Leading change

The Senior Nurse for district nursing services at Whittington Health NHS Trust led a project to move from a paper-based model to a digital e-Community service model. The transformation has resulted in a more streamlined, efficient service, with increased continuity of care and better use of resources locally, improving experience.

Where to look

The Queen’s Nursing Institute (2009) observe that district nursing services often care for patients with complex needs. The care environment adds to that complexity. It is important to recognise the expert knowledge, skills and capabilities of district nursing teams and the value of strategic workforce planning as well as operational workforce allocation, to ensure that a caseload is managed safely. Maybin et al. (2016) identified nine characteristics of good quality district nurse services as: caring for the whole person; continuity of care; personal manner of staff; scheduling and reliability of appointments; being available between appointments; valuing and involving carers and family members; nurse acting as co-ordinators and advocates; clinical competence and expertise; and patient education and support for self-management.

The Senior Nurse for district nursing services at Whittington Health NHS Trust identified unwarranted variation in standardised delivery of high quality care. There was variation in waiting times, missed appointments, complaints and continuity of care. With colleagues, the senior nurse recognised this as an opportunity to implement an e-Community online system to create a safer, simpler, responsive system for managing the challenging complexity of district nursing services.

What to change

The Whittington Health NHS Trust District Nurse (DN) Service works across two London Boroughs. The Trust’s primary focus is the promotion of independence, by working closely with local networks to support people to remain in their own homes and avoiding unnecessary use of acute care.

In September 2015, there were 284,000 district nursing ‘patient contacts’. This is projected to rise to 339,241 by the end of 2018/19. The service receives around 200 new referrals per day. Before the change, the service leads identified that the existing system for identifying capacity within the service, triaging patients referred in for care and allocating workloads was contributing significantly to the observed unwarranted variation.

The senior nurse led on a project of work to review existing systems and consider other tools available to streamline and improve care. In identifying an appropriate solution for improvements, the senior nurse approached a digital technology organisation who created a bespoke system, developed specifically to address the unwarranted variation in practice – the key areas of development. The following elements were considered paramount for inclusion:

• Standardising a review of patients on the DN caseloads: Investigation showed that effective review at 28 and 56 days led to patients who did not need to be on the caseload anymore having a greater chance of being discharged, setting identified discharge alerts after an identified number of visits.
• Matching skills and patient visits through training and competency records: Nursing and Midwifery Council professional registration requirements and the Trust’s existing competency documents were used to provide the system with knowledge of skills and competency so that triage and patient allocation could be standardised and informed.
• To equip the system with rostering information: elements included integration of ESR shift patterns and annual leave, triage allocation, geographical mapping, competency mapping / skill levels and electronic case load. This supported staff and managers to identify areas of potential opportunities (and minimise risk), to maximise service delivery and patient care.
• The development of an electronic system: the system is user friendly, easy to navigate, has all key information and forms uploaded, and provides access to other support: this includes linking to other services and can be used remotely from an electronic tablet / device.

How to change

Using the e-community technology solution, this project addressed the requirement to move towards a paper light and integrated process for the community nursing and patient interface. The Senior Nurse led a series of round table discussions on ‘how digital technology can support community nurses’. These were attended by staff and partners to support the development of the project. An e-community user group was developed and following several meetings, the below objectives were agreed:

• Ensure visibility of where DNs are or are expected to be, supporting lone workers;
• Ensure triage is undertaken at the point of access to the service: the e-community system identifies the nearest DN and adds the patient to their clinical visits list;
• Develop a suite of standard operating procedures to support DNs when with patients;
• Have a system compatible with the DN electronic tablet to support real time recording of their clinical assessment, patient needs, time schedule, geographical location and progression through their clinical list of visits;
• Continue to deliver patient-centred care;
• Include a robust built-in competency framework to support patient care;
• Build a robust background architecture of the system to support a range of products for the DNs;
• Health Roster linked with ESR to inform the e-community; and,
• Up-to-date training and competency identification for the DNs to ensure that the e-community has the correct profile for each person and can skill-match visits.

Adding value

Better outcomes – Following implementation, the average waiting time for a DN is 4.98 days, significantly lower than the national average of 7.1 days, despite increased caseloads. Relatedly, improved caseload management and continuity of care through using the new system has reduced missed appointments from 6-10 per month to 0-1 per month. Using the e-community has allowed for a faster referral and triage process, and staff can be more responsive to meeting 24 and 48-hour response times to referrals. The improved ‘real-time’ access to patient caseload information following the implementation of e-community has supported caseload review and discharge. These strategic changes and digital response systems have supported integrated working across organisations and partnerships, which is enabling a reduction in emergency admissions by focusing on proactive, community nursing care closer to home.

Better experience – There was a significant reduction in complaints regarding late and missed visits. For staff, the provision of a tablet device for all DN staff combined with advocating a ‘safer’, more consistent and ‘user-friendly’ system has made a positive impact on their experience. This is already starting to impact recruitment to the Trust as well as supporting retention. A reason for this is that they have been able to demonstrate increased patient facing time whilst reducing travel time in an inner London area.

Better use of resources – There have been several positive consequences following the introduction of this new digital system including staff efficiency, as well as increased location and communication benefits for staff. There was a release in capacity of 6.4 WTE band 6 nurses to care for patients using the new system compared to traditional manual coordination and allocation. When using the e-community to book temporary staff and to process expenses such as mileage claims into the roster, the new system has provided improved financial efficiency. The nurse leaders have estimated a cost-saving of £300k following the implementation of the programme. Staff experience improvements seem also to have had an impact on staff turnover with an 8% decrease in staff turnover observed in the first year. Further, the system is also promoting an improved skill and competency mix with a move towards integrated working and a refreshed DN service model.

Challenges and lessons learnt for implementation

Change and improvement takes time. Persistence is key and will deliver long term benefits if you stick with it. You also need to be aware of timing to make sure a programme stays on track.

It is important to understand cultural and system environments before you make changes.  These factors can support the roll-out of a programme if everyone is on board; leadership and effective engagement is key.

Finding the capacity to implement the change was challenging in such a busy demographically large service; it was difficult to create the capacity from within the DN service to stop and move forward.

Planning and staff training plus support from colleagues with exceptional clinical IT knowledge and skill were key to success.

For more information contact

Lisa Basi – District Nursing Service Manager
Whittington Health NHS Trust
lisa.basi@nhs.net