24. 24. In Transition: Key Objectives• Keep the system safe in transition• Drive sustainable innovation and service excellence• Modernise planning to deliver a patient centred approach that embraces patient pathways• Enable service transformation – Move general services closer to patients’ homes – Centralise specialist services to leverage expertise and drive economies of scale – Integrate across health and social care The Royal National The Royal Free Throat, Nose and Hospital Ear Hospital
  25. 25. Top Tips• Have clear and measurable goals and realistic timeframes when planning the changes.• Engage staff early in the change process and gain as much agreement with the project goals as possible.• Ensure that all meetings have minutes taken and they are distributed to all staff• Ensure negotiations with staff are reasonable and managed well• Skill changes provide positive training and development opportunities for all staff and enable flexible rosters The Royal National The Royal Free Throat, Nose and Hospital Ear Hospital
  26. 26. Top Tips• Develop key baseline measures and track the measures to demonstrate the improvements to all stakeholders…Win/Win• Be prepared to modify original plans where possible so that staff are involved and are part of the decision making• Allowing staff to design the shift and rosters system worked well• Recognition of staff in their staff review The Royal National The Royal Free Throat, Nose and Hospital Ear Hospital
  27. 27. Types Time Staff numbersof Shift HCS MLAEarly 8.00 am to 4.30 pm 1 1Core 9.00 am to 5.30 pm 15 7Late 11.30 am to 8.00pm 2 2Nights 8.00pm to 8.00am 1 0 7.30pm to 7.30am 1 0 The Royal National The Royal Free Throat, Nose and Hospital Ear Hospital
  28. 28. Night Person Night Person 2 19:30 Hand over Hand over 20:30 Blood Cultures Start final put up of all left 21:30 over samples 22:30 Fluids Help with follow up 23:30 " 00:30 Follow up of both benches Lunch 01:30 Urines Lunch " 02:30 Any urgent samples PLUS " 03:30 Help on urines " 04:30 " " 05:30 Make sure all samples " 06:30 are booked in plus blood " 07:30 cultures put on analyses " The Royal NationalThe Royal Free Throat, Nose andHospital Ear Hospital
  29. 29. Sections Sat 21.04.12 Sun 22.04.12 SECTION LEADER RECEPTION ▲ Taufiq am –please note reception / spa done Early Sat only sorted ▲Taufiq am –please note reception / spa done on night shift + tristel Late on night shift + tristel No colour= Core Night ® kumar (V) >2 ® kumar >1 Over time / SPA Komal ☼< 1 pm ▲ Taufiq pm Xtra hours Urines Put up ♣ ▲ Taufiq pm;♣Sarah>4 ♣Sarah Waste collection / autoclave ® kumar (V) (minimal) priority<2 ® kumar ( minimal) <1 Michelle ♦Michelle Team Stool Put up + Stool Put up ( priority for CDT) + Stool Put up ( priority for CDT) leader: &CDT( 12.30) + Sub SF/APW/Acetamide + Sub SF/APW/Acetamide + OCP Prep / Crypto stain + OCP Prep / Crypto stain + Send TDM levels @ 10 am and 3 pm + Send TDM levels @ 10 am and 3 pm Owen Maria ( No Maldi) Maria( No Maldi) Please ensure BLOOD CULTURES + IQC Oxidase / Nephelometer + IQC Oxidase / Nephelometer + report TDM + GC