PSIP 7 Test Submissions

PSIP Test submissions

Test submission 1

Initial ideas for improvement: using Model For Improvement Questions

Q1: What are you trying to accomplish? i.e. What overall improvement do you want?

N.B. Focus on what needs improving overall and NOT a solution or intervention. Does NOT need to be quantifiable or target driven (i.e. ‘how much’ ‘by when’).

Overall I need to make the team work more efficiently to meet the demands upon it. I would like ultimately to be able to roster time for ward work, emergencies and administration related to clinics. The overall improvement I want to see will only be achieved by one smaller improvement at a time (1000 lives). REF

Q2. How will you know that a change is an improvement?

N.B. What would it ‘be’ like, what could you ‘evidence’ as improvement? Leads on to how you might be able to ‘measure’ or ‘evaluate’ that.

I hope to demonstrate that the change is an improvement by measuring the increase in time available to trained staff, which can then be utilised to enable further improvements. Efficiency could also be quantified in a lower cost per patient appointment. Satisfaction with the new service could be measured by patients completing the existing friends and family cards and perceived quality could be measured by the opinions of colleagues, managers and the relevant consultants. The safety of the change will be examined by audit id datex reports.

Q3. What changes can be made that will result in improvement? (May not be known yet of course, or just some basic ideas)

3a) What is wrong

It is necessary to understand the problem to understand the solution (1000 lives)REF .The Nurse Practitioner team are not able to spend the time which they would like with ward patients and emergencies. In order to improve waiting times for urology patients it is vital to increase the frequency of Nurse led clinics. There is increasing demand for further elective appointments. Currently the Nurse Practitioner on call for emergency admissions also has scheduled appointments at the same time, meaning delays to both the emergency patient and the patient with

the routine appointment. The constraints concerning the availability of facilities currently dictate when particular clinics can run e.g. the availability of clinic rooms and other staff.

N.B. focus on the underlying problems or issues in relation to what needs to be improved.

3b) What might work?

Restructuring our work pattern could work, but I feel that there are too many conflicting requirements.

I feel that fully developing the Band 3 HCA role in our team, enabling her to manage more patients independently, will liberate more time in the team as a whole. I have previously improved other areas such as working more efficiently together and fully utilising our volunteer. There are a few areas of our elective work that I think could be taken on by a HCA experienced in Urology with appropriate training. These areas include trial without catheter for patients after radical prostatectomy, removal of a tethered stent after ureteroscopic stone surgery, and possibly female catheterisation to administer a bladder treatment. In order to simplify this project I have chosen to concentrate on removal of tethered stents ( Appendix 2).

N.B. Focus on any changes that might work to bring about that improvement.

Test submission 2



The purpose of my service improvement project is to try to improve the quality of

information / evidence in Guardianship reports in my local authority. I would like to

help make the gathering of information more focused, more relevant to welfare

issues, which Guardianship is all about and therefore to make the evidence in the

reports less open to potential legal challenge.


I am aware that improvement is a very subjective term. My view of an improvement

may be totally different from my colleagues or my manager’s views. So I am

approaching my SIP with this in mind and hopefully the end result will be seen as an

improvement by all stakeholders (or at least most of them).

Following a change in the way information is gathered and reports are written,

improvements in the Guardianship application process could be observed /

measured by workers feeling more confident about their guardianship applications;

by managers observing a high quality of report writing, by the local authority having

few challenges to Guardianship applications from tribunals or by Nearest Relatives

objecting to the orders. Finally, it will hopefully enable service users and carers to

have a greater understanding of the process which could lead to increased levels of

compliance with the orders.


3a) Anecdotal evidence from colleagues in my own local authority and others indicate

that many AMHP’s do not like completing Guardianship applications. They believe

the paperwork is not fit for purpose; they are not always certain whether

Guardianship is the most appropriate piece of legislation or whether the individual

needs a different framework (such as the Mental Capacity Act).

When writing AMHP reports for Guardianship applications the AMHP’s in my local

authority use the same form that they use for Mental Health Act assessments. These

forms primarily focus on the risks to the person from their mental disorder rather than

their social situation. The problem many AMHP’s find is that they can feel deskilled

when making Guardianship applications. There is also a risk of the work just

becoming a paper exercise with little room for evidencing the use of professional

judgement in these cases.

3b) Some possible options that may improve the Guardianship applications may include

specialist training for AMHP’s, a ‘checklist / aide memoir’ that AMHP’s could refer to when

completing Guardianship assessments or changing the Guardianship reports themselves.

