Discharge Improvement Workshop. Picker Institute Europe. Wrightington, Wigan and Leigh NHS Foundation Trust. December 2015

Transcription

1 Discharge Improvement Workshop Wrightington, Wigan and Leigh NHS Foundation Trust Picker Institute Europe December 2015 Vincent Coole Emily Davey Eileen Irvin Sarah Gancarczyk

2 Contacting Picker Institute Europe How to contact us: Picker Institute Survey Team: Vincent Coole Lucas Daly Emily Davey Eileen Irvin Sarah Gancarczyk Tim Markham Picker Institute Europe Buxton Court 3 West Way Oxford OX2 0JB Tel: Fax: surveys@pickereurope.ac.uk Website: Results website: Charity Registration No: Quality Assurance and Information Security Management: Picker Institute Europe has UKAS accredited certification for ISO20252:2012 (cert. no. GB08/74322) and ISO27001:2005 (cert. no. GB10/80275). Picker Institute Europe is registered under the Data Protection Act 1998 (Z ).

3 Introduction Inpatient Survey 2014: Areas for Improvement Picker Institute conducted the 2014 Inpatient Survey on behalf of Wrightington, Wigan and Leigh NHS Foundation Trust. Out of 850 patients, 814 were eligible for the survey and 365 completed the questionnaire, giving a response rate of 44.8% (national average 45.2%). Out of all patients who responded, 147 (40.8%) reported that their discharge was delayed. In addition, 174 (47.9%) of all patients definitely felt involved in decisions about their discharge and 121 (47.5%) of all patients felt that staff definitely gave the information required for aftercare to friends/family who needed it. Out of all the patients whose discharge was delayed, 95 (68.8%) reported that the wait for medicines was the reason for their delay. Moreover, 91 (64.0%) patients said that their delay lasted between 1 and 4 hours, and 37 (25.9%) reported that their delay was longer than 4 hours. About the Discharge Improvement Workshop Wrightington, Wigan and Leigh NHS Foundation Trust requested Picker Institute to run a discharge improvement workshop as part of the improvement work offered by Picker Institute. The event was held Tuesday 17th November 2015 at the Wigan Cricket Club. Approximately 120 people attended, with a mix of both trust staff, community staff, governance and patients Picker Institute presented the trust s results for the 2014 Inpatient Survey with specific focus on questions related to discharge, including subsequent breakdowns of these questions by age, gender, disability, site, and specialty. The presentation also included the trust s results from the Picker Institute Always Events and Real-Time Feedback. Following the presentation, attendees participated in an experienced-based workshop in which they highlighted areas for improvement based on their own experience of the discharge process at the trust. The results presented in this report show the analysis of these comments and the key themes that emerged Picker Institute Europe. All Rights Reserved. 1

4 Workshop Overview: Summary with frequent themes identified 2015 Picker Institute Europe. All Rights Reserved. 2

5 Section A: Reviewing Trust Performance Following the presentation on the Trust results on discharge procedures, participants were encouraged to discuss the results as a group and then to individually complete sheets with information about their personal experiences of the discharge process at WWL, under the following headings. Broad themes have being highlighted in bold: Where does the Trust get it right on their discharge process? Most participants gave positive examples from their experience, which often referred to provision of good communication, both with the patients and between departments and with families, friends, carers, as well as with external providers. They also regularly referred to setting reasonable objectives and plans with all relevant participants, including the patient, family, carers, medical staff, and those outside the hospital, such as social workers. Many participants were positive about the discharge lounge. However, one participant mentioned they found being discharged directly from the ward more efficient than when leaving via the discharge lounge. Several participants gave specific examples of areas or wards where they felt discharge was working well. These included one participant who said I can only speak for the discharge process from the Coronary Care Unit - which was excellent, another who highlighted Ward D at Wrightington as being a positive example and a third who said that although they had not been happy with discharge at Wigan, the pre op and post op treatment and follow up at Leigh Infirmary was exemplary. However, a few participants commented that in their experience Nothing appears to be done right. Another participant said The intention to do a good job is there but I felt they were too busy to do it properly. Where do you think the top areas for improvement are? The majority of responses to this question mentioned empowering patients, families and carers and improving communication and information available. This included one participant mentioning the importance of focusing on a patient s individual situation: Patients should be told the reason they were being discharged is because their present situation is no longer the appropriate place for them to be - not their bed was required for someone else. There was also a particular focus on the quality of verbal communication, with one participant saying Information is only 'ink on paper' until it is 'understood' and useful. Some participants also mentioned the importance of good communication between staff to ensure information was passed on and that all the patients needs were met before they were sent home Picker Institute Europe. All Rights Reserved. 3

6 Many participants raised waiting times as an area that needed improvement, particularly waiting for prescription from the Pharmacy prior to discharge or waiting for transport. Others suggested ensuring discharge planning was started earlier, and setting up consistent procedures and checklists, so these were in place beforehand, to speed up the process and ensure that nothing was missed. The importance of this discharge taking place at a safe time was also raised by several participants. That many services, including the Pharmacy, are closed on weekends at Wrightington was raised by two participants as an issue delaying discharge. Several participants mentioned ensuring post-discharge support at home was in place, by including involving families and carers, as well as community groups and community departments, throughout the process. As one participant put it: [it is important to involve] the 3rd sector who can speed up discharge, food - clothes - shopping - cleaning - follow up calls etc. Tell us about your own experiences of the current discharge process? Many participants had already referred to their personal experiences when answering the previous two questions. Many participants referred to the speed of discharge, some referring to long delays, including waiting for prescriptions or for specific targets to be met. However, a few others described their discharges as reasonably quick. Some participants referred to negative experiences of staff throughout the discharge process, with problems with communication between departments and inconsistencies between what they were told by different members of staff. One participant said nursing staff informed me and my family I would be released to a care home. This was contradicted by consultant and I went home. Several participants wrote about experiences of unsafe discharges, including where links with community services and GP practices were not made in advance Picker Institute Europe. All Rights Reserved. 4

7 Section B: Setting Objectives Participants were then asked to work in groups to set objectives or standards they would like the Trust to always achieve and prioritise them as High, Medium or Low priority. The full comments are available in the appendix, but below are some common areas that were raised: Top 3 Priorities and High Priority Objectives: In preparation for the Action Planning task in Section C, groups were also asked to select their Top 3 priorities to action plan. Every group had at least one of their top 3 priorities on the theme of communication, both with patients and their families and carers, and between health care professionals. When establishing their High Priority objectives, many participants focused on continuity of care throughout the discharge process, including linking with primary care and any additional care providers or relevant community organisations. This also included continuing care for patients waiting in the discharge lounge and Day Surgery patients still in hospital when the ward closes. It was also suggested that particular support be provided to patients returning home without family and/or carers. Many groups also focused on the overall patient experience such as ensuring patients were treated with respect and with a person-centred approach. This also included involvement for patients, their families and carers, throughout the discharge process with both general and disease specific information being provided. Several groups also suggested setting expectations as a key part of these communications. Some groups focused on limiting waiting times for discharge, both through speeding up access to prescriptions and ensuring prompt and easy access to transport. It was also suggested that assessing additional equipment needs prior to discharge would make the return home smoother and ensure the correct equipment was available as soon as possible. Several groups mentioned the need for consistency across the Trust, through guidelines and established discharge plans, and some groups suggested dedicated discharge coordinators to implement these. The importance of safe discharge during the day, rather than late at night, was also raised. Medium Priority Objectives: The themes of continuity of care, reducing waiting times and involving and supporting patients, families and carers throughout the process and in the community were also raised as Medium priorities. One participant particularly raised the issue of ensuring that care stays at a high standard between when the decision to discharge is made and when the actual discharge takes place Picker Institute Europe. All Rights Reserved. 5

8 Some participants suggested practical measures to ensure consistency and increase speed of discharge, such as ensuring discharge is planned as early as possible, preferably before admission, and having standardised templates set up for discharge. Some groups also raised facilities such as the furnishings in the discharge lounge, as well as the location, which some participants felt was too far from the Pharmacy, increasing the waiting time for prescriptions. Low Priority Objectives: Of the objectives set, few were categorised by participants as Low Priority. Some groups mentioned calls to families prior to discharge, and follow-up calls to patients following discharge, in order to ensure that everyone was fully informed and had opportunities to ask questions and receive support throughout the process. Also on the theme of communication, some groups mentioned the possibility of making more use of technology and written information to pass on important information. In addition, several groups mentioned the provision of items to entertain or interest patients while awaiting discharge. One group mentioned the possibility of male and female specific discharge areas, for patients who may still be in hospital gowns or nightwear. Section C: Action Planning the Objectives Participants were then asked to agree in their groups on their top 3 objectives and to begin to action plan what would be needed to implement these on a short, medium and long term basis. The full comments are available in the appendix. On communication, which every group had at least one objective on the theme of, there were a variety of suggested action plans. In the short to medium term, several groups suggested establishing Discharge Wallets, Passports or Packs, with all relevant information already set-up and in one place, both general and condition specific. It was also noted that it was particularly important to focus on those conditions associated with emergency admission. Some groups also mentioned reminding and training staff on the importance of keeping information (like the white boards ) up-to-date and effective, supportive communication throughout the discharge process, including if calls are made shortly after discharge for more information or due to a concern. In the medium to long term, several groups mentioned the possibility of moving towards more technology use and paperless correspondence with patients, to ensure that information is available and can easily be sent. Several groups also focused on establishing consistency in their discharge procedures. This included in the short to medium term establishing standardised checklists and setting plans of actions, working backwards from time of discharge through to admission, for a range of conditions. One group suggested developing fragility profiles or personal pictures to inform admission process. Several groups also suggested organising how patients will get 2015 Picker Institute Europe. All Rights Reserved. 6

