What is the challenge your project is going to address and how does it connect to the theme of 'How can we improve across system boundaries?​

To improve the current referral process for inpatient Community Care Assessment (CCA).

At present this requires an emailed proforma for each patient. There are often multiple calls between social work and the ward to confirm/clarify additional information, this is inefficient and wastes time.  Referrals are sent from many different emails, so it is not conducive to auditing for improvement.

We believe the process can be streamlined to provide the required information in a clear, consistent format. This would reduce inefficiency and waste in Social Work and nursing staff time and would reduce delays to commencing CCA. This would also impact on reduced overall inpatient stays, and improve integration between health and social care.

Having a single streamlined referral process would also allow us to review and continuously improve, identifying areas for learning, and embed better practice (Avoiding duplication, identifying clear and relevant information, getting referrals right first time, every time).

What does your project aim to achieve?

Using established QI methodology (Model for Improvement/PDSA approach) we hope to achieve the following objectives:

1.      Collaborating with relevant stakeholders, identify the key information required for CCA referral – agreeing the dataset.

2.      Devise a straightforward, consistent system for referral, ideally with a technological solution that allows easy access to accurate information while maintaining adherence to GDPR – developing the tool.

3.      Test this process and gain feedback from staff and patients – testing the process/listening to the stakeholders/cycle of tests.

4.      Measure the impact by developing a measurement plan with clear process and outcome measures.

We believe this will reduce inequalities by creating consistency across CCA referrals and minimising unnecessary delays.

We intend to develop clear, measurable aims as we develop the improvement proposal including:

Reducing incomplete CCAs sent
Reducing time taken for referrals to be accepted/processed
Reducing nursing time spent on the referral process
Reduced LOS
Reduced delayed bed days
Improved staff and patient experience

How will the project be delivered?

We aim to deliver this project applying improvement methodology (Model for Improvement/PDSA) with direct support from trained QI colleagues who will form part of the project team.  We will develop an understanding of the system and processes before developing and testing a technological solution to the current cumbersome process of CCA referrals.

We believe that creating an electronic template that is easily accessible, traceable and auditable, and can be readily populated with the relevant referral information would be of huge benefit and reduce substantial inefficiencies compared to the current system.

We believe the relevant stakeholders to be social work staff, ward nursing staff, and admin staff. We think that cost spent on improving this system would rapidly be recouped in time and efficiency savings.

The main risk relates to information sharing and governance around this, and we understand the need for adherence with GDPR guidelines and information governance.

How is your project going to share learning?

We will share learning locally throughout our improvement journey with key stakeholders to the process and through established specialty and governance structures.

We will share our improvement data and learning from tests of change and we will develop a poster/other output of our results.

Although local processes will vary, the learning from this project will be very much transferable across multiple specialties in terms of a robust, efficient referral system, reducing inefficiencies and waste, whilst delivering improved experience for patient’s and cost saving benefits for health and care organisations.

If successful we would share with a wider national audience by submitting for presentation at relevant QI events and relevant society meetings (e.g. British Geriatric Society).