Milton Keynes Hospital NHS Foundation Trust Case Study – Lean Patient Discharge

Lean Patient Discharge Case Study ABOUT WCI  About WCI -  A focused management consultancy spanning 21 years with a 20 year partnership with the NHS  Lean Health –  We simplify processes to reduce waste and improve patient care and are experts in integrating systems in a clinical environment  Case Study – Lean Patient Discharge  Milton Keynes Hospital NHS Foundation Trust  Context & Issues  Process Improvement  Technology to support the process  Design for the Future

There has been discussion about patient Discharge Summaries for over 20 years Patient discharge summaries have been a part of the patient record and communication to GPs for approximately 100 years The value and content of summaries / letters has been debated since at least 1986¹ (perhaps longer) both in the UK and abroad In recent years constructive interest seems to have gathered pace … Wilson² observed the need for electronic discharge summaries Munday³ pointed out the need for more information about drug changes was needed The DH produced a discharge pathway process in 2003 … Such that the NHS Institute for Innovation & Improvement produced Achieving timely ‘simple’ discharge from hospital, 2004 ¹ Structured discharge letter in a department of geriatric medicine, Howard, 1986 ² GP-hospital communications-A review of discharge summaries, Wilson et al, 2001 ³ Do GPs & Pharmacists want information on the reasons for drug therapy changes implemented by secondary care, Munday et al, 1997

The NHS Alliance raised the profile of the debate this year A Very Present Danger – A national survey into information provided by hospitals to GPs when patients are discharged¹ The findings: ¹ A Very Present Danger – A national survey into information provided by hospitals to GPs when patients are discharged, NHS Alliance, Feb 2007

In addition to poor information about care, the patient experience¹ of the discharge process is less than ideal 27-43% of patients have their discharge delayed 55-63% have to wait for medicines Of those delayed 20-27% have a delay of ≥4hrs 42-75% did not receive a copy of a letter from the hospital to the GP Despite Department of Health guidance² ¹ Inpatient Questionnaire, Picker Institute, 2007 ² Copying Letters to Patients, Department of Health, 2003

The impacts of producing poor discharge information are significant to the patient and hospital Continuity of care is disrupted Community-based care, including social care and support, is harder to plan and organise Patient safety is at risk The NHS Alliance survey respondents have provided anecdotal information that patient care is compromised The risk of readmission may be raised van Walraven¹ pointed out “The risk of rehospitalisation may decrease when patients are assessed following discharge by physicians who have received the discharge summary.” Hospitals revenues are under threat NHS Alliance has called for discharge summaries to be a contractual obligation … … Evidence is that this is happening locally PCTs are linking payments to improved discharge information improvement Impact on pharmacy operations and fulfilment Illegibility is dangerous Amendment of shorthand and poorly defined prescriptions is time consuming Amended forms are harder to read Impact on Clinical Coding De-ciphering treatment details can be next to impossible … and be very time consuming ¹Effect of Discharge Summary Availability During Post-discharge Visits on Hospital Readmission, 2002

Internal External 2. Completion 1. Initiation On the Ward: At the time of admission & treatment At point of discharge decision In Pharmacy: Modified if necessary Verified as complete: At point of discharge Started on admission or initiated at time of decision to admit Demographics & admission data fields auto-populated from Millennium 3. ‘Transmission’ GP receives a copy Patient receives a copy Clinical Coding informed of discharge Coded electronically Enters patient’s eMedical Record Less paper Overall Design

Web Service HSS RadiologyLegacy PAS Clustered BizTalk 2006 R2 SQL Server 2005 Trust Integration Engine Message Replay BizTalk 2006 R2 Pharmacy Pathology ADT SQL Server 2005 Patient Master Index ADT SQL Server 2005 Data Warehouse ADT GPs SharePoint 2007 InfoPath 2007 Active Directory eDischarge Summary ADT SQL Server 2005 Trust Dashboard (2008) Clinical & Admin data ADT Milton Keynes Architecture Audiology Maternity other Dept’l Systems ADT

Nine eDS Benefits 1.Provides GPs with the patient information they have defined as necessary 2.On completion makes the Summary available to GPs immediately 3.Provides a legible record of treatment and planned after- care to the GP 4.Provides a standard format for prescribing TTOs 5.Reduces completion time by auto-populating selected fields 6.Allows Pharmacists to make amendments to prescriptions without ‘defacing’ the Summary 7.Improved workload management in Clinical Coding 8.Provides an interim solution until CRS is able to meet the needs of the GPs and PCT 9.The Hospital gets paid!

Milton Keynes Hospital NHS Foundation Trust Case Study – Lean Patient Discharge ABOUT WCI