9 home following discharge, Aids and Adaptations Assessments and ordering of any prescriptions, for example, as early as possible, to streamline this process. In the medium to long term, several groups suggested establishing designated discharge co-ordinators, to manage the discharge procedure. Other suggestions to speed up the collection of prescriptions included, in the short term, assessing why medication is delayed and mapping a consistent approach for pharmacy referrals. In the long term, a few groups mentioned reviewing staffing levels in the Pharmacy. Other action plans included increasing staff availability of social workers, 7 days a week, to help smooth complicated discharge, ensuring there is a Trust policy not to discharge patients after 9pm, and providing an electronic referral system to promote smooth access to community services Picker Institute Europe. All Rights Reserved. 7

10 Section Three Top 3 Themes Identified 2015 Picker Institute Europe. All Rights Reserved. 8

11 Top 3 Key Themes Following analysis of the information provided in the workshop prevalent key themes were identified via a frequency count of all subjects. In order to structure the count into three key overall themes, we identified the following: Communication, Timings and Processes Resources These are broad themes and therefore to achieve a better understanding of their coverage, each one has been further broken down into subsections. A summary explanation of how the themes have been constructed into sub-themes is provided below. Communication Overall, communication came up most frequently in the group comments, with a total of 154 different comments. Communication is inextricably linked to all other aspects of a patient s care. For this reason, we have broken the comments down into three subsections: Communication directly with the patient Communication with the patient s family or carers Internal communication between hospital staff In all of these subsections, there are also a number of positive comments from the workshop about communication. It should be noted that the focus of the workshop was on areas of improvements rather than identifying where the trust is doing well, so it is unsurprising that the volume of negative or constructive comments outweighs those that are positive. However, when attendees were asked Where do you think the trust get it right on their discharge process? one person responded that there was generally good communication about who to contact, and what to expect in recovery at home. Furthermore, two attendees commented here about good communication with nurses after discharge. Another attendee stated that staff generally liaise well with family, and regarding internal communication between staff, one attendee said that staff generally liaise well with surgery though some inconsistencies Picker Institute Europe. All Rights Reserved. 9

12 However, when asked what the top areas for improvement are there were 27 separate comments that made reference to some form of communication, with patients, family/carers and staff, out of a total of 50 comments. Communication with the patient In total, across all questions there were 99 comments regarding communication with the patient. Including some of these and in addition, there were 48 comments about the use of written information on discharge. Of all the 71 comments about communication with the patient before/during discharge, a significant proportion refer generally to communication with the patient and allowing them to ask questions. A number of these seem to suggest using communication as a mechanism for support. For example one comment states ask [patients] if there are any other questions or concerns they have ; another says staff communication well to all patient. Not rushing having time to reassure and answer ALL questions that are important to that individual. Similarly, there are some comments which mention involvement of the patient in decisions about their discharge 5 comments relating to on communication with the patient on discharge time and date. Of these, some concern ensuring the patient has an accurate idea of the discharge time in advance and being updated if it changes while one concerns communicating with the patient that the discharge date may change There were 14 comments regarding communication concerning medication, of which the majority (10) referred to explaining what medication was being prescribed and providing information about how to take this medication. However there were 3 comments referring to keeping patients aware of the procedure for obtaining medication. A further 10 refer to ensuring that the patient is fully aware of what will be involved in discharge. 31 comments refer to communication with the patient about processes after discharge or communication with the patient when they have been discharged. 13 of these comments either concerned explanations about the procedure for aftercare. The most common theme among these is the provision of contact details for the patient so that they will be able to get in touch after discharge and the availability of someone to talk to when the patient does ring up. There were also five comments regarding communication with patient after discharge via use of modern technology, such as or social media. There are 48 comments regarding written and verbal information in general, 6 of which were recorded in the top areas for improvement section, and 11 were considered high priority. 9 comments refer specifically to a discharge wallet or pack, 6 refer to a discharge letter, form or passport for the patient, and 3 mention leaflets Picker Institute Europe. All Rights Reserved. 10

13 Communication with families and carers There are 21 comments regarding communication with the patient s family/carer. The comments referred to different stages of the discharge process, including planning. In addition, there are two comments concerning other methods of communication with families or carers, one concerning access to a helpline directing families/carers to relevant health professionals, the other regarding use of . These two comments fall into medium and long-term implementation respectively, indicating that the attendees writing them felt that these should be goals to work towards. 7 of these 21 comments raise the idea of communication with the family regarding collection and ensuring the patient is discharged to a suitable home situation. For example, one comment entered into the short-term implementation section of the action-planning sheet states ensure that their exit is set up with their family. Another, considered to be a high priority, states lack of communication e.g. staff to be explicit of where the patient is to be picked up from. Involvement has been included under Communication and is mentioned frequently in connection with the patient s family/carer. 8 comments bring up the idea of the patient s family/carer being involved in decisions regarding discharge or discharge planning. Notably, three of these comments were considered top areas for improvement and another three were marked as high priority. Internal communication between hospital staff There were 22 comments recorded regarding internal communication between members of staff, as well as four general comments about communication (e.g. communication with liaison as a two way process ) which are likely to include communication between staff. Thematically these comments are quite uniform. Some refer to communication specifically between staff members (e.g. Communication between professional staff is imperative ) while others specify that there is a need for better communication across departments (e.g. Communication is vital, across all departments ). Three comments describe a need to engage with hospital consultants and junior doctors, senior staff and MDTs to ensure speedy processes and patient understanding. These is one comment about communicating feedback to members of staff and another two about providing better staff training around discharge Picker Institute Europe. All Rights Reserved. 11

14 Timings and Procedures Timings and Procedures takes into account all the different elements of planning and protocol that work together to ensure that the patient is discharged in a timely and safe manner. In total, this section covers 150 patient comments, marginally fewer than the total about communication, which can be divided into three main categories: Medication Planning and Protocol Patient safety Medication As noted in the section above, some of the comments about medication raised the need for communication with and information for the patient about their medication, both about the procedure of obtaining them and details about taking them. In addition to these, there are 66 comments about medication, more specifically concerning procedure itself during discharge. 21 comments were about medication or pharmacy out of a total of 50 (42%). There were also 10 comments about medication in the high priority objective section out of 73 (13.7%). Thematically, the comments can be fairly uniformly divided into three sections. Firstly, there were 41 comments concerning the length of time medication took to arrive (e.g. provision of medication in timely manner on discharge ). In addition, there were 10 comments where the comment did not specify what the problem related to medication was (e.g. From a personal point of view, I've been assured medication problem is improving, but can still be improved ). Secondly, there were a total of 17 comments regarding the procedure or processes of obtaining medication. Evidently, this is closely linked to delays as a smooth procedure is likely to minimise delays. Four of these comments concerned the checks that take place to ensure the patient receives the right medication one of these was positive, saying the trust gets it right on their Safety checks - ensuring right medication. Thirdly, there were 6 comments about allowing patients to use their own medicines if they already had them available or collect them from their local pharmacy. For example Patients who have all necessary medication at home should not be delayed at discharge by pharmacy reviews and Let a patient cash their own prescription if suitable fitness to do so. Planning and Protocol A total of 63 attendee comments were about the processes that are involved in discharge. In the top areas for improvement section there are 12 comments in total. Six of these comments refer to the speed of the discharge process; four mention discharge dates and 2015 Picker Institute Europe. All Rights Reserved. 12

