Timely Discharge from Hospital

you.

Section 1

The fundamentals of discharge practice

Chapter 1

What is best practice for timely discharge?

Liz Lees

This chapter discusses the principles of best practice in discharge planning and transfer, and offers suggestions regarding the application of ‘Ready to go?’ (DH 2010a) in clinical practice (Lees 2010). For each of the ten steps in the discharge process, the Lean methodology (which improves flow and eliminates waste) has been systematically applied (NHS Institute, www.institute.nhs.uk).

In early January 2010, the Department of Health published a new policy: ‘Ready to go? Planning the discharge and transfer of patients from Hospital and Intermediate Care’ (DH 2010a). The title of this document leaves readers in no doubt that the scope of discharge practice has undergone permanent change. ‘Discharge and transfer’ are presented as synonymous, and there are planned discharge pathways, with a series of coordinated steps in the process of planning a patient’s discharge or transfer from ‘Hospital and Intermediate Care’. As with any health policy, ‘Ready to go?’ needs to be considered in conjunction with other policies that have preceded its development (DH 2003, DH 2004, NLIAH 2008, HSE 2008).

The ‘High Impact Changes for Nursing and Midwifery’ policy document (NHS Institute 2009) is also crucial, incorporating a standard for ‘ready to go – no delays’. This is where nurse-led discharge and the skill of estimating dates for discharge should come to the fore, supporting an array of existing measures aimed at reducing overall length of patient stay and seven-day working (Lees 2004, Lees 2007, Webber-Maybank and Luton 2009). While the simplicity and clarity of ‘Ready to go?’ has revitalised the whole discharge debate, readers should not be lulled into a false sense of complacency regarding the ease of implementing its recommendations (DH 2010a).

‘Ready to go?’ specifically explores ten principles or steps, which – if adopted – would promote timely patient discharge from hospital (see page 7). The ten steps require tenacity and sustained commitment to achieve and embed appropriately, throughout the wide range of services where they will be applied.

The context in which ‘Ready to go?’ will be applied to discharge practice

Although the principles of discharging patients from hospital have not changed for many years, the process and pace of discharge planning have changed beyond all recognition. These changes have come about as a result of cultural, political and financial pressures on the NHS, which is required to provide for an increasingly ageing population with sometimes complex needs.

The discharge process now encompasses a great many services, which collectively aim to reduce the length of patient stay and expedite their discharge. These new services are predominantly at the front door of the hospital, and some may adopt innovative methods of assessing and referring patients. There are in-reach and outreach services, rapid access clinics interfaced with acute medicine, surgical admission units and Emergency Departments, all aiming to increase the pace of discharge or transfer. At the same time, we have developed a whole new vocabulary in order to talk about the discharge and transfer of patients; we now commonly use terms such as: capacity, flow, pathway, variation, predictability and breaches.

Clinical areas can no longer be introspective, simply looking after their own issues and ignoring others. Discharging a patient from hospital requires each clinical area involved in the patient’s discharge – (from pharmacy to transport services) to collaborate with others in order to reduce overlap, waste and the frustrations caused by needless delays. Finally, to create effective and efficient discharge practice, clinical staff (including managers) have to understand all the new terminology, new technology, new services and new process steps, in the context of a whole-system approach (DH 2010b). This is a key theme of future workforce planning and role design – to promote responsiveness to patient needs well into the future, when readers of this book will probably have become consumers of the services they help establish.

Discharge practice and older people

Numerous health and social care policies were introduced in 2009, perhaps demonstrating the complexity and challenges faced by the health and social care services in providing appropriate care for patients with dementia while also accommodating safe discharge and transfer (DH 2009a, 2009b). Importantly, these earlier policies have significant implications for the implementation of ‘Ready to go?’, which must be carefully considered when planning a patient’s discharge from hospital (DH 2010a). For example, discharge and transfer for patients with dementia may require a new breed of healthcare worker and new support services, to encompass the whole pathway of care for a society that is growing older and living longer, with increasing frailty (DH 2009a). General awareness of these issues needs to be increased, and dementia care must become mainstream within acute and intermediate care settings, rather than forever being viewed as the domain of ‘specialists’ (DoH 2009b).

