What is the challenge your project is going to address and how does it connect to the theme of 'How can improvement be used to reduce delays accessing health and care services'?

Many of us can cite a long list of barriers and constraints which cause, or contribute, to delays in the flow and discharge within our hospital system. And these are likely to exist in every other hospital system too.  However, within each, individual, hospital system, we often don’t know our own “pareto”, which are our biggest drivers and inter-dependencies, and therefore which issues to tackle first.

At Whipps Cross Hospital, we are setting up an ambitious, long-term Flow and Discharge Programme, recognising that this is a ‘wicked problem’, without one, optimal, correct, solution – we recognise that we will never “solve” it. We therefore aim to spend a period of time first, using a QI Framework, to understand our current Whipps Cross flow and discharge system, to inform our short- and longer-term QI plans, co-designing with patients and colleagues, to continuously improve our system and processes.

What does your project aim to achieve?

Our project aims:

• To develop and test a QI model and toolkit on a general medical ward, for use in a ward observation, to identify the “pareto” of the drivers causing flow and discharge delays, alongside other qualitative observations, including patients’ experience of delays and contribution to health inequalities. It should be easily adapted for use on other wards across this, and other, Trusts.
• To test the applicability and usefulness of a shadowing app (Go Shadow) in streamlining the observation data collection and analysis process.
• To use the output to inform the work priorities of our actual Flow and Discharge programme, ensuing we focus on high impact problems first.

This will lead to improvements, such as reduction in length of stay, increase capacity to treat more patients in a timely way, improve patient experience – all which will benefit patients and staff.

How will the project be delivered?

We will develop, plan and undertake a one-week observation of a ward, testing the model, toolkit, and shadowing app.

General medicine ward selected because

• Multi-specialty,
• Lower number of complex discharge patients, therefore more likely to identify wider system issues common to patients on all wards.
• High degree of patient activity,

We have a diverse multi-professional project team which includes, medical and nursing QI leads, an IHI faculty member and patient rep, who will help us shape the patient survey which will capture the impact on patients from delays. We are working in partnership with Curie ward to ensure all staff are engaged and involved in this project.

Risk: Manage organisational expectations. Output is;

• Unlikely to identify immediate change ideas.
• Likely to identify issues which themselves require further QI diagnostics before moving to change ideas and test

because this is a system level observation.

How is your project going to share learning?

Our model and toolkit will consist of observation templates for data collection, and a project plan for running an observation on a ward, including the workup and the observation exercise itself, recommendations on if and how to use the app and scale of projects that would benefit, and hints and tips. It should be adaptable for different specialties or hospital sectors. We will support other Bart’s Health hospitals to implement this.

The learning gained from this project will be shared at our Whipps Cross Hospital programme board, with the expectation that a secondary observation will be undertaken on a different ward.

We aim to promote our learning from this exercise across the Q community and beyond, including offering our expertise through Hexitime, and through publication in the BMJ open Quality.