Patient care - daily dynamic discharge approach: guidance

Execution of the plan

4. Daily Dynamic Discharge Whiteboard Meetings

What are they?

Every day, getting together for 10 minutes to discuss, agree and prioritise the day's tasks first thing in the morning, answering the question for the whole team, 'of all the things I could do today, which should I do, and in what order'?

What do they achieve?

They ensure that time is not lost and avoid delays caused through poor communication of the plan, or incomplete tasks which have been 'forgotten' or 'lost in translation'. They ensure that the team do not make subjective choice of what to do today, and in what order, but that care is delivered consistently in a patient-centred way and prevents delay. They ensure that patients are able to leave the ward without delay on the MORNING of their discharge, as everything they needed was planned and executed in advance of their EDD. They ensure that any potentially delay-causing issues are escalated first thing.

This is a brief introduction to the prescribed process, full details, scripts and supporting documents can be found in the appendices section of this document.

The DDD Whiteboard Meeting Process

• Display your whiteboard by EDD order and sort the patients closest to EDD first
• Review the EDD - is this still correct?
• What do we need to do TODAY to make sure this patient is discharged on their EDD?
• Complete the task sheet in order of 'first to complete'
• Agree a 'catch up and capture' follow up time to check on task completion and to escalate anything which could delay the discharge
• Agree the order of patients to be seen first
• Follow the whiteboard meeting with a golden hour ward roundw

Conditions for starting:

• Everyone is at the whiteboard (Therapists, Nurse in Charge, Doctors)
• There is a facilitator leading
• There is a scribe for tasks
• There is a task sheet

5. 'Golden Hour' Ward Rounds

Ward rounds are either daily short sharp 'golden hours', or infrequent, full consultant led ward rounds held several times a week. This will be locally agreed however several principles exist to ensure prompt discharge and minimal waits and delays in the transfer of care.

The order in which patients are reviewed in the ward rounds has an impact on how promptly appropriate tasks are carried out, which supports the optimal operational flow of patients and therefore quality of care; by discharging patients as soon as they are ready to go, thus ensuring timely admission to appropriate specialties.

The order of the 'golden hour' round is always:

• sick patients from overnight or anyone who the team are worried about
• new patients who are unwell and have not been seen yet
• patients who require a discharge review
• patients who require discharge tasks to be completed
• all other patients.

This has proved to be effective in terms of reducing 'on the day' delay and improving the level of morning discharges.

Although it may feel inconvenient to weave across a ward, the benefits are a reduction in boarding with appropriate patients being pulled to specialty beds, reduction in delays to discharge and transfers of care, and fewer interruptions to the ward round ensuring those patients who are unwell can be prioritised.

6. 'Non-slip' Task Management

The outcome of the morning whiteboard meeting should be a completed 'task sheet' with tasks identified as being a priority for completion within a certain timescale and named 'task managers'. The aim is to make sure that these tasks are completed without delay.

The facilitator of the morning meeting will agree a location for the task sheet and a time to 'catch up and capture' the progress with the MDT. This would usually be after the ward round and would follow the guiding principles below.

• Did what we agree needed to happen today, happen?
• Are there any outstanding tasks which need to be escalated or which anyone needs help with?
• Did the patients we agreed would be discharged this morning, go?
• If not, why not, and what do we need to prioritise over the rest of the day?
• Are there any extra tasks which were identified in the ward round for patients who could go home later today which need to be allocated and prioritised for the afternoon?
• Are there any changes to EDDs?
• Are there any tasks which need to happen this afternoon for patients who may now be discharged tomorrow?

This ensures that the morning meetings are not 'updates' and remain short, sharp and focused on agreeing and prioritising the days tasks.

7. Check, Chase and Challenge

Check, Chase and Challenge ( CCC) is used during implementation, in order to maximise the early impact of implementation, rapidly eradicate the acceptance of delay and to ensure sustainability. Lead Nurses, Service Managers and General Managers should provide additional support to the Wards by promoting enhanced discussion and exploration of alternatives.

This process should be utilised every day until established by the nurse in charge and then may form part of an escalation process.

This supporting role uses the 'check, chase and challenge' script.

Check:

• Is the meeting ready to start; attendees convened?
• Are we making timely/reasonable decisions?
• Are all tasks agreed and responsible person identified?
• Have we completed previously agreed tasks?

Chase:

• Anything outstanding that can be escalated

Challenge:

• Is there an alternative to an inpatient stay to consider?
• Does 'x' need to happen as an inpatient?
• Can the EDD be earlier if I can help you get 'x' ?
• If this patient can be a 'criteria led' discharge ^[10]
• The acceptance of delay

On implementation the CCC script has been found to be useful in helping to identify frequent delaying tasks and 'myths' which keep patients in hospital unnecessarily, beyond the implementation phase they continue to use it as part of escalation in times of pressure to identify potential additional discharges.

8. Ward Access Targets

• Understanding the 'ought to be' numbers

Every day in hospitals, there is a relentless balancing act between demand and capacity, get the balance wrong and the consequences for everyone are severe; for patients - long waits, poor care, increased risk, poorer outcomes, boarding, increased length of stay. For staff this can be challenging to ensure patient safety and experience are not compromised by waits, delays and bottlenecks encountered.

The front door is the barometer for the rest of the hospital, and the only way to ensure that patients who require admission, get into the right bed, and in a timely way, is to ensure that the downstream wards understand the 'ought to be numbers' on any given day and at the times they are most often required and work to create that capacity.

The Basic Building Blocks ^[10] analysis toolkit allows Boards to calculate this data for each ward, and allows the Check, Chase and Challenge discussions a focus.

9. Pre-noon Discharge

Managing Capacity and demand at hospital level and ensuring admissions and discharges align is a key operational and performance goal.

Afternoon peaks in attendances with a rise in required admissions is the norm for many hospitals. The same afternoon peak in discharges also occurs causing crowding to occur in ED and assessment units as patient flow slows down or stops.

The solution is early in day discharge or transfer.

A key improvement measure of the 6 Essential Actions to Improving Unscheduled Care programme aims for is 40% of ward discharge to occur before 12.00 midday. Achieving this goal will require the MDT to work together across the Daily Dynamic Discharge model and ensure all elements are in place.

This includes communication of the discharge plan, and timely completion of the tasks necessary for discharge.

External

• Communication with family or home support as early as possible to understand estimated date of discharge
• Early identification of transport needs - own transport where possible and only ambulance if physical/medical need
• Early identification of support needs - principles of discharge to assess should be followed
• Expectation that discharge from the ward will be before noon as the norm (and via the Discharge Lounge if appropriate or necessary)

Internal

• Follow the elements of the Daily Dynamic Discharge approach
• Ensure any decision making diagnostics are completed early in day
• Ensure all pharmacy requests are timely
• Ensure Immediate Discharge Letters are completed in advance of discharge (the day before if possible, if not - must be available before noon)
• If not discharged directly from ward - transfer to Discharge Lounge