Osborn 3 - Discharge Process and TTO's



The Princess Royal Spinal Injuries Centre is a unit based at Sheffield Teaching Hospitals NHS FT, providing comprehensive Spinal Cord Injuries services for patients, with facilities for acute, rehabilitation and continuing care. The centre is a 60 bedded unit (equipped to support 6 ventilated patients) across 3 wards.

We have been meeting as a team, having weekly hour long meetings since June 2015, using a structured approach to improvement using the Microsystems improvement methodologies.  The team have now completed improvements to their weekly MDT, aiming to improve the structure of our ward rounds. The team returned to their 5P’s assessment and reviewed the current state of the Microsystem re-focusing their improvement efforts on the theme of discharge.

As part of the regular Microsystem meetings the team developed a global aim statements from the discharge theme:



As with their earlier work the team used the weekly meetings to review the 5P’s assessment of all aspects of the ward (microsystem) as a whole. Following this review the team spent time understanding the Discharge process in more detail.  A Fishbone and review of the discharge process highlighted several opportunities to improve the overall discharge process. In addition to the information provided from  process map and fishbone diagram staff provided valuable feedback about the current impact of the discharge process. Staff expressed concern that often “things happen at the last minute” and a concern that they didn’t want the patient’s last memory of their care on Osborn 3 to be a stressful one which didn’t meet expectations.

From the process map and fishbone diagram a number of areas for improvement were highlighted around discharge.

  • Although patients have a planned discharge date, with clear timescales and some actions for discharge, including the  TTO process was not starting until immediately  before discharge
  • It was not always clear who was responsible for each step of the process
  • Co-ordination of some parts of the process and the communication between medical teams, ward staff and pharmacy was challenging and used multiple systems.


The team agreed to focus on the TTO process as a specific area for improvement and worked to assess and understand the process and opportunities in more detail.



To fully diagnose the problems it was agreed to collect data the current state of the TTO process. Using data within the ICE system the team gathered information on how long the process currently took and when it was completed, relative to the patients discharge date from the spinal injuries unit. This data showed, that although the team planned discharge dates well in advance, the submission of the TTO was not happening until immediately before discharge.

The team also process mapped the TTO process which helped the team visualise the process and begin to understand key steps in the process and how co-ordination of the process happened in the current state.

Using the process map, baseline data and feedback from staff the team had a clearer picture of opportunities for improvement.

  • Patients reported that they were not always clear on the medications provided
  • Staff reported that “everything happens at the last minute”
  • Discharges were not cancelled but errors, delays and communication challenges resulted in a stressful experience for patients, staff and the MDT
  • An invisible, poorly understood process


The team set a specific aim with a clear target of how much to improve the TTO process by, and when:


“We aim to increase the number of TTOs (TTO submitted) that are sent to Pharmacy at least one week before our patients expected discharge dates on Osborn 3 from 0% to 100% by Nov 2016”



The team agreed that they wanted the TTO process to be commenced earlier in the process of discharge planning, completed within agreed timescales and the status of each patient to be visible to the ward staff and pharmacy

To achieve this the following changes were tested;

  • For each patient the team identified two key dates at the weekly MDT, the discharge date and the date that TTO’s were needed on the ward (to allow clinical checks and a review with the patient to take place).
  • The dates were clearly recorded in the Dr’s workbook and this was handed over to Pharmacy and the ward team
  • The medical team (SpR and F1’s) ensured that the TTO and ICE Discharge were completed within the agreed timescale. Once completed, this information was recorded on the E-Whiteboard and the Pharmacy team were contacted directly to make them aware.
  • The TTO’s were managed using the main trust process – any issues were addressed directly with the medical team.
  • The medications were signed onto the ward once completed with the aim of prompting and earlier review with the patients.

What we achieved


  • Understanding and awareness of the TTO process increased within the MDT
  • Clearer roles and recording of the process steps supported visibility of the process.
  • TTO’s are now completed by the ward team on average 8.6 days before the patient discharge date (previously this happened 3.4 days before discharge)

Next Steps


The team continue to meet to discuss and monitor their data and improvements to the process. They plan to continue to improve the TTO process and review errors and other delays in the process and achieve their specific aim.

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