NHS Lothian case study: testing Daily Dynamic Discharge at St John's Hospital

St John's Hospital Pilots New Approach to Patient Discharge

In order to: improve the experience of patients and staff every time, without waits, delays and duplication

Deliver: safe, person-centred, effective care to every patient,

The 6 Essential Actions:

Clinically Focused and Empowered Management

The operation of basic hospital and facilities management, visible leadership and ownership through managerial, nursing and medical triumvirate team, creation of clear escalation policies and improved communication supported by safety and flow huddles.

Capacity and Patient Flow Realignment

Establishing and then utilising appropriate performance management and trend data to ensure that the correct resources are applied at the right time, right place and in the right format. This will include Basic Building Blocks, Bed Management Toolkit, Workforce Capacity Toolkit and alignment with Guided Patient Flow Analysis.

Patient Rather Than Bed Management

Managing the patient journey requires a coordinated multi-disciplinary approach to care management, dynamic discharge processes: access to diagnostics, appropriate assessment, alignment of medical and therapeutic care; home when ready with appropriate medication and transport arrangements, discharge in the morning, criteria led discharge, transfers of care to GP.

Medical and Surgical Processes Arranged for Optimal Care

Designed to pull patients from ED through assessment/receiving units , provide access to assessment and clinical intervention, prompt transfer to specialist care in appropriate place designed to give care without delay, move to downstream specialty wards without delay and discharge when ready, utilising criteria-led discharge where appropriate.

7 Day Services

The priority is to reduce evening, weekday and weekend variation in access to assessment, diagnostics and support services focussed on where and when this is required to: avoid admission where possible, optimise in-patient care pathway, reduce length of stay and improve weekend and early in the day discharges safely.

Ensuring Patients are Cared for in Their Own Homes

Considers pathways to support avoiding attendance, and how someone who has an unscheduled care episode can be optimally assessed without need for full admission, if required they will be cared for and discharged to their own home as soon as ready. Anticipatory Care Plans, redirection to appropriate health care practitioner and shift from emergency to urgent care is the focus for sustainability.

When Health Boards are under pressure to tackle patient flow problems, the temptation is quickly to introduce wholesale improvement measures without giving much thought to baseline measurement, evaluation or team engagement. While such changes can sometimes be effective in the short-term, they can be difficult to sustain long-term and it can be hard to evidence improvement without the data to back it up.

St John's acute hospital in NHS Lothian has taken a different approach. It has introduced a small scale test of change on a single ward in the hospital, using the Daily Dynamic Discharge approach developed by the Scottish Government's 6 Essential Actions for Unscheduled Care Programme. This is their story…

Patient Flow Problems

Like most acute hospitals, St John's often experiences a mismatch between demand and capacity. Patients requiring admission tend to arrive earlier in the day while patient discharges typically take place much later in the day. This inevitably impacts on the availability of beds.

One of the causes of non-clinical delays in discharging patients is the fact that there is no clearly defined approach to prioritising discharge-dependent tasks. Sometimes, it isn't until the day of discharge that multidisciplinary teams become aware of the tasks that are still to be completed before the patient can go home. Inevitably, this leads to discharge delays and a drop in performance against the four-hour emergency access standard. Patients who are ready to go home spend longer in hospital than is clinically necessary due to systemic inefficiency, while other patients are waiting in A&E for hard-pressed staff to try and find them a bed.

Prioritising Patient Discharge

The Daily Dynamic Discharge approach facilitates early discharge planning. It enables ward teams to make logical choices about the tasks that need to be completed each day to prevent discharge delays and includes a series of steps that they can take to improve patient flow. One of these is to implement twice daily discharge planning meetings.

St John's decided to introduce the Daily Dynamic Discharge approach to Ward 9, which is one of its busiest general medical wards in the hospital with a rapid throughput of patients. Service Improvement Manager for Unscheduled Care, Megan Reid explained why:

"When patients are discharged in a reactive way it leads to massive pressure on the system and a poor experience for the patient. We were really keen to try something different. We chose Ward 9 because it is a busy ward with a high patient turnover, so there was a big opportunity for improvement."

Service Improvement Manager for Unscheduled Care, Megan Reid

Co-Creating a Solution

Lessons learned from previous service improvement projects taught Megan that it is essential to establish baseline measures and to work closely with the ward team to bring about improvement:

"You can go in with the best intentions but, in my experience, what works best is to co-create a solution with the team involved. A ward is a complex environment with many different dynamics in play. You need to get to know the team, understand what their challenges are and ask them "what would work for you?" The success of a service improvement project lies with the team that will live and breathe it day to day."

Establishing a Baseline

As well as working closely with the ward team, Megan was keen to use the available data to establish a baseline and to measure any improvement. "There is a wealth of data," she commented, "but you need to know how to use it and how to communicate it. I looked at things like the number of discharges daily, which days of the week saw the peaks, what time of day most discharges occurred and what caused hold-ups."

Data showed that Ward 9 was discharging around 12-13 patients a week, the majority in the afternoon or early evening. There were a number of causes of discharge delays, including patients waiting for their prescription for take-home drugs to be processed or delays in arranging care packages at home or nursing home places.

(left to right) Melony Gannon - Physiotherapist, Julie Soutar - Ward Charge Nurse, Lyndsey Watt - Discharge Hub Co-ordinator, Rachel Roberts - Occupational Therapist, Joe Cooney - Junior Doctor, Susan Scott - Discharge Hub Manager, Hazel Lloyd - Pharmacist

Twice Daily Huddle

St John's took a systematic approach to improvement, implementing elements of the Daily Dynamic Discharge model that they believed would make the biggest difference in the shortest time. They introduced a 9am multi-disciplinary team huddle meeting where staff look at the patients who are to be discharged that day and complete any outstanding tasks to ensure discharge is achieved without unnecessary delay. There is a follow-up meeting at 2.30pm, where the focus moves from reactive to proactive discharge planning. The huddle comprises a brief review of the morning's actions, and a checklist of tasks that still need to be completed, an assessment of any changes from the now-completed ward rounds, and a forward plan for patients who will be discharged in the next few days.

Megan explained:
"We start having the conversations much earlier now. If patients will need transport, we plan it in advance. We start talking to specialist nurses and district nurses and discuss what we will need to put in place for the patient. We organise for prescriptions to be written up in advance so they are ready to send to pharmacy in advance of day of discharge."

Shared Responsibility

The daily action summary for each patient is written on a task sheet, which is held by the nurse in charge, but there is also a whiteboard showing the status of each patient so every member of the multi-disciplinary team can see what needs to happen and by when. At certain times, for example if outbreaks of norovirus occur in the hospital, some members of the multidisciplinary team can't attend the team meeting. In these instances, the nurse in charge takes responsibility for conveying to absent members of the team what they need to do to facilitate discharge for patients.

Overcoming Challenges

As with any service improvement, the introduction of the Daily Dynamic Discharge approach was not without its challenges. Changing the way that patient care is prioritised has led to staff having to adapt their working practices, which can be difficult. For junior doctors in particular, the need for prescriptions to be written earlier in the day created a potential problem as mornings are when the consultants visit the ward and the junior doctors need to be available to accompany them on their ward rounds. St John's is getting around this problem by planning discharge prescriptions a few days in advance, wherever possible, so junior doctors don't have competing demands in the morning. This also helps to streamline the discharge process for patients who are waiting for a nursing home place or a package of care at home.

"Sometimes patients would be waiting for a care package to be put in place before they could be discharged," said Megan. "We might hear in the morning that the care package is ready to start or the patient had got a nursing home place, but then the discharge would be further delayed because we were waiting for a prescription for their take-home medication. This happens less frequently now as prescriptions are written when a patient is safe for discharge, before the actual day of discharge wherever possible."

Positive Impact

After a month, St John's reviewed the patient discharge data to assess what impact the Daily Dynamic Discharge approach was having on the ward.

The average number of discharges per week has doubled from 12 to 24. More patients are now being discharged far earlier in the day, typically between 10am and 2pm rather than late afternoon or evening. The ward is succeeding in discharging more patients on a Saturday (previously the average was only one patient, now it is averaging four) and the number of Wednesday discharges has trebled from an average of two to around six. Patients are also being referred to occupational health far earlier in their inpatient stay. Before the introduction of Daily Dynamic Discharge the average time from admission to referral was 8.7 days. Since implementation, the wait is 3.8 days. Discharge scripts are being received by technicians earlier in the day too. The pilot has brought benefits for all professionals in the ward team.

What's Next?

Having tested this model of improvement on one ward, St John's is keen to roll it out to other parts of the hospital and plans to implement the Daily Dynamic Discharge approach on another medical ward in the next few weeks. "As we did with the first ward, I am keen to take a pragmatic approach to their particular challenges and issues," said Megan. "I won't be going in with a tried and tested approach to implement. I will be co-creating something with the team that suits their needs and that will work for them."

The Health Board also plans to build on the success of discharge planning using Daily Dynamic Discharge by communicating and involving the patient and their family earlier in the process. The team plans to introduce a way of engaging with the patient and their family on admission to the ward to capture background information so they can understand the patient better. They will discuss opportunities to work together with families, whether that be the family providing transport on discharge or helping to bridge a gap in care prior to the package of care starting. The team hopes that this will further improve the patient experience, allow them to accommodate appropriate amendments in the patient's care and also manage expectations of all involved.

Key Learning Points

One of the points that emerges as a clear factor in the success of this project is the Health Board's willingness to co-create a new way of working alongside the ward team. "The success of this project lies with the team," said Megan. "It is a big commitment to ask them to introduce twice-daily meetings and it is crucial that they are fully on-board with the idea and can understand why they are doing it. For this reason, I was very careful to communicate the data showing the difference this was making and also to show my appreciation for their hard work. For any change to work and be sustained, the team needs to own it and to see that it makes a difference."

The project helped to shine a spotlight on sub-optimal ways of working and the team has shown a great willingness to address these practices. For example, junior doctors now write prescriptions for take-home medicines far sooner than the day of discharge, in many cases. This requires planning and commitment. As the junior doctors rotate, it will be important for the Health Board to re-engage with each new cohort and explain why it is necessary to work in this way. St John's recognises this and is committed to maintaining this practice.

Megan concluded:
"We are very pleased with the way this pilot project went. Ward staff now receive a weekly summary showing how they are doing and what the obstacles are to discharging patients. It is a very helpful and insightful way of using the data we have and the team is fully engaged in discussing what we could do differently next time. Communication and collaboration is the key."

Acknowledgments

We would like to thank everyone who has contributed to this case study. By openly sharing your experiences, your challenges and your learning, you are helping to spread best practice and drive system-wide improvement.

These stories serve to inspire others and celebrate the hard work of individuals who are committed to making things better for patients. In particular, we would like to acknowledge:

St Johns Service Improvement Manager for Unscheduled Care, Megan Reid; The multi-disciplinary team, managers, executives and staff at St John's Hospital; Case study writer, Kate Philbin; and the National Unscheduled Care Team.

If you are inspired to share your improvement story, we'd love to hear from you. Please get in touch at UnscheduledCareTeam@gov.scot