15 times; four use the word planned or planning. Other key words include protocol, timeline and ticklist, all of which come up once, and time slots comes up twice. To distinguish planning from procedure, planning has been understood to mean plans relating to a specific individual while procedure refers to standard protocol which happens across the board, though comments that are quite general may well fall into both, e.g. the discharge process should begin (in as many cases as possible) on admission. There were a total of 16 comments regarding discharge planning. Two of these mention having written information to aid planning and two concern meetings. Three concern having everything needed for a patient s discharge ready in advance, and six raise the idea that discharge planning should begin as early as possible, of which four use the phrase on/at admission. Planning also concerns having an expected time and date of discharge of which there are 10 comments. One of these is a positive comment, stating planned discharge date generally in operation, but all others are objectives or areas for improvement. 33 comments were in regards to procedure are those which raise the need for a uniform discharge process in operation for all patients.3 comments describe a need for a maximum length of discharge to be put in place, e.g. have a uniform discharge time and push for a maximum additional time of two hours and a further four express a desire for quicker discharge e.g. reduction in the time from when told you are going home to when your discharge moves. 12 comments raise the idea that the process needs to be standard, standardised, uniform or consistent, applying to all patients, indicating that the perception of the attendees is that the discharge process is variable and inconsistent.the word checklist (or ticklist ) is used five times (e.g. continually use and update the checklist as standard procedure ), time slots is used three times (e.g. patients should be given allocated time slots for their discharge ) and timetable is referred to once. Patient Safety Patient safety emerges from a number of comments referring to the safety of the discharge and the different ways that patients needs are either met or not met during discharge. Overall, there were 36 comments regarding patient safety in the discharge procedure, 7 of which were considered top areas for improvement and 9 of which were considered high priority. There were 8 different comments regarding the time of day that patients were discharged. Of these seven made reference to discharge late in the evening, one to discharges early in the morning and one states discharge out of hours. Of these comments, one specifies that this should apply to patients with dementia and one to patients who are elderly. All the others are general comments without specifying a particular patient group. There are a total of 8 comments that raises the need for particular attention to patients with complex needs. 4 make reference to a particular condition (e.g. dementia and mental health both come up twice). These comments refer to the discharge procedure, e.g. waiting for medication, transport home and follow up after discharge. 10 comments raise the need to take into account a patient s home situation or need for assistance at home when discharging them. Five of these comments suggest that patients 2015 Picker Institute Europe. All Rights Reserved. 13

16 must be discharged to a safe home environment, i.e. where there is someone to care for them, food to eat, neighbours etc. depending on that patient s situation. Finally, there are 9 comments regarding the patient s health on discharge, e.g. Making sure patients are fully recovered before discharge and Patients should be asked if they have any concerns about being discharged. Do they feel well enough?. Resources Resources covers all comments referring to organisations (internal and external) through to use of space. Many of these resources are already in place and available for the trust to use but there may be room for improvement in how they are used. There are a total of 105 comments in this section. They have been divided into 3 sub-themes that have been referred to frequently: External Parties Discharge Lounge Transport and Equipment External Resources External Resources includes social work teams, third sector parties, community link workers, primary care, other external specialists (such as physiotherapy) and community workers who support the patient in particular after discharge. In some cases therefore, these comments may also be classifiable under internal communication or use of staff (below). This section therefore contains all comments (33 in total) which make reference to other parties that the hospital could make use of to support the patient through discharge. The frequency that each different service is mentioned is shown in the table below: Social care 13 General Services 12 Primary care 9 Third sector 6 Community workers/nurses 5 Care home 4 Community link worker 3 General services, is where the author of the comment has not specified which service, such as connect with appropriate services/organisations with an aim to co-ordinate discharge into primary care Picker Institute Europe. All Rights Reserved. 14

17 Social care was the most commonly mentioned external resource. The content of the comments about social services varies: some are general, for example social service issues, while others are more specific about a particular aspect of social care, e.g. social input services stops at the weekend and social care arrangements to be finalised with patient and family. The majority of comments about primary care discuss how information was passed on to GP after discharge. Comments relating to the third or voluntary sector are frequently concerned with making use of links with them, e.g. involving the 3 rd sector who can speed up discharge and use the third sector who are already based within the hospital. This is also the case with the three comments about Community Link workers, grouped separately from other community worker comments because of the presence of a group of Community Link Workers on the day. Discussion at the end of the workshop indicated that they feel there is more that they can do to enable smooth discharges, partly through increased awareness of their role, both among staff ( engage with hospital staff to increase awareness of the community link worker service ) and patients ( patients will have opportunity to talk to a CLW to discuss social/personal issues and discharge time ). Discharge Lounge There were 20 comments referring to the discharge lounge. The content of the comments is quite varied (6 are positive), however the location of the discharge lounge, with six comments suggesting that location needs review, either because of the distance from the pharmacy or because it is not well signposted. Aside from these, comments concern ensuring that the patient s medical needs are met in the discharge, improving the facilities such as furniture and keeping the information on screens up to date. It should perhaps be noted that only one of the 20 comments was in the high priority category, whereas six were considered medium or low priority. Transport and Equipment 27 comments refer to transport home and equipment, 17 of which are referring to transport. 5 of these specifically refer to the availability of ambulance services for those patients who need them. 3 of the comments concern having parking for people/taxis collecting patients. There were 10 comments regarding the availability of equipment. Two of the comments specifically refer to equipment being available for the patient at home, though more may implicitly refer to this (e.g. Additional funding for equipment provision ), and two concern storage of the equipment, presumably within the hospital (e.g. Allocation of a room for storage ) Picker Institute Europe. All Rights Reserved. 15

18 Appendix: Full Comments 2015 Picker Institute Europe. All Rights Reserved. 16

19 Discharge Improvement Workshop: Full Comment ordered by themes Communication with patient and patient involvement Where does the trust get it right on their discharge process? All medication was explained. A cardiac nurse saw my husband on the ward and called at our home the day following his discharge Yesterday my husband had an aniogram. I was shown where to pick him up. I was delayed due to the road being closed due to an accident. The staff stayed on until I arrived. He was told what to do and given paperwork to bring home. Excellent service throughout. The discharge should be the responsibility of the professional workforce, the patients must have realistic expectations When a patient requested more help 90% got it Discharge lounge; advising people in middle band what to do on discharge Where do you think the top areas for improvement are? Communication Seems like the communication with young and older ends of spectrum may need to be examined Pharmacy - not open weekends are Wrightington; Xray limited at weekends at Wrightington; Social services - service stops at weekend and out of areas difficult to navigate; prompt staff on checklist to remember to give contact details and ask if there are any other questions or concerns they have Xray; pharmacy at weekends; social services - in the hosp; checklist; PT's awareness of discharge process Communication at all level; timely discharge - not late in the evening!; All concerned being involved (family, carers); Medication being ready; ensuring equipment is available when requested; checking on patients in discharge lounge. If they are there any length of time as they need food, water, meds; informing carers/family when next meds due if long discharge Faster discharge would definitely be a big improvement!; Information regarding actual discharge time is required A better patient training programme to encourage patients to ask for help with all points on the survey before (24 hrs) of discharge Delay in discharging patients with complex meds; working/contact with ambulance service; telling older and younger people what they must do on discharge; Getting medication ready for patients Medication - to ensure patients are aware of when/how to take any meds; well-planned social care (if to be provided) so that family and individual know who is coming to their home and when; knowing who is in charge of their after-care e.g. sister, D, nurse Standard protocol for discharge - for all patients recognising - medications, contact points, concerns, complex conditions, social services appliances etc, plus verbal communication; 2015 Picker Institute Europe. All Rights Reserved. 17

20 ensure A&E patients (all) receive *** info; ensure pharmacy deals with prescriptions quicker; speed up completion of discharge documentation To make sure that each patient gets individual attention and does not get 'left out' keeping patients informed throughout the discharge process; 2. medication and correct medication being given in a timely manner Patients should be told the reason they were being discharged is because their present situation is no longer the appropriate place for them to be - not their bed was required for some one else. Explain why. Ask how they felt about this i.e. involve them in the decision Discharge times (late night); length of time in discharge lounge; lack of practical advice/information to take home; lack of face to face time with staff re discharge; patients not being able to discuss concerns/worries about discharge/illness/medication etc./ lack of discharge planning meetings between ward/families Information is only 'ink on paper' til it is 'understood' and useful. Making the information available is only the beginning. People being discharged from hospital are usually vulnerable or/and concerned about the details of their lives at home. Support is vital! Medication; Communication Tell us about your own experiences of the current discharge process. Sister on ward was key link in ensuring my wife home with an O2 service. She also took time to ensure my wife felt safe and cared for Family friend discharge to lounge in evening - still very unwell and confused; no one at home to prepare house; different staff telling patient/family different things re discharge/not being discharged Excellent - I was given very caring treatment and informed and consulted at every stage. I was given written information to take home and had a contact number in the event of problems My care was fantastic during my stay in hospital. However once I was advised that I probably would be discharged that day the level of care decreased and the staff attitudes changed Informed by patients regularly not being involved in decisions re discharge; family not being told of discharge plans; patients being discharged to empty home as family not aware or expecting them Objective/Area for Improvement Talk to the patient and relatives, don't ignore them Communication Communication! Make sure patients ask all the points the survey is critical of Patients should be kept informed of when discharge will be so that the people coming to collect them can be advised. It is imperative that patients are informed of the medications that are being prescribed. Patients are well enough to be discharged Talking directly to patients and making it clear what they have to do on leaving hospital Target time for the discharge e.g. 1, 2 - do not keep patients waiting - tell patient exactly what is happening - maximum time stipulated Patient awareness of discharge procedure i.e. length of time due to number of patients being discharged, H+S checks and balances by Pharmacy, doctors letters. Also need information earlier in their hospital stay (Discharge wallet a good idea) Home care options - cost etc - explained in full before discharge Discharge dates - better communication with patient about changes to discharge date(s) 2015 Picker Institute Europe. All Rights Reserved. 18

