Introduction and aim of the project

The National Healthcare Service is continuously facing challenges of making changes to

improve patient safety and quality of care (Ham, Berwick and Dixon, 2016). A student nurse
introduces this project as it was observed in clinical placement that hospital discharge is not done
in a timely matter, which leads to delays. Delay discharge in hospital is when a patient is
medically fit to leave the hospital back to their own home or in other healthcare setting but
remain to occupy a bed (The King’s Fund, 2018). This service improvement project aim is to
reduce delay discharge in the hospital through the chosen solution of discharge checklist tool-
using service improvement methodology of Six Sigma: DMAIC that will help to improve quality
of care and patient safety. There are no ethical issues addressed in this project. Therefore, this
service improvement project did not require any ethical approval. In accordance with the Nursing
and Midwifery Council (NMC) Code of conduct (NMC, 2018) there were no involvement of
patients or healthcare professionals (HCP) and confidentiality will be maintained throughout the
proposal.

Problem, context and background

Timely hospital discharge is a growing problem, not just affecting the NHS but many hospitals
worldwide (Department of Health, 2004 citied in Mustafa and Mahgoub, 2016). While in a
clinical placement, it was acknowledged by the author that hospital discharge was not done in a
timely manner as several situations caused delayed discharge for elderly patients. Furthermore, it
has an impact on a new patient to access hospital bed, delay transferred, and it prolonged some
patient’s hospitalisation due to hospital-acquired infection as observed in clinical placement by
the author. This led to patient safety at risk due to the consequences of delay hospital discharge
(Apkon and Friedman, 2014)

In literature review that was completed by the author for this unit regarding factors associated
with delay hospital discharge, indicated that older patients and those with cognitive impairment
are more likely to experience delay discharge as they require additional support such as post-
discharge facilities, consultation and referrals (Hendy et al., 2012; Jasinarachchi et al., 2009; Ou
et al., 2009; Majeed et al., 2012; Challis et al., 2013; Bo et al., 2015 and Salonga- Reyes and
Scott, 2016). Additionally, a result from an inpatient survey that was published in 2014 by Care
Quality Commission (CQC, 2015)indicated that there are several features of discharge process
that needs improvement as they were still experiencing delay discharge. Hospital discharge is a
complicated and challenging method for HCP’s as there is a high pressure for them to discharge
patients as soon as possible from the ward (Pellett, 2016). Moreover, when discharge is done in a
timely process and related to the patient’s health needs will help to prevent delay in hospital
discharge (Bailey, 2012; El-eid, Kaddoum, and Tamim, 2015). Furthermore, it will enable to
improve patient safety and quality of care as discharge process is completed promptly that
prevent the patient from readmission and prolonged hospitalisation that can lead to acquired
hospital infection.

Patient safety is the protection of service users within the healthcare setting by preventing
avoidable errors that can cause harm to service users (World Health Organisation, 2018).
According to the Royal College of Nursing (RCN, 2015), patient safety is a vital part of nursing
care as it provides a high quality of care. Quality can be defined in several ways, but the World
Health Organisation (2017) defined quality in healthcare as the extent of making sure that service
users are provided the best care that improves their health outcomes.

Service improvement

In a healthcare setting, service improvement is a process that aim is to make a difference for
service users by improving the care system, patients experience, make cost-saving and lessen
clinical errors which include implementing specific methods or technique to provide a safe and
improved services (Health Foundation, 2013; Academy of Medical Royal Colleges, 2016). It is
also acknowledged as an element that improves health outcomes and has a fundamental role in
developing the quality of care for service users (Leatherman et al., 2010). Alderwicket al., (2017)
and Department of Health (DoH,2015) emphasised that all healthcare professionals should be
involved and is essential to lead changes for improvement and deliver an enhanced service that
will benefit the patient quality of care and their safety. According to a study conducted by
Craig(2018), service improvement may not be sufficient alone to help improve the patient’s
quality of care and positive outcomes. Hence, this project will help to minimise delays in
hospital discharge that will lessen the strain on the financial cost to the NHS due to prolonged
hospitalisation and its negative impact on the patient’s health.

Several service improvement framework and methods are adapted by healthcare organisations
for improvement to ensure that care setting is safe, effective and has a holistic patient-centered
care approach (Agency for Healthcare Research and Quality, AHRQ 2013; Jones, Vaux and
Olsson-Brown, 2019).
Plan, Do, Study, Act (PDSA cycle)

PDSA cycle is the commonly used method in National Health Service as an improvement
approach to trial ideas and constructs changes in the healthcare setting to help improve patient’s
quality of care (Taylor et al., 2014 and Donnelly and Kirk, 2015). A study conducted by
Sangpikul (2017)specified that the PDSA cycle provides an experimental learning method to
examine the ideas for improvement before addressing the changes in the healthcare setting. It
indicates that continuous development and learning to analyse whether the idea is effective and
apply appropriate changes if needed to maintain the chosen idea for improvement. The model of
the PDSA cycle is comprised of four stages, including planning, testing the preferred solution,
studying the results, and lastly implementing the changes if the solution is successful
(Chandrakanth, 2016). According to Gage (2013), the process of change is safer for patients
using the PDSA cycle as it enables to continuously evaluate the changes throughout the stages to
address and identify any problems that may occur. The method is perceived as an easy and
simple approach to undergo. However, Reed and Card (2015) specified that it requires
knowledge and leadership skills to solve the problems and help to make changes for service
improvement.

