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In recent times, the National Health Service (NHS) has been characterize by surging high cost and with regards to frequent readmissions (Revolving Door) in Psychiatric Inpatient Wards there has been widespread attempt to improve discharge planning and community care to minimize frequent readmission. This has prompted several policy and service improvement frameworks in an attempt to promote a positive change to help manage and improve quality (Morgan and Bering-Jones, 2016). As more people are now experiencing mental health problems which are often present with a number of co-morbidities, hospital discharges are becoming more and more complex (WHO, 2016). Although, most impatient wards engaged in discharge planning there are many important factors that are missed in discharge planning which negatively impacts patient satisfaction, safety, hospital capacity and financial performance (Kent and Morrow, 2014). These important factors need to be considered to enhance efficient and effective facilitated patient discharge. This report identifies and focuses on some significant factors which are important and should be checked to facilitate effective discharge which will ensure that, the chances of frequent readmission (revolving door) are significantly reduced. This is a report which describes a service improvement proposal project that was identified by the author, a student nurse during a clinical placement in an acute psychiatric ward as part of his pre-registration nursing course. The propose intervention will increase the effectiveness and efficiency of patient discharges and make it more standardised which will go a long way to reduce frequent readmissions and improve patient outcomes.
Employing the use of PDSA methodology, the author conducted a systemic review of discharge planning process patients which indicated that patient discharges are hastily carried out, with lack of standardisation in terms of procedure and record keeping mostly to the dissatisfaction of patients, their families/careers and the community mental health team.
The proposed service improvement gained the approval of many people including the doctors, nurses, social workers, Occupational Therapists and community psychiatric nurses. Although, the multi-disciplinary team accepted that there was the need for change, there was clear indication from the nursing team that this change could add to their already stretched workload. Thus, the author could anticipate a little resistance to change if the proposed service improvement was to be implemented due to staff workload despite the benefit to patient outcomes and financial burden on the NHS.
The UK government has placed much emphasis on psychiatric deinstitutionalization. That is moving care and support to the community. However, the problem of frequent psychiatric readmissions poses a significant challenge, as it exposes the fragility of the network of mental health services in the UK. According to the Parliamentary and Health Service Ombudsman, (2016), the government is pursuing an ongoing programme to consistently improve both safety and quality within healthcare, whiles at the same time looking at ways to reduce the pressure of cost in the NHS year upon year. This agenda makes it incumbent upon healthcare professionals to offer a framework for service improvement and innovation in the NHS. This assignment will propose a plan to provide a small scale local service improvement in psychiatric impatient ward discharge planning to enhance effective and efficient patient discharge which will go a long way to improve quality of care and patient outcomes as well as reduce the financial cost of frequent readmissions (Revolving Door Syndrome). Bringing in experience from clinical practice, the author (a student nurse), identified that many important factors were not checked and address before discharging patients from psychiatric inpatient wards, this practice is widespread in the NHS leading to frequent readmissions and the resultant concomitant cost and poor patient outcomes, (Morgan and Brenig-Jones, 2016).
As there is emphasis on shifting care and support of patients with mental illness from psychiatric institutions into community based settings, healthcare is becoming increasingly complex (WHO, 2016), there are a number of factors that may contribute to frequent psychiatric readmission (i.e. the ‘revolving door syndrome’), an effective discharge from the ward would ensure the chances of frequent readmission is minimize. This propose service improvement project aims to highlight a number of significant factors which are not checked and address before discharging patients from the ward, resulting in frequent readmission which negatively impacts upon hospital beds and capacity, financial cost, patient safety and satisfaction. The aim of the service improvement project was to identify the factors and issues that are not address before discharges from the ward and develop a feasible solution (standardised patient discharge checklist – See Appendix 1) to ensure effective patient to reduce frequent psychiatric readmission. In this report, the author will explore the concept of service improvement as well as examined relevant methodologies and provide a rational as to why the Plan, Do, Study, Act (PDSA) model was chosen. Furthermore, relevant contextual and literature will be analysed and theories relating to change management will be employed to evaluate the potential impact of change on stakeholders and challenges this raise.
Ethical implications with regards to the chosen service improvement will be considered and links will be made to patient safety and quality care to ensure the best possible outcome. Finally, the project will be evaluated, and the predicted effectiveness will be discussed.
