Leading change

A nurse-led project has successfully achieved improvements in aspects of working processes and culture at the University Hospitals of Leicester NHS Trust (UHL). The result has been an improvement in patient flow and experience – particularly through more timely discharges.

Where to look

Senior nurses identified unwarranted variation across UHL wards, in relation to delayed transfers of care (DToCs), discharges and patient waits for tests, reviews and medication.

What to change

The nursing clinical leads with hospital management agreed that a step-change was needed in the way the Trust delivered services, to sustain a safe high-quality service. Supported by the Trust’s executive team, the nursing leadership identified the need to change processes in line with NHS Improvement’s ‘SAFER’ patient flow bundle and Red2Green bed days approach. The evidence suggested that:

• All patients should have a senior clinical review before 11am
• All patients should have an estimated date and clinical criteria for discharge
• Patient movement from assessment units should begin by 10 am
• 33% of patients should be discharged before midday
• All patients should be reviewed after a stay of more than seven days

How to change

Senior nurses were seconded into the clinical lead roles for the project. The initial focus was on 14 specialist medicine wards, later extended to four renal and 12 respiratory/cardiology wards.

Following initial trials of the changes, the roll-out style has been one of staff empowerment and engagement – using the Listening into Action approach which UHL is signed up to, involving staff in problem-solving and transformation. Listening into Action is an approach used within the Trust to engage with its multidisciplinary teams when undertaking change projects. The approach enables all staff to be involved and have their say which is important if the change is to be sustained.

Staff have taken on board the effects of cultural practice on a patient’s time, safety and experience and an emphasis on patients rather than beds.

Patients should know the answer to four key questions:

1. What’s going to happen to me?
2. What’s going to happen today?
3. What’s needed to get me home?
4. When am I going home?

Under the theme “Get Moving To Get Home,” ward teams have been supported to encourage their patients to get out of bed each day to help aid their recovery. Progress has been measured by a set of agreed metrics, with charts displaying the impact of changes at ward level.

Daily ten-minute Red2Green (bed days) meetings are held on wards before midday. This enables data to be shared which captures all red days and related impacting events. The information is given to internal and external partners and enables plans of action. Every month an award is presented to a ward for Red2Green contributions.

Adding value

• Better outcomes – The average length of stay has fallen which is better for patients. Comparing current data with the same weekly period the year before showed a 1.2% reduction in bed occupancy to 94.6%, and a 10.3% increase in the proportion of patients discharged before noon.

• Better experience – Elderly frail patients are getting home earlier in the day and have more time to settle back into their homes or any new placements. Patients and their families have a better understanding of why they are in hospital and what their next steps are – patients and carers feel more informed and also more involved in decisions about the care they receive.

• Better use of resources – Cross-boundary working with healthcare partners has improved, with the creation of new integrated discharge teams. Use of the discharge lounge has increased, freeing up ward beds for those who need them more.

Challenges and lessons learnt for implementation

• Staff are more aware that patients may spend hours of unnecessary waiting in hospital for the next step in their care and are trying to prevent this.
• Staff Empowerment Outcomes: The clinical leads have tried throughout the work stream to empower staff to be partners in the care journey transition. A ‘Champions network’ has been created on the wards to ensure a multidisciplinary approach to decisions on behalf of the patient. The network takes on the role of ensuring that the patient knows what care they will receive throughout their stay. They are the on-location advocates of the ‘home first’ approach and the continuation of the project.
• Always putting the patient and their time at the heart of everything.
• It would have been easy to view achievement of this change as too difficult. Taking the first step to make a difference often appears harder than it actually is.
• Work with community colleagues has increased over this period to ensure that patient care is delivered in the best place for the patients at the earliest stage in their pathway.

Find out more

For more information contact:

Gill Staton

Clinical lead Red2Green

gill.staton@uhl-tr.nhs.uk