The Atlas of Shared Learning

Case study

Improving care in mental health services – an acute care pathway

Leading change

The ward manager at Harplands Hospital, Stoke-on-Trent led on the development and implementation of an Acute Care Pathway (ACP) programme of work to foster new ways of working, standardise good practice and improve experiences for both staff and patients within the Trust. This programme of work has led to both improvements in outcomes and use of resources.

Where to look

The Care Quality Commission (2017) reported that more people than ever are receiving treatment and care for mental health conditions; in part due to a reduction in the stigma associated with mental ill-health. Treatment can only truly succeed if it is supported by mental health service provision that gives people the help they need, when they need it, where they need it (Care Quality Commission 2017). Supporting this, the Five Year Forward View for Mental Health (NHS England 2017) highlights the need to move towards a future where people have access to high-quality care close to home, and they are able to exercise choice – reflecting true shared decision making and personalised care.

The ward manager identified unwarranted variation in the higher than expected incident rates, staff sickness rates, staff vacancies and enhanced observations of patients who were awaiting mental health support.

What to change

The ward manager worked collaboratively with the ward team to review current practices and establish areas for improvement. Through discussion some key elements of improvement were developed, which included a review of:

  • The use of clinical observation to support effective patient care;
  • Patient safety incidents to identify risks and potential opportunities for change;
  • Bed occupancy to identify opportunities to support patients to have a better service and experience;
  • Ways of working to support staff in delivering care, developing a culture of encouraging new staff to join the ward and have a good working experience;
  • Patient experience feedback to identify areas for improvement or change;
  • How the ward works in collaboration with partners across the acute wards and the community partners, identifying areas for improvement and change.

How to change

An ‘Acute Care Pathway’ programme of improvement was developed and led by the senior nursing team, this includes:

  • Introduction of a standardised initial discussion with all patients at the point of admission, carers were actively invited to initial ward reviews and care coordinators invited to 72-hour reviews;
  • Introduction of an agreed set of ward values, common goals and culture to ensure the ward staff felt part of a wider team and supported each other effectively. Formal and informal engagement with patients, their carers’ and families regarding the ward’s values and goals ensuring they could contribute and support the work underway;
  • Introduction of a daily ‘rapid Multidisciplinary Team (MDT) handover’ to improve collaborative working and encourage effective communication;
  • Adaption and amendment of the ward’s patient review process and documentation templates to facilitate the new ways of working;
  • Review and development of the ‘ward literature’ for patients, carers and families to ensure all relevant information was incorporated;
  • Development of appropriate ward signage to support navigation for patients, carers and families;
  • Increased supervision and support to staff, supporting a culture of reflective practice.

The programme was rolled out across the ward with support of the Trust’s senior nursing team as well as across the MDT using a continuous cycle of change and evaluation.

Adding value

Better outcomes – Patients’ length of stay have been reduced, with their care being planned and supported more effectively. A reduction of more than 10% has been seen in average length of stay. Patients are now being effectively supported and encouraged to engage effectively with community care teams and other care providers reducing their perceived dependency on inpatient services, which promotes the delivery of care in the least restrictive environment. Patient related incidents within the inpatient setting have also reduced by 60% since the launch of the programme and this continues to be monitored for shared learning. The programme has also increased the ward’s capacity due to the reduced length of stay, which has also led to fewer out of area admissions. As out of area placements are associated with negative impacts on recovery, this has been a very positive secondary finding.

Better experience – Since the implementation of the ACP, a staff survey was undertaken with the following results:

  • 87% of staff report feeling safe;
  • 86% report feeling well-led;
  • 78% report feeling more effective;
  • 69% felt their work was more patient-centred.

Qualitative staff feedback includes:

Practice feels more effective and appropriate for diagnosis. The care we now provide is more recovery focused. Lastly job satisfaction is much improved.

The acute care pathway has enhanced care delivery. Better communication and planning with staff. Makes it a great place to work.

The implementation of the ACP has seen the biggest change to the way we nurse patients who are acutely unwell since I started in Acute 15 years ago. The positive effect on patient care and staff morale has been tremendous.

Patients have also welcomed the change, reporting:

I didn’t like or understand it at first, but I get it now and I think its loads better.

My care was well co-ordinated and I was involved in all the decisions.

The staff were excellent, I like the new structure and still have freedom of choice.

Better use of resources – There is increased capacity within the ward setting, with fewer people being transferred out of area for an inpatient bed. This is saving £660+ per day per patient for the inpatient bed and associated costs. The pathway has also freed up ward staff capacity with fewer crises, incidents or enhanced observations, leaving staff more available to provide continuity of care and support.

Challenges and lessons learnt for implementation

It is possible to work differently, but you need partners in care on board before the change for it to be successful.

A challenge with developing new ways of working and quality improvements will always be competing demands from your existing workloads. It is important to consider what will be needed to sustain both and seek help to do this.

Communication with stakeholders is vital; people need to be clear how things will change and what this will mean for them. Time for this is essential.

It is important to consider your role in leading – people will buy into you, your brand, your pathway, your belief in the benefits – so be honest about potential difficulties and challenges in order to avoid disappointment.

Following the successful launch of the programme, the team continue to be passionate about the pathway. The next steps include working closely with community teams to help them engage in the pathway, reviewing progress to see if the process can be further streamlined, and where technology can better assist.

Find out more

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