I labour this point because there is currently a shortage of services needed to adequately accommodate patients with dementia, despite frequent reviews of service provision and self care. Even the most innovative services frequently have criteria that exclude patients with dementia. For example, discharge lounges often have inadequate facilities and lack of appropriate equipment for people with dementia. In such cases, it may be concluded that the problem is the dementia, when it is in fact a lack of the infrastructure that should support a discharge plan for a person with dementia.

Two questions to answer before you start the ten steps

Before embarking on the implementation of the ten steps, two preparatory questions need to be answered, which are not cited in the Department of Health guidance:

1.Can you define your discharge process steps?

2.Can you define your multidisciplinary team membership?

1.I firmly believe that the discharge process should be clearly identified. Firstly, from a corporate perspective, the process should be identified within the Trust Discharge Policy. The question is: What are the core steps in your discharge process? Answering this question will inevitably raise issues relating to Step 2 in the ten steps (see page 7) – differentiating between simple and complex discharges.

Also, from an individual ward perspective: Are there any added stages, or does what you do broadly fit under each process heading?

For simple discharges, which are carried out at ward level, the process used should be standardised throughout an entire hospital. If standardisation is incomplete or not properly embedded, simple things often get missed, making discharge a lot more complex than it really needs to be. And simple things that are missed can have a big impact in practice, especially if they involve duplications or omissions of care.

The key to making a simple discharge process work consistently in your organisation is to adapt it to fit existing systems and clinical processes with which it will interface. The key to making it happen in practice is to ensure that the process is widely disseminated and to establish firm expectations about its implementation. This adaptation process will be easier if there is a willingness to learn on the part of patients, carers and family members, who will help design a system that is fit for purpose. Patients and their carers are, after all, the ones who experience the process in action.

2. Although it is widely accepted that discharge planning needs to be carried out by a multidisciplinary team (MDT), following a recognised process, the composition of the MDT will vary according to the clinical setting. For example, some wards may have access to their own social worker, while others will rely on area social workers or the emergency duty service. Sadly, there is no consistency. The table below illustrates some of the other potential changes in team composition, according to the environment. The clinical scope of each staff member depends on their situation. They may work in an acute hospital ward, or in the community, or they may have both perspectives because they alternate between areas. What is critical is that each MDT member should respect the knowledge of their fellow team members, and the way in which they may work, albeit differently, to help bring about effective discharge.

Potential MDT members

Implementing the ten steps

Having answered these two contextual questions, the ten steps can be perhaps more easily considered in practice (see below).

The ten steps

Adapted from ‘Ready to go?’ (DH 2010a)

You will notice some overlaps and interfaces between some of the steps, which may be quite subtle. For example, Step 6 and Step 7 suggest patient involvement at two levels, firstly by being adequately informed to be able to make a choice, and secondly (where required) to assess their progress according to the choices made. Patient choices need to be enabled by advocates, who are members of the multidisciplinary team. These advocates must have the skills and knowledge required to navigate through available and appropriate services with the patient (Birmingham 2009). Furthermore, Steps 6 and 7 are dependent on Step 3 (the clinical management plan) being in place. Step 8 and Step 10 are inextricably linked but, by looking at them separately, we can consider two different perspectives: the organisational processes required to make seven-day services available; and the clinical infrastructure needed to include senior clinical decision-makers across a spectrum of care (RCPL 2007).

After each step, I have included some tips for the implementation of that step in practice. These tips include ‘no-no’s’ (major stumbling blocks), ‘nice ifs’ (helpful changes if you are able to make them), ‘niggles’ (minor problems that often occur) and ‘nuggets’ (main lessons or golden rules).

While the ten steps are not prescriptive, they should all be considered. If not, the effect will be like ‘a house of cards’, where one vital ‘card’ (part of the process) being absent will result in the inevitable collapse of the whole process. The ten steps form the framework for an audit and review of the discharge process. They can also tell us where improvements in quality need to be made. Clinical areas where steps may be routinely missed, or where implementation has failed, or where there is entrenched opposition to any of the ten steps, should be exposed and explored when consolidating or redesigning processes to expedite patient discharge and transfer.

Step 1: Start planning for discharge or transfer before or on admission

If we first consider elective care, this step can be implemented in the preoperative admission phase, and may take the form of a screening tool, risk assessment or care pathway. The aim is to anticipate potential delays, and to respond by managing those potential delays in a proactive manner. With the advent of the Liverpool Care Pathway and the renewed focus on end-of-life issues, care pathways have been developed to facilitate rapid discharge for patients at the end of life – on admission to acute services (National End of Life Care Programme 2009).

