Valuing Patient Time

What is a change package?

A change package developed at the end of a Breakthrough Series Collaborative is a curated set of interventions, strategies, and tools that have been tested and shown to improve outcomes during the collaborative. It serves as a practical guide for others who want to replicate the improvements.

The change package is a resource for wards to use to help implement the quality improvement techniques and best practice ideas to standardise the way we work across all wards. 

A printed copy will be made available on the wards and a digital copy is available here.

The IHI Model for Improvement is a framework developed by the Institute for Healthcare Improvement (IHI) to guide effective Quality Improvement in healthcare and other industries.

It is simple, adaptable, and designed to help organizations improve processes, outcomes, and systems. This is the method the collaborative wards used to test, evaluate and develop the change ideas you see within the change package.

It is a simple yet powerful tool for accelerating improvement, and is made up of two parts:

A driver diagram is your plan on a page that illustrates a theory of change and the team’s contribution to the overall aim. It clarifies the big picture by breaking down any broad aim, visually, into increasing levels of detailed actions.

TTOs

The Idea: Ensuring that TTOs is an assigned role within the ward routine and time is Allocated for TTO completion following morning board round. How can I use it? Patients who need TTOs are identified at the morning Board round and assigned to appropriate team member e.g Resident Doctors. The lead medic allocate time following the board round for the assigned team member to complete these TTO’s. This person then joins the ward round. TTO’s can be written and submitted to pharmacy 72hrs prior to EDD.

See Page 12 in the change package for more info  

Therapy referrals

The Idea: The therapy team tried a more proactive approach of screening and assessing all patients on admission to the ward. They created their version of a handover with all patients on the ward with the below details. Then they screened all the patients notes via PENS to triage whether they felt they needed input from PT/OT. The list was updated daily before board round with any discharges or new patients.

See Page 13 in the change package for more info  

6am Bloods

Idea 1: Post ward round huddles with medics and nurse staff where patients who require 6am bloods are identified. Day staff use handover to night staff to inform who needs 6am bloods, night staff then ensure the blood are taken. The results are then are then available for the medics to review and decide if a patient is medically fit for discharge during their morning ward round.

Idea 2: Using a blood label box and PENS to document 6am bloods and criteria for earlier discharge. After Ward round medics, print blood labels and put them in a box labelled 6am bloods. The medic then documents in PENS if “bloods x patient can be discharged” The night staff check the blood box on their shift and identified patients have the bloods taken at 6am. If the blood results match the criteria details in PENS the patient can be discharged that day.

See Page 14 in the change package for more info  

Criteria Led Discharge

The Idea: Patients who have been admitted will be assessed and a decision is made on their estimated discharge date (EDD), their clinical criteria for discharge (CCD) and whether they are suitable for CLD, at their 1st MDT board round/huddle. Following this being agreed an estimated discharge date is agreed with the patient and MDT. The process then allows suitably qualified clinicians to take responsibility for the discharge of the patient, with their discharge and aftercare planning already underway during their admission.

See Page 15 in the change package for more info  

SHOP Model

How can I use it? The Board Round will prioritise patients for the subsequent Ward Round, focusing on the sickest patients, patients who can go home today and any other patients who are identified as benefiting from a multi-disciplinary, board round discussion The SHOP (sick, home, others, plans) model is a way to conduct ward rounds that go to where the patients’ needs are. The consultants or senior medics should see the sick patients first, followed by those patients who can go home, taking the actions required for them to be discharged.

See Page 19 in the change package for more information

Improved Board rounds

The Context: Board Rounds give the opportunity to meet as a clinical team involving doctors, nurses, therapists, pharmacists and discharge planners, to help the team communicate and provide the best care for patients.

By having a clear diagnosis and plan for every patient means that each person in a hospital bed will have clearer and more consistent information about what is happening to them.

An effective board round sets a plan for every patient with clear tasks for all team members every day

See Page 21 in the change package for more information

MDT Working Efficient & Effective Board Round

The Idea: To use a whiteboard to structure board round conversation allowing for specific accountable actions to be set and documented daily to facilitate discharge (including setting EDD). Board round to be led by the ward coordinator who has a comprehensive of all patients needs

See Page 22 in the change package for more information

Setting an Estimated date of discharge (EDD)

Purpose: The EDD serves as a target date for discharge, helping to streamline the patient's journey through the hospital.  #VPTAcrossL’pool

Ward Processes Setting the EDD: It's typically set at the first consultant review after admission or the first post-take ward round.

