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Lean Events Archive

Non Elective Patient Flows

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The Problem, Approach & Objectives

The Problem:

RUH staff identified through the 'what makes your blood boil' event that patients are pushed through the system, often move un-necessarily and staff are constantly fire fighting. 

The Approach:

The programme held a three day event on the 19th, 20th and 21st September to look at the entire non elective pathway from GP/ED Attendance to Discharge (Medical and Surgical).

The Objectives:

A team of 35 members of staff from across the Trust attended the event with the intention to deliver on the following objectives;

  • Document the current no-elective pathway from GP referral to 'Green to go', quantifying min and max time to discharge.
  • Identify waste and non-value added steps for the patient.
  • Document what good looks like incorporating ideas from our patient story.
  • Create a future state non elective pathway and associated action plan to deliver the changes

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A 3-day Lean event mapping the current state process, identifying waste in the process and designing the future state process was held on the 19th, 20th and 21st September.

Some of the staff who participated in the 3 day Lean process

Key stakeholders that attended the event include:

Kevin Roles,
SAU ward manager
Mariska Oddy (change agent),
Junior Sister Surgical Ward (FB)
Jill Wiseman,
MSS Ward Clerk
Jo Flint,
Surgical Ward Manager Ward (Waterhouse)
Becky Solly,
MAU Ward Clerk
Jo Harris,
Medical Ward Manager (MSS)
Dr Dominic Williamson,
ED Consultant
Anita West,
Medical Ward Sister (Victoria)
Mr. McFarlane,
Urology Consultant
Gayle Wynn,
Mr. Simon Evans,
Urology Consultant
Dionne Wilkinson (change agent),
Sister Acute Stroke Unit
Ms. Rebecca Winterborn,
Vascular Consultant
Julian Hunt,
Nurse Consultant ITU
Dr Lesley Jordan,
David McClay (change agent),
Business Development Manager
Dr Carol Peden,
Simon Jack,
Bed Manager
Dr Bob Marjot,
Melanie Mahoney,
Access to Care Sirona
Dr Anu Garg,
Acute Physician/Cardiologist
Jessica Flower (change agent),
IT Change Analyst
Nigel Roberts,
Diana Hall-Hall,
Yvonne Thompson (change agent),
OT Team Leader
James Scott,
Chief Executive
Helen Davies,
Physiotherapist Assistant
Clare O’Farrell,
Divisional Manager Medicine
Alison Norbury (change agent),
Sister, Theatre 1 coordinator
Suzanne Wills,
Divisional Manager Surgery
Helen Brewer,
DAT rep
Fiona Bird,
Specialty Manager Medicine
Sue Vost,
DATE and DLN rep
Lisa Hunt,
Chief Operating Officer and Facilitator
Simon Andrews,
Ward Manager Surgical ward (FB)
Lisa Lewis,
Project Manager and Facilitator

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Current State Mapping

The group split into two (medical and surgical) and mapped the current state pathway for a non-elective patient from ED or GP expected attendance to 'Green to Go' (discharge).

The vast number of processes clearly
demonstrated by a post-it for each step

It is clear that the processes are quite complicated and one attendee commented 'it's no wonder the patient get lots in our system, look at how complicated it is?'  The group then did some analysis on the numbers e.g. length of stay, number of admissions and discharges through a ward.  By looking at this data you can start to quantify the time it takes for a patient to go through the system.  The conclusions were;

  • It can take up to 4 days to get a full assessment and diagnosis
  • It can take up to 56 hours for Emergency Surgery
  • Patients can stay up to 90 days (for sick patient + all the waits and delays)
  • One entry point through ED and admit everyone

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The hospital from a Patient's perspective

Day 2 started by listening to a patient story; Diana Hall Hall, an active member of the Banes Link Patient group and her Husband Jake.  Diana is the sole carer of Jake and both Jake and Diana have been through the Non Elective Pathway a number of times.  Below is an extract of Diana's story or you can listen to the audio file to hear the full story.  Diana starts her story in the ED department:


  • Facilities:
    Uncomfortable, dingy chairs in the waiting area before you get into the cubicle.
    Refreshments not easily to come by.
  • ED White board:
    Carer learnt how to read the board, knew her husband was a medical patient and how long he'd been waiting.

    Nurse in change told the carer off as it was meant for the staff not patients. Suggestion to anonymise the patient names as it's in such a public place.
  • Communication:
    Whilst in ED the not knowing was the worst part of the experience. Even if it's going to be a long wait the patient would rather know this rather than no nothing. Suggestion to have volunteers just to keep you up to date and perhaps make tea.


Good that it's open all hours and visitors can go in on a regular basis. Difficult to get through on the phone however. Waited for some considerable time for doctor opinion to know if the patient was staying or moving onto another ward.

General Wards

Older People's Ward and Acute Stroke are excellent, can't commend highly enough. Doctors always there to speak too. On occasions patient has been admitted to inappropriate wards e.g. Cheseldon and Day Surgery. Patient stayed in hospital longer as they had to constantly find out information from specialist doctors on how to treat him.


