Background: Due to changes in regional provision of care for paediatrics, I started at GNCH as it began it’s busiest ever winter. Historically the Paediatrics department already had one of the worst In Time Completion rates within 24hours in the trust (standardly varying between 70 and 80%), missing the trust’s target of 80% and best practice standard of 90%. This looked set to only get worse at the hospital became busier. Process: I explored previous interventions to challenge this and the perceptions and barriers around In Time completion with a range of staff members including nurses, junior doctors and senior doctors. I realised that the main issues had previously been the lack of computers to complete the In Times on and this had subsequently been resolved. The main issues seemed to be that nursing staff would discharge patients without the junior doctors knowing, and that the junior doctors did not feel that this was an important piece of paperwork to complete when the ward was busy. I sought out a senior mentor – the clinical director of NUTH – and worked with him to map the In Time completion process. We then tested this model with a range of staff members. We tried to identify the reasons why In Times were not seen to be important. We identified that a lot of these were issues in common with any assessment unit and therefore coordinated with the adult assessment unit to ask about their experiences and any learning from these. This led to them agreeing to work with us to push this issue over the winter. We then had an awareness-raising campaign: ‘Remember, Remember, InTime November’ which had a new policy poster, a poster demonstrating the Intime process and some of the reasons it was important, emails and presentations to different sets of staff members. This coincided with following up repeat offenders or particularly bad shifts to ask what the challenges had been. Reflection: This project highlighted to me the challenge of changing culture. I really saw the value of processmapping, a new skill I had gained whilst undertaking my Trust’s leadership course. I was prompted to read more about cultural changes in large teams and this helped me realise that the ‘stick’ approach favoured by my clinical director was unlikely to be successful and that my initial thoughts about offering cake to the team every time 80% had been passed might have been more helpful. Whilst there was some improvement it was small and there were a number of confounding variables like increasing numbers of admissions. However the value of departments collaborating was noted and the efforts led to a personal thanks from the trust’s medical director. I also appreciated the value of run charts to feedback to all members of the MDT so we had a sense of how we were progressing.
Intime completion rates August - December 100% 90% 80% 70%
78% 77% 80%
82%
79% 81%
89% 89% 87% 85% 84% 83% 84% 84%
70% 64%
Percentage
60% 50% 40% 30% 20% 10% 0% 1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
August - September - November - December
Intime breakdown for August - December 250
Number of intimes
200
150 Incomplete Completed
100
50
0 1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16
The arrows indicate the time of the intervention.