The team wanted to see the following benefits from this work:
- More efficient use of time and less duplication when discussing and planning care
- Care planning discussions to include broader and more hollistic themes (i.e. transition, therapeutic activities)
- Improved co-ordination of care with a consistent and clear message throughout a patients stay
- Discussions which result in a clear and implementable care plan for all members of the team
- For patients, relatives and carers to be included in care discussions
- Relevant stakeholders involved when planning a persons care
Once the team had agreed on their Theme and Objectives, they set about trying to understand the issues and challenges which contributed to co-ordination of care discussions not being as effective as they would have liked.
They did this through various techniques such as:
- Process mapping all existing meetings and how they relate to one another
- Fishbone diagrams to identify the challenges to effective communication
- Reflecting on the positives and negatives of current meetings
The teams diagnosis enabled them to consider change ideas that would start to improve the co-ordination of care.
The team identified that care discussions were being duplicated across the various ward meetings and that not all of these discussions were necessary to have at a meeting. In particular this had led to the Daily Planning Meeting overrunning beyond the allocated time. This was a source of frustration as it took staff away from the ward and the consensus was that it:
- Duplicated some of the handover discussions
- Often just restated what is already happening on the ward
- Many of the discussions did not need to happen at a Daily Planning meeting
- The information coming out of the Daily Planning was not always clear and adds confusion
To address some of these issues the team came up with a 'Task Dashboard' to monitor and record the completion of core ward tasks. This would help to co-ordinate key tasks outside of the Daily Planning Meeting so that everyone is aware of what needs to be done without having to wait for an outcome from the meeting. The impact of this change has been that the meetings rarely overrun but more importantly the discussions are focused on areas that need to be discussed in a Daily Planning forum and the team are finding the meetings much more valuable. The next steps for this change are to make it a real time electronic dashboard, which is more accessible and visual for the team to follow, integrating it into the teams way of working.
To improve co-ordination of care, the team decided it would be logical to start at the beginning of the inpatient process. It was felt that improving information and communication during an admission was essential for improving care co-ordination throughout the rest of a patients inpatient episode. The team acknowledged the issues associated with the admission, such as, completeness and relevance of documentation, the absence of a purposeful admission statement, the delay between admission and the first MDT, information collected to inform the first MDT etc.
The team decided to redesign the admission process so that it included a Formulation Review for every patient and they would aim to hold this 72 hours after each admission. Through working on this process the team were able to clarify and refine the essential information needed during a patients first 3 days on the ward so that this helped to inform the Formulation Review. The team could concentrate on completing this essential information, allowing them to focus more time on helping the patient to settle on the ward.
As part of this change the team have:
- Redesigned the Joint Admission Document
- Created and implemented a Formulation Review Information Sheet
- Established 30 minute Formulation Review Meetings for all admissions
- Developed an essential information checklist
It is still early days but here is some of the feedback for the Formulation Review:
the Formulation Review meeting I attended was great"
lots of really useful information discussed"
comprehensive pre-work and really good summary"
completing the documents helped me familiarise with the admission"
the named nurse is clearer on the plan as a result"
we can give relatives and patients a clear plan sooner"
there is much more clarity across the team"
information was brought together sooner"
patients attending the Formualtion Review helps inform the discussion"
formulated a plan which included employment and family"
less daunting than MDT as only had 4 staff"
having the patient involved was beneficial and important"
review and detailed discussion helped to expedite discharge"
it is helping to clarify the purpose of admission"
it can help manage expectations of those first few days"
Inevitably there are still challenges to overcome and through the Microsystem Meeting the team are able to raise and address any concerns or issues as they arise. As a team they are working through solutions and evolving the process so that it continues to improve.
- Every patient is now having a Formulation Review on admission
- An audit is ongoing to look at completion of documents (early findings show some are 100% complete)
- Recording the quality of Formulation Reviews
- Monitoring how many patients attended their Formulation Review
Now that Formulation Reviews and the Task Dashboard are implemented and are being trialled on the ward the team have turned their attention to the MDT Meeting. The current MDT process is a long standing feature on the ward and is bound in tradition. Any changes to this will inevitably cause uncertainty amongst the team and so it is important that any changes to the MDT are owned by the team and are informed through sounding out ideas in the Microsystem Meeting. At each stage the team are able to raise concerns so that they are worked through and mitigated against going forward. It is envisaged that the improvements made via the Task Dashboard and the Formulation Reviews will provide opportunities when considering improvements to the MDT process.
The main principles for a new approach to MDT meetings are:
- It is more accessible and welcoming to patients and relatives
- It is more responsive to patients needs as they arise
- There is time and space to have detailed MDT discussions when required
- The new MDT approach complies with AIMS standards
The team are working through this complex change in a methodical way by addressing the following three considerations: