Action learning at the Future Hospital development sites
Background
In September 2014, the Future Hospital Programme (FHP) selected four development sites – clinical teams each committed to implementing an innovative project aligned with the vision of the Future Hospital. Through these sites the programme aims to illustrate how the recommendations of the Future Hospital Commission1 can translate into practice.
This update provides an insight into their successes and challenges over the first year.
Betsi Cadwaladr University Health Board
The primary aim of the CARTREF project is to provide increased access to specialist opinion for frail, elderly people in rural north Wales, as close to home as possible, through the use of telemedicine.
Through ongoing Plan, Do, Study, Act cycles, over the first year of development, Betsi Cadwaladr University Health Board (BCUHB) have established clinics in two community hospitals, Ysbyty Alltwen near Porthmadog and Ysbyty Bryn Beryl near Pwllheli, 25 and 30 miles respectively from the main district general hospital, Ysbyty Gwynedd, in Bangor.
The clinical team at BCUHB has also benefitted from input from local patients and links with the RCP Patient and Carer Network, to develop the patient satisfaction questionnaire used at the time of video consultations.
Plans are now in place to extend video consultations into a local nursing home and a GP practice in Nefyn for people with Parkinson's disease/movement disorders – connecting Dolgellau hospital in Meirionnydd to Llandudno hospital by video will save the consultant an approximately 100-mile round trip, releasing time to extend the telemedicine clinic.
Initially, the team experienced challenges with setting up the infrastructure and equipment and have learned to provide sufficient time for consultations (minimum 30–35 minutes) allowing for any unforeseen issues. Appointing a digital inclusion officer has helped to support patients to overcome any initial apprehension about the new technology and provide practical help to those with hearing or visual impairments to use the video consultations.
80% of patients have stated that they would definitely or probably recommend the video consultations to family and friends. Building on this positive feedback and response to the technology, the focus is now on raising awareness and acceptability of video consultations as a way to receive high-quality healthcare closer to home.
East Lancashire Hospitals NHS Trust
The transformational programme at East Lancashire Hospitals NHS Trust aims to deliver safe, personal, effective care for frail older people, at or close to home where safe and appropriate. This incorporates comprehensive patient assessment with care planning and case management; rapid inpatient assessment by a frailty team, if required; and safe and effective patient discharge, with improved transfer of care information.
A multidisciplinary frailty assessment team was formed, comprising nursing, therapists, medical and social services input. The team monitored clinical input to the medical assessment unit (MAU) over a number of selected days. This included identification of frail older patients potentially suitable for discharge the same day with the MAU nurse coordinator, rapid comprehensive geriatric assessment by the multi-professional team and, where appropriate, the multidisciplinary team (MDT) liaised with community services and primary care and made plans for same-day discharge. During this preliminary study, 59% (13/22) of admissions were avoided.
The MAU, however, had a short length of stay, which reduced the opportunity for rapid frailty assessment. A change in the acute medical model to an acute medical unit with longer length of stay (up to 72 hours) has been implemented.
There are two clinical commissioning groups (CCGs) and two local authorities within the health and care economy of East Lancashire, each have different approaches and ways of working with healthcare providers. The team have overcome this challenge by establishing a single ‘frailty pathway’ which is now widely recognised and part of a programme of change with a single governance structure and more connected planning.
The team have worked hard in this first year to build and grow relationships across the health and care community for joint care of older people with frailty. The community service transformation partnership has been co-designed and produced with the CCG and consists of three main strands.
Integrated neighbourhood teams that bring together MDTs who work closely with neighbouring GP practices.
Intensive home support service – a rapid response multi-professional service to prevent unnecessary hospitalisation to the emergency department. It also supports earlier discharge from hospital, through in-reach to the emergency department in Royal Blackburn Hospital.
Integrated discharge service which brings together hospital complex case managers, social workers and therapists from four organisations into one team. It aims to enable early discharge through intensive home support or intermediate care, reduce hospital stays and improve communication and support to patients and carers.
Mid Yorkshire Hospitals NHS Trust
Mid Yorkshire Hospitals NHS Trust are implementing an older persons assessment unit which will allow for the early assessment of people by a consultant geriatrician at the start of the inpatient pathway. The service aims to improve the patient and relative/carer experience for older people, providing prompt appropriate care and discharge planning.