1.1 Confidentiality and Permission
In accordance with the Nursing and Midwifery Council (NMC) Code of Conduct (NMC 2015), the author has ensured that confidentiality is maintained throughout this project, all information relating to the clinical area, trust, staff or patient will be cited using fictitious names. Moreover, the author obtained appropriate permission from both his personal tutor and placement mentor before proceeding on this project.
2. CONTEXT AND BACKGROUND
Drawing from a clinical placement experience on an acute psychiatric ward, the author, a student nurse was able to identify significant lapse in patient discharge planning using standard audit approach. The relevant checks for patient’s aftercare needs prior to discharge was inadequate and not standardised which at times leads to patients being readmitted into the ward from issues that could have been address prior to discharge. The fact that NHS budget are constantly under review coupled with the increasingly demand on service and beds availability implies that even a small change and improvement locally can impact on the efficiency and seemingly quality of service provided to patients (DoH, 2015).
According to Department of Health (DoH), 2015, up to 13% of mental health patients are readmitted shortly after discharge with the unit cost per bed for overnight stay in an inpatient ward is £404.11. Discharge planning is a routine feature of health systems which aim to reduce hospital length of stay and unplanned readmission to hospital, and to improve the co‐ordination of services following discharge from hospital. Discharge planning that ensure successful transitions to community care may play a key role in preventing early readmission, (Saver, (2009)).
Discharge planning is the development of a personalised plan for each patient who is leaving hospital with the aim of improving patient outcomes and reducing costs. It should ensure that patients leave hospital with thorough checks of their aftercare needs and provision of post-discharge services organised to reduce the chances of readmissions ((Saver, (2009).
3. SERVICE IMPROVEMENT
3.1 What is Service Improvement?
According to Morgan and Brenig-Jones (2016), service improvement involves the promotion of a positive change coupled with rigorous and structured approach to help manage and improve quality. The NHS Constitution stipulates that all staff has the responsibility to be involved in improving services’ which in turn will have a positive effect on working life, enabling them to do their job more effectively and sustain safe and quality care, (DoH, 2015). This will help to promote better outcomes and quality care as well as make healthcare more safer for patients and their families.
Jane and Mullen (2007), maintained that nurses often lack the confidence, knowledge and skills required initiate the process of service improvement and to effect change. Accordingly, the NMC (2015), emphasize the importance of service improvement in healthcare training and curriculum to ensure safer and quality patient care is maintained as well as encouraging students nurse to get involved in service improvement initiatives and projects within clinical practice (WHO, 2016).
Consequently, the NMC, (2015) initiated the introduction of service improvement into pre-registration nursing course which will ensure all healthcare professionals irrespective of grade or discipline are conversant with service improvement process and can apply what they have learn in their future work to improve the quality of healthcare services, (NMC, 2015). Thus, Lord and Smith (2014), argued that the involvement and engagement of pre-registered nurse in improvement projects in their training will go a long way to provide a good platform for their post-registration career, (Langley et al., 2009). Also, the use of service improvement methodology helps to guide healthcare professionals in the NHS to identify and resolve problems promptly in a cost-effective way (DoH, 2o15).
3.2 Service Improvement – Process Tool
4.1 Six Sigma
In 1987, Motorola introduced the Six Sigma methodology aim to eliminate waste in the system but still continue to produce best value to the customer, (Freiesleben, 2004)
In improving existing processes, the six sigma methodology employs a 5 step systematic approach known as DMAIC, (i.e. Define, Measure, Analyse, Improve and Control. These stages to process improvement are predominantly steered by first, identifying the weaknesses within a process instead of initially focusing on possible solutions. This approach has the advantage of ensuring all stakeholders have a full understanding of a process and its weaknesses before implementing any changes to that process.
However, a major disadvantage of the six sigma approach is that it is seen to be complicated and can be time consuming, therefore more suited for large organisational changes. Moreover, according to Liberatore (2013), it tends to focus mostly on past and present processes, thus not proactively lending itself to future changes and development. Due to these limitations the author decided to adopt the PDSA (i.e. Plan, Do, Study, Act) methodology for this relatively modest service improvement project.
4.2 PDSA (Plan, Do, Study, Act) Methodology
A healthcare quality improvement process tool which is widely used and recommended by NHS is the Plan, Do, Study, Act (PDSA) cycle, (DoH, 2015).
