1. Opportunities for Sustainability
Reducing Long Length of Stay at Barnet Hospital
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Barnet Hospital: Using a collaborative improvement methodology to reduce the number of long length of stay patients (>21 days) on the medical wards
Barnet Hospital faced a consistent challenge of promoting patient flow from ED through to the base wards. The UEC improvement teams
From ECIST and HLP were requested to run a diagnostics and recommend opportunities that would improve flow.
As winter approached in 2018, the number of admissions increased at Barnet Hospital, putting pressure on internal flow onto the medicine base wards. Following a review of the Medicine and Urgent Care Wards in December 2018, recommendations were made to introduce and embed long length of stay (LLoS) reviews (patients with over 21 days stay), over a six week period. ECIST and Healthy London Partnership (HLP) Improvement Managers approach consisted of engaging with key senior stakeholders across the system, training and coaching of the LLoS programme leads, commencement and implementation of LLoS Reviews, QI methodology to influence weekly changes, facilitation of detailed case reviews. Further improvement work continues within the system, including a review of the discharge pathways and trusted assessor model, the creation of a delirium pathway into community services and the financial agreement for the discharging of complex patients on the Discharge to Assess Pathway 3.
What we did
TIPS REGARDING FORMATTING
Use graphic elements, like boxes, to highlight each section of your poster.
Use space to create emphasis.
Use no more than 2-3 colours, and dark type on a light background.
Conclusions first, keep them short and to the point in the upper left-hand corner.
Simple graphs are effective graphs.
Make the text big enough to read.
Use Arial or Lato font.
ALWAYS left align the text.
Keep your headings the same size and style throughout.
Avoid chaos, keep the layout easy for the eye to follow.
Images and graphs say more than words, so keep your poster visual.
If you are using a photo, avoid web images – use at least 150 dpi, but no more than 300 dpi.
Don’t forget any other logos where necessary.
Training delivered by ECIST and HLP on how to conduct LLoS Reviews. Direct supporting and coaching of Clinical Lead for reviews
Key stakeholder engagement across the system, including: NCL Adult & Social Care Leads, BCF Leads, STP Directors, UEC Commissioners, NHS RightCare, Clinical Network Groups, Barnet Exec Team
Improvement methodology to implement and embed reviews throughout the six week implementation period. Qualitative and quantitative data tools used to track weekly developments
Delivered on establishing a site-based optimal rhythm of hosting weekly reviews, including escalation processes. HLP analysed the data over the six week period: As weekly numbers of patients in the day LLoS bracket increased (from 27% to 40%), the discharge rate of these patients the following week remained high (16-19%)
Introduced weekly clinically-led complex patient meeting
With an investment in continued improvement and sustainability of these reviews, a decrease in the LLoS numbers is expected. HLP continue to offer arms length support to the site team
Findings & Impact
Opportunities for Sustainability
Flow:
Every week, 6%-18% of LLoS patients became unwell, from being medically optimised the previous week (data: weeks1-4)
The highest rate of discharging occurred for patients with LLoS days, with remaining complex patients requiring more input (multi-agency, clinical, external factors etc)
Variability in discharge planning skills between wards and understanding of pathways
Engagement & Participation:
Medical input on the wards (when available) along with the system-wide partners’ contribution enhanced patient-centric discussions
Unclear issues with the interface between Trusted Assessor model and Jewish care homes
Noticeable improvement in the quality of the 1.30pm Wednesday system-partner DToC meeting reported by participants
Knowledge:
Use of electronic patient records as part of the review process helped with obtaining most accurate up-to-date information, including social services and discharge team updates
Doubling up of information/disconnect of information held at ward level and with discharge team
Training:
Evidence of deskilled nursing staff: reliance on flow coordinators
Variability in early active parallel discharge planning
Mental Health Capacity Act – how/when it should be used not fully understood by all staff during discharge processes in some cases eg. decisions for patients with capacity being taken
Ward to Board leadership visibility: increasing the confidence of staff to ask questions, face challenges and instil #HomeFirst way of working
Share successes: social media movement of “hearts and minds” – promoting patient care, reducing patient harm, linking with staff, CCG, community, volunteer sector
Review alignment of information: between new clinically complex patient meeting, LLoS reviews and daily multi-agency partner meeting
Visibility: share findings of progress with ward – SPC charts can be shared with staff to illustrate the improvement journey
Embed the DPTL toolkit and share/develop best practice: sustain the SRO support for the LLoS Reviews and nominate Clinical lead involvement in national LLoS Collaborative programme
Offer of objective reviews of LLoS Reviews with any recommendations every three/four weeks for over the next three months
To find out more, please contact:
Eileen Sutton
@healthyLDN