Ayo Olomolaiye, Jennifer Smith

Ahmed El-Muntasar, Trish Duncan

Agalya Sivakumar, Adnan Sheikh, ​Uma Krishnamoorthy

Name
Gillian Woods 

Role
Trainee Advanced Practitioner - Colorectal Surgery 

Place of work
Colorectal Surgery, East Lancashire Hospitals NHS Trust  

Background 
Delayed discharges from hospital have more than doubled in the last 6 years; and are thought to cost the NHS around £900 million per year, with patients reporting delays as having a negative impact on their overall satisfaction of care (Department of Health [DH], 2015 & Care Quality Commission, 2015).
 
In The Local Trust, a retrospective audit of 28 patients who had undergone a colonic resection within a 6 month time period showed that 25% of these patients experienced a delay with their discharge that could have potentially been avoided.
 
Aim 
To tailor the project to service demands, the baseline audit results were categorised into the recurrence of common causes for delay:
1) No senior review/ decision to discharge when medically fit.
2) Waiting for discharge summaries and medications
3) Waiting for diagnostic tests/ results
 
These key themes were used alongside evidence-based practice, to form the basis of this strategic approach, to facilitate an effective discharge process and reduce avoidable delays.
 
Method 
This is a two-phase project, consisting of two PDSA cycles with 28 patients in each cycle, to allow comparison to baseline audit.
 
The processes are:

• Give patients a ‘predicted date of discharge’ (PDD) to help plan care that is timely and necessary.
• Introduce ‘Weekend plan stickers’; to provide continuity over 7 days a week
• Devise a protocol to complete discharge summaries and medication checks 24 hours, prior to discharge

 
Kurt Lewin’s ‘Three stage model of change’ (Unfreeze – Change –Refreeze) has been used to plan the implementation and drive the changes forward (Lewin, 1951). To refreeze, sustain the change and embed the strategies into the organisational culture, key stakeholders were kept informed of the progress by sharing pertinent information at relevant forums. Qualitative feedback was gathered and was used to modify and improve processes; giving the stakeholders ownership over their ideas and improvements.
 
Evaluation 
The project consists of two phases, using the PDSA cycle to allow for continual evaluation and contemporaneous modification (Langley et al., 2009). Evaluation was conducted using Donebedian’s process of ‘Structure, Process, Outcome’ (Donebedian, 2003).
 
The processes were evaluated on an individual basis and data collected from the prospective audit at each phase analysed against the baseline data to ascertain if an improvement has been made.
 
Conclusion 
The implementation of the various processes should improve the discharge process, to facilitate timely care and interventions and reduce avoidable delays.
 
Three key learning points  
1. Avoidable delays in discharge have a huge impact on patient satisfaction and also represent one of the biggest causes of avoidable compromise to the financial stability of the NHS.
2. Engaging with key stakeholders to implement sustainable strategies and processes to facilitate timely care and plan discharge from admission can help to reduce avoidable delays.
3. By reducing avoidable delays, patient flow should be improved, which will result in less cancellations for surgery and should also improve breech times for ED.

Name
Aleyamma Abraham 

Role
Trainee Advanced Nurse Practitioner 

Place of work
Theatres, Royal Blackburn Hospital, East Lancashire Hospitals NHS Trust  

Background  
Rising waiting times, changes to surgical training and the introduction of European Working Time Directive have generated huge logistical challenges in the East Lancashire General Surgical Services to achieve government targets (Kings Fund, 2016). Locally, a preliminary audit demonstrated the referral pathways for low risks minor surgery is micromanaged in order to maintain the achievement of 18 week targets (NHS Trust, 2015).
 
An Advanced Practitioner who has the advanced clinical skills set and is trained to deliver minor surgery service can play a vital role in providing minor surgery service. Evidence suggests their contribution can reduce waiting times and maintain surgical services (Kingsnorth, 2006). Costs can be reduced and the surgical training of junior doctors supported (King’s Fund, 2016).
 
Aim  
The aim of this project is to implement an Advanced Nurse led minor surgical pathway with the aim of increasing efficiency and productivity to reduce delays in achieving 18-week patient journey.
 
Method

• Kotter’s change theory (2007) was used to develop strategies to support the project implementation.
• Involvement and engagement with key stakeholders after identifying bottlenecks in service delivery using a process map exercise.
• Devised a business plan based on demand capacity analysis and financial appraisal.
• Development of an ANP training pack, competencies and clinical governance framework based on Royal College of Surgeons SCP Curriculum Guidance.
• Concurrent list alongside consultants to ensure proximal supervision (observe 20cases /shadowing 4 sessions).
• Devised an inclusion and exclusion criteria for patient selection to offer safe effective harm free care.

 
Evaluation  
Using the PDSA cycle, formative evaluation was attained at regular intervals. Re- audits were performed to assess the number of cases completed / sessions used, complication rates and waiting list / times. Results were analysed to measure the impact of service provision on 18 week waiting rule using the Donabedian (Structure, Process and Outcome) Conceptual model (Donabedian, 1966). Patient satisfaction was measured using Friends and Family test.
 
Conclusion 
The ANP would provide integrated care for patients while working in partnership with consultants will free up surgical workforce to treat more complex patients in a timely manner. Alongside this, the project aimed to improve the utilisation of capacity within theatres by increasing day case activities, revenue and reduce waiting times.
 
Three key learning points 
1. Interconnect your vision and involve all staff in the implementation of the initiative early in your change process.
2. Applying theoretical frameworks in change management can enable effective and sustainable project management.
3. Keep patients informed of new developments and try to find out if they find your plans acceptable. Be prepared to be flexible for patients who prefer to see a surgeon.