21 Need to be told what meds are to be taken on discharge and why and if any meds have been removed and why Communication at every level - explanation of what is happening now and next steps Improve communication Short term: Activities implemented straight away Communication! Never allow a patient to feel they are 'forgot' because their recover has been slower etc.; ensure that their exit is set up with their family. One to one liaison between nursing staff/doctor and patient. Assessment of patient's capability Go to' person for each individual to share or request info Assess what's available now - what works well v what doesn't - and when e.g. weekend cover patients need assurance re the help that is available. Make sure they know Medium term: Activities within a month Communication! All with clear advice to indiviual patients Prepare advice and guidance for a range of conditions, especially associated with emergency admissions Encourage patients to ask questions - concerning their own circumstances Long term: Activities over next 6 months High Priority Patients will receive all info required about post op medication. Communication is of the essence. Patients should be asked if they have any concerns about being discharged. Do they feel well enough? Lack of communication e.g. staff to be explicit of where the patient is to be picked up from. Ensure that the patient has the correct information that is relevant to them/their condition and discharge. Time for the patient to ask questions. Communication! What's happening now, what will happen later, next steps. Communication! Patient on discharge must know what will happen and when and by who before they go home. It is not acceptable to be waiting hours for medication All wards will have a dedicated discharge coordinator who will liaise with both staff/patients/families Information regarding medication must be provided, explained and understood by the patient before discharge patients need to be aware of procedure that has to take place before medication is ready - doctors letters, pharmacy checks, 14? Wards/discharge of 10? Paients day patients need to be involved earlier in their stay about arrangements/plans/dates - discharge wallet? Full information regarding condition and medication. Medication options - blister packs, if a medication issue was a concern? Discharge dates - better communication (verbally) with patients that discharge date written above bed is an estimate and will be subject to review 2015 Picker Institute Europe. All Rights Reserved. 19

22 Patients will know the 'details' of their discharge ie meds etc, They will also know who to ask if they feel vulnerable about their discharge No to *** medication without telling the patient. This patient needed this medication for other ailments. Medium Priority Staff communicating well to all patients. Not rushing - having time to reassure and answer ALL questions that are important to that individual. Patients will always be involved. Updated daily. Communication! All with clear advice to individual patients Make sure patients ask all the points the survey is critical of There should be no deterioration in the level of care in the period between decision to discharge to actual discharge Low Priority Info packs, step by step laminated sheet detailing discharge process. Info verbally passed on often forgotten, written info can be referenced at a later date. Communication with patient after discharge Where does the trust get it right on their discharge process? Nurses contacting patients post discharge All medication was explained. A cardiac nurse saw my husband on the ward and called at our home the day following his discharge Generally good communication about who to contact, and what to expect in recovery at home; Where do you think the top areas for improvement are? Pharmacy - not open weekends are Wrightington; Xray limited at weekends at Wrightington; Social services - service stops at weekend and out of areas difficult to navigate; prompt staff on checklist to remember to give contact details and ask if there are any other questions or concerns they have Not let a patient leave if he/she is still sleeping; Have some reasonable special parking for the driver or taxi of patients; I was still in pain and discomfort, which the consultant is treating; A blanket on my bed would have been an improvement. There was no 'at home' checkup; a recovery; nobody introduced me to the discharge lounge Formal notification of 'after care' and sure of any medication. Could make better use of modern technology e.g. gmail, text, pdf etc Medication - to ensure patients are aware of when/how to take any meds; well-planned social care (if to be provided) so that family and individual know who is coming to their home and when; knowing who is in charge of their after-care e.g. sister, D, nurse Waiting time for being discharged by the doctor getting medicines and transport home and when you phone up they tell you to phone back after 11am 2015 Picker Institute Europe. All Rights Reserved. 20

23 Tell us about your own experiences of the current discharge process. I have always been told to ring the ward if there were problems. Surely most people are noted as receiving copies of discharge My father in law went home on oxygen. He was in with pneumonia. The ward moved due to a deep clean and he was transferred to another ward and then referral to community nurses was lost. He was at home 3 days on oxygen until I contacted community nurses for a visit. Sister on the ward was very apologetic and said she would give feedback to the staff. Arranged by the surgeon himself at Salford after Maximum radiotherapy and removal of complete bowel - resection and ileostomy; I have a *** phone no to reach him with anything concerning my conditions follow up for frequency due to radiotherapy Objective/Area for Improvement Improve communication/information for aftercare following an emergency/urgent admission. Discharge letter Discharge helpline' for soon after discharge for any queries. Single point of contact. Readmission Formalise discharge process info - what is expected on recovery. Individuals to contact if concerned. Discharge communication to GPs/carehomes etc. Housing Benefits. Care package clear and linked To have a written care plan on discharge outlining: 1) medication - what/when/how, 2) social care (if applicable) who/when, 3) follow up - who/when, 4) named care coordination (if applicable), 5) who to contact in event of problems Told to ring back if any problems but when you do, not felt listen to and 'fobbed off' Short term: Activities implemented straight away Discharge passports to be provided including relevant and accurate information inside of which is relevant to the admission and speciality. Confidentiality permitting potential for correspondance via as to paper and post if wanted on a case by case basis engage senior staff and MDTs. Patient information. Social services notified if patient has needs. Contact details given to patient Relevant information on discharge letters and prescriptions; Provide contact details to patient should they have concerns Medium term: Activities within a month explored confidentiality issue in regards to correspondance. Ensure option for paperless correspondance is being made available. Patient leaflets. Outreach teams. Phone contact with wards. Support groups/social media Outreach team. Managers clinicians Staff to be reminded patient are told to ring if concern and act appropriately Aim to implement a systematic helpline process that can direct patients/relatives to the relevant professional. Determine hours of operation e.g. scan - spun (?) Mon-Sun based on resources and clinical/admin set up Long term: Activities over next 6 months Patients' home and mobile telephone numbers to be provided to staff and/or contact made with the person collecting them 2015 Picker Institute Europe. All Rights Reserved. 21

24 Ensure all future follow ups are in place. Continually use and update the checklist as standard procedure. digital technology ie ipad/pdf to print if necessary - links to community and GP High Priority To be met with respect when phoning with concerns following discharge. Medium Priority Patients need to be aware of home and mobile numbers (for discharge ward staff) to help process going home process: (plus suitable clothing) Low Priority Follow up appointments - can be sent out in post. Follow up contact courtesy calls Information Where does the trust get it right on their discharge process? Information presented up front - oral and written; I can only speak for the discharge process from the Coronary Care Unit - which was excellent. A discharge pack contained full information on the rehab expectations over a six week period. General information information regarding post op care is very good; discharge pack was given to me after Hernia op Where do you think the top areas for improvement are? White boards; 2) Patient information on procedure that takes place between having told they can be discharged and medication, social issues being in places Info and support for the family and carers (e.g. how to take medication, who to call), either through packs for carers, discharge lounge, involvement in decisions, referred to VCS support e.g. carers centre, stroke group, etc. Waiting time - especially long waits for medication; Better liaison with other services; Better planned discharge all round - info packs or wallets needed Discharge times (late night); length of time in discharge lounge; lack of practical advice/information to take home; lack of face to face time with staff re discharge; patients not being able to discuss concerns/worries about discharge/illness/medication etc./ lack of discharge planning meetings between ward/families Information is only 'ink on paper' til it is 'understood' and useful. Making the information available is only the beginning. People being discharged from hospital are usually vulnerable or/and concerned about the details of their lives at home. Support is vital! Tell us about your own experiences of the current discharge process. 3 or 4 experiences of day surgery that went well, though had to wait for medication. Was given some information/advice about recovery. Info sent to GP as expected 2015 Picker Institute Europe. All Rights Reserved. 22

25 Excellent - I was given very caring treatment and informed and consulted at every stage. I was given written information to take home and had a contact number in the event of problems Objective/Area for Improvement Create a discharge form which informs the patients, carers and family about who the patient will need to see before and after discharge Improve communication/information for aftercare following an emergency/urgent admission. Discharge letter Formalise discharge process info - what is expected on recovery. Individuals to contact if concerned. Discharge communication to GPs/carehomes etc. Housing Benefits. Care package clear and linked All patients should receive some basic info on discharge, written and verbal. Aim for specific time from medical discharge to leaving hospital Patient awareness of discharge procedure i.e. length of time due to number of patients being discharged, H+S checks and balances by Pharmacy, doctors letters. Also need information earlier in their hospital stay (Discharge wallet a good idea) Full information regarding medication. What is does - can patient manage to medicate without help Full information regarding condition, future prospects/progress Written discharge information - who to contact for advice Short term: Activities implemented straight away Aim for consistency at approach (followed discussion re when patients can drive after various procedures - people are advised different things by various professionals). Also assess what info is provided/not provided Discharge passports to be provided including relevant and accurate information inside of which is relevant to the admission and speciality. Confidentiality permitting potential for correspondence via as to paper and post if wanted on a case by case basis Relevant information on discharge letters and prescriptions; Provide contact details to patient should they have concerns Some information given at pre-op for planned surgery. Estimated date of discharge given on admission. EPR Letter. SOS card on discharge. IMC team engage senior staff and MDTs. Patient information. Social services notified if patient has needs. Contact details given to patient Discharge pack - collate all info from admission to discharge (out with patient) Medium term: Activities within a month Prepare advice and guidance for a range of conditions, especially associated with emergency admissions Discharge wallets for all areas Patient leaflets. Outreach teams. Phone contact with wards. Support groups/social media Increase training for staff. Preparing leaflets giving information Written explanation of expectations ie. Timeframes Long term: Activities over next 6 months More use of technology ( s, texts, pdf - postoperative care and medicines) 2015 Picker Institute Europe. All Rights Reserved. 23