Conversely, in emergency (unscheduled) care, advance planning is not possible. Robust systems to gather patient information have to be in place – and the information must then be shared with all members of the multidisciplinary team to ensure early engagement in the process. Rich sources of information often get missed in the activity surrounding assessment and transfer (Helleso 2006); pivotal sources include the GP and primary care team and carers, who may have been providing most of the support but receive little mention. Further complexity is added by the numerous types of documentation used in hospitals and intermediate care settings to catalogue discharge communications. If each ward uses its own type of documentation, this will slow the process of retrieval and discharge from hospital (Lees 2010).

Practice tips for implementing Step 1

Step 2: Identify whether the patient has simple or complex discharge and transfer planning needs, involving the patient or carer in your decision

The aim of this step is to identify the likely patient pathway from the outset, at admission or earlier. This should make it possible to recognise the point at which a simple discharge becomes complex. A simple discharge is one that can be executed at ward level with the MDT. A complex discharge involves funding issues, change of residence and/or increased care needs negotiated between health and social care (provision of care packages). Taking the time to predict whether a discharge will be simple or complex is infinitely preferable to an insidious deterioration of the patient’s condition while in the ‘waiting process’, with risk issues perhaps not being recognised before the discharge date is set (HSE 2008). It may also prevent some ‘failed discharges’ and help all those involved to understand what to expect.

Practice tips for implementing Step 2

Step 3: Develop a clinical management plan for every patient within 24 hours of admission

Most patients admitted by junior medical staff will have an outline (initial) management plan. The extent of the MDT involvement will depend upon the time of day of the patient’s admission. For example, admissions after 5 pm will be reviewed by the whole team the next day on the ward round. Ward rounds therefore become inextricably linked to management plans (Lees et al. 2006). Ultimately a management plan should engage and focus the whole MDT, with the patient, to plan the aspects of care required, leading to discharge. Clinical management plans do not have to be prescriptive – they should serve as a guide and be revisited as the patient moves through the continuum of care (Lees & Delpino 2007, Thompson et al. 2004). For those patients on a care pathway, there will be different stages of care that mark progress through the ongoing plan. The care pathway is a vital element in the handover between clinical settings (including nursing homes, intermediate care and GPs), and should prevent delays or lack of clarity regarding which stages of care have or have not been completed.

Practice tips for implementing Step 3

Step 4: Coordinate the discharge or transfer of care process through effective leadership and handover of responsibilities at ward level

The pace of discharge and transfer is such that most clinical areas have developed systems in which they have a discharge coordinator allocated to this role. There is a lot of disparity between these systems, with some using clerical staff to coordinate simple tasks and others employing up to Band 7 nurses (see Chapter 10 on discharge coordinator roles). Some clinical areas rotate nurses in a daily shift coordinator role, while others hold the full-time role of discharge coordinator. Certainly, a ‘one size fits all’ approach cannot accommodate all simple and complex discharges. Communication, MDT working and assessment are three key roles for discharge coordinators (Rose et al. 2009). In addition, they need to look after the transfer of information, which may otherwise be missed (Helleso 2006). Paradoxically, the setting up of coordinator roles to manage complexity in discharge planning, promoting flow and increased capacity, may sometimes cause a loss of the skills and experience required to carry out discharge planning across the nursing team. Nevertheless, this concern should be balanced against the fact that communication and coordination are the essence of good practice in achieving effective, timely discharges (Macleod 2006, Pethybridge 2004).

Practice tips for implementing Step 4

Step 5: Set an expected date of discharge (EDD) or transfer within 24–48 hours of admission and discuss with patient and carer

This area of practice has proved incredibly difficult to implement and embed within organisational philosophy. Essentially, the patient’s discharge date is estimated or predicted, and this EDD is intended as a guide for the patient in the discharge planning process. It is not intended to be exact, and it will need to be refined as the patient’s progress, set against the clinical management plan, is reassessed towards the anticipated discharge date (Webber-Maybank and Luton 2009).

