RAPID IMPROVEMENT EVENT involving partner organisations DISCHARGE PLANNING RAPID IMPROVEMENT EVENT - involving partner organisations

70 57 670 Patients registered with a GP Practice 505 231 524 127 373 30 524 127 22 373 2235 3 310 3018 Skerryvore 7132 Brief description of Orkney and demographics – challenges to service delivery Heilendi 3372 1337 407 2 2

Priorities leading to involvement with LA Many issues surrounding discharge process A complex process involving many staff from a range of organisations A number of incidents and complaints relating to this area Issues relating to unsatisfactory discharge thought by staff to impact on quality of care No current joint discharge policy Orkney Health and Care – substantive from April 2010 Core Team – multidisciplinary team representing all aspects of the service from Voluntary sector, Health and Social care Opportunistic

Goals of the RIE Implementation of agreed patient focused pathway from admission to discharge ‘home’ All planned discharges will be safe and appropriate Timely access to health and care services To have an agreed, relevant, up to date, joint discharge policy, owned by all Effective communication with all agencies at all relevant stages to support patient pathway Initiate a process to achieve a shared and unified IT system across Orkney Health & Care.

Achievements during the week Agreed to initiate Multi-disciplinary team meetings on a daily basis (MDTs) at 11am each day in the Acute area to plan discharge for each patient in the Acute area in a proactive manner Agreed to develop Standard Operating Procedures for pre-admission and admission Agreed to develop Standard Operating Procedures for the MDTs with immediate effect Agreed to undertake reflective practice

Longer term actions An action plan was agreed at the end of the RIE with 48 actions all of which were owned and had a timescale associated with them Some of the major ones included: Improving communication between acute care, primary care and social care Improved admin support Transport review Development of Admit to discharge documentation

Outstanding Actions Improved patient information A new joint discharge policy Widespread use of PARIS across health & care IT system for Minor Injuries Improved (web-based) discharge system Pharmacy improvements including self medication assessments where appropriate Linked governance systems for joint working Education and training to staff to underpin principles of discharge planning

Measurable Benefits Reduction in number of emergency readmissions to hospital following discharge Reduction in length of stay for above Reduction in number of incidents reported and complaints regarding discharges Red Cross - improved flow due to improved patient transport and hostel service (reducing inpatient length of stay) and communication Questionnaire responses from staff and patients

Learning and Challenges Opportunity to foster good partnership working and improved integration Opportunity to understand each others challenges and perspectives (intra and inter-agency) Opportunity to develop joint aims and visions and joint training Cultural differences (e.g. incident reporting) Work towards development of joint policies and protocols Joint governance – person centred approach/involvement Joint discharge arrangements A seamless service Ensure all voluntary sector partners with an interest are involved where possible

Where Next? Ensure actions continue to be followed up Overcoming barriers that were identified e.g. cultural differences – shadowing and joint training Ongoing challenge to access separate IT systems Continue to improve communication Roll out to other hospital areas