Q Exchange
Digital transformation of Criteria Led Discharge
- Winning idea
- 2022
What is the challenge your project is going to address and how does it connect to the theme?
Our existing MDT Cracking Discharge group wants to increase the use of the Criteria Led Discharge (CLD) pathway to facilitate more timely discharge of patients and improve patient flow.
CLD enables a experienced member of the MDT(e.g. junior doctor, registered nurse or therapist) to discharge a patient when they meet pre-agreed criteria for discharge, removing the need for the lead clinician to approve discharge.
Functionality to support the CLD pathway is a new feature within our self-built electronic health record (EHR).
We know that CLD works: comparing patients on CLD pathway with patients not on CLD pathway, a greater proportion (46.1% vs 38.7%, 95% CI 41.1% to 51.2%, p=0.003) were discharged by 15:00 hours. Fewer than 2% of inpatients have been added to the CLD pathway since December 2021.
Undertaking focussed interventions to increase the numbers on the CLD pathway will enable more patients to benefit from this innovative digital pathway.
What does your project aim to achieve?
Our project has 3 aims:
1. To identify the major obstacles to adoption of CLD by clinical teams
2. To pursue discrete, targeted interventions to remove the obstacles to increase numbers of patients on the CLD pathway and facilitate earlier discharge
3. To measure the impact of those interventions in near real time and regularly report the results to clinical teams, completing PDSA cycles in a timely manner
Our CLD functionality is supported by a sophisticated reporting function – we can see the impact of interventions in near real time and will report results regularly to clinical colleagues.
The advantages of timely discharge are already well documented. Increasing the numbers of patients on the CLD pathway should enable more patients to benefit from this novel functionality.
Achieving these outcomes will help to achieve the objectives of the Trust’s Cracking Discharge strategy and COVID-19 recovery plan.
How will the project be delivered?
Our project is led by a group of skilled individuals from a variety of professional disciplines including patient partners trained in QI methodology.
Our proposed focus is successful adoption of CLD amongst surgical elective pathways understanding barriers. Using the Pareto principle, we will explore recommended changes to surgical pathways, propose new policy and consider further changes to the digital CLD functionality.
We will run a campaign to increase the awareness of the benefits of CLD amongst public/patients – this should increase patient activation.
Discharge coordinators are important stakeholders. They will receive training in influencing skills; better equipping them to interact with clinicians and champion use of this functionality.
The risk associated with our project is minimal. We know that CLD already brings about tangible benefits to patients and wider organisation. We plan to use an agile approach, informed by reporting data to scale up adoption and deliver improvements in discharge processes.
How is your project going to share learning?
We are lucky that our CLD multidisciplinary project team include Q Members, NHS Digital Academy alumni and a 2022 Florence Nightingale Foundation Digital Leadership Scholar – bringing a wealth of contemporary learning and experience to this project.
We have established a range of KPIs which will have both patient focussed and clinician intervention outputs. We will share how QI methodology influences the uptake and sustained adoption of the new CLD functionality, in addition to the technical architecture of digital solutions. We are committed to share our learning so colleagues throughout the health system can be the beneficiaries and replicate our successes.
Learning will be shared with locally with colleagues in the Yorkshire & Humber Improvement Academy; West Yorkshire Association of Acute Trusts and ICS , in addition to nationally through Q and associated Digital Improvement Networks. We will also publish our findings in peer reviewed journals and present at conferences.
How you can contribute
- Q members feedback has anyone embedded CLD on surgical pathways
- What have been the challenges and wins
- How can we make this work for elective surgical pathways?
- We have some baseline data feeds - numbers on CLD pathway by ward and directorate. As neutral observer what data would you like to see that evidenced success.
Plan timeline
| 1 Jun 2022 | Engagement with surgical teams |
|---|---|
| 1 Jun 2022 | Review CLD reporting matrix |
| 6 Jun 2022 | Patient partner project engagement |
| 20 Jun 2022 | Commission medical illustration |
| 20 Jun 2022 | Develop patient information |
| 1 Jul 2022 | Review exisitng digital e forms |
| 1 Aug 2022 | Clinical Leadership Fellow in post |
| 8 Aug 2022 | Commence monthly project review boards |
Project updates
4 Sep 2023
The project had the ambition to implement criteria led discharge (CLD) in an orthopaedic ward with aim of improving discharge processes and reducing waiting times for patients. CLD, enables staff to discharge patients without further medical review, once the patient has achieved a range of pre-agreed clinical criteria (examples: eaten and drunk post-surgery or blood tests within range). A digital CLD eform, had previously been developed for use within the electronic health record. The project focus was to embed the use of the form, with a view to improve discharge processes. CLD is one of several interventions the organisation is using to improve discharge for patients.
The ward embraced the philosophy of CLD and there was enthusiastic support across the MDT. Training and engagement sessions were undertaken, which included recruiting Allied Health Professionals (AHP) to support the projects. AHPs are intrinsic in undertaking mobility assessments for orthopaedics patients. Unfortunately, the case mix of patients, some with complex socio-economic backgrounds, precluded many patients from being recruited onto CLD pathway, or achieving their CLD clinical criteria. The clinical teams are to be commended for continuing to drive the project, against a background of very complex patient. However, the project team were not to be deterred. The lessons learnt from the ward have already been evaluated, and other less complex ward and day case environments have already been chosen to use CLD as a phase 2 project.
CLD has been widely supported by the Executive team. This support is invaluable, especially where a project may not have achieved its initial ambitions.