26 Publish formally both for distribution and online; ensure consistency where relevant; review implementation Producing leaflets. Auditing results of actions and assessing where improvements are needed digital technology ie ipad/pdf to print if necessary - links to community and GP Info packs per person detailings med, professionals involved; anything else High Priority Patients will receive all info required about post op medication. Patients who need a care package will have the confidence that this will be done in line with their discharge. Ensure that the patient has the correct information that is relevant to them/their condition and discharge. Generic patient discharge information supplemented with disease/situation specific information Discharge documentation - patient information, written. Care package clear and linked Families/patients will always be given the right information on discharge ie. Medication, support organisations, review appointments, equipment etc Patients should always have a hard copy of their discharge letter to take home with them Information regarding medication must be provided, explained and understood by the patient before discharge patients need to be involved earlier in their stay about arrangements/plans/dates - discharge wallet? Full information regarding condition and medication. Medication options - blister packs, if a medication issue was a concern? Medium Priority Standardised template of patient recovery that could be used as patient discharge letter at touch of a button. Has this been incorporated into HIS. Low Priority More use of technology - , text, PDF --> postopoeration care, medication Communication with family/carers Where does the trust get it right on their discharge process? Generally liaise well with family; Where do you think the top areas for improvement are? Info and support for the family and carers (e.g. how to take medication, who to call), either through packs for carers, discharge lounge, involvement in decisions, referred to VCS support e.g. carers centre, stroke group, etc. Discharge lounge, consultation with patient, family regarding home situation and possible requirements including *** of other agencies 2015 Picker Institute Europe. All Rights Reserved. 24

27 Involving family and carers more; 2. Discharge planning being looked at on admission; communication as 1& 2 Communication at all level; timely discharge - not late in the evening!; All concerned being involved (family, carers); Medication being ready; ensuring equipment is available when requested; checking on patients in discharge lounge. If they are there any length of time as they need food, water, meds; informing carers/family when next meds due if long discharge Discharge times (late night); length of time in discharge lounge; lack of practical advice/information to take home; lack of face to face time with staff re discharge; patients not being able to discuss concerns/worries about discharge/illness/medication etc./ lack of discharge planning meetings between ward/families Family friend discharge to lounge in evening - still very unwell and confused; no one at home to prepare house; different staff telling patient/family different things re discharge/not being discharged Tell us about your own experiences of the current discharge process. Informed by patients regularly not being involved in decisions re discharge; family not being told of discharge plans; patients being discharged to empty home as family not aware or expecting them Objective/Area for Improvement Talk to the patient and relatives, don't ignore them Talk to patients relatives and carers Once the doctor has seen the patient for the first time upon admission he should let the family, carers and staff know how long they'll be an inpatient for Improve communication with staff, patients and carers to identify patient's issues/needs and connect with appropriate services/organisations with an aim to co-ordinate discharge into primary care. Short term: Activities implemented straight away per trust policy no discharges after 9pm. This policy needs to be adhered to regardless of pressures. Family desire needs to be considered. Never allow a patient to feel they are 'forgot' because their recover has been slower etc.; ensure that their exit is set up with their family. Liasing with social services and family Engage with consultants and ward staff to ensure better understanding by patients that date is estimate and subject to change. Also keep patient and relatives updated discharge planning Medium term: Activities within a month Establish relationships with hosp staff to improve knowledge of service and impact of appropriate referrals on patients/carers and possible bed availability GP. Carer/care home/family district nurses Aim to implement a systematic helpline process that can direct patients/relatives to the relevant professional. Determine hours of operation e.g. scan - spun (?) Mon-Sun based on resources and clinical/admin set up Long term: Activities over next 6 months 2015 Picker Institute Europe. All Rights Reserved. 25

28 Patients' home and mobile telephone numbers to be provided to staff and/or contact made with the person collecting them Using correspondence for relatives and other professionals Data to confirm activities in previous months. Continue relationship building - advertise success All facilities are available e.g. pharmacy follow up for carers High Priority Communication is of the essence. Patients and family been involved in whole discharge plan. From times being discharged to all info/meds being ready. Lack of communication e.g. staff to be explicit of where the patient is to be picked up from. Carers should always be involved in the patient discharge pathway All wards will have a dedicated discharge coordinator who will liaise with both staff/patients/families Families/patients will always be given the right information on discharge ie. Medication, support organisations, review appointments, equipment etc Patients will be asked if they rely on an informal carer or family member, involve them in the discharge pathway Involve carers in the discharge plan - communication between staff/patient/carer Better communication - with patients and patients relatives more routinely without having to ask Medium Priority Patients/carers involved in discharge process. Social Care arrangements to be finalised with patient and family Low Priority Contacting relatives/relevant parties 24 hours before discharge Total comments about family/carer communication: 35 Internal communication Where does the trust get it right on their discharge process? Generally liaise well with surgery though some inconsistencies; It would appear that there are many good discharge procedures in place but that they are not being universally implemented. This could well be because not all interesting and involved internal services are made fully aware of the situation Where do you think the top areas for improvement are? Communication at all level; timely discharge - not late in the evening!; All concerned being involved (family, carers); Medication being ready; ensuring equipment is available when requested; checking on patients in discharge lounge. If they are there any length of time as they need food, water, meds; informing carers/family when next meds due if long discharge Communication between professional staff is imperative and our concern ** the patient must be diminished owing to fear Communication is vital, across all departments 2015 Picker Institute Europe. All Rights Reserved. 26

29 Cooperation between ward staff, consultants and doctors to be closely bonded together Discharge times (late night); length of time in discharge lounge; lack of practical advice/information to take home; lack of face to face time with staff re discharge; patients not being able to discuss concerns/worries about discharge/illness/medication etc./ lack of discharge planning meetings between ward/families Tell us about your own experiences of the current discharge process. Not impressed lack of cooperation between wards and doctors and consultants; 2. I thought the sisters on the discharge ward hard to extremely hard because patients had not the correct tel. nos to contact relations that they could be picked up As a 'professional' I heard of the delays and the lack of communication between departments. As 'nice' as the Discharge Lounge may be, it is not somewhere you want to spend a lot of time - you want to get home! Objective/Area for Improvement Once the doctor has seen the patient for the first time upon admission he should let the family, carers and staff know how long they'll be an inpatient for Employ 'discharge' specific nurse to liaise with 'staff' and patients (improve patient's experience); reduce re-admission Communication at every level - explanation of what is happening now and next steps Short term: Activities implemented straight away Improve communication with staff, patients and carers to identify patient's issues/needs and connect with appropriate services/organisations with an aim to co-ordinate discharge into primary care. engage with hospital consultants and junior doctors to speed up the discharge letters Engage with consultants and ward staff to ensure better understanding by patients that date is estimate and subject to change. Also keep patient and relatives updated discharge planning engage senior staff and MDTs. Patient information. Social services notified if patient has needs. Contact details given to patient Medium term: Activities within a month Increase knowledge of staff via provision of feedback i.e. use of case studies via meeting s to staff. Use of data targets and impact of service to motivate further referrals Increase training for staff. Preparing leaflets giving information Written procedure and protocol for all staff; Training (including process and consequences) liaising between staff (nurses to consultants, and between consultants) Long term: Activities over next 6 months Communication with liaison as a two way process Using correspondence for relatives and other professionsals High Priority Communication is of the essence. Communication across the board. Different departments giving different answers to the same questions Picker Institute Europe. All Rights Reserved. 27

30 Departments need to communicate better to achieve a speedy discharge: ie social services, occupational therapy Medium Priority Earlier MTD meeting to plan discharge and patient requirements post discharge Low Priority Medication Where does the trust get it right on their discharge process? Safety checks - ensuring right medication When everything fits into place on getting your medicines and transport home From a personal point of view, I've been assured medication problem is improving, but can still be improved Where do you think the top areas for improvement are? Patients from out of area bougrhs; medication; estimating discharge Waiting time - especially long waits for medication; Better liaison with other services; Better planned discharge all round - info packs or wallets needed Waiting times, particularly for medication; Location of discharge lounge not ideal - needs signposting; Parking for people picking patients up Expected date of discharge; discharge communication / transfer info; unsafe discharges; Provision of medication in timely manner; transport; who to contact if a problem Shortening wait for medication Long waits for medication - 4+ hours Pharmacy - not open weekends are Wrightington; Xray limited at weekends at Wrightington; Social services - service stops at weekend and out of areas difficult to navigate; prompt staff on checklist to remember to give contact details and ask if there are any other questions or concerns they have Getting discharge medication from Pharmacy; Waiting for Social Services Input; Transport More staff available to prepare drugs in the pharmacy - this will avoid increasing work for the nurses - walking backwards and forwards while drugs are ready Pharmacy!!! Lack of provision of medication and having to wait many hours i.e. 4+ for pharmacy; 2. ensuring there is some person at home in case of emergency to assist patient Delay in discharging patients with complex meds; working/contact with ambulance service; telling older and younger people what they must do on discharge; Getting medication ready for patients Waiting time for being discharged by the doctor getting medicines and transport home and when you phone up they tell you to phone back after 11am Reduction in the time from when told you are going home to when your discharge moves and medications are received Standard protocol for discharge - for all patients recognising - medications, contact points, concerns, complex conditions, social services appliances etc, plus verbal communication; ensure A&E patients (all) receive *** info; ensure pharmacy deals with prescriptions quicker; speed up completion of discharge documentation 2015 Picker Institute Europe. All Rights Reserved. 28

