Transcript Discharge-to-Assessx

Discovering Great Care:
How Sheffield discovered Discharge to Assess
Paul Harriman
21st January 2016
GREAT CARE IS DISCOVERED,
NOT DECIDED
from Steven Speir and modified by Tom Downes
Topics
• Health warning!
• How we started the journey
• Understanding our system
• Discharge to Assess
• Some messages/thoughts
• Open for discussion
Health warning!
• Do not just copy and paste our solution; it may not be
appropriate for your system.
• You need to do the hard graft to understand your multiorganisational, multi-silo systems and their constraints.
• Do not just copy and paste our solution; it may not be
appropriate for your system.
How we started the journey
• Lots of anecdote
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Why does GSM always have outliers?
Bed blockers
Increase in frail elderly admissions in winter
If only we had daily ward rounds it would improve
• Little evidence to support some of these
• Started as an offshoot of “Flow, Cost, Quality” work
Our approach
The Big Room (Oobeya)
A place to meet; the Big Room in action
Physiotherapist
Discharge
Liaison
Service
Improvement
GSM
Matron
Senior
registrar
General
Manager
For
Medicine
Community
Services
manager
Secretary
Physiotherapist gives an
account of the test of change
to get a patient home on the day they
were discharged by the GSM consultant
Social
Services
Manager
Understanding our system
• Make it visible – map it
• Think about the system from the patients perspective
• Measure it
• Demand, supply, time and WIP
• What is the root cause problem (disease not symptoms)
The Emergency System (High Level)
Death
Surgical
Ortho
Assessment
Medical
Assessment
Assessment
Units
Assessment
Unit
Unit
Units
NGH
A&E
RHH
Minor
Injuries
Darzi
Centre
Radiology
Pathology
Pharmacy
Social Services
Intermediate
care
RHH
Specialties
Specialties
Specialties
Specialties
Specialties
EAU
RHH
Walk-in
Centre
GP Co-op
NGH
Specialties
Specialties
Specialties
Specialties
Specialties
Radiology
Pathology
Pharmacy
Social Services
Permanent Place of Residence
Social Services
23 sets of notes
No medical issues
Windows of opportunity
2,259 days could have been 515
Discharge to Assess (D2A)
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Words are important
Traditional working is Assess to Discharge
Mrs H
Frailty Unit change highlighted a new constraint
Multiple PDSA cycles on FU
It should work on a base ward as well
Discharge process – 1 patients experience
Flow Map Following Mrs D’s Transfer of Care Document Process
Monday 10th Dec
·
·
Ward
·
Ward decide
to discharge
·
Contact
Assessment
Medications
Authorisation
Request for
Services
Transfer of care
Completed by ward
OT
Took about 60 mins
Transfer of Care team
Mrs D was admitted on 3rd Dec via AE.
Transferred to Frailty Unit where Contact
Assessment was done the same day. FDRT
started ToC on 4th Dec. She was transferred
to RH6 on 6th Dec
Photocopy
all 21 pages.
Takes 10-15
mins
Done at
≈11:30 10
Dec
Fax machine takes 2 pages
Double sided papers
Single sided copier
Remove staples
Only 1 fax machine on ward
Takes around 50 mins to fax
Place
document in
tray on ward
Done at
≈12:00
Tuesday 11th Dec
Wednesday 12th Dec
Comments
Mrs D was ready to be discharged on
Monday 10th Dec. Her CICS/STIT start date
was Tuesday 18th Dec. However, her ward
bay was affected by Norovirus...
Process takes about 60
mins
Taken down
by OT to
Transfer of
Care (ToC)
Admin at
≈16:00
Ward OT
receives
request for
missing data
Obtains new
data from
notes
Ward receive CICS and
STIT start dates
Faxes data to
ToC Admin
About 08:45
Refile
originals in
notes
75% have items
missing often due to
fax problems
Check to see
if documents
are complete
Scan into
SystemOne
(S1)
Register
patient to
ToC team on
S1
Receive
phone call
from CICS re
start date
Send
referrral
electronically
to SPA using
S1
Received ≈
12:50 on 11th
Dec
Done at
16:23
Send
documents
to SW dept
at NGH
including
CICS start
date
Receive call from
SW Admin
requesting missing
data
ToC Admin
receive new
data by fax
Ring ward
OT to
request new
data
Receive phone
call from NGH
SW with STIT
start date
ToC Admin
fax new
sheets to SW
Admin
Received at 13:39
Ring ToC
Nurse with
this info
ToC Nurse
rings/visits
ward with
start dates
Whole process took 46 hours
About 08:30
Process takes about 5
mins
Single Point of Access (SPA)
No push
notiffication
Refresh S1 to
pick up new
referral
Done at
16:27
Electronically
refer to
appropriate
CICS team
Done at
16:29
If urgent/
same day
then ring
CICS as well
Work done was about 4 hours
CICS
Only 28 slots
available per
week on
Discharge
Pathway
Referral
“pings” up
on CICS
screen
Push button
to accept
Done at
16:28
STIT
NGH Social Work Department
Process should take
about 20 mins
If request is “late” the
queued overnight for
batch next day
CICS work to 1800
ToC work to 1700
SW work to 1730
Print of copy
of attached
images
Update/add
data to S1 as
required
Select next/
appropriate
date in Excel
spreadsheet
Check on
InSight to
see if record
exists
If yes add
flag to
spreadsheet
record
Place
documents
in folder for
relevant date
Has to run up
stairs and
write data x3
Ring ToC
with CICS
start date
Tried at
17:08 – no
reply
Re-ring next
day
To get 2 dates takes about 5 mins
Write on
board in
office (holds
2/52 ahead)
Run upstairs
an write on
board in
therapists
office (holds
1/52 ahead0
This happened twice as
second piece of missing
data identified after
first iteration
If incomplete add
to incomplete
spreadsheet and
file documents in
folder
Receive fax
from ToC
admin
Received≈13:
09
Check to see
if documents
complete
Add details
to CareFirst
system
Process takes about 30
mins
Review
patient
details to see
if any open
contacts
Receive
email into
duty email
box
Fax
documents
to STIT
Update info
as required
Ring ToC with
start date
Done after
17:00
Add activity
to STIT
Ring STIT
Receive
documents
by fax from
SW
Received at
15:29
Print off
documents
Collect any
relevant data
Give to Julie
Hart (?) for
checking and
allocation
Look at diary
for next/
matching
date
Email date
back to SW
dept at NGH
Done at
16:46
Process takes about 75
mins
Re-ring
Done at
08:30
Does the process add any value to
the patients care…………..
What’s the problem at ward level?
This is a symptom not the disease!
Testing
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1 patient
2 patients
Repeat with 2 patients
5 days
Results
D2A
starts
Implementation
of D2A
Implementation
of D2A
Wider impact of redesign
9,078 pts in 2015
Some thoughts/messages
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Understand the whole system (visualise and measure)
Top down doesn’t work (buy-in)
Staff need to own the problem and the solution
Use PDSA (properly) and start small
Give teams the space and time to experiment
Commissioners (both health and social) need to be involved –
the front door saga.
• Good care costs less, causes less harm and improves morale
“It’s changed the way we think.”
GREAT CARE IS DISCOVERED,
NOT DECIDED
Thank you
[email protected]
#Improvingflow
#sheffieldmca