Rollinson, T.J.et al | 2021 | Learning from Lean: a quality improvement project using a Lean-based improvement approach to improve discharge for patients with frailty in an acute care hospital | BMJ Open Quality | 10 | e001393 | doi: 10.1136/bmjoq-2021-001393
This quality improvement project (QIP), known as the ‘discharge QIP’, focused on improving discharge within two particular wards to begin with at Queens Hospital Burton (QHB), part of University Hospitals of Derby and Burton NHS Foundation Trust (UHDB). These wards were chosen as they provided care largely for patients who were frail. Ward X was a 28-bed medical ward and Ward Y was a 20-bed, largely surgical ward, with prenoon discharges for both wards being less than 10 of the total discharge before the QIP commenced. The team was taken through a set ‘improvement practice process’, employing key Lean principles and tools aimed at increasing value for the patients and removing waste.
The initial aim of this QIP was ‘For frail patients on Ward X and Y at QHB to not be situated in acute beds for any longer than necessary by first December 2019’. This aim was made Specific; Measurable; Achievable; Relevant; Time-bound (SMART) by focussing on improving the prenoon discharge to 33 per cent of patients discharged per day.
Those implementing this project, and the authors of this paper, acknowledge that the original aim of achieving 33 per cent was not achieved for either ward despite there being improvement seen in prenoon discharge measures. In addition, despite focussing on ‘discharge of patients’, this QIP centred only on what improvements can be made internally in the trust (Source: Rollinson et al, 2021).
Abstract
A Lean-based improvement approach was used to complete a quality improvement project (QIP) focused on improving speed and quality of discharge of frail patients on two wards at a large teaching hospital in the UK. This was part of a national initiative to embed continuous improvement within the trust. The aim of the QIP was to improve the proportion of prenoon discharges to 33 per cent of total patients discharged from the ward each day. An ‘improvement practice process’ followed, which included seven discrete workshops that took the QIP through four distinct phases—understand, design, deliver and sustain. Several improvement methods and tools were used, including value stream mapping and plan–do–study–act (PDSA) cycles. Ten PDSA cycles were implemented across the clinical areas, including improved planning and data collection of discharge, improved communication between nursing and medical staff, and earlier referrals to community hospitals for discharge. Improved performance was identified through the outcome metric prenoon discharges on both wards, with the average increasing from 8 per cent to 24 per cent on ward X and from 9 per cent to 19 per cent on ward Y, with no other significant change seen in other measures. Pettigrew et al’s context–content–process change model was used to structure the learning from the QIP, which included the impact of varying ward contexts, the format of conducting improvement with staff, the importance of organisational support, the need for qualitative measures, agreeing to an apposite aim and the power of involving service users. The original aim of 33 per cent prenoon discharges was not achieved, yet there was clear learning from completing the QIP which could contribute to ongoing improvement work. This identified that the Lean-based improvement approach used was effective to some degree for improving discharge processes. Further focus is required on collecting qualitative data to identify the impact on staff, especially related to behaviour and culture change.
BMJ Open Quality Learning from Lean: a quality improvement project using a Lean-based improvement approach to improve discharge for patients with frailty in an acute care hospital[ paper]
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