Six Sigma: DMAIC

Six Sigma DMAIC is another service improvement approach which focuses on evaluating a
process that improves services quality and patients satisfactory through reducing cost, waste, and
developing efficiency (Knapp, 2015). Even though this method was initially established in
manufacturing, it is widely applied and successfully adapted within the healthcare setting, such
as improved medication dispensing time and quality of care lead to patient satisfaction. (Arafehet
al., 2018) Moreover, DMAIC is a framework that uses five stages are Define, Measure, Analyse,
Improve and Control to identify and reduce problems in the process (see appendix 2) ( Ahmed,
Manaf and Islam, 2013; Morgan and Brenigh-Jones, 2016) According to Linderman et al., (2003
citied in Vijay, 2014) identified that DMAIC is a framework that provides a systematic approach
to the process of improvement. Therefore, the author decided to apply the DMAIC service
improvement methodology beside using Lean principles as it can help to address and identity
problems regarding the project topic of reducing delay hospital discharge to provide a high
quality of care that will lead to improved services, less financial cost and better patients
satisfactory.

Applying Six Sigma: DMAIC methodology.

DEFINE
The first stage of the DMAIC cycle is identifying the problem and what needs to be improved
while underlying the project objective and include staff members that are involved in delivering
the service.
The problem was acknowledged as patients were not discharged in a timely manner. It was
evident in clinical placement as observed by the author as there were recurrent delays in
discharging patients because of several situations such as transport, in taking out (TTO’s) and
awaiting referrals. However, TTO’s was observed the most cause of delays in discharge that
occur for those patients who does not require transport. Therefore, this problem also causes
someone who is MFFD still occupies delay of admission for a new patient as the bed space.
Furthermore, delay in discharge caused stress due to staff being pressured to discharge patient
quickly for new patients, and this led to some patients having to wait in the day room or leave
without TTO’s to be picked up the next day as seen by the author in clinical placement. The
project objective is to reduce patient delay discharge by ensuring all things are with the patients
before the discharge time or day.

MEASUREMENT –
The next phase of the DMAIC cycle involves taking a measurement and collecting data
regarding the problem that has been recognised before implementing any approach (Nandi et al.,
2014). Measuring and collecting data is an essential part in quality improvement as it helps to
acknowledge the performance of how well the care is facilitated and create a judgement on how
to implement improvement in the healthcare setting ( Health Resources and Services
Administration, 2011 and Amar, 2019). According to Grol et al., (2013) project requires relevant
baseline data for comparison between the current and future implementation of the process to
regulate if there are changes.

Data collection happens pre and posts implementing a change. Information will be collected
through various methods such as taking part in a multidisciplinary team (MDT) meeting to
identify and record patients who will be discharged from the ward and those who experienced
delays discharge due to various reason. This will be measured five days a week over four weeks
as MDT occurs during weekdays (Monday to Friday). Another method of measuring patient
delay discharge is through asking staff to identify the most common cause of delays in the ward
that will help to determine the area of discharge process requires improvement. Additionally,
liaising with the discharge coordinator to figure out the amount of delay discharge pre and post
implementing a solution. All the information obtained will be gathered weekly that can be
applied in table form to measure and identify the frequency of the problem occurring and
understand the reason behind. Furthermore, a study conducted by Curcin et al., (2014)
emphasised that continuous collection of data is vital to achieving changes to improve in
healthcare.

Analyse

Analysing data is the third phase in DMAIC framework that helps to identify the root cause of
the problem and understanding why, for a better possible approach towards the problem (Mogan
and Brenig-Jones, 2016). There are various causes that contributed to influence delay in patient’s
discharge that was observed by the author in the clinical placement. However, the main reason
for delays that was observed were, respectively, waiting for medication to take out (TTO’s) was
witnessed the most in the busy ward that lead to patient’s delayed discharge as TTO’s were not
in the ward at the time of discharge. Secondly, the author also observed that patient who is in
need of social services cause delays due to awaiting package of care that causes discharge date to
be pushed back. This, consequently, affected new patients to have the bed space as it’s still
occupied by patients deemed MFFD and causes pressure to nurse to quickly remove patients
from the bay which can affect patient satisfaction.
Effective communication is essential in making changes regarding the problem process (Cook,
2018). It is crucial that approval from the ward manager/sister is gained through a face to face
meeting and email before recommending the proposal to be put as a method.

IMPROVE

The fourth phase of DMAIC approach is ‘improvement’ involves gathering several solutions that
focus on the problem and determine the best solution to implement to help tackle the uncovered
problem that will improve patient safety and quality (Morganand and Brenig-Jones, 2016). To
improve delays in hospital discharge and quality of care delivered, therefore, three possible
solutions have been addressed to develop an approach for the problem.

Solution 1: Colour coding (Red, Yellow, Green) discharge tool sign with estimated
discharge date.