There is also some confusion of terminology evident in practice areas, with use of similar but subtly different terms such as ‘predicted length of stay’, ‘estimated length of stay’ and ‘estimated date of discharge’ (Lees 2008). Regardless of what we choose to call it, if the EDD is to have any meaningful application in practice its underpinning principles must be understood at three levels:

1. Strategically – to predict overall hospital capacity

2. Operationally – to assess progress and outcomes of clinical plans

3. Individually – for patients to understand expectations, limitations and what engagement is required from them in the process of planning discharge (Lees & Holmes 2005, DH 2004).

The third point, ‘patient engagement’, is often absent from the process or conducted on a very superficial level (Sargent et al. 2007). This is where I believe the greatest improvement could be made in the whole process of estimating a discharge date.

Estimating dates for discharge requires a change of mindset for both health and social care professionals towards a culture where ‘time’ is of the essence, and lost ‘time’ (or waiting) in the process of discharge planning should be minimised. Time can, after all, be translated into money. In estimating length of patient stay, the aim is to focus on planning the time carefully and accounting for variance (except for deterioration in the patient’s condition).

Practice tips for implementing Step 5

Step 6: Review the clinical management plan with the patient each day, take any necessary action and update progress towards the discharge or transfer date

Provided that the clinical management plan was commenced on admission, reviewing it with the patient should be a relatively straightforward process. Review, action, progress (RAP) is the process suggested (NLIAH 2008). The important aspect is to update the plan with input from the MDT and the patient (Efraimsson et al. 2003). Clinical management plans will reflect progress towards both medical and therapy milestones. In some cases, the management plan may also form part of an MDT meeting or will be utilised in an MDT meeting, depending on the frequency of these. Ideally there should be only one plan, which is central to the discharge process, to avoid confusion and duplication of documentation and to ensure transparency.

Practice tips for implementing Step 6

Step 7: Involve patients and carers so that they can make informed decisions and choices that deliver a personalised pathway and maximise their independence

This step is aimed at managing patient/carer expectations and understanding potential issues, involving therapy, nursing, medicine and predominantly (but not exclusively) social care partners, who should be guided by the clinical referrals and actions in the clinical management plan (Sargent et al. 2007). There needs to be careful consideration of patient choice to utilise supporting services in intermediate care, care pathways and/or dementia care. Involvement is an ongoing core principle, not a one-off action. Patient involvement may require experience and patience, with a series of meetings being arranged with the patient’s carers, the MDT and social care services. It is about genuine and meaningful engagement with patients throughout the entire discharge planning process. It requires nurses not simply to deliver care, as members of the team, but to represent the patient and understand their own barriers to truly shared decision-making (Milton-Wildey & O’Brien 2010). Patients should be assisted to understand and embrace their responsibilities, with support, and they may need to be helped to ask the appropriate questions (Borthwick et al. 2009; see also Chapter 14 on patient involvement). One suggestion is to ask carers if they feel they can cope or if they anticipate problems (Princess Royal Trust 2007).

Practice tips for implementing Step 7

Step 8: Plan discharges and transfer to take place over seven days to deliver continuity of care for the patient

This step relies upon engagement from services that support discharge. Some of these may not be ward based (for instance, therapy services, x-ray services, transport, district nursing, and intermediate care services). Only by means of seven-day working on the part of hospital and community services will continuity over seven days of the week be possible (DH 2004). For example, generally therapists only work Monday to Friday, although this is slowly changing in some areas of practice, such as acute medical units. This means that the discharge plans that have been put in place have to continue at the weekend with nursing staff support – although in some areas with early supported discharge schemes. This step is vital, and seven-day services should be established as new contracts, posts or services are established.

Practice tips for implementing Step 8

Step 9: Use a discharge checklist 24–48 hours prior to transfer

The discharge checklist has proved to be a difficult area of practice to sustain. The principle of a checklist is not new (Lees 2006). What is new is the concept of uniformity, of one checklist being used across a whole trust/organisation, and ensuring that it is developed with input from both the primary care trust (PCT) and social care services. Such checklists are more commonly seen in integrated care pathways, often for surgical conditions. Their purpose is not to duplicate information but to ensure that, amid all the heightened activity before discharge, vital planning aspects are not missed or forgotten.

