This NHS Foundation Trust employs more than 6,000 staff and is one of the largest mental health and disability Trusts in England. Spread across more than 60 sites in an area totalling 2,200 square miles, it serves a population of approximately 1.4 million. Services offered include: Inpatient Care, Community Services, and Specialist Services
In August 2015, Meridian were invited to carry out an analysis following a successful project with the forensic inpatient wards for the same organisation. This time, the focus was on five acute wards.
The overall objective of the Trust was to achieve the behavioural change required to reduce the occupancy of the adult acute wards in two locations, which in the long run would lead to closing of a male acute ward. This had to be achieved through working in synergy with other Trust’s initiatives ongoing at the time of the project.
The study had shown that there was a lack of consistency in behaviours among nursing staff, medics, and managers, which reflected in a significant difference between the ALOS in the two locations of the acute wards (45 days in the first location, and 29 days in the other location). Furthermore, there were no discharge dates set for patients from the point of admission, and therefore no discharge planning towards a SMART objective. There was also a perception among the ward staff that the attendance to the key patient reviews by the Community Team was very poor which was causing delays, and very little contact between the patients on the wards and the Community Team could result in slower recovery.
The programme agreed was a 10-week-long Improvement Project. The overall goals were as follows:
- Focused and more effective discharge planning leading to a reduction in ALOS by 10 days
- Embedding of the discharge driven culture and behaviours to assist the long term objective of closing a ward
- Improvement in the cooperation between the Inpatient and Community services to support the cross-departmental work
Meridian worked with the management team, medical and clinical teams within five acute wards, as well as the Community Teams through a series of one to one sessions, meetings and workshops. During these various sessions, a new management control system was designed to ensure effective running of the acute wards.
The key focus was to implement management controls to support the reduction of the ALOS to enable the Trust to permanently reduce the bed base by closing a ward. The main controls and systems designed, agreed and installed throughout the project were as follows:
- A tool showing the state of Inpatient/Community transition by looking at the frequency of contact between the patient and the Community team, but also at the attendance of the Community Team to the key meetings on the wards.
- Weekly meetings between the Service Managers of the Inpatient and Community services in which the state of the Inpatient/Community transition is reviewed using the installed tool, issues are identified and actions are allocated.
- A new SMART objective for each patient’s stay on the ward in a form of an expected discharge date set within 72 hours from admission to the ward through a collaborative effort of the whole MDT. The new objective allows for an immediate planning for the discharge from the point of admission. This is supported by a simple and visual tool which shows the state of the main barriers to discharge. The tool serves as a prompt to focus the attention of the whole MDT on removing the discharge obstacles prior to the expected discharge date to facilitate a timely discharge.
- SMART intervention plan embedded into the Daily MDT Reviews, constituting of a list of actions which, if followed, should lead to a timely discharge on the expected discharge date.
The main results of the programme are:
- A significant improvement in the frequency of contact between the Inpatient and Community teams where the number of days since the last contact between a patient and the Community Team has decreased by an average of 14 days. The Directorate Manager of the Community Services described the new controls as a ‘breakthrough’ for the Trust where the work of the Inpatients and Community Teams used to be conducted in isolation and therefore created a gap in communication and unnecessary delays.
- An improvement of up to 50% in the Community Team’s attendance to MDT meetings (such as, 72-hr Review, Discharge Meeting, etc.)
- During the course of the project, the ALOS of discharged patients in the location with a higher ALOS who were admitted after the project start and therefore fully impacted by the programme, was never more than 17 days (Base ALOS: 45 days).
- Increase in the weekly number of discharges in the location with a higher ALOS, where in every single week of the project there were more discharges than the Base average number of discharges (5.7). The increased discharge activity did not impact the quality of them – in 5 of 9 weeks of the project no readmissions within 28 days were recorded, and the other 4 weeks saw an average of 1.5 readmission in one week.
- The project saw collapsing of 2 beds which directly contributes to the better experience for the Patients during their stay on the Ward and closing of a ward in the future.
- Discharge focused approach of the whole MDT which allows for synchronisation of efforts of all professionals. One of the controls developed and installed during the project (expected discharge date) has proven to be successful to the point that it is being rolled out on the other acute wards within the Trust.