31 Information about medication - dos and donts/when involve patients; Bring process for ordering medication early, so *** it's ready for discharge; support services that are available for patients who are medically fit to leave hospital but cannot go home; provide safe care home services Always that meds are an issue keeping patients informed throughout the discharge process; 2. medication and correct medication being given in a timely manner Medication is an area of concern at Wrightington at weekends; doctors ward rounds; uncertainty on discharge date; especially at weekends; time slots medication dispensation Medication; Communication Tell us about your own experiences of the current discharge process. 3 or 4 experiences of day surgery that went well, though had to wait for medication. Was given some information/advice about recovery. Info sent to GP as expected Husband discharge following major surgery - leaving him needing small amounts of food every hours. Waited four hours for medication but only able to get one meal; Friend's husband discharged yesterday at lunchtime. Is a cancer patient, admitted with Pneumonia. Discharged at 1pm. After two hours went home without medication. Phoned at 8pm for someone to go to hospital as medication was now ready! Had to wait over four hours for medication - occupying a bed on the ward I personally had over four hours in the discharge lounge on one occasion resulting from my medication being sent to the ward in error. Discharge lounge should be relocated R.A.E.I - 7/8 hr delay after hernia op. Medication and discharge papers delays September 2014: 1. I was still in pain, everyone around appeared OK which made me anxious. Had not done all activities that were necessary for discharge; 2. Managed activities but in pain which meant I could go home; 3. Waited for medicine and discharge doctor (Wrightington) Objective/Area for Improvement What is the reason for delays in medication being available? Staff to collect / bad pharmacy stocking? Medication prepared in a more timely manner especially when no change Provision of medication in timely manner on discharge Patients should have the correct medication available ahead of their discharge and be provided with information they understand re dosage etc (inc dressings) Patients who have all necessary medication at home should not be delayed at discharge by pharmacy reviews Improve timescale for medication for discharge Medication delays Medication to improve the communication and efficiency Medication brought in to be used by the nurses (own meds) Short term: Activities implemented straight away Let a patient cash their own prescription if suitable fitness to do so Assess why meds are delayed for no apparent reason or not ordered when decision made to confirm discharge 2015 Picker Institute Europe. All Rights Reserved. 29

32 urgent review from requesting medication for discharge to being ready for collection. Possible make discharge medication ready prior to being discharged. Possibly only inform the patient that they are ready for discharge once the medication is ready for collection Patient; pharmacy; healthcare professionals Act on results of today. Do what is promised. Why cannot meds be picked up from local chemist instead of hospital (fax prescriptions to chemist) Discharge coordinators and runners to go to pharmacy when required. Discharge runners Map a consistent approach for pharmacy referrals (some wards do their own TTOs - some forward drug boards and forget to input to computer) Medication and equipment required is prepared and ready for the discharge time Go through, check all meds to ensure stopped/carried on as needed. Patients' own times carried on and documented Medium term: Activities within a month Set a standard timescale for discharge letters (poss 2 hours from decision to discharge) to pharmacy; Set standard timescale for pharmacy response to discharge meds Ensure the check between staff and patients is carried out (NB we know this comment is about medication checks in context) Long term: Activities over next 6 months Review discharge medication procedures and ambulance/patients transport needs High Priority There are many delays caused by the pharmacy. Is it not possible for patients to take prescriptions to their own pharmacy? Length of time waiting for medications is sometimes excessive. Pharmacy - awaiting medications. Medication - ready quicker. What is reason for delays in medication being available - staff to collect? Bad pharmacy stocking? Patient on discharge must know what will happen and when and by who before they go home. It is not acceptable to be waiting hours for medication Provision of medication in a timely manner Patients who have all necessary medication at home should not be delayed at discharge by pharmacy reviews Patients should have the correct medication available ahead of their discharge from the ward Medication - improve timescales for preparing medication for discharge - is there a better system? Medium Priority Discharge lounge is situated too far from pharmacy. Staff have to walk too far to get medication. This causes delays to discharge. More staff available to prepare drugs in the pharmacy. This will avoid unnecessary work for the nursing staff walking backwards and forwards to *** drugs are ready. Reduce waiting time for medication. Delays to pharmacy often occur when the pharmacist has to query what the medication and dosage had been written on the drug board by the consultants Picker Institute Europe. All Rights Reserved. 30

33 Own medication either not used, not available or taken away. And not given at appropriate times. reducing wait for medication before discharge Low Priority Planning/protocol Where does the trust get it right on their discharge process? Planned discharge date generally in operation Setting objectives at the start is very important by the patients and staff By trying to ensure people can leave hospital when medically fit - not prolonging stays when not necessary It would appear that there are many good discharge procedures in place but that they are not being universally implemented. This could well be because not all interesting and involved internal services are made fully aware of the situation Where do you think the top areas for improvement are? Everything ready for discharge time/date when it's set Patients from out of area bougrhs; medication; estimating discharge Waiting time - especially long waits for medication; Better liaison with other services; Better planned discharge all round - info packs or wallets needed Expected date of discharge; discharge communication / transfer info; unsafe discharges; Provision of medication in timely manner; transport; who to contact if a problem Involving family and carers more; 2. Discharge planning being looked at on admission; communication as 1& 2 Faster discharge would definitely be a big improvement!; Information regarding actual discharge time is required Making sure that patients are treated properly and waiting time is no more than one hour Reduction in the time from when told you are going home to when your discharge moves and medications are received Standard protocol for discharge - for all patients recognising - medications, contact points, concerns, complex conditions, social services appliances etc, plus verbal communication; ensure A&E patients (all) receive *** info; ensure pharmacy deals with prescriptions quicker; speed up completion of discharge documentation Discharge timeline; discharge procedure ticklist; discharge timeslots (Morn, afternoon, evening), pharmacy +ask if patient req's IT between Wards+doctors+patient, discharge planning should start at admission Medication is an area of concern at Wrightington at weekends; doctors ward rounds; uncertainty on discharge date; especially at weekends; time slots Discharge times (late night); length of time in discharge lounge; lack of practical advice/information to take home; lack of face to face time with staff re discharge; patients not being able to discuss concerns/worries about discharge/illness/medication etc./ lack of discharge planning meetings between ward/families Tell us about your own experiences of the current discharge process Picker Institute Europe. All Rights Reserved. 31

34 On site at Wrightington discharges at the weekend are slower due to the above issues resulting in delayed discharges for patients Have had colonoscopy and endoscopy, also Barium Meal xrays and in each case discharge was reasonably quick; had ** Hernia op earlier this year (day patient). My care before and after op was excellent but I felt that I was kept in too long, reason given was I had to pass a specific amount of urine. Apparently if I hadn't managed it I might have been kept overnight! Not delayed but seemed unnecessarily long- no doctor involved; Day operation, Hernia operation My mother in law who is 91 years old and had shingles on tummy and back waited 7 hours and didn't get home to the care home till the day after she was discharged I have been in R.A.E.I on a number of occasions- *** for emergency treatment and elective surgery and I have never been discharged until at least 4/8 hours have elapsed: also the last time I was kept in the ward and not sent to the discharge lounge - therefore my bed was not available for the next patient September 2014: 1. I was still in pain, everyone around appeared OK which made me anxious. Had not done all activities that were necessary for discharge; 2. Managed activities but in pain which meant I could go home; 3. Waited for medicine and discharge doctor (Wrightington) Objective/Area for Improvement The discharge process should begin (in as many cases as possible) on admission To have a written care plan on discharge outlining: 1) medication - what/when/how, 2) social care (if applicable) who/when, 3) follow up - who/when, 4) named care coordination (if applicable), 5) who to contact in event of problems All patients should receive some basic info on discharge, written and verbal. Aim for specific time from medical discharge to leaving hospital Protocol for discharge same throughout hospital - checklist. Someone to oversee all aspects of discharge Target time for the discharge e.g. 1, 2 - do not keep patients waiting - tell patient exactly what is happening - maximum time stipulated To improve discharge procedure/patient satisfaction Discharge planning should start at admission with patients allocated time slots for their discharge day Discharge - plan earlier, equipment; Avoid duplication of assessments Everything needed for discharge in place before date/time Short term: Activities implemented straight away Have a uniform discharge time and push for a maximum additional time of two hours Aim for consistency at approach (followed discussion re when patients can drive after various procedures - people are advised different things by various professionals). Also assess what info is provided/not provided The timetable for day is adhered to - making sure they are adequately staffed for the discharge procedure; Making sure patients are fully recovered before discharge Standardisation of process. Ticklist/checklist. Transport. home Standardised checklist. Expected date of discharge Advance care plan - say 24 hours before discharge, especially for patients who live alone consistent discharge procedure throughout hospital 2015 Picker Institute Europe. All Rights Reserved. 32