If used appropriately, a discharge checklist can counteract complaints about the discharge process, and assist compliance with the standard for discharges within the Clinical Negligence Scheme for Trusts – ‘The organisation has an approved documented process for managing the risks associated with the discharge of patients that is implemented and monitored’ (NHSLA, Standard 4, Criterion 10, 2010/2011). There is potential for the checklist to be merged with the discharge letter and carbonated, to enable copies to be given to the patient upon discharge from hospital.

Practice tips for implementing Step 9

Step 10: Make decisions to discharge and transfer patients each day

The key difference between this step and Step 8 is the requirement to make a decision. Many publications have dealt with issues surrounding safety, suggesting that the consultant’s decision is critical to safe, effective discharge (RCPL 2007). This raises a whole new debate, concerned with the reduction in junior doctors’ working hours, and changes in roles and responsibilities required across a team to support this change (RCPL 2007). Each clinical area needs to decide on a discharge structure for the future, which takes into account decision makers regardless of profession.

The High Impact Changes (NHS Institute for Innovation and Improvement 2009) reiterate earlier publications and have made nurse-led discharge a key deliverable. Nurse-led discharge will never replace the role of the MDT and senior clinical decision-makers such as consultants, but well thought out implementation will support the MDT to deliver services over seven days (Macleod 2006, Lees 2007). The evidence base is gradually increasing – but it is crucial that the nursing profession grasps the opportunity to develop this new way of working as part of the existing discharge process (Lees 2004; see also Chapters 3, 18, 22, 24 and 28).

Practice tips for implementing Step 10

Conclusion

It is often quite a challenge to know where to start implementing a new policy. However, the clarity of the ten steps enables specific areas to be audited in order to focus on where work should be undertaken on particular points in the care pathway. Equally, it is very important to look at what the current process consists of, and in doing so understand the obstacles that staff might face on a day-to-day basis, in order to design a sustainable discharge process. For example, if there is no clinical management plan, this alone may cause staff to dismiss the process and ‘execute discharge in their own way’.

The process used on each ward must be the same, underpinned by ‘specialist’ aspects of discharge planning pertaining to the individual area. For example, adding to the process may be acceptable but leaving out parts of the process will delay the eventual discharge – if not in the clinical area where it was started then further on, at a later stage in the care pathway. The discharge process must work out of hours and must not include delays caused by lack of availability of transport, medications, and so on. The discharge policy must also support the process – and a wise step may be to reconsider the elements within your discharge policy. For example, you could ask: does the policy include the ten steps?

If we can consider and start to conquer these problems at a micro level, policies at a macro level (supporting organisational safety, patient satisfaction and a reduction in length of stay) should start to become integrated within practice. The discharge process at all levels is central to the efficiency and effectiveness of any healthcare organisation; and on this basis it is well worth a systematic review, using the ten-step approach outlined in this chapter.

References

Birmingham, J. (2009). Patient choice in the discharge planning process. Journal of Professional Case Management. 14 (6), 296–309, Maryland: Lippincott Williams & Wilkins, Inc.

Borthwick, R., Newbronner, L. and Stuttard, L. (2009). ‘Out of Hospital’: a scoping study of services for carers of people being discharged from hospital. Health and Social Care in the Community. 17 (4), 335–349.

Department of Health (2003). ‘Discharge from hospital: pathway, process and practice’. London: HMSO.

Department of Health (2004). ‘Achieving simple timely discharge from hospital: a multidisciplinary toolkit’. London: HMSO.

Department of Health (2009a). ‘Living well with dementia: a national dementia strategy implementation plan’. London: HMSO.

Department of Health (2009b). ‘Joint commissioning framework for dementia’. London: HMSO.

Department of Health (2010a). ‘Ready to go? Planning the discharge and transfer of patients from hospital and intermediate care’. Department of Health, Quarry House, Leeds.

Department of Health (2010b). ‘Liberating the Talents: Developing the healthcare workforce: a consultation on proposals’. Department of Health, Quarry House, Leeds.

Efraimsson, E., Rasmussen, B.H., Gilje, F. & Sandman, P. (2003) Expressions of power and powerlessness in discharge planning: a case study of an older woman on her way home. Journal of Clinical Nursing. 12 (5), 707–716.

Health Services Executive (2008). Code of Practice for Integrated Discharge Planning. 31–33 Catherine Street, Limerick, Ireland. www.hse.ie

Helleso, R. (2006). Information handling in the nursing discharge note. Journal of Clinical Nursing. 15 (1), 11–21.