The PDSA methodology offers a structured way which allows for ideas to be tested gradually before implementation. The ideas will be refined and adapted during the PDSA cycle, thus being less risky to patient cycle and promoting best practice, (DoH, 2015). Furthermore, PDSA methodology offers less resistance from stakeholders as it allows time for new ideas to be adapted to local conditions and also for teams who are affected to be part of the testing and planning, helping to inspire confidence in any change that is implemented, (Lindberg, 2013)
The reason for the author choosing the PDSA cycle is that, the size of the project makes the use of a simple cyclical approach more suitable ensuring that all steps are included and allows for individual steps to be re-evaluated along the cycle for continuous improvement. In addition, the PDSA tool is widely used and acknowledged within the healthcare setting, (Batalden and Davidoff, 2007).
The cycle consists of 4 stages: the Plan stage which outlines and define the change aim at improvement and generates a plan. The Study stage where data is collected, analysed and reflected upon. The Act stage where any required modification to the plan is highlighted and dealt with before implementation.
Figure 1 shows the steps to follow in the PDSA cycle. At the planning stage there are three questions aimed to provide a framework for the improvement process.
5.1 Aims of the Project (What are you trying to achieve?)
- To reduce frequent patient re-admission (revolving door) due to lapses in the discharge process
- Increase patient satisfaction
- Save Money
- Improve hospital capacity
- Promote efficient and effective use of nurse’s time
Measurements were taken with an aim to highlight reason are readmitted after few months of being discharged from the ward. The pre-measurements were obtained over a 3 months period, the author, a student nurse participated in ward meetings involving discharging and readmission of patient to the ward and noted some of the patients who were readmitted frequently has issues which will not checked or dealt with at the time of their discharge. These patients come across obstacles in their aftercare exposing them to frequent readmissions (i.e. revolving door). The first solution option that the author identified was to resolve this problem by involving the patient’s Community Care Co-ordinators. However, there was a procedure for discharging patient from the ward which involves the input from the Care Co-ordinators which was not effective in addressing the issues or lapses in the discharge process. The chosen solution involves designing a standardized checklist (Appendix 1) for nurses and patients to go through prior to discharge to ensure issues that will impact patient aftercare are addressed to prevent frequent readmissions. This is in line with the local trust guidelines and Academy of Royal Colleges of Nursing call to standardised patient’s healthcare procedure and records, (HSCIS and Academy of Royal Colleges, 2013).
Miller and Oliver (2015), defines stakeholders as “a group, organisation or an individual who can affect or is affected by change”.
To enable the project to be a success the stakeholders,(See Appendix 2) in this case being the Nurses, Doctors, Social Workers and Occupational Therapist and Patients would need to fully comply with the change in procedure. However, often it is at this stage where service improvement project fails due to resistance to change. Therefore, providing guidance, explanation and training will help ensure stakeholders are on board with the aim and benefit of the proposed improvement and change.
5.3 Change Management
In regard to competence, the NMC states in its code of standards that “All nurses must act as change agents and provide leadership through quality improvement and service development to enhance individual’s wellbeing and experience of healthcare” (NMC, 2015).
According to Murphy (2006), change management involves assessing, planning and implementing strategies, processes and policies which ensure any change made will be beneficial and worthwhile. This implies that in order to manage change successfully and achieve the best possible outcome, there is the need for thorough planning, laying down a clear transitional route and putting someone in charge of the transition as well as allowing flexibility to inspire individual management and responsibility, Decker et al, (2002).
As posited by Lewin’s theory of change, the opening of lines of communication in order to balance power and authority, will impact on the success of any improvement or change project. Lewin presented a three stage theory (see Figure 2) in managing change successfully. The stages consist of The three stages of managing change successfully involves unfreezing old behaviours and introducing new behaviours as well as making sure the new behaviours are re-freeze and sustained, Bozak, (2003).
The second stage in the PDSA cycle is the “Do Stage”. In order to carry out the task involved in this stage effectively, the Crown Prosecution Service (CPS) suggest the use of Process Maps to help highlight the lapses and inefficiencies in the existing process or procedure. The use of process maps is backed by the NHS who implies that this helps to create a visual image of a process inefficiency and ineffectiveness and the impact on patient safety and quality of care which reinforce the need for change, (Morgan and Brenig-Jones (2016).