35 Importance of accurate 'white board' information on discharge dates. At present very few are accurate - some have only the month (sometimes wrong month) Some have date in the past Medium term: Activities within a month Timed plan of action from admission to discharge for a range of conditions, with focus on working backwards from time of discharge (EDD) Set a standard timescale for discharge letters (poss 2 hours from decision to discharge) to pharmacy; Set standard timescale for pharmacy response to discharge meds Monitor the input/output: 1) length of stay, 2) why long stays, 3) transport!! Some information given at pre-op for planned surgery. Estimated date of discharge given on admission. EPR Letter. SOS card on discharge. IMC team Written procedure and protocol for all staff; Training (including process and consequences) Checklist for staff to follow you to discharge so that everything is ready (discharge letter, other agency involvement, meds/equipment) Long term: Activities over next 6 months Publish formally both for distribution and online; ensure consistency where relevant; review implementation Monitoring of standards in place Ensure all future follow ups are in place. Continually use and update the checklist as standard procedure. High Priority Day Surgery unit closes approx 1900 hours so if you are kept in later you are transferred to a ward and left to sit at side of a bed, if one is empty! Patients are looked after in the discharge lounge and guaranteed waits of a minimum. Discharge planning earlier. Realistic estimated date of discharge. Ensure everything needed to discharge is in place and ready prior to setting discharge time/date. Including any equipment needed. Transportation waiting times, general organisational structure. Have a uniform discharge time and push for a maximum additional time of 2 hours The discharge process should begin (in most cases) on admission A discharge procedure to be formulated by serious management and medical staff. Discharge planning should start at admission Patients should be given allocated time slots for their discharge patients need to be involved earlier in their stay about arrangements/plans/dates - discharge wallet? What are the reasons for delays in complex cases ie. Resp, orthopaedics/trauma Medium Priority Estimated date of discharge on admission. Earlier MTD meeting to plan discharge and patient requirements post discharge Low Priority 2015 Picker Institute Europe. All Rights Reserved. 33

36 Total comments about Planning/Protocol: 68 Safety Where does the trust get it right on their discharge process? Considering clients for continuing health care; picking up complex clients and attempting to get their needs met Where do you think the top areas for improvement are? Expected date of discharge; discharge communication / transfer info; unsafe discharges; Provision of medication in timely manner; transport; who to contact if a problem delays owing to delay in delivery of discharge; delays owing to availability of transport; support for patients who need reassurance owing to dementia - experience of transfers late at night owing to lack of transport leading to anxiety of patient Communication at all level; timely discharge - not late in the evening!; All concerned being involved (family, carers); Medication being ready; ensuring equipment is available when requested; checking on patients in discharge lounge. If they are there any length of time as they need food, water, meds; informing carers/family when next meds due if long discharge Not let a patient leave if he/she is still sleeping; Have some reasonable special parking for the driver or taxi of patients; I was still in pain and discomfort, which the consultant is treating; A blanket on my bed would have been an improvement. There was no 'at home' checkup; a recovery; nobody introduced me to the discharge lounge Lack of provision of medication and having to wait many hours i.e. 4+ for pharmacy; 2. ensuring there is some person at home in case of emergency to assist patient When mental health patients are discharged, especially when they live alone, need more help and follow up. It can get stressful waiting for medication when they "just want" to get home My mother in law who is 91 years old and had shingles on tummy and back waited 7 hours and didn't get home to the care home till the day after she was discharged Tell us about your own experiences of the current discharge process. Awful! I was still bleeding and urine incontinent, yet I had to walk for Wigan AEI to the top end of the Standish Gate; I was shocked at my discharge; The ward certainly expressed a need for my bed, not mine though In my own case nursing staff informed me and my family I would be released to a care home. This was contradicted by consultant and I went home. In contrast our friend asked to go to a care home following a replacement hip operation. This was refused. We attend her funeral in 2 days My father in law went home on oxygen. He was in with pneumonia. The ward moved due to a deep clean and he was transferred to another ward and then referral to community nurses was lost. He was at home 3 days on oxygen until I contacted community nurses for a visit. Sister on the ward was very apologetic and said she would give feedback to the staff. Objective/Area for Improvement Do not let a patient out of hospital who is bleeding and incontinent. Therefore a walk to transport was a real problem Inappropriate times of discharge e.g. late at night 2015 Picker Institute Europe. All Rights Reserved. 34

37 Patients should be kept informed of when discharge will be so that the people coming to collect them can be advised. It is imperative that patients are informed of the medications that are being prescribed. Patients are well enough to be discharged Ambulance transport (if applicable) - who is taking me home and who is bringing me to follow-up appointments; Making sure that patient is going to a suitable home environment e.g. warm, somebody to care; Not being discharged late evening or nightime Arrangements have to be in place for discharge - patients *** *** going back to an inappropriate home or care home with **** Review of social issues that prevent discharge - pathways/range of facilities available/support Home care options - cost etc - explained in full before discharge Transport - improve timescale to reduce discharge patients' wait for transport - take account of people with MH and dementia Short term: Activities implemented straight away per trust policy no discharges after 9pm. This policy needs to be adhered to regardless of pressures. Family desire needs to be considered. The timetable for day is adhered to - making sure they are adequately staffed for the discharge procedure; Making sure patients are fully recovered before discharge Advance care plan - say 24 hours before discharge, especially for patients who live alone On admission agree with patient how they will get home on discharge. Where ambulance (or other) required avoid elderly/confused patients being transferred late at night or when dark Medium term: Activities within a month Assess for Aids and Adaptations earlier in discharge procedure Long term: Activities over next 6 months High Priority Make sure the patient is discharged at a time when family/friends can accommodate - not too late at night or early morning. So patient is not having to stay up late when feeling unwell. Patients without family/carers are supported with their discharge to ensure the home environment is safe to return. Food/heat/etc. Don't let a patient out of hospital who is bleeding and incontinent to walk to their transport Patients should be discharged to a responsible person who is capable of caring for them Safe discharge that avoids readmission Priority given to individual patient's needs, rather than trying to rush discharge to make room for the next patient Patients should be asked if they have any concerns about being discharged. Do they feel well enough? Options available for home care on release - cost etc or reablement What are the reasons for delays in complex cases ie. Resp, orthopaedics/trauma Medium Priority Premature discharge 2015 Picker Institute Europe. All Rights Reserved. 35

38 Discharges out of hours? Support Agencies? -council, -social care, -vol. sector --> availability Low Priority Numbers come down to individuals. E.g. Home situation? Any ***? Any food/neighbour/family? Short term - long time - good recovery. Total comments about safety: 20 External Resources Where does the trust get it right on their discharge process? Referral process to ** handling *** social work team working Discharge lounge, consultation with patient, family regarding home situation and possible requirements including *** of other agencies Where do you think the top areas for improvement are? Info and support for the family and carers (e.g. how to take medication, who to call), either through packs for carers, discharge lounge, involvement in decisions, referred to VCS support e.g. carers centre, stroke group, etc. Waiting time - especially long waits for medication; Better liaison with other services; Better planned discharge all round - info packs or wallets needed Communication between hospital staff and services available within the hospital; involving the 3rd sector who can speed up discharge, food - clothes - shopping - cleaning - follow up calls etc Medication - to ensure patients are aware of when/how to take any meds; well-planned social care (if to be provided) so that family and individual know who is coming to their home and when; knowing who is in charge of their after-care e.g. sister, D, nurse Information about medication - dos and donts/when involve patients; Bring process for ordering medication early, so *** it's ready for discharge; support services that are available for patients who are medically fit to leave hospital but cannot go home; provide safe care home services Tell us about your own experiences of the current discharge process. 3 or 4 experiences of day surgery that went well, though had to wait for medication. Was given some information/advice about recovery. Info sent to GP as expected I am lucky because I have always had a family member to ensure and assist me at discharge - not everyone is so fortunate! Lack of communication and explanation caused problems with my continued treatment by my GP after discharge Objective/Area for Improvement Formalise discharge process info - what is expected on recovery. Individuals to contact if concerned. Discharge communication to GPs/carehomes etc. Housing Benefits. Care package clear and linked Increased access to information/voluntary sector local services and support groups to minimise delays in discharge. Ie fuel poverty, food-bank, Age UK 2015 Picker Institute Europe. All Rights Reserved. 36

