The Red and Green Day approach was created by Dr Ian Sturgess a number of year ago. His quick guide can be found here.
“The Red:Green Bed day is a visual management system to assist in the identification of wasted time in a patients journey. It is most applicable to in-patient wards in both acute and community settings” (Dr Ian Sturgess)
At the end of March 2016, one of our wards at Mid Cheshire Hospital NHS Foundation Trust tested this approach and we have learnt a lot since. We have been approached by a few people to ask what we do so here is our story so far:
- First, you need a team. The picture above is our great team.
- Second, start thinking like a patient. Ask yourself, would you want to be sat in a bed worrying about why you are in hospital, wondering what will happen next and why you have to continually wait for things to happen?
- Third, take a moment each afternoon to step back and look through the patients on the ward. Have they had a day that has progressed their care pathway? Was it worth their time being here? Sounds simple, right?
What is less simple are the next steps:
Staff on the ward started to feel uncomfortable. “We are all working really hard and this constant reviewing is taking time away from our patients”. You then discover 30-50% of your patients are on a Red day and what that really means about the care they are receiving, there’s too much waiting (from a patients perspective).
By challenging ourselves we were able to identify the main causes for delay and in some cases put them right the same day. Pulling together the information on a database, we discovered how we could work at all levels (ward, Trust and with our external partners) to change things for the better and reduce the number of red days.
As we discussed the patients at a ward level we identified what was in our gift to influence and we put some delays right the same day. For the other causes, we coded them according to recurrent themes (see list below) and assigned responsibility (ward, Trust and external partners) and the centralised database provided us with information about the frequency of specific delays.
- Diagnostic test not requested
- Diagnostic test not reported/ conducted
- Diagnostic test not acted upon
- Internal referral not requested
- Internal referral not occurred
- Internal referral advice not acted on
- TTOs not ready
- No management plan/ senior review/ intended day of discharge
- Social referral delay (ward)
- Social referral delay response
- Social referral delay delivery e.g. package of care
- Internal transfer delay
- External referral delay
- Rehabilitation ward referral delay
- Rehabilitation ward response
- ICT (integrated care team) referral
- ICT response
- ICT delivery
- Therapy required
- Green bed
This helped ward teams to see where they could have the most impact, identifying specific areas they could work on to improve the timeliness of the patient’s journey (the constraints).
Trust and external issues were escalated and this enabled day to day delays to be quantified and explored. The challenge was to not accept any delay. Improvements that have been delivered following this work include:
- Electronic consultant to consultant referrals
- Regular MDT meetings
- Increased emphasis on the intended date of discharge.
The Red and Green day approach is currently taking place on three of our wards with plans to roll out further.
What have we learned?
Urgent and emergency care is a complex adaptive system. This means we need simple rules.
Red and green days is a perfect example of simple rules, the approach really works to help reduce the amount of time our patients wait unnecessarily.