Screen / Read & record AST + GC Screen / Read & record AST relevant plates + GUM +Sub ATCC Ctrls Sub ATCC Ctrls (if applicable) for closed + Report TDM + Report TDM sections are placed in the FLUIDS NW+FU *Owen( No Maldi) *Owen( No Maldi) fridge RESPIRATORY NW+FU Rizalea ( V) Includes reporting on Sunday *Owen RESPIRATORY NW Putup Komal ☼>2pm Rizalea( V) MRSA CULTURE & PCR Mohammed Mohammed + CDT PCR if required + CDT PCR if required HVS Kanti 9-1 CLOSED Read the NW only and complete the FU RNOH & MALDI ♣Sarah<4 ( RNOH Maldi only) ♣Sarah( RNOH Maldi only/ SPA URINES NIGHT Jasim CLOSED WOUNDS/ E.N.T/ACIN NIGHT NIGHT ENTERICS Komal ☼ only to Screen for Salm/ Komal ☼ start to finish + reporting Shi < 11-45 SEROLOGY CLOSED CLOSED VIPER CLOSED CLOSED Computing CLOSED Owen Night staff Lucy Lucy • Wounds / ENT • Wounds / ENT • Leave reporting for Sun night if • Leave FU on bench with instruction necessary Jasim • Night duties Jasim: urine start to finish • Help Lucy with FU + reporting • Read TVs/BVs and Record + Sub LIMs Paul • Night duties • Read TVs/BVs and Record + Sub LIMs • Help Lucy with + reporting HSPU Day Maria Maria Night Jasim Lucy Sickness Andrew Andrew The Royal NationalThe Royal Free Throat, Nose and MICROBIOLOGY WEEKEND ROTA (Prepared by ABhamra)Hospital Ear Hospital
  30. 30. MICROBIOLOGY WEEKLY ROTA (Ed 23 March 2012) Rota Prepared by:A.BhamraSections / Section-leaders Monday 23/04/12 Tuesday24/04/12 Wednesday 25/04/12 Thursday26/04/12 Friday 27/04/12Deputy Rota Maker + weekly overdues Rajita Monica am Victoria Rajita Rajita Rajita : SL Rajita Chris , Angela Chris Angela Chris AngelaJudith Yonas Angela Chris Angela Victoria 0n tuesday Judith Shaila Judith Shaila Shaila, θAudrey pm Judith Andrew Judith Andrew Fitzroy 8-9 Fitzroy 8-9 Fitzroy 8-9 Fitzroy 8-9;Rita Fitzroy 8-9 Rita Ward Duties Jenny closed Yonas closed Yonas URINE/ GU MED : Section leader Owen rine Phx + Urine NW +AP •Maferim<11.30 •Maferim<11.30 •Maferim<11.30 Temitayo Temitayo Temitayo Temitayo Temitayo Dr Lakshi Dr Lakshi Dr LakshiUrine NW & FU +Microscopy Saroj ♥Komal>4.30 Saroj γRizalea<4.30 Saroj♥ Komal>4.30 Saroj⊗Kanti >4.30 Saroj ⊗Kanti >4.30 HVS+ GC+ settle plate < 4 Alan Vicky Alan Alan Alan + MALDI SPOTTING GC ONLY SWAB CULTURE: Section leader Kanti read / report Kanti, ♥Komal Kanti ♥Komal Kanti, ♥Komal ⊗Kanti,Komal ⊗Kanti,Komal follow-up < 3 Kanti, ♥Komal Kanti ♥Komal ♦Vicky >11 ♦Vicky >11 ♦Vicky >11 up (SPA) ↓Samer >10 Andrew JennyChika>4.30 ♦Vicky <11 Jenny ♦Vicky <11 ♦Vicky <11 •Maferim>11.30 •Maferim>11.30 •Maferim>11.30 ↓Samer >10 ↓Samer >10 Dr Anna pm ↓Samer >10 Andrew Andrew↓Samer >10 Shaila°Mod >2 Shaila°Mod >2 HAI : Section leader Gemma (am/pm) Kumar/ωMonica brief Kumar Kumar Kumar Kumar + MALDI SPOTTING culture) +transferx2 runs ωMonica am θAudrey am/2 pm θAudrey am/2 pm θAudrey am/2 pm θAudrey am/2 pm MYCOLOGY: Section leader Rebecca (Tues & Fri) Shanti ♠Shanti koh Dr Daniel=dopsx2 * Rebecca/Shanti ↓Samer 9-10 ↓Samer 9-10 ↓Samer 9-10 ↓Samer 9-10 ↓Samer 9-10 (Mon & Thu) Rebecca/Shanti+koh Rebecca/Shanti+koh BLOOD / FLUID: Section leader : Monica