Aims and objectives:
The aim was to improve the quality of the discharge process by promoting pro-active decision-making and multi-disciplinary goal setting, to reduce the length of stay for patients admitted to the Hospital, without compromising the quality of care provided. This was achieved by devising, implementing and evaluating a new multi-disciplinary goal setting document, [supported with guidelines] for completion at the established weekly multi-disciplinary team meetings.
By improving the discharge process we can contribute to the local delivery plan objective to reduce emergency bed days by 5%, by 2008. The increased access to beds through the improved discharge process would prevent inappropriate GP emergency admissions to acute trusts. It would also prevent patients who require transfer to Ilkeston Community Hospital waiting in an acute bed.
By providing care locally, we also contribute to the national target to support older people to live in their own homes, as those patients discharged from the Hospital would have their continuing care needs addressed prior to discharge.
Support for the change:
Project initiated at request of Chief Executive, so had executive sponsorship. Small Project Group and larger Stakeholder Group established, with all multi-disciplinary teams, administration, senior managerial and GP representatives. Members of the Project Group attended the national "Clinical Micro-system" programme being piloted by the Coronary Heart Disease Collaborative, and utilised the 4 P's methodology and questionnaires with staff and GP's to understand the current systems at Ilkeston Community Hospital with regards to Patients, People, Patterns and Processes.
Action plan with timescales and responsibilities developed and regularly reviewed. Project also supported by the PCT's Service Development Team.
To sustain the change regular reports are given to the Hospital Medical Committee and a project notice board was erected within the hospital, for staff and patients/carers to read, this displays information and results from the project. A newsletter was produced for ward staff and articles have been included in the PCT "Insight" magazine for staff.
Length of stay data is included in the monthly Board report to monitor progress. Ultimately, the members of the project team act as champions and are continually driving the project forward within each discipline.
Patient and public influence:
All patients admitted to the Hospital are informed of the discharge process shortly after admission. This ensures that patients and carers are aware of the process, and that anticipated length of stay is identified on an individual, patient centred basis.
Increased involvement of Care Managers at ward level has reduced the referral time for a Care Manager to be involved in discharge from 5 to 2 days. Whilst requests for informal Care Manager visits to the ward have increased, to address ad hoc patient/carer concerns.
Currently piloting an electronic patient satisfaction tool on the wards where the new multi-disciplinary goal setting document has been used. Initial results are reporting high levels of patient satisfaction.
Impact on the workforce:
The project has increased knowledge of all staff disciplines, [including students and junior members of each team] regarding the complex discharge process and the role and function of the Hospital.
The long established multi-disciplinary team meetings are now more structured and focused on goal setting for discharge. This has developed how the teams work and reduced the time spent in meetings, thus freeing up all disciplines for direct patient care activities.
Time-out sessions, open to all disciplines involved in the discharge process, are planned for early 2005. These will be used to further promote and inform multi-disciplinary staff development in discharge planning.
Measuring the results:
From the outset, the team were aware that the Hospital had a higher than average length of stay compared to other community hospitals in the area.
The length of stay and delayed discharges are now measured monthly and reported to the Board, the project Stakeholder Group and the Hospital Medical Committee. The data is displayed on the project notice board at the Hospital, for staff, patients and visitors to see.
The project group are also reviewing case notes of patients that are re-admitted from home within 28 days of discharge, to identify if any lessons can be learnt, to further improve the discharge process.
Improved performance:
Since the start of change we have reduced length of stay by 7.1 days, from an average of 43.5 days to 36.4 days.
Statistical process control [SPC] charts have been introduced to demonstrate the impact of the change and natural variation in the discharge process. This has developed a constructive and inquisitive approach to the data, ensuring that the improvement is a continuous process. Data is now embedded into the reporting process at the Hospital and the format of the Board report has been changed to more accurately reflect length of stay data.
Reflecting diversity:
The project aimed to improve the patient's journey, and reduce the length of stay. Some patients still stay in hospital for more than 100 days, because this is the level of care they require. However, the numbers of these patients has significantly reduced.
The Project Group and Stakeholder Group members are from different sections of the workforce representing all staff groups at the Hospital. The "Clinical Micro-Systems" questionnaires were distributed to all staff groups to ensure diverse views were taken into account.
At the multi-disciplinary team meetings, patient goals are set taking into account the skills and knowledge of all staff groups.
Sharing the learning:
Shared information at discharge study day with colleagues from Trent SHA, and with colleagues involved in the "Clinical Micro-systems" workshops.
Project Group members share information with colleagues at team meetings, the Hospital Medical Committee and the project notice board at the Hospital is updated quarterly. Articles have also been included in the internal PCT "Insight" magazine.
The project entered the PCT Service Improvement Awards and won the "Working Together" category. Details of the project are included on the PCT Service Improvement intranet website.
Outstanding features:
The changes made have been sustained, positively evaluated and shared.
Project Group and Stakeholder Group members are continually identifying new ideas for further changes, which is fostering a culture of continuous improvement.
