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

Initial ideas for improvement: using Model For Improvement Questions

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

want?

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.

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

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.

Q3. What changes can be made that will result in improvement? (May not be

known yet of course, or just some basic ideas)

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

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’).

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.

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.

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.

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?

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.

3b) What might work?

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.