Lees, L. (2004). Making nurse-led discharge work to improve patient care. Nursing Times. 100 (37), 30.

Lees, L. & Holmes, K. (2005). Estimating a date of discharge at ward level: a pilot study. Nursing Standard. 19 (17), 40–43.

Lees, L. (2006). ‘Not Just another sheet of paper: discharge checklists’. The Communicator, RCN discharge planning and continuing care forum. Summer 2006, 4–5. www.rcn.org.uk/liaisondischarge

Lees, L., Allen, G. & O’Brien, D. (2006). Using post-take ward rounds to facilitate simple discharge. Nursing Times. 102 (18), 28–30.

Lees, L. (2007). Nurse Facilitated Hospital Discharge. Keswick: M&K Publishing.

Lees, L. & Delpino, R. (2007). Facilitating timely discharge from hospital: Combining patient name boards and discharge planning information. Nursing Times. 103 (29), 30–31.

Lees, L. (2008). Estimating patients’ discharge dates: applied leadership, Nursing Management. 15 (3), 30–35.

Lees, L. (2010). Exploring the principles of best practice discharge to ensure patient involvement. Nursing Times. 106 (25), 10–14.

Macleod, A. (2006). The nursing role in preventing delay in patient discharge. Nursing Standard. 21 (1), 43–48.

Milton-Wildey, K. & O’Brien, L. (2010). Care of acutely ill older patients in hospital: clinical decision-making. Journal of Clinical Nursing. 19 (9–10): 1252–1260.

NHS Institute for Innovation and Improvement (2009). ‘High Impact Changes for Nursing and Midwifery’. Coventry House, University of Warwick Campus CV4 7AL. www.institute.nhs.uk

NHS Litigation Authority (2010/2011). The risk management handbook supporting the risk management standards. www.nhsla.com

National Leadership Innovation Agency for Health Care (2008). Passing the Baton – A Practical Guide to Effective Discharge Planning. The Welsh Assembly.

National End of Life Care Programme (1 October 2009). Liverpool Care Pathway: response to media reporting. http://www.endoflifecareforadults.nhs.uk/case-studies/lcp.

Pethybridge, J. (2004). How team working influences discharge planning from hospital: a study of four multidisciplinary teams in an acute hospital in England. Journal of Interprofessional Care. 18 (1), 75–80.

Princess Royal Trust for Carers (2007). Out of Hospital Project, Report from Stage 1. Malton, York: Acton Shapiro Consultancy and Research.

Rose, M., McCarthy, G. & Coffey, A. (2009). Discharge planning: the role of the discharge coordinator. Nursing Older People. 21 (1), 26–31.

Royal College of Physicians of London (2007). ‘Acute medical care: the right person in the right setting first time – report of the acute medicine task force’. London: Royal College of Physicians of London.

Sargent, P., Pickard, S., Sheaff, R. & Boaden, R. (2007). Patient and carer perceptions of case management for long-term conditions. Health and Social Care in the Community. 15 (6), 511–519.

Thompson, A.G., Jacob, K., Fulton, J. & McGavin, C.R. (2004). Do post-take ward round proformas improve communication and influence the quality of patient care? Postgraduate Medical Journal. 80, 675–676.

Webber-Maybank, M. & Luton, H. (2009). Making effective use of predicted discharge dates to reduce the length of stay in hospital. Nursing Times. 105, 15.

Chapter 2

How senior nurses can maintain strategic organisational momentum in safe discharge practice

Sam Foster

The first line of the professional Nursing and Midwifery code states: ‘The people in your care must be able to trust you with their health and wellbeing’ (NMC 2008). It is therefore the responsibility of the senior nurse, when leading the practice of safe discharge, to develop local policy that is fit for purpose, and to ensure that this policy is successfully implemented. The senior nurse also needs to monitor the policy, to ensure that patients and their families and carers have a safe, high quality experience.

This chapter relates to both the strategic and the clinical practice considerations that guide senior nurses in maintaining strategic momentum in discharge practice. It will review policy development, implementation and monitoring processes.

Local policy development

When developing local discharge policy, it is essential that the senior nurse reviews relevant national policy drivers and related regulatory standards; and that lessons learnt from any complaints or patient safety incidents relating to discharge are integrated as guidance/protocols.