Victoria 0n Tuesday pm + MALDI SPOTTING Sirilaksmi Sirilaksmi Sirilaksmi Sirilaksmi SirilaksmiFluids + MALDI SPOTTING Harry Emma Monica am /Dr Anna ♠Shanti +koh Anna Emma Anna Emma am Victoria Emma <2 Sini /Mohammed Sini /Mohammed Sini/ Mohammed+caf °Mohammed °MohammedMain Lab cover 1-2 Kanti/Komal Purnima/Gemma Harry Sirilaksmi Anna Sirilaksmi Rajita Audrey RESPIRATORY / TB: Section leader Kanti + MALDI SPOTTING Manpreet Manpreet Manpreetam Victoria Manpreet ManpreetDr Anna amRNOH Tissues + MALDI SPOTTING Anna /Rachel Anna Rachel Rajita Rachel Rajita Rachel Rajita Rachel Xpert-CepheidPCR) Rizalea/Chika+ind -AL γRizalea&Chika<4.3 Rizalea Chika Harry Chika Harry Chika ENTERICS / IQC: Section leader : Purnima Gemma ( Wed) + CDT/HP transfer 4-4.15 Purnima Gemma Purnima Gemma Gemma Purnima Gemma Purnima Gemma H.pylori prep only( Mon & Thu) ◊ Michelle ◊ Michelle Stool/CDT /OCP prep &CDT assay ◊ Michelle Yonas Michelle ◊ Michelle Michelle IQC am (all day Wednesday) Ω Rajita am till 7pm θAudrey pm Harry θAudrey pm θAudrey pm SEROLOGY: Section leader Rajita( Purnima on Tuesday) / TDM (if closed) Rita Rita Rita Night(Paul) Night(Sini)MLA Serology prep + send aways Fitzroy 9 -4.30Kristine Fitzroy9 -4.30 Fitzroy 9 -4.30 Fitzroy9 -4.3Kristine Fitzroy 9 -4.30 i DS2 on Mon/Thu only +H.Pylori DS2 Kristine Kristine +H.Pylori DS2 Kristine MOLECULAR (VIPER): Section leader Victoria( Mon-Wed),Gemma( Thu-Fri)Chlamydia Viper / CDT & HPYL via DS2 Night( Sarah) Night( Sarah) Night( Sarah) Jenny JennyCT/GC Transfer results Night( Sarah) Night( Sarah) Night( Sarah) Night( Lucy) Night( Lucy) MOLECULAR (Other): Section leader Victoria( Mon-Wed),Gemma( Thu-Fri)Molecular (16s & others) / Atypical PCR ↑Damion Kevin ↑Damion Kevin Damion Kevin Damion Kevin Damion Kevin am ( half day 2 staff ) Anna Rob Rizalea Rob Rizalea RobOther Activities + R&D Rebecca=maldi sort Monica am =caf sort Monica =caf sort Rebecca/♣Owen ΩRajita 7pm =Audit +dops for Dr Daniel- Maria pm= audit ‘f’ std maldi sort ,Abh= Rota writMonica pm =caf sort see Amrat Sini= audit –see mk Monica =strep phx Victoria =Eucast plan Abh= Rota Maria till 7= audit : ↑ Damion =CoSurv Owen↑Damion pm Owen ICE+CoSurv Owen/Maria am ♣Owen +CoSurv MEDIA / WASH-UP: Section leader Adrain Media stock Tues / delivery Weds Taufiq Taufiq Taufiq Taufiq TaufiqRegistrars office /Enquiries Kelly, Valeria Kelly, Valeria Kelly, Valeria Kelly, Valeria Kelly, Valeria SR,Abh,Mk am,AL Abh Mk AL Abh,Mk am AL SR,Mk AL Mk AL Lucy Sarah Paul Sarah Paul Sarah Paul Lucy Sini Lucy LEAVE (Med) = Medical (S) = Study L:Yonas,Dallas,Audrey L:Dallas, Gina L:Dallas,Gina, L:Dallas,Gina, O: L:Dallas,Gina,Jasim(E) = Emergency (O) = off duty due to 24/7 GinaPaulO:TomMaria, O:,Michelle, RebeccaO:TomLucy, Maferima,Tom,Sarah Kevin pm, SR,Chika (L) = Annual / Time-In-Lieu Leave Owen,Jasim , Mk pm Tom,Lucy,Maria, Purnima,Jasim, Victoria,Jasim, MP: O: Maferima,Tom, (MP) = M/Paternity (MT) = Meeting S:VickyRob MP Jasim Rajita MP: MK pm,Monica pm Anthea MT:Monica Sarah,Victoria,Paul, Francis @georgeds,Fenella rfh –virology, AntheaMT:Michelle/Ab AntheaSHarry,Manar S: Maria, Manpreet 10-11.30 & 1-2 MP: Anthea Catherine r&d @ rfh,Ingrid@Barts,Manar @ ccrp1-2,Sini & Abh Alan,EmmaSamantha pm MP: Anthea S: Manpreet pm Over time Kristine Mon 9- 12.15-12.30, Sam/Abh RobMT:Yonas/Abh MT:SR Thu/Fri 9-11.30,Judith tue 9- 12-12.15 ccrp 12-1,Monica pm,SR,AL10.30-11 Night Training Late shift Early HCS 1.5hrs Dr Rita Oladele: observer from ECCMID in dept for I month The Royal National The Royal Free Throat, Nose and Hospital Ear Hospital
  31. 31. Sections / Section-leaders Monday 23/04/12 Tuesday24/04/12 Wednesday Thursday26/04/12 Friday 27/04/12 25/04/12Deputy Rota Maker + weekly overdues Rajita Monica am Victoria Rajita Rajita Rajita RECEPTION: SL Rajita Chris , Angela Chris Angela Chris AngelaJudith Yonas Angela Chris Angela Monica am Victoria 0n tuesday Judith Shaila Judith Shaila Shaila, Judith Andrew Judith Andrew Ward Duties Fitzroy 8-9 Fitzroy 8-9 θAudrey pm Fitzroy 8-9;Rita Fitzroy 8-9 Rita Fitzroy 8-9 Jenny closed Yonas closed Yonas URINE/ GU MED : Section leader OwenUrine Phx + Urine NW +AP •Maferim<11.30 •Maferim<11.30 •Maferim<11.30 Temitayo TemitayoUrine NW & FU +Microscopy Temitayo Temitayo Temitayo Dr Lakshi Dr Lakshi Saroj ♥Komal>4.30 Saroj γRizalea<4.30 Dr Lakshi Saroj⊗Kanti >4.30 Saroj ⊗Kanti >4.30 Saroj♥ Komal>4.30GU MED HVS+ GC+ settle plate < 4 Alan Vicky Alan Alan Alan + MALDI SPOTTING GC ONLY SWAB CULTURE: Section leader KantiWounds / Ent read / report Kanti, ♥Komal Kanti ♥Komal Kanti, ♥Komal ⊗Kanti,Komal ⊗Kanti,KomalWounds / Ent follow-up < 3 Kanti, ♥Komal Kanti ♥Komal ♦Vicky >11 ♦Vicky >11 ♦Vicky >11Swab put-up (SPA) ↓Samer >10 Andrew JennyChika>4.30 ♦Vicky <11 Jenny ♦Vicky <11 ♦Vicky <11 •Maferim>11.30 •Maferim>11.30 •Maferim>11.30 ↓Samer >10 ↓Samer >10 Dr Anna pm ↓Samer >10 Andrew Andrew↓Samer >10 Shaila°Mod >2 Shaila°Mod >2 HAI : Section leader GemmaACP MRSA (am/pm) Kumar/ωMonica brief Kumar Kumar Kumar Kumar + MALDI SPOTTING ωMonica am θAudrey am/2 pm θAudrey am/2 pm θAudrey am/2 pm θAudrey am/2 pmHAI (MRSA culture) +transferx2 runs MYCOLOGY: Section leader RebeccaMycology (Tues & Fri) Shanti ♠Shanti koh Dr Daniel=dopsx2 * Rebecca/ShantiMLA 1HPLC (Mon & Thu) ↓Samer 9-10 ↓Samer 9-10 ↓Samer 9-10 ↓Samer 9-10 ↓Samer 9-10 Rebecca/Shanti+koh Rebecca/Shanti+koh BLOOD / FLUID: Section leader : Monica Victoria 0n Tuesday pmBlood culture + MALDI SPOTTING Sirilaksmi Sirilaksmi Sirilaksmi Sirilaksmi Sirilaksmi The Royal National The Royal FreeFluids Hospital + MALDI Throat, Nose and SPOTTING Harry Emma Monica am /Dr Anna ♠Shanti +koh Anna Emma Anna Emma Ear Hospital am Victoria EmmaMALDI LAB <2 Sini /Mohammed Sini /Mohammed Sini/ Mohammed+caf °Mohammed °Mohammed
  32. 32. Summary• To ensure that workforce planning, training, & education drive sustainable innovations• To deliver a capable and flexible workforce now and in the future.• An aim to improve the quality of care and the experience of patients and staff at all levels and enable them to embrace change and improvement.” The Royal National The Royal Free Throat, Nose and Hospital Ear Hospital

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