39 Community link workers. Engage with all hospital staff to increase awareness of community link worker service and how the team can support the patient and/or carers in hosp through to discharge and link to primary care CLWs Communication with community nurses and other outside agencies Review of social issues that prevent discharge - pathways/range of facilities available/support Social service issues Short term: Activities implemented straight away Improve communication with staff, patients and carers to identify patient's issues/needs and connect with appropriate services/organisations with an aim to co-ordinate discharge into primary care. Info on patients needing advice/support from hospital staff. Staff aware/understand service and links with voluntary sector/primary care services/support groups. List of services based in the hospital. Given on admission that can provide information linkworker. Age UK, COPD, Think Ahead, STroke etc engage senior staff and MDTs. Patient information. Social services notified if patient has needs. Contact details given to patient Copy of referral letters from hosp doctors or consultants to external specialists i.e. OT, Physio, Falls clinics etc given to patient or carer at time of discharge 7 day social workers team Medium term: Activities within a month Review effectives with other services/stakeholders Liaising with social services and family GP. Carer/care home/family district nurses Long term: Activities over next 6 months CLW based within IDT at front and backdoor. Liaison with IDT, social workers, ward staff and patients. Shared responsibility with discharge co-ordination Electronic referral system - will community workers have access to this system GP. Questionnaires surveys. Follow up clinics. Patient responsibility. GP Increase availability of access to social service/community services/beds etc. for medically discharged patients digital technology ie ipad/pdf to print if necessary - links to community and GP High Priority Social input services stops at the weekend. Out of area assessments. discharge communication to GPSs / care homes etc. housing, benefits Wards will always signpost or refer to the right community organisations prior to discharge. This will lead to seamless post discharge support Departments need to communicate better to achieve a speedy discharge: ie social services, occupational therapy Patients will have the opportunity to talk to a CLW to discuss social/personal issues and discharge time Use the third sector who are already based within the hospital 2015 Picker Institute Europe. All Rights Reserved. 37

40 Medium Priority Closer working between other services to ensure community care is available, be that in care homes or patients own home. Discharges out of hours? Support Agencies? -council, -social care, -vol. sector --> availability After care in the community - district nurse follow up / prescriptions for dressings etc Social Care arrangements to be finalised with patient and family Low Priority Use of staff Where does the trust get it right on their discharge process? Discharge Charter; discharge group; complex discharge team Dedicated nurse after operation (at least in my case!); The intention to do a good job is there but I felt they were too busy to do it properly Where do you think the top areas for improvement are? Tell us about your own experiences of the current discharge process. My own discharges have been clearly thought through and implemented by good strong leadership skills. Brought into focus by sound professional knowledge Objective/Area for Improvement Protocol for discharge same throughout hospital - checklist. Someone to oversee all aspects of discharge Employ 'discharge' specific nurse to liaise with 'staff' and patients (improve patient's experience); reduce re-admission Short term: Activities implemented straight away Discharge coordinators and runners to go to pharmacy when required. Discharge runners The timetable for day is adhered to - making sure they are adequately staffed for the discharge procedure; Making sure patients are fully recovered before discharge Medium term: Activities within a month Have a dedicated member of staff to liaise discharge Treating healthcare professional A&E, ward sister, admissions team, pre-op Ward nurses Reinstate discharge team. Ensure patient does have understanding Long term: Activities over next 6 months Review and amend. Plan to replicate to cancer specialist nurse system which is known to make a difference to patient satisfaction Nurses consultants Someone to take over all responsibility for discharge to ensure it is safe and effective to reduce readmission 2015 Picker Institute Europe. All Rights Reserved. 38

41 High Priority All wards will have a dedicated discharge coordinator who will liaise with both staff/patients/families A dedicated nurse to support patients discharge Medium Priority More staff available to prepare drugs in the pharmacy. This will avoid unnecessary work for the nursing staff walking backwards and forwards to *** drugs are ready. Quality and not quantity. Employ more staff. Low Priority Discharge lounge Where does the trust get it right on their discharge process? Sounds like discharge lounge is a good idea that needs explaining better Discharge lounge can work well Where discharge was directly from the ward it was more efficient and medication/discharge letter was available sooner than the discharge lounge Discharge lounge, consultation with patient, family regarding home situation and possible requirements including *** of other agencies Understand have a good discharge lounge Discharge lounge; advising people in middle band what to do on discharge I have been in a discharge situation numerous times in the last 18 months and the discharge lounge is to be commended and recommended Where do you think the top areas for improvement are? Info and support for the family and carers (e.g. how to take medication, who to call), either through packs for carers, discharge lounge, involvement in decisions, referred to VCS support e.g. carers centre, stroke group, etc. Waiting times, particularly for medication; Location of discharge lounge not ideal - needs signposting; Parking for people picking patients up Although facilities in discharge lounge were good and staff ***, I found its location was too far removed from pharmacy/wards causing staff to have to walk long distances to get the medication/letters for each patient making delays in the discharge longer Communication at all level; timely discharge - not late in the evening!; All concerned being involved (family, carers); Medication being ready; ensuring equipment is available when requested; checking on patients in discharge lounge. If they are there any length of time as they need food, water, meds; informing carers/family when next meds due if long discharge Not let a patient leave if he/she is still sleeping; Have some reasonable special parking for the driver or taxi of patients; I was still in pain and discomfort, which the consultant is treating; A blanket on my bed would have been an improvement. There was no 'at home' checkup; a recovery; nobody introduced me to the discharge lounge Tell us about your own experiences of the current discharge process. I personally had over four hours in the discharge lounge on one occasion resulting from my medication being sent to the ward in error. Discharge lounge should be relocated 2015 Picker Institute Europe. All Rights Reserved. 39

42 Family friend discharge to lounge in evening - still very unwell and confused; no one at home to prepare house; different staff telling patient/family different things re discharge/not being discharged I have been in R.A.E.I on a number of occasions- *** for emergency treatment and elective surgery and I have never been discharged until at least 4/8 hours have elapsed: also the last time I was kept in the ward and not sent to the discharge lounge - therefore my bed was not available for the next patient Objective/Area for Improvement Discharge lounge in wrong place, not big enough Short term: Activities implemented straight away Medium term: Activities within a month Make a discharge ward/area and move the appropriate patients to it Discharge lounge is not ideal environment. Too many chairs wheelchair access not good into toilets. Develop 'fragility profiles' or 'personal pictures' to inform admission process and 'knock on' for appropriate discharge More ward based pharmacy discharges Long term: Activities over next 6 months High Priority Patients are looked after in the discharge lounge and guaranteed waits of a minimum. Medium Priority Discharge lounge is situated too far from pharmacy. Staff have to walk too far to get medication. This causes delays to discharge. Accessibility / location of discharge lounge - not well signposted. Thought given to furniture in discharge lounge e.g. availability of seating, space etc Low Priority What's on the TV screen Discharge lounge - drive through / parking collection separate discharge rooms for male and female patients. Some patients are waiting in nightwear and can feel embarrassed Equipment/transport Where does the trust get it right on their discharge process? When everything fits into place on getting your medicines and transport home Where do you think the top areas for improvement are? Waiting times, particularly for medication; Location of discharge lounge not ideal - needs signposting; Parking for people picking patients up Expected date of discharge; discharge communication / transfer info; unsafe discharges; Provision of medication in timely manner; transport; who to contact if a problem 2015 Picker Institute Europe. All Rights Reserved. 40

43 delays owing to delay in delivery of discharge; delays owing to availability of transport; support for patients who need reassurance owing to dementia - experience of transfers late at night owing to lack of transport leading to anxiety of patient Getting discharge medication from Pharmacy; Waiting for Social Services Input; Transport To speed up and prevent duplication on assessments with equipment - by having community moving and handling equipment at the hospital Not let a patient leave if he/she is still sleeping; Have some reasonable special parking for the driver or taxi of patients; I was still in pain and discomfort, which the consultant is treating; A blanket on my bed would have been an improvement. There was no 'at home' checkup; a recovery; nobody introduced me to the discharge lounge Delay in discharging patients with complex meds; working/contact with ambulance service; telling older and younger people what they must do on discharge; Getting medication ready for patients Waiting time for being discharged by the doctor getting medicines and transport home and when you phone up they tell you to phone back after 11am Communication at all level; timely discharge - not late in the evening!; All concerned being involved (family, carers); Medication being ready; ensuring equipment is available when requested; checking on patients in discharge lounge. If they are there any length of time as they need food, water, meds; informing carers/family when next meds due if long discharge Tell us about your own experiences of the current discharge process. Sister on ward was key link in ensuring my wife home with an O2 service. She also took time to ensure my wife felt safe and cared for Objective/Area for Improvement Ambulance transport (if applicable) - who is taking me home and who is bringing me to follow-up appointments; Making sure that patient is going to a suitable home environment e.g. warm, somebody to care; Not being discharged late evening or nightime Transport - improve timescale to reduce discharge patients' wait for transport - take account of people with MH and dementia Discharge - plan earlier, equipment; Avoid duplication of assessments Short term: Activities implemented straight away Provision of some community equipment for assessment purpose On admission agree with patient how they will get home on discharge. Where ambulance (or other) required avoid elderly/confused patients being transferred late at night or when dark Medium term: Activities within a month Allocation of a room for storage Long term: Activities over next 6 months Liaising with ambulance service Review discharge medication procedures and ambulance/patients transport needs Provision of equipment room and additional MHs post High Priority Additional funding for equipment provision. Assessment on ward with equipment to be used at home Picker Institute Europe. All Rights Reserved. 41

44 Ensure everything needed to discharge is in place and ready prior to setting discharge time/date. Including any equipment needed. Transportation waiting times, general organisational structure. Transport. Transport - prompt access to transport Medium Priority Car parking - charging? Low Priority 2015 Picker Institute Europe. All Rights Reserved. 42

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