See Page 23 in the change package for more information & Page 24 for a step-by-step guide

Patient Flow Discharge Checklist

The Idea: Everyday the discharge co-ordinator updates the discharge checklist with all patients who are for discharge that day. The discharge co-ordinator is then able to follow the prompts within the checklist to ensure all key elements required for discharge have been completed, ensuring the patient has a successful discharge.

This document is also used to handover any outstanding discharges to the Ward Co-ordinator at the end of the shift. This provides the nursing teams with a clear list of out-standing actions, which they can they pick up after 3pm.

See Page 25 in the change package for more information

Parallel Planning

The Context: Parallel planning in a hospital setting is crucial because it helps manage uncertainty and improve patient outcomes by preparing for multiple possible scenarios simultaneously.

Here’s why it’s important: Manages uncertainty, improves decision-making, resource optimization, enhances communication and coordination, patient-centred care and reduces risks.

See Page 26 in the change package for more information

A strength based approach

A strengths-based approach acknowledges individual strengths in patients - whether those are related to their heart (emotional resilience), hand (skills and abilities), or head (knowledge and expertise).

Shifting focus from solely addressing problems to identifying and building upon existing strengths fosters a more empowering and collaborative patient-healthcare professional relationship, promoting a sense of partnership in their journey.

Open-ended questions and conversations encourage patients to share important information about their health, experiences, and preferences, enabling healthcare providers to gain a comprehensive understanding of the patient's needs and values. By acknowledging patients as experts in their own lives and involving them in the decision-making process, healthcare providers can enhance overall outcomes and increase patient satisfaction, ultimately improving the quality of care delivered.

See Page 28 & 29 in the change package

Purple dots

The Idea: Visual prompts where placed throughout the ward to encourage patients to become more active during their stay in hospital. A series of purple dots were placed across the floor with different goals achievable to the patients depending on their recovery progress. A leaflet is also provided with further guidance around the importance of mobility.

How can I use it? The purple dots can be used as rehab activity to positively engage patients in movement and avoid their health deteriorating due to loss of strength and muscle viability. It can be used in conjunction with therapists and patients families to set visible goals and reduce harms such as falls.

See Page 30 in the change package

Activity hour

The Idea: PT + OT developed ‘content toolbox’ including multi-component exercise/ reminiscence/self-care and OT functional elements. The session is 30 mins (allowing an hour for patients to mobilise/transport to the group area) and is led by B4 therapy APs with support of ward HCA staff and dementia + delirium team when they have capacity. Patients are identified as being appropriate from discussions with qualified therapy staff on the ward; no formal referral is required.

Did you know Social isolation in hospitals increases the risk of cognitive decline by 40%. (Source: BMJ & WHO reports)

How can I use it? This can be pulled together with commitment from the therapy and ward team in your area. Staff have self-purchased some items such as soft balls, skittles and hoop-la etc (if you have a budget that’s great). Be creative with the space on the ward/zones considering access for urgent medical care and infection control. Music often adds to the fun atmosphere to get people moving and active!

See Page 31 in the change package

Nutritional Reconditioning

The Idea: In older patients admitted to a hospital, the prevention of sarcopenic dysphagia might be possible by early implementation of rehabilitation, early ambulation and early oral intake. Timely evaluation of the condition of the entire body and swallowing function as early as possible after admission. In patients with aspiration pneumonia, who were placed nil by mouth (NBM) had a prolonged period of hospitalisation and deteriorated swallowing function compared with those in patients who started oral intake promptly after admission.

See Page 32 & 33 in the change package

Mobility Goal Setting

Idea 1: Daily GOAL setting for patients. Both therapy and nursing teams set daily goals for patients, which encourage them to move more whilst in hospital. Goals include, mobilise to the toilet, sit out of bed for longer periods of time, or for one patient who was blind a goal was set for him engage in social communication and to gie thumbs up. The goals set are patient dependant and involve some strength based conversations with the patients to understand what they can do rather than what they can’t. The team keep a weekly record of the daily goals in the patients folders

Idea 2: Alongside goal setting, the team created a floor marker (ladder) which was measured out by the team so they can monitor and record the lengths patients have walked. The floor ladder also supports Parkinson's patients with freezing episode. The team used both ideas and created GOALS for patients which involved walking laps of the floor ladder.

See Page 34 & 35 in the change package

Patients out of bed and dress in the day

“Patients being up and dressed early makes a massive difference and feels so much better on the wards. The patients are more engaging and more willing to work with the therapy teams” Therapy Lead, Aintree

See Page 36 in the change package

Quality improvement team: QI.Team@liverpoolft.nhs.uk

ECIST—The Emergency Care Improvement Support Team—Sharing examples of great practice

Visit ECIST's Youtube Channel here: ECIST1 - YouTube