Sharing best practice – improving patient flow within local services

The problem

Like many trusts, we have experienced significant pressure within our local services, particularly adults. These challenges have focused on patient flow into inpatient beds and then delays in discharging patients in a timely way.

Teams across our inpatient service in Hammersmith & Fulham, Ealing and Hounslow, particularly within the men’s wards, saw sustained and high levels of patient demand. This often meant that there was very little capacity to accept new patients. This has also led to increased use of private sector mental health beds. It meant that patients would sometimes be housed in unsuitable locations, such as Section 136 units (used for Mental Health Act Section 136 assessments) or seclusion rooms (facilities where acutely unwell patients are temporarily in seclusion) to manage the overflow.

This issue was compounded by challenges working with Local Authority partners to resolve onward funding for a patient’s care, which often means we have patients in beds when they don’t clinically need, or even want, to be there.

The context

Although the number can fluctuate, the Trust has approximately 192 acute adult inpatient beds, across 11 wards in 3 separate London boroughs. The wards are made up of 5 assessment wards, 4 recovery wards, 1 ward for over 50s and 1 psychiatric intensive care unit (PICU) for men.

The Trust was an outlier on a number of indicators, when compared with other mental health trusts.

  • The Trust had the highest number of delayed discharges of any Trust in London, with the problem particularly acute in the London Borough of Ealing.
  • The Trust had a very high number of patients staying over 50 days. Between July and October 2016, there were 132 patients staying longer than 50 days (highest average length of stay of any Trust in the London region).

What we did

To improve the patient and staff experience, the Trust put in place a continuous improvement plan of measures over time, starting in February 2017, when pressure was at its greatest, with 118 patients staying over 50 days in an inpatient setting.

  • Appointment of discharge coordinators – Tasked with reducing the number of patients staying over 50 days, they were specifically recruited as senior social workers. We felt that the skill set of senior social workers and their focus on community assets, recovery-focused attitude and knowledge of the wider system would be crucial discharge the long stay patients. They had an instant impact and over 8 weeks on from their appointment, the number of patients staying longer than 50 days reduced by nearly 22% from 132 to 103.
  • Thematic review of long stay patients - The Trust carried out a thematic review root cause analysis for long stay patients and delayed discharges. The review found that there were key opportunities to reduce length of stay on the Trust’s acute wards by improving in internal processes and clinical practice. There were also a series of recommendations for action across the whole system, with external CCG and Local Authority (LA) partners, to achieve sustainable improvements.
  • Clinical engagement plan – The Trust developed a clinical engagement plan with the goal of building good relationships with front line staff and the primary agents of change. This set out 7 key principles for how the senior management within the service would engage with those directly caring for patients.
  • Delayed Transfer of Care (DToCs) Action Plan – Developed by CCGs, LAs and the Trust in partnership, accompanied by a series of weekly phone calls to monitor performance against the plan. This resulted in discharging a number of significantly long stay patients (some who had been with us over 12 months). On-going actions are focusing on more pro-active reduction of DToCs.
  • Review of bed management processes – This resulted in:
  • An escalated bed management meeting chaired by the Clinical Director which seeks to highlight on-going long-stay patients/DToC cases that are not being resolved at a local level.
  • A daily bed ‘huddle’, call monitoring daily demand and capacity.
  • Ownership of the problem - All levels of staff, from frontline nursing staff, right through to the Consultants and the executive team had ownership of the problem and worked towards a sustainable solution.
  • Setting metrics on key areas of performance – The Trust has established a performance management framework, and performance against metrics is distributed each month to the ward teams. A typical example of metrics would be:
  • 17 discharges per month.
  • Average length of stay: 30 days.
  • Number of patients staying over 50 days: 2.
  • Private Sector Placements Monitoring Team – The Trust established a team to focus on reducing the number of patients placed in private sector beds. This allowed them to dedicate some protected time to this cohort of patients.
  • Support from the senior team - the Chief Executive issued an open letter to the staff in the directorate and the Medical Director and Executive Director of Local and Specialist Services jointly wrote to the consultants in the service. These letters stressed:
  • The role the Crisis Assessment and Treatment Team (CATT) has in gatekeeping patients. The CATT provides fast, responsive assessment and care to people referred via the trust’s Single Point of Access who live in the London Borough of Hammersmith & Fulham. Depending on the needs of the person being referred, we may visit people in their homes or ask them to come to one of our clinics.
  • The importance of clearly setting out the purpose of an admission and the required intervention to meet the patient’s needs, including discharge.
  • When making the decision to admit, all on-call consultants must speak directly to the relevant CATT senior on duty.
  • Each admission must have a named admitting consultant. The admitting consultant will promptly outline to the inpatient team the purpose of this acute admission and what needs to be achieved to discharge the patient.
  • Borough based meetings – Borough based, face-to-face meetings were held between senior managers and staff on the wards from across disciplines including Liaison Psychiatry, CATT, access and urgent care. A wide range of staff attended including clinical directors, consultants, other clinicians, team and bed managers and nursing teams. Staff were encouraged to discuss additional barriers and speak directly to senior managers. These meetings were supported by the Trust’s Medical Director and Executive Director of Local and Specialist Services.
  • Red2Green initiative – #Red2Green is a visual bed management system, originally from the acute hospital sector, that assists in the identification in wasted time of a patient journey.

