Establishing discharge-focused action planning for patients in a mental health trust
The PSC Performance team supported South London and Maudsley NHS Foundation Trust to kickstart a “right care, right place, right time” transformation programme by implementing a blueprint for more discharge-focused action planning on its inpatient wards.
Like so many providers in mental health, the Trust experiences intense pressures on its beds. COVID-19 increased demand for mental health inpatient care, whilst the range of barriers to discharging patients presented a constant challenge to timely admission of new ones.
Safely reducing the length of patients’ stay on the wards and discharging earlier in the day was key to reducing some of this pressure – and providing a better care experience for the patients themselves.
Over 8 weeks, our team worked in partnership with the leadership, clinical multidisciplinary teams (MDTs) and quality improvement advisers on two of the Trust’s inpatient wards to:
• Diagnose key barriers to discharge and identify appropriate solutions
• Run Plan-Do-Study-Act (PDSA) improvement cycles to test out solutions
• Articulate the blueprint approach and prepare the Trust for a sustainable roll-out
Diagnosing barriers and identifying solutions
We conducted ward-based snapshot studies of (i) the breakdown of medically well and medically unwell patients with and without practical barriers to discharge, and (ii) the most common reasons for delayed discharges. The key insight to come out was that several frequent barriers to discharge – especially those associated with onwards accommodation and community care – could be addressed by earlier discharge planning and more reliable flows of information between teams within the Trust. This informed the discussions we facilitated with ward MDTs as they identified the solutions they wanted to try.
Running PDSA improvement cycles
Through short and focused daily improvement huddles, we supported the ward teams to plan out, do, study and act on the results of their improvement cycles. Although both wards tailored implementation to their respective team cultures, they both settled on a similar set of solutions:
1. Information gathering from community teams:
- Within 24-72 hours of a patient’s admission, use a pre-existing meeting to elicit information from the community team with caseload responsibility for that patient – covering (i) patient’s baseline mental health, (ii) other professionals involved, (iii) expected treatment plan, (iv) safeguarding, (v) accommodation, (vi) finances
- Live input this information to the patient’s electronic record so it becomes immediately available to the ward for the purpose of early discharge planning and identifying any barriers
2. During the weekly ward round:
- Identify aims of admission and an estimated date of treatment response in the patient’s first ward round
- Check for any new information from the community team which requires an update to the care plan
3. During the daily MDT morning huddle:
- Use a short, scripted set of questions for each patient to ensure a consistent, action-oriented discussion focused on addressing barriers to discharge
- Write up actions on a physical or virtual whiteboard with named owners assigned
4. During the day:
- Designate protected time to individuals for completing actions
- Tick off and record the status of actions, for review at the next morning’s MDT huddle
We drove the momentum of this work and mentored staff through the process. We created supporting tools and templates, liaised with other Trust teams whose involvement was critical, wrote team briefings, tracked compliance with new processes, and suggested further improvement opportunities.
Articulating the blueprint and preparing for sustainable roll-out
We built on learning from the PDSA cycles to refine and articulate a blueprint approach, which we distilled onto a single visual slide to make it easy for other ward teams to replicate.
We also carried out a comprehensive assessment – based on a recognised NHSE/I tool – to identify the key ingredients for sustainability. From this, we developed a set of practical recommendations to support roll-out across the Trust.
A follow-up snapshot study on the two wards towards the end of our support identified a 53% reduction in the number of patients medically fit for discharge but still on the wards. Our modelling extrapolated from this a potential opportunity to reduce average length of stay across both wards (50 days) by between 1 and 5 days. This potential opportunity is just the start of the transformation that’s possible.
Staff on the wards commented that they felt more involved in their patients’ care, were taking on more actions, and had seen positive change in how they worked as a team. Management staff embraced our blueprint approach and recommendations, and felt equipped to maintain the momentum.
The value of The PSC’s practical and collaborative approach shone through in feedback from senior staff at the Trust:
‘Thank you for your professionalism, endeavour and support – I believe this work will lead to some game-changing outcomes and it would not have got off on this footing without your input, structure and guidance.’
‘It’s been exactly what we needed … you’ve hit the right blend of instruction, role modelling and support to give the front-line teams the confidence required to act with purpose and continue the work.’