A structured approach to implementing change

Using the NHS Change Model as a framework for the project, the team planned how the vaccine programme could be delivered. Working through the model, two components in particular were invaluable and underscored the PCN’s approach.

Our shared purpose

The following shared purpose was developed and embraced by all across the PCN. ”Work together to vaccinate the most vulnerable people, giving that person the gift of life and a hug from a loved one.”

Leadership by all

Getting the programme up and running would require everyone to lead in their own sphere of influence, take responsibility for implementing change and be available, accessible, accountable and brave.

Motivate and mobilise

Recognising team members’ different motivational behaviours and emotions early on was important as it helped with the following.

• Recognising when people were in conflict, so communications were tailored to the needs of the individuals, recognising that in times of stress clear communications are even more important.
• Agree where to best allocate team members so they work to their strengths g. the PCN’s director for transformation kept up to date with all the national information, guidance and governance, and flagged any actions that were required with the contracts and finance director.  These were roles they both preferred and complemented each other.

Three days to plan a vaccine programme

With only three days before the Pfizer vaccine arrived, PCN managers rapidly mapped out what the process would look like from when a patient was identified and booked into a clinic, through to inoculation. A copy of the process map was shared with practices for staff to consult on. Here a clinician flagged that the whole patient consent process had been missed out. On reflection the PCN managers recognised that without initial clinical input, they had focussed heavily on the admin side of the process. This highlighted that Leadership by all needs to include “everyone who is involved in the process”.

Once the process was agreed the PCN identified patients that were eligible.

• A list was compiled of all patients across the PCN aged 80 years and over who were not housebound.
• Each patient was reviewed by a clinician and removed if there were any contra indications e.g. taking blood thinning medication.

Patients were then contacted and invited to attend the vaccine site. The PCN found some patients were unable to attend the early morning slots because their bus passes were off peak and could not be used until 9.30am. After raising the issue at a system-wide meeting where the CCG and local authority were present, the local authority contacted the Nexus bus company who agreed to allow the travel passes to be accepted before 9.30am.

Ensuring every vaccine is used

With demand for the vaccine high and supply limited, the PCN worked through the Measurement component of the NHS Change Model to ensure as many patients as possible were vaccinated safely and all doses of the vaccine used. This would require the following.

• Monitor the time it took to inoculate a patient and add extra slots to clinics if there was capacity.
• Keeping constant track of DNAs and offering slots that become available to other patients on the reserve list as soon as possible.
• Monitoring vaccine levels to ensure they were used before going out of date i.e. monitor hourly from halfway through the clinic, then half hourly during the last two hours.

The PCN adopted a contingency aim to vaccinate a reserve list if the need arose, which would be made up of NHS staff in high-risk groups. Staff capacity to ring people was planned into the process.

In total 975 doses of the vaccine were received to administer over four daily clinics at one site. The clinics were scheduled to take place from Monday (which was a two hour clinic which would also be used as an opportunity to test the process), through to Thursday which were full day clinics.

Testing and making tweaks in real time

As the PCN had so little time to plan and get the vaccine site up and running, it had to test the process in real time and make any tweaks promptly.

• On the first day of the clinic it was taking 12 minutes to inoculate a patient, by the following day staff had become so familiar with the process they reduced the time to 6 minutes and then eventually 5 minutes per patient, and now 4 minutes per patient. This freed up capacity and allowed the PCN to offer more slots; impact on social distancing and observation of patients was considered. This testing helped to identify the sixth dose of vaccine early in the process.
• When offering more slots the PCN found patients at its Oxford Terrace practice might have difficulty travelling to the vaccine site at short notice, but Birtley practice patients would not. As a result, Birtley practice patients were contacted first to fill up new slots as they were more likely to take them.
• On the last day clinics were fully booked but there were 16 DNAs. As the vaccine had a limited shelf life and needed to be used that day, slots were offered to those on the reserve list to community staff.

The real time testing and tweaking of the process enabled the PCN to make rapid improvements where needed and limit wasted resource so all available vaccines were used.

Impact

• Over 3.5 days the PCN inoculated 965 patients most at risk of COVID-19, giving them a good protection from coronavirus. Only 10 went to waste due to leakages in the phial which was beyond the PCN’s control.
• Feedback from patients has been hugely positive, they are grateful for this life-saving vaccine and feel assured they are now better protected against the coronavirus.
• This was a real team effort across the PCN, from clinicians to managers, right through to administrators and patient coordinators. All staff stepped up to the challenge and worked collectively to extremely tight deadlines in a highly pressured situation.
• Successful working with the system e.g. local authority and local bus company, helped the PCN work to full capacity and inoculate as many patients as possible.
• Using quality improvement tools and techniques provided the team with a safe environment to plan, putting in place reliable systems to test and successfully deliver COVID vaccine clinics.
• The PCN now has a tried and tested COVID vaccine programme that it will use for future vaccine clinics as more doses of the vaccine become available.
• The PCN will continue to use quality improvement to test new national and local developments as its knowledge about vaccine delivery increases to include care homes, housebound patients and other cohorts. It will also consider and test new models of delivery as the weather changes.