Test submission 3



N.B. Focus on what needs improving overall and NOT a solution or intervention. Does NOT need to be quantifiable or target driven (i.e. ‘how much’ ‘by when’).

Through this service improvement project I aim to improve communication

between our team of ANP’s, and older patients who have been discharged

home from our care. The purpose of this is too provide older patients with a

means of directly speaking with an ANP with specialist knowledge and skills,

should they encounter any problems or have any questions once they have

been been discharged from hospital. Due to our current job role and access to

community services we would then be able to signpost patients to community

services or bring them into our ambulatory emergency clinic to assess them. It

is hoped this will provide a better service for older patients and potentially

prevent inpatient admissions to hospital.


N.B. What would it ‘be’ like, what could you ‘evidence’ as improvement? Leads on to how you might be able to ‘measure’ or ‘evaluate’ that.

If this change is an improvement I would expect to see an increase in

communication on discharge between ANP’s and patients. I would hope there

to be increased patient satisfaction and reassurance for patients and relatives

alike on discharge. Statistical information and documenting communication

between ANP’s and patients on discharge which shows the reason for

interaction between ANP and patient, and the outcome would aim to evidence

this improvement. Equally, this service improvement may may also lead to a

reduction in hospital admissions by signposting patients to primary and

secondary services as required, although this may be difficult to evidence as it

would be based on personal judgement.


3a) What is wrong?

N.B. focus on the underlying problems or issues in relation to what needs to be improved.

At present it is suggested there is a lack of access to specialist services, poor

care planning and communication for older patients who have been

discharged from hospital (Cornwell 2012). This is also reflected in my

personal experience of working as an ANP for older patients being discharged

from hospital, and on occasions the reasons they re-attend to the hospital.

Similarly Witherington et al. (2008) also suggest poor communication on

discharge is a problem and a likely reason for adverse events and re-

admission to hospital for older patients.


N.B. Focus on any changes that might work to bring about that improvement.

A telephone service for older patients to contact myself and the other ANP’s

with any concerns or queries on discharge, may address the problem of

communication and access to specialist service and improve this problem.

However, older patients represent a large cohort of patients within the

hospital, therefore initially limiting the telephone service to a select group of

patients to test the service improvement idea would be my preferred

approach. I would then envisage the telephone service to be rolled out to all

the older patients who are seen and treated in our Ambulatory Emergency

Clinic, depending on the success of the telephone service.

Test submission 4

Service improvement within the health sector, aims to improve patient care through what Boyle (2003a, p.223 cited Ashworth et al, 2010. p.3) describes as “a closer correspondence between perceptions of actual and desired standards of public services”, of which the NHS is still a part. That is to say, the drive behind my chosen service improvement project, the improving of the level of information provided on the hospital’s patient discharge summaries, could be improved and, therefore, closer to what I would desire within my practice.

On occasions within the community, the presence of a hospital discharge summary can provide reliable evidence in the clinical decision making process, in providing an overview of the reason behind their last admission, the outcome of relevant investigations, the treatments they underwent prior to their release from hospital, a list of their medication, and a plan for onward care. These letters have proved wholly invaluable at many times in my career, and in the working lives of my colleagues and other health care professionals within the out-of-hospital setting, as they provide a robust set of reference notes which can help guide the current consultation.

A feature, however, of the discharge letter that has never been included, but which would have proved invaluable in trying to better manage patients within the community, is a copy of the 12 lead electrocardiogram (ECG); a recording of the patient’s latest ECG. Whilst there are occasions when patients are discharged from hospital inappropriately (Rayner 2015), it would generally be a reasonable belief that when patients are discharged, their last set of clinical observations, including their ECG, could be regarded as an accepted benchmark finding for that specific patient.

Working as I do within the Out of Hospital setting, providing around the clock care, the routine of my shift will place me in direct contact with patients with varying ailments; shortness of breath, chest pains, dizziness, and many other health concerns. In these instances, it would be pertinent to record a copy of the electrical activity of their heart on an ECG, which Hampton (1992, p.v) regards “as an extension of the history and physical examination”. That the ECG is just one piece of the jigsaw of signs and symptoms of the presenting complaint (ref

ref), it can nonetheless, be a determining factor in onward care decisions. At present in most instances, the clinician on scene when evaluating the ECG is comparing the patient’s rhythm and the electrical waveform against a predetermined set of ECG parameters dating in their origins to the work of Waller and Einthoven in the 19th century (Hurst 1998). For patients with pre-existing cardiac disease, who may be older in life and, or, may have been the subject of cardiac surgery, or have a congenital cardiac defect, their accepted norm is a deviation from the accepted standard.