In this service improvement proposal, the utilization of two process map, prior implementation and post implementation would have allowed stakeholders to visualize and detect problems which need improvement. The first process map would have explained the current process at the point when a patient is discharge, which highlights lapses and important issues which are not checked leading to frequent readmissions.
The second process map would have highlighted areas of potential post implementation benefit, simplifying the process to ensure checks are done at the point when a patient is about to be discharged to pick up all important issues to address to forestall problems leading to frequent readmissions.
This is the stage where audits are carried on determine if the implemented change has resulted in actual improvement.
Assuming the proposed change was implemented, the indicative measurements and audits obtain of the service improvement proposal are as illustrated in below.
Cost and improvement in service quality can be demonstrated comparing the figures between the pre and post implementation of the proposed change.
Pre: Cost of impatient readmission over a 28 day period after discharge, and on average over a three months period 7 patient were identified as fitting the revolving door description of readmission. On the basis that an acute hospital bed cost an average of £404.11 per night stay, this shows that it is costing the trust £1,838.48 a week, £7,353.92 a month for readmissions of a patient.
Post: Post Implementation measurements were obtained via indicative estimates on the basis that the improvement in discharge process can commence on the ward and readmission reduce using the discharge checklist sheet (appendix 1). Over a three month fourteen patient were discharged, on average there would be only 4 readmission (instead of the actual 7 patients) if the checklist was utilized and issues identified dealt with before discharge. This would mean that by implementing the service improvement project it could save the trust: £5,515.44 week, £22,061.73 a month, £66,185.28 per quarter. It must be noted that, this would be a significant cost improvement if rolled out within the trust and the NHS in total.
The indicative results support the idea that having a standardise discharge checklist which can identify a patient problem before discharge from the ward will reduce frequent readmissions, therefore positively impacting on patient satisfaction, safety, hospital capacity and finances.
6.3 Act (Evaluation)
The last stage of the PDSA cycle includes evaluation and reflecting on the whole service improvement proposal process. Evaluation after implementation offers the chance to analyse the strengths and limitations encountered throughout the project. Upon reflection on this service improvement proposal, it became clear to the author that most of the time it is small incremental steps rather than huge strides that create a more objective change mind set to precipitate service improvement (Bingham, 2016).
7. ETHICAL CONSIDERATIONS
The NHS, (2005) stress the need to consider ethical implications that may come up when introducing a change to improve clinical practice. The NMC (2015), requires that nurse protect and promote patient’s health and wellbeing by using available resources judiciously to ensure their actions results in providing safer and quality care for patients. According to Beauchamp and Childress (2001), the principles of autonomy, justice, beneficence and non-beneficence should underlie all nursing care. The author ensured a number of ethical issues was addressed throughout the service improvement proposal, confidentiality was maintained for all individuals and places referred to in this project and verbal consent was seek from course tutor and clinical place mentor before the project was carried on.
The provision of safer and quality care for patient should be the main priority of all healthcare professionals. However, frequent readmissions due to poor patient discharge is failure patient care implying there can the discharge process can be improved for better patient outcomes as well reduction in cost. Following a PDSA cycle the author has demonstrated how improvement can be achieved in the process by utilizing the use of a standardised Discharge Checklist to ensure effective aftercare prior to patient discharge which can go a long way to reduce unplanned frequent admissions (i.e. revolving door syndrome). Rather than working in a reactive way, going through a standardised checklist will enable nurses to work proactively, which eventually will save time, money and ensure a positive improvement on patient safety and outcomes.
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Figure 1: PDSA Cycle
Kurt Lewin’s Theory of Change
Appendix 1: Standardise Discharged Checklist
Patient Discharge Checklist (To be completed before Discharge by th Nurse in Charge)
Family/Career informed of Discharge
Appropriate Housing in place for patient (Social Services Referral Required?)
Take Home Medication (TTO’s) Ordered (Enough Supply for a week) until GP or Local Pharmacist take over
Care Co-ordinator Appointed (Patient informed)
Is Patients Finances in place (Social Services Referral Required?)
Does Patient require Day Hospital input – (Has referral been made?)
Care Co-ordinator Appointed (Patient informed)
Does Patient require Special Services (i.e. Referral to Alcholic Anonymous, Drug AbuseServices, etc) – (Has referral been made?)
Does Patient require Employment/ Social Benefit – (Has referral to Social Service been made?)
Has the Community Mental Health been informed of Patient Discharge
Has the patient been informed of a follow-up after 4 days of discharge
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