The second solution is colour coded discharge sign/label which includes estimated discharge date
that can be stuck to patient’s identification board on the nursing station or by the patient’s
bedside (see appendix..). Each colour identifies the patient’s possibility of being discharged in
the week such as unlikely is signposted by red label, probably yellow label and green indicate of
being discharged. This intervention of identifying patients like the hood of being discharge will
help staff to prioritise patient discharge and indicate to start the discharge to prevent any delays.
However, a concern is that it can cause a high level of curiosity from patients and relatives
visiting as they might ask what colour labels to means/indicate if it located by the patient
bedside. Therefore, this solution is eliminated due to the accuracy of the colour coded depends
on the daily work flow as ward can get very busy that it may not be updated to indicate a change
in patient probability of being discharge.
Solution 2 : Discharge checklist tool

The second solution was to create a discharge checklist tool which indicates events that should
be done prior to or on the day of discharge for patient who are medically fit for discharge (
appendix ..) the checklist is to be printed out for patient who has been declared fit to go home by
the doctors for nurses to see what has or not been completed regarding the patients discharge.
Once printed, it should be placed on the first page of the patient’s bedside folder easy access for
nurses. Therefore, this tool will inform staff tasks that are done and by whom in addition to tasks
that need to be done before patients leave the hospital for safe discharge and prevent delays.

Solution 3: Discharge board.

The third solution was a discharge board needs section to be included in the patient identification
board in the nurse’s station, which indicates what the patient needs before discharge (See
appendix…). The discharge board is located in the nurse station means that all the staff can see
what needs to be completed for the patients who are medically fit for discharge. Identifying that
the patient is MFFD and its discharge need such as TTO’s, and transport will help to reduce
delay in discharge due to waiting for medications to take out. However, this option can be time-
consuming as going towards the nurse station just to indicate one of the discharge needs has been
done for a patient also the ward gets busy throughout the day. Therefore, this solution is
eliminated.

The chosen solution

Regarding this project, the selected solution that would benefit the staff and patient satisfaction is
adapting to solution 2 (See appendix..). The use of printed “discharge checklist tool” is a possible
approach in comparison to other solution. This solution was selected due to it being practical,
does not cost a lot of money and easy to implement. However, there might be a conflict
facilitating this solution, as it will be additional paperwork for the staff to complete, but the
proposed solution will help to minimise delays in discharging patients. Moreover, it enables staff
to work efficiently and promote effective communication between staff members regarding
events that need to be completed and signed they had done before or on the day before the
patients get a discharge. Furthermore, it is only required when the patient is declared medically
fit for discharge by the doctors and on the day prior to the patient being discharged to help
prevent delays.
Several studies suggest that implementing a discharge checklist is an effective approach that not
just prevent delays but also facilitate safe hospital discharge (Soong et al., 2013; Gilliam et al.,
2017 and Rochester et al., 2018)

A post-process map has been produced to demonstrates how the process of change will be
achieved when the chosen solution is implemented (see appendix 4)

POST measurement

Evaluating the effectiveness of the recommended improvement solution would need to be

measured, which is vital to determine whether the chosen solution cause improvement or not
regarding the problem (Brewster et al., 2015). Therefore, the pre-measurement method that was
used before implementing the changes will be used to assess for post-measurements. The
decision to implement or decline the solution depend on the result of measurement after applying
the solution.

CONTROL

Control is the last phase of the DMAIC framework which focuses on ensuring improvement is
well maintained through feedback communicated from the stakeholders regarding the project
approach to construct the desired outcomes (Arafehet al., 2018). Continuously evaluating will
help to ensure that the solution is working and well managed. Furthermore, Mitchel (2013)
highlighted that healthcare changing is a fundamental part of nursing that is beneficial in
practice. Nevertheless, effective leadership skill is required and essential part to facilitate
positive changes in the healthcare setting that will guide staff member to continue carrying out
the goals and objective of the process solution (Hao and Yazdanifard, 2015)

SUSTAINING CHANGE

In relation to this service improvement project to sustain the changes is through audits, which
can occur at the end of every month. This can be done by auditing the number of patients who
experienced delay discharge regardless of what caused it to happen. By doing this will help to
recognise the strength and weakness of the discharge checklist tool and justify whether the
solution improved the problem or not.

Stakeholders

Graham and Portny (2015) indicated that stakeholders are a person who maybe is affected by
implementing or supporting the changes. Huotari (2016) states the importance of involving,
communicating and working collaboratively with stakeholders as they provide support by
communicating any specific project needs, and it enables to deliver a high quality of care for
patients. In this service improvement project, the stakeholders will consist of nurses, ward sister,
consultant, junior doctor, patients, and their families.

Conclusion

In conclusion, service improvement is essential in providing a high quality of care and improving
patient safety and satisfaction. The author identified an area in clinical practice that reveals a
problem which needs improvement as it can affect the people negatively. The DMAIC service
improvement method has been applied to understand in greater depth the root cause of the
problems and implementing a new idea. Discharge checklist tool has been selected as a proposed
solution due easy to use, straight forward, and cost-effective. It is to prevent delays in discharge.