STH’s Community Stroke Service team is comprised of Administrators, Nurses, Occupational Therapists, Pharmacists, Psychologists, Physiotherapists, Rehabilitation Assistants and Speech and Language Therapists who provide therapy and support to approximately 700 patients per year. Representatives from across the professional groups formed a microsystem team that began meeting in December 2014.
Using the 5Ps (Patients, Purpose, Professionals, Patterns and Processes) approach to assess the system highlighted various opportunities for improvement. A recurring issue was members of staff working in different ways which meant that patients were likely to be having different care experiences depending on which therapists they saw. This became increasingly apparent as the team worked together to produce a detailed process map of the patient journey (see below). The team felt that this was inequitable for patients and as a result were keen to work on standardising their work processes. As the time that patients spend with the Community Stroke Service is limited to a maximum of 12 weeks, the team were also keen to minimise delays to treatment.
As a result of the above analysis, the first key theme for improvement chosen was Timely and Equitable Service with the broad global aim of achieving optimum potential within the 12 week timeframe whilst having a positive patient experience.
The team’s first specific aim was to improve the quality of initial assessment and documentation by standardising the process. This decision followed a review of how the initial assessment was currently carried out and documented which highlighted a wide range of variation in approaches and content. Due to this variation, staff frequently repeated elements of the initial assessment that had been completed by other professionals. The team surveyed their colleagues to ask how they thought the initial assessment could be improved and designed a new assessment proforma based on this feedback.
The team have also worked on reducing the time that patients spend on their waiting lists after it was identified that there was significant variation in the amount of waiting time patients experienced which was felt to be inequitable. At the time, there was no defined process in place for therapists picking up patients from the waiting list so the team decided to trial a weekly 15 minute ‘huddle’ in their professional groups to discuss patients who are waiting and to match these up with therapists who have capacity to see them. The ‘huddles’ also give staff the opportunity to discuss who is best placed to pick up patients based on geographical location, which has the potential to decrease travel time and therefore increase face to face time with patients.
What has been achieved so far
The team now has a better understanding of their patients and are aware of how to make improvements to the service using the microsystems process. The team now has a better understanding of their patients and are aware of how to make improvements to the service using the microsystems process. M
apping out the service from start to finish has clarified, for all staff members, how the service currently works.
It feels like we as a team have started to understand the processes more, and have started to be more cohesive in our thinking because of this. Through the microsystems process we have highlighted how much variation there is within ways we work as a service, and our microsystem coach has helped us think about this in an objective, productive way
By looking at a range of data we have been able to see how we are currently performing which informs us for areas we need to improve. We are realising more that time spent on service improvement is important, as it could improve our service delivery and effectiveness. This in turn will make us more clinically effective and more cost effective and hopefully will improve patient satisfaction and equality of service delivered by the team.
The initial assessment proforma the team developed is used as a prompt across the wider team and as a result the quality of information recorded as part of the initial assessment process has improved leading to a reduction in duplication by staff from other professions. This is also more equitable for patients as they now receive a more standardised initial assessment which has a knock-on effect on downstream elements of their care.
The weekly waiting list huddle has led to significant decreases in waiting list times, including a 44% reduction in average waiting time to see a physiotherapist - down from 117 to 66 hours (see chart below). The variation in time patients wait has also decreased significantly (upper limit down from 299 hours to 146 hours) so this test of change has had a positive impact on both the equity and timeliness aims set out by the team. The team are continuing to monitor the impact of the waiting list huddle with a view to extending it out to other professional groups and are currently working on a tool to help clarify the complexity of workload across the teams.