Delivering sustainable discharge and flow improvements across East Surrey

Implementing a new discharge operating model across an acute hospital that puts the patient at the centre of decision making, founded in behaviour and culture change.

November 2022 – August 2023

beds saved through length-of-stay reductions

fewer patients residing in hospital for 14+ days per week

39%

fewer patients discharged to long-term placements

Identifying new opportunities to improve outcomes and save money

East Surrey Hospital, part of Surrey and Sussex Healthcare NHS Trust (SASH) is one of the major acute providers in both Surrey and Sussex. Its geographical location results in the added complexity of serving two systems and being the recipient of a significantly high number of emergency care ambulances. Such pressures, along with those faced across the country, resulted in more patients staying in the hospital longer, which put extra strain on the emergency department and frontline staff across the hospital.

Following an initial commission from Surrey County Council in November 2022, SASH and East Surrey Place commissioned IMPOWER to provide discharge and flow support in East Surrey, and deliver better outcomes that cost less. The work focused on ensuring patients are discharged in a safe and timely way with the right care and support that maximises their independence, reducing avoidable pressure and costs to health and social care – improving patient outcomes.

With health and care partners, we implemented our Theory of Change to enable frontline staff on acute hospital wards to bring greater clarity and consistency to patient journeys that brought significant improvements for patients. This was delivered via a hospital-wide improvement programme called Let’s Get You Home.

Let’s Get You Home focuses on tackling barriers to safe and timely discharges by optimising behaviours and processes to achieve the system’s new inclusive ambition of good hospital discharge. A range of interventions were included in Let’s Get You Home to help reduce length of stay and improve patient outcomes, including:

Standardised ward work, including ward and board rounds, and embedding national best practice, criteria to reside and SAFER standards
New high-quality, accessible information for patients and carers upon admission to enable them to make informed decisions about their discharge
Integrating social workers onto wards
System standards for Pathway 0, 1, 2 and 3 to be incorporated into targeted discharge dates agreed to by all partners
Let’s Get You Home Policy providing a fair and consistent approach to managing patient choice
Executive sponsors allocated to each ward to provide additional support and rapid resolution to discharge delays

Creating confidence in seizing these opportunities

After a rapid diagnostic of the hospital’s discharge and flow systems, behaviours, and processes, we quickly began trials on three wards to deliver impact and create real confidence in seizing the opportunity for better patient and hospital outcomes.

The team worked closely with frontline staff, including doctors, nurses, therapists, discharge coordinators and social workers to implement a range of interventions that would reduce the time patients spent in hospital once they no longer required acute care.

In two assessment units, we trialled the use of criteria to reside, targeted discharge dates, new board round structures and afternoon discharge huddles to discharge more patients per day and increase