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Improving patient flow in west London

Source: NHE March/April 2019

Sonya Clinch, West London NHS Trust’s head of operations for access and urgent care, tells us how her trust dealt with significant pressures in its services.

Maintaining good patient flow is challenging in many trusts, often because the discharge process is lengthy and convoluted. Discharge can be disjointed for the patient when there are various partner agencies, other health professionals, and local authorities involved. With more integrated care, this is getting better.

West London NHS Trust currently has 174 acute adult inpatient beds across 10 wards in the three London boroughs of Hammersmith and Fulham, Ealing, and Hounslow. An additional 16 bedded ward was excluded from this project.

In 2016, the trust had the highest number of delayed discharges compared to other London trusts. The trust also had the highest average length of stay of any London trust, with patients staying over 50 days.

Our teams in our inpatient services across the three boroughs looked at how patient flow could be improved to create a better experience for patients and staff.

We took a step back and reviewed our processes, together with all those staff involved. We took a system-wide view to stop looking at each part of the system as single entities, instead thinking about how to work more collaboratively to make the service user’s journey a smoother one as they transition from one service to another. 

A number of opportunities were identified and actions implemented to reduce the number of patients staying in beds unnecessarily for long lengths of time.

A daily bed ‘huddle’ call was introduced, chaired by me, which monitors daily demand and capacity across the three boroughs. Complex cases are also discussed during these calls, with representation from the Planned and Primary Care service line.

The Red2Green initiative, a visual bed management system, although used more predominantly in acute trusts, gave us the focus for multiagency working. Our staff met with colleagues from the local authorities and other health professionals on a weekly basis to mark progress as a team as a green or a red day. A green day is when the staff are taking positive action to facilitate patient discharge, and a red day is when no such action takes place. This focused staff on the patients’ next stage of treatment and safe discharge. NHS Improvement has been working closely with us on Red2Green and the acute bed management toolkit to produce a mental health equivalent. We will be the first mental health trust to pilot this.

We introduced seven-day standard, which set out key expectations of what needs to happen in the patient’s journey over the first seven days of their inpatient stay. This kept the focus on the patient and was an early reminder to staff to identify barriers that may cause delays in discharge so that these could be worked through before the patient was due to be discharged.

A Delayed Transfer of Care (DToC) action plan was developed in partnership with the CCGs and local authorities in each of the three London boroughs. Weekly calls to monitor performance against the plan saw a significant number of long-stay patients being safely discharged. Ongoing actions are focusing on more proactive reduction of DToC cases.

Staff buy-in has been key to the success of this initiative, from the chief executive down to ward-based staff. The energy and enthusiasm of all the staff involved was amazing to see, particularly as they could see the changes having such a positive impact on both patients and staff.

All of the work we have done has paid off. We have seen a significant downward trend of the number of patients staying over 50 days, from 132 patients in 2016 to 61 currently in February 2019, our lowest being 51 in October 2017.

Top image: Andrew Stawarz via Flickr


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