In recent years, safe, high quality patient care has been the guiding principle of all policy drivers and regulatory standards aimed at setting the direction for the NHS. The Department of Health White Paper ‘Equity and excellence: Liberating the NHS’ (DH 2010) launched the government’s plans for a new direction for the NHS. The paper outlined an ambitious programme of reforms, starting with revisions to ‘The Operating Framework for the NHS in England’ (DH 2011). The Framework recognised the challenges involved in implementation. The first full year of the transition was seen as a critical period that would require all parts of the NHS to respond positively to the principles and purposes set out in the White Paper, whilst ensuring that service quality, productivity, efficiency and financial performance were maintained and improved. Furthermore, a new requirement was included in the Framework, which identified safe discharge as an area for improvement.

The challenge for an Acute Trust now is that hospitals will no longer be reimbursed for emergency readmissions within 30 days of discharge, following an elective admission. All other readmission rates will be subject to locally determined thresholds, with a 25 per cent decrease in activity desired where achievable. Strategically, NHS organisations now need to balance the potential financial penalty against the requirement to deliver patient safety by ensuring that length of stay is appropriate to patient need. Estimating dates for a patient’s discharge from hospital plays a crucial part in getting this balance right (see also Chapters 13 and 27).

The Care Quality Commission (CQC) provides a regulatory function for all health services and adult social care services in England. In order to provide health or social care services, organisations are required to register with the CQC, and make a formal declaration of compliance with a set of standards. A number of these standards include the need to ensure safe discharge. Organisations must declare compliance in the following areas:

•Cooperating with other providers to ensure safe transfer of care or discharge

•Ensuring that a patient’s length of stay will be as short as possible in order to meet their needs, or as required by legal restrictions

•An organisation’s accommodation must not limit patients’ freedom any further than is agreed in their plan of care, wherever possible

•Patients should know the names and job titles of the people who provide their care, treatment and support, and how to contact them

•Patients must have adequate plans in place for when they leave the service and be fully involved in this planning, where they have the capacity and the wish to do so.

(CQC 2010, Regulations 24 and 9)

The National Health Service Litigation Authority handles negligence claims and works to improve risk management practices in the NHS (NHSLA 2010/2011). It has a framework of standards by which it assesses the level of risk that organisations pose in their delivery of care, based on the level achieved (0–3). Organisations pay a premium and the NHSLA provides an indemnity. (See NHSLA standard 4 (2010/11), relating to discharge.)

Standard 4 - Criterion 10: Discharge of Patients

The NHS Confederation is the independent membership body for the full range of organisations that make up the NHS. The Confederation works to influence policy in the interests of patients, the public and NHS staff. It supports leaders to deliver strong and innovative leadership within the NHS. Part of the Confederation’s work is ensuring that users of the NHS know their rights. Through a variety of media, such as the NHS Choices website, it clarifies patients’ rights to safe discharge, stating:

•In England, you should not be discharged from hospital until your care needs are assessed and arrangements made to ensure that you will receive any necessary services when you are discharged.

•Any assessment should take into account your wishes, the wishes of your family and of any carer. You should be kept fully informed and involved, be given sufficient time to make decisions, and be told how to seek a review of any decisions made. You can ask for a reassessment of your needs if circumstances change in the future.

(NHS Choices website: http://www.nhs.uk/Pages/HomePage.aspx)

If patients, their families or carers are not satisfied with discharge plans, NHS Choices reminds them:

•Before discharge takes place, you, or your family, carer or representative, have the right to ask for a review of the decision, which has been made, about your eligibility for continuing NHS care. In England, you can also ask for a review after discharge.

To summarise, patient safety and the quality of patient experience underpin all current political and regulatory drivers. This in turn must influence all senior nurses involved in local policy development and ratification, to ensure that local policy is fit for purpose (see Chapter 14).

Local policy implementation

The method of implementing local policy is crucial for sustainability. John Overtveit (cited in Maher et al. 2007) stated: ‘The challenge is not starting, but continuing after the initial enthusiasm is gone’ (p. 23).

Evidence shows that change is most successful if it is locally owned. However, a practitioner’s enthusiasm, once gained, has to be channelled to ensure action. This can