Clinical digital informaticians have also played a crucial role of being a conduit between clinical and digital. Providing support, guidance, and training reflective of colleagues learning styles has been widely welcomed by the operational teams.
Comments
Emma Brangwin 12 Mar 2024
Hi Both,
It's really good to come across this project and thank you for the update from last year. I'm a physio by background and completed a secondment in 2022 which was to roll out CLD within our acute Trust in Coventry (to varying extents) and know how challenging it can be to implement.
I started a PhD in September last year exploring CLD (with Liz Lees-Deutsch as my supervisor) and think I will be looking at the behaviours which are key to the motivators behind implementation and try and unpick a bit more around where it has and hasn't worked.
But first, I'm doing a scoping review of policies, guidelines and Toolkits surrounding CLD so would be extremely grateful if you would be willing to share yours for inclusion in the review. I know many Trusts have them, but not all are coming up via Google/Google Scholar!
Likewise, if anyone else from another Trust/area would like to send me theirs then I would really appreciate it. My email address is brangwine@uni.coventry.ac.uk.
I'm also looking to expand my network of contacts relating to CLD as will be looking to collect data/conduct interviews/surveys across a range of sites.
Any support would be much appreciated.
Kind Regards,
Emma
Zoe Lord 22 Aug 2022
Hello Georgina and Anna, I'm involved with some discharge programmes and would love to have a conversation about what you're doing. My details are: zoelord@nhs.net 07870213106. Hopefully speak soon,
Gillian Janes 20 May 2022
Love this idea to focus on why something so well proven with benefits for multiple stakeholders isn't working as well as it might and address that using PDSA/live data. Really good to see the patient/family activation element - and speaks to my aim to support staff wellbeing during digital transformation so you got one of my votes and good luck with it. Best wishes. Gillian
Georgina Duncan 23 May 2022
Thank you so much for your feedback and support Gillian. We really look forward to to seeing how we can continue to embed CLD within a range of areas.
Georgina Duncan 10 May 2022
Data: we all love data. If you were reviewing the data we have, what would you like to see? Criteria Led Discharge against normal discharge? Time of day of discharge? Identifying other influencing factors? Be keen to hear your thoughts? What would encourage you to give CLD a try in your own organisation?
Gurjit Chhokar 21 Mar 2022
CLD works very well when understood and used - and therefore in my experience can be very sensitive to adoption - where it is not embedded, use and understanding tails off to the point where it's benefits are not seen. It is also an important to tool that helps flatten hierarchy and reduces the lack of decision making to progress plans - it encourages non- consultant members to be making decisions, supports them by providing criteria and helps them to know when to escalate an issue if there is deviation. So glad that this project is focusing on the adoption and embedding of it's use having already shown its benefits.
Georgina Duncan 21 Mar 2022
Thank you so much for your observation. I couldn't agree more, whatever we can do to support safe discharge across MDT. By focussing and embedding in an area such as surgery we can learn from their experience, adapt and change. Plus enabling a range of colleagues to take on responsibilities.
Andrew Webster 21 Mar 2022
Demonstrates that however good the idea is in theory implementation and adoption is challenging. Hopefully this project will embed CLD into standard working
Georgina Duncan 21 Mar 2022
Couldn't agree more. Embedding and becoming normal business. Thanks for support and comment.
Jackie Nam 21 Mar 2022
A good project building on the positive outcomes seen using the CLD pathway.
Georgina Duncan 21 Mar 2022
Thank you for your support Jackie. It is important to ensure all our patients (for those it is appropriate) can benefit from CLD.
Guy Dickie 20 Mar 2022
Great project and very much needed. Key to scale up the number of patients as quickly as possible.
Georgina Duncan 21 Mar 2022
Thank you for your support you are right scaling up, and learning from using QI methodology will be key.
Shaun Treweek 18 Mar 2022
This sounds like a really promising initiative, especially since CLD shows benefit in early work. Key now is to figure out how to get more patients on CLD and continued evaluation of this approach, both of which are what your current proposal aims to do. The ability to look at the effect of interventions in real time is particularly impressive.
Good luck!
Georgina Duncan 18 Mar 2022
Thank you for your encouragement. Your are correct undertaking PDSA and reviewing the impact data live is hugely important. Having a focus on surgical pathways is very important as we believe once embedded it will pay dividends for the whole surgical pathway.
Begonya Alcacer-Pitarch 15 Mar 2022
Well done, that is a great project and much needed.
Following an agreed predetermined discharged criteria will not only lead to a quicker discharge process but also fairer for the patient, as his/her needs will also be taking into consideration.
best of luck
Georgina Duncan 18 Mar 2022
Putting patient our patient's at the centre of what we are working on has been really important. Our patient partners are crucial to these developments. Thank you for your support.
andrew barr 15 Mar 2022
I really like this project. I hope it can be routinely adopted to help with the current and ongoing bed crisis.
Georgina Duncan 15 Mar 2022
Thank you Andrew. We are really passionate about proactively doing anything we can to support safe effective discharge, especially in the current climate.
Sophie Blow 15 Mar 2022
What a great project, you've already shown CLD has made an impact (when used) to support patients going home at a reasonable time (i think its states 3pm) and now you want to increase it use. Sounds brilliant.
Georgina Duncan 15 Mar 2022
Thanks Sophie whatever we can do to improve patient centred discharge
april daniel 15 Mar 2022
I support this project idea!
Georgina Duncan 15 Mar 2022
Thank you for your support April
Comments are now closed for this post.