DISCHARGE PLANNINGRAPID IMPROVEMENT EVENT

-involving partner organisations

1

5770

670

505

373

310

407

2235

524

231

1337

127

3018

22

3

30

Skerryvore 7132

Heilendi 3372

Patients registered with a GP Practice

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

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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.

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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

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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

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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

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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

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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