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

2. 70 57 670 Patients registered with a GP Practice 505 231 524 127 37330
524
127 22
373
2235 3
310
3018
Skerryvore 7132
Brief description of Orkney and demographics – challenges to service delivery
Heilendi
1337
407 2 2

3. 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

4. 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.

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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