Sometimes given 1 hours' notice sometimes none. Discharges don't seem to be planned, one occasion they waited in the corridor for a long time as the bed was needed and TTAs and transport wasn't ready.


Very difficult to get hold of, you have to work hard to get it. One occasion patient had broken collar bone and was asked if she could still drive.


Not written until 4.30 when they were told in the morning he was going home.

Communication on wards

Carer is a demanding relative so always asked what's going on, 'I've had to ask but not afraid to ask' 'information was not withheld but I've been doing the asking'. Those who don't know much about healthcare might struggle as our carer knew what to look out for and what questions to ask.

Out of Hours

When admitted at the weekend and some evenings the carer was told by the doctor that he couldn't get his medical records as it was Friday evening, not really 21st century! Due to the lack of notes for some days the carer had to repeat medical history constantly. Summary care record will be great as patient's allergies can be recorded so everyone knows the risk.

Community Services

There is a gap in provision in the community – patient was once unsteady onhis feet but not acutely unwell – he was admitted to acute stroke taking up a valuable bed, he didn't need to be there. Other occasion ambulance informed patient the RUH was full and contacted GP to arrange other arrangements. Nothing in the community could be found so patient was admitted.

General feel of the hospital

Carer could feel the stress of the hospital, everyone so busy. Not always possible to speak to the named nurse, 'they know the sort of things that you want to hear that you're worried about'. I.e meds given at different times, 'with anti-epileptic they have to be given at set times, this doesn't happen in hospital and patient used to strict routine'. Patient does get worried about drug taking at different times.

If you could change three things about your stay what would it be?

  1. In ED, better communication, the not knowing is very worrying as you can’t plan anything. Volunteers could be used.
  2. Discharge – waiting for TTAs, not well planned. Sat in the corridor for some time as they needed the bed, sometimes felt rushed.
  3. Overall the treatment that has been provided at the RUH is excellent and nothing really to complain about.

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What does good look like?

Intense discussions around the table by some of the attendees.

In the afternoon on day 3 the group spent some time thinking about what good looks like for Diana and how we could have done thinking differently for her and Jake. 

The rest of the afternoon the group did a session on creative thinking to get the group thinking differently about our services.   

They then split into groups and designed what good looks like, being created with magazines cut outs, flip chart paper and pens. 

Jointly the two groups came up with the same themes for what does good look like? They were;

  1. One touch assessment – diagnostic hub with MDT input within 2 hours
  2. Expected patients into assessment areas not into ED
  3. Ring fenced emergency theatre lists
  4. Develop IT to share information internally so wards can PULL patients and externally so Community can PULL patients out of Acute Care.
  5. Patients navigated through the system, discharge destination agreed on admission
  6. 'Seamless patient journey with agreed expectations and outcomes'

Consultant Vascular Surgeon Rebecca Winterborn presenting 'What Good Looks Like' from Surgery's perspective to the group

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Turning 'What good looks like' into actions

On day 3 the group focused on putting the results of 'what does good look like' and lessons learnt from the current state review into a new and improved future non elective pathway.  Key points in designing a future state map are:

  • Incorporate your 'just do it's
  • Be achievable in 6 to 9 months (medium term)
  • balancing long term actions with quick wins
  • Challenge the rules, don't let history dictate the future

The group successfully produced a future state map that included improved access to front door assessments, ring fenced theatre lists, wards pulling from ED and direct admit wards and discharge plan agreed on admission. 

The document below shows the draft process maps for the future non elective pathway:

Non Elective Future State Value Stream

The action plans are designed to structure the delivery of the new future state pathway.  They are separated out into front door and ward, theatres, Forrester Brown assessment and ITU.  The action plan below contains the detailed task, the owner and timescale for delivery.   Updates to the plan will be via the website and via the Programme Steering Group.

Non Elective Future State Action Plan

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What happens next?

James Scott, Chief Executive thanking the
attendees, and discussing their plans.

A programme board chaired by Lisa Hunt will be supporting the staff that came up with all the solutions to implement the plans. 

James Scott came along to the final day and also gave the programme his full support.

Involving all staff

This programme will affect all staff and we need your support to make these changes in the interest of our patients. 

We'd like to invite you to find out more; The key outcomes will be presented at the next open staff meeting on the 18th October at 1pm.

We will have stand outside the Atrium on Friday 5th October

We will be doing a trolley dash around the wards on the 5th October. 

We'd like to provide an update at departmental meetings and those that attended the event are asked to provide an update to their colleagues (attendee names below). Also go to our website for the outputs of the day via our logo on the intranet home page.

Non Elective Communication Bulletin

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Involving GPs and Community Teams

The already established Urgent Care Network, attended by RUH staff Fiona Bird, Dr Dominic Williamson (attendees of the lean event), GPs and other health professionals are in the process of working through some of these ideas e.g. GP referral pro forma.

Other ideas generated from the lean event will be discussed with the Urgent Care Network Group and taken forward as a joint initiative.

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