The benefit of an ECG for comparison becomes clear, as the clinician evaluating the patient with shortness of breath or chest pain, can gauge whether there has been any acute changes to the electrical waveform which would warrant immediate admission into hospital.

Test submission 5Initial ideas for improvement

Q1: What are you trying to accomplish?

The aim of this SIP is to improve practitioner confidence and the quality of MCA

record keeping, in particular for Mental Capacity Assessments and Best Interest

decisions.


I will know if there has been an improvement if practitioners report higher levels of

confidence and there is an increase in the quality of record keeping. At this stage I

do not know how this will be measured, as this will depend on the intervention.

However, I am considering self-reporting confidence levels via a questionnaire or

focus group, an assessment audit and feedback from supervisors.

Q3. What changes can be made that will result in improvement?

3a) What is wrong?

In order to understand the difficulties in implementing the MCA locally, I ran a

‘Barriers and Solutions’ workshop, (See Appendix I & II). Common barriers reported

were; managing disputes regarding best interest decisions; lack of confidence

around risk; knowledge and confidence to challenge others; time; and budget

restrictions.


Common solutions were; effective supervision; larger budget; increased public

awareness; better advocacy; training; more time; multi-disciplinary working; and

objective/clearly evidenced paperwork. The solutions identified were less specific

than I had hoped. Practitioners informally reported that this was due to not knowing

what would help. The LA already has projects in relation to improving supervision,

public awareness and partnership working. As it has already been recognised that

the current MCA paperwork needs to be revised; a new assessment tool could

incorporate some of the solutions suggested such as, prompts around risk and more

detail around the views of others. Move over, if the quality of reports are improved,

this will reduce repeated assessments (saving time), speed up the CoP process

(less additional hearings due to lack of evidence) and potentially increase

practitioner confidence.

Test submission 6


The Model for Improvement (Langley et al 2009) is made up of a set of fundamental

questions that drive all improvement and the Plan-Do-Study-Act (PDSA) Cycle and the

answers to the following three fundamental questions form the basis of improvement

(Langley et al 2009). These three questions are set out below.

Q1: What are you trying to accomplish?

The main aim is to make the monitoring of INR for patients in the surgery more consistent,

auditable and ultimately provide safer patient care for patients on warfarin incorporating the

computerised INR monitoring software.


Fundamental to the success of any improvement is the understanding that all improvement

requires change but not all change results in improvement (Langley et al 2009). Change

should impact on the measures and as a result over time if should be possible to demonstrated

whether the change has led to improvement. To know if change is an improvement outcomes

will need to be measured. Recognising that output measures which focus on the quantity,

quality or efficiency of the service can be criticised that within public services these measures

can encourage distorted behaviour of game playing behaviour and tactics to meet these

outcomes, an attempt to define and measurement improvement remains a legitimate enquiry

(Ashworth et al 2010). It is the focus on change and an understanding of basic principles of

improvement that contribute towards efficient and effective improvement efforts (Langley et

al 2009).

If improvement has occurred then all patients on warfarin should be on the electronic INR

software with records of all their INR testing and warfarin prescriptions on their system.

Patients who are stable with their INR should have reduced attendance figures, when they do

come in are seeing the same clinicians who have expert knowledge in the field on INR and

warfarin prescribing. Longer term audits would also demonstrate improved time in

therapeutic target ranges for patients.

Q3. What changes can be made that will result in improvement?

3a) What is wrong?

From a brief audit prior to the start of this project it was quickly evident that patients on

warfarin within the surgery are not on the INR electronic system and the recording of their

treatment around warfarin and INR at present is not following a clear systematic process.

This has led to some important safety concerns and uncovering of documentation errors

which has led to promoting the importance of this SIP.

Patient satisfaction with the current arrangements for their INR monitoring is also very low,

frustrated with having to wait in corridors and not seeing the same clinicians.


The CCG guidelines and funding make it clear that the use of the electronic system must be

utilised and by implementing and following this system this will overcome many of the

problems identified. Furthermore by establishing a Nurse Led Service this will give the

patients consistency in being able to see the same clinician within a set clinic, leading to

improved satisfaction, consistent care and increased patient safety.

PSIP 7 Test Submissions

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