NHS Fife: getting it right for our most vulnerable patients

Key Lessons Learned

• Identification of frailty should happen at the earliest opportunity.

• Frailty screening at front door areas highlights patients requiring CGA early and with the right rapid response from an MDT can facilitate early discharges and prevent inappropriate admissions to acute in-patient areas.

• Huddles don’t cost anything and allow invaluable decision-making and pathways are set which are truly patient-focused and centred on reducing harm and improving patient experience.

• Multi-professional approach to frailty provides the best outcomes.

• Advanced practice and senior decision-making are essential to drive complex discharges from door areas and ensure smooth transfer to community teams.

• Rapid response times are required for assessment of the older adult at the front door, especially to the ED.

• When redesigning services plan for seven days and extended length of day.

• Multiple changes through service re-design are exciting and can naturally and spontaneously eliminate barriers/issues.

• Involve key players and partners from the outset. This works well when clinicians delivering new service are leading the changes.

• Timely feedback of new processes is essential to refine and embed. Encourage staff to challenge and have a solution-focused approach.

• It is important for staff to understand data and quality improvement at every level and recognise that new ways of working are enhancing patient experience and making system improvements.

• Don’t worry about making mistakes or things not going according to plan. These are valuable learning opportunities so build upon them.

• Empower staff to deliver the change.

• Working across health and social care partnerships is essential for front door areas to develop effective care pathways for patients.