In the first year a MDT of consultants, specialist nurses and therapists has been recruited to assess patients and provide access to services and treatment to bring forward discharge. This rapid elderly assessment care team (REACT) has incorporated the Rockwood Frailty Score2 into their assessment of elderly patients.
The team have sought to further improve patient experience by developing a communications policy to inform people about their participation in the Future Hospital Programme and the new REACT service. Displaying information on posters around the hospital has helped to educate hospital visitors and staff about REACT. Following patient experience feedback, a patient-focused leaflet to promote the REACT service has helped to raise awareness among the patients and facilitate information sharing between patients and carers and the healthcare professionals.
The hours of service for REACT have now been extended to cover 12 hours a day, 7 days a week. The team are currently considering how services will run in nearby Dewsbury and District Hospital, as part of a wider reconfiguration. The team aim to extend the REACT model to carry out patient assessments within the emergency department to avoid admissions where possible.
Worthing Hospital, Western Sussex Hospitals NHS Foundation Trust
Worthing Hospital set out to transform the delivery of acute care, dissolving traditional boundaries between surgical, adult medical and frail elderly patient pathways with a new emergency floor which opened in December 2014. On the emergency floor, care is organised around the needs of patients by co-locating acutely ill patients, irrespective of pathway, embedding MDT support and ensuring rapid access to diagnostic investigations and treatment to improve patient outcomes and safe transfer of care.
Admission pathways for patients have been standardised and an e-whiteboard is used to track all unscheduled care patients arriving on the emergency floor. The floor includes an ambulatory emergency care area, the use of which has increased significantly, particularly for surgical admissions.
A major success of this Future Hospital development site project has been the improvements in MDT working, with daily ‘safety huddles’, MDT board rounds and input from multiprofessional and multispecialty teams. The working practices have been constantly reassessed and revised.
Preliminary results indicate a reduction in average length of stay by 22% for surgical patients and by 3% for medical patients. This has been achieved at the same time as modest reductions in readmission rates (3% reduction in 30-day readmission rate for medical patients and 5% reduction for elderly patients). Measures of patient experience through the Friends and Family Test have provided consistently good feedback, with average scores of 4.2–4.6.
December 2014 was a very challenging time to open the new emergency floor, with high demand for services over the winter period and a 17% increase in admissions of people aged over 80 in that month. There were particular pressures around nurse staffing and, on reflection, it was recognised that recruitment of additional staff, above the required numbers, at the start of the project may have helped to prevent this.
An important lever in a major change programme, such as this, is dedicated project management support time. As such, board-level management support is key to protect the availability of clinical and non-clinical staff.
These elements, together with rapid frailty assessment in the acute medical unit, comprise the frailty pathway; and plans for multidisciplinary staff to work across the pathway are being implemented.
Shared learning
Building a community of learning with the other Future Hospitals development sites has broadened our view of what is possible…It has strengthened our professional networks considerably…We believe that the successes and challenges we have faced and can share will inform other organisations doing similar work – East Lancashire Hospitals NHS Trust development site project team.
Common emerging themes for learning
Trust Board support is essential from the outset for change management and to ensure dedicated project management.
The facilitation of joint working and sharing of experiences/challenges across the four development sites helps to bring about learning outputs more rapidly.
Local communication of project outcomes is required to maximise support, understanding and engagement with the project for all, such as through patient stories, members’ magazines, online blogs etc.
Wellbeing and engagement of all staff involved in the project is key. The value of regular support and feedback, high-quality communication, and participation in decision making and problem solving cannot be underestimated.
Prioritising patient involvement in service design, ongoing delivery and quality improvement is vital to success in improving care for patients. This should be established and prioritised from the start.
Identify the key outcome measures of success at the outset in order to understand what data are needed and how they will be collected.
When changing a system one needs to ensure everyone is aware of what this involves, from booking clerk to patient.
What’s next?
All four Future Hospital development sites will report their progress and reflect further on the barriers and levers they have experienced to date at the RCP annual conference, Medicine 2016, in March 2016.
A further four development sites were selected in January 2016, carrying out clinically led and patient-experience focused quality improvement projects delivering integrated care for people across a health economy. See Update on the Future Hospital Programme for more information.
- © Royal College of Physicians 2016. All rights reserved.
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