The Trust piloted the Red2Green initiative in the Hammersmith & Fulham mental health unit and it is currently (Nov/Dec 17) being rolled out in Ealing and Hounslow. In Hammersmith & Fulham, the initiative sees staff from across boroughs and professional disciplines come together to mark progress against a green or a red day. A green day is when the clinical staff are making active positive interventions to appropriate discharge and a red day is when no such action takes place. It has seen a focus on making sure that staff are focussed on the next stage of treatment and moving patients toward safe discharge, by adding value to the care they receive.

The initiative has come from acute trusts and we have fitted it to work in a mental health inpatient setting, along with a similar pilot at WorcestershireHealth and Care NHS Trust.

Staff have been trained in the tool and it has replaced the daily bed management spreadsheetand forms the key part of the weekly bed management meeting. As at the end of November 2017, the initiative has been in place for 16 weeks and we have seen a significant improvement in working culture as a result.

This is supported by the performance on the wards, for example:

  • When the project was first initiated on 7 August 2017, Ravenscourt Ward in Hammersmith & Fulham had 6 red days, patients across the ward collectively waiting 145 days for discharge and an average length of stay of over 54 days. As of 20November 2017, the Ward has patients waiting only 6 days collectively, with only 3 red days and an average length of stay of just over 22 days.

Ravenscourt Ward, 07/08/2017

Ravenscourt Ward, 20/11/2017:

  • 7 day standards - These standards set out key expectations of what needs to happen in the patient’s journey for the first 7 days of their inpatient stay. These standards, initially piloted in Hammersmith & Fulham, are now in place across all our teams. A key component is a ‘crib sheet’ completed within 72 hours which identifies all potential barriers to discharge and this informs the patient’s discharge plan at an early stage.

Some of the expectations include, a discharge meeting with the patient, their carer, other involved agencies and staff leading care to discuss purpose of the admission, patient views, carer views, what needs to happen to support safe discharge- and an estimated date of discharge.

From feedback, we know that:

  • Managers in the inpatient units report more visibility and better rapport between the wards and recovery teams.
  • Recovery team managers are now prioritising inpatients to improve flow and free up capacity.
  • Engagement of recovery teams at an early stage in the planning for discharge has been key

Staffing

The Trust has also significantly improved its medical staffing within access and urgent care.

Across inpatient services in our three boroughs, the number of consultants per patient has increased. Previously, the number of inpatient consultants was 7.2 whole time equivalents (WTE), this has now been increased to 10.3 WTE. This has in part been achieved by a reduction in agency expenditure and consultants moving over to substantive posts.

In addition, we have recruited an additional inpatient middle grade doctor within the inpatient service, an additional 0.5 WTE consultant in the Hammersmith & Fulham CATT and a 0.6 WTE middle grade doctor in the Hounslow CATT.

We have also put in place a range of measures to try and recruit and retain more qualified nursing staff (more info available on our recruitment microsite).

The results

Taken together, this package of measures has had a really significant positive impact, as evidenced by:

  • The occupancy rates in October 2017 (86%) are better than those at same time in the previous year (95%). Our aim is to get and maintain the occupancy rates close to 85% for optimum operational efficiency.
  • The position of the male bed base has seen significant improvement since the middle of August. In addition all private sector use for both male and females has been nil (excluding female PICU) since the 20th of September 2017.
  • Since the 2nd November to date we have a daily mean of 10.5 available male beds.
  • Since the 20th October to date we have a daily mean of 14.3 available female beds.
  • The Trust has historically had a very high number of patients staying over 50 days. Between July and October 2016, there were 132 patients staying longer than 50 days (which made it the highest average length of stay of any Trust in the London region). There has been a consistent downward trend since May 2017 with the number at 54 as at 22nd of November.

The package of measures has also had a positive impact on our financial position:

  • The productivity gains resulted in animprovement on the financial position, with a reduction in our predicted overspend within the directorate by £2.9million.
  • This was achieved by steady reduction of private sector use over 2 months, with zero private placements by mid-September.
  • In addition, due to the improved bed capacity, the service line was also able to generate income of c£80,000 over a two month period by selling beds to other Trusts.

Risks

We are mindful in talking about this work – and as a demand led service- that the position remains fragile and we see fluctuations. However, when taken as a package of work,the Trust is confident that we head into our busiest time of year in much better shape than previous years. The challenge is to maintain this good work going forward, continue to innovate and build on how our different teams work together to get the best result and support for our patients.

What next?

  • Continue to focus on reducing delayed transfers of care
  • Continued implementation of the Red2Green and 7 Day Standards; this level of patient flow requires daily oversight at a senior manager level. Our next step is to embed this throughout out all levels of staff.
  • Exploring the possibility of moving to a generic inpatient ward model and away from having specific wards for over 50s and recovery wards.
  • Implementation of co-produced standards for transforming inpatient care
  • Roll out of our framework for admissions and continued scrutiny and audit of admissions on a daily basis.
  • Reinvest savings in improving patient care
  • There is a need to invest in community based recovery teams,that have been historically neglected in terms of additional funding.

We are keen to share the learning from this work with colleagues elsewhere in the system and have already hosted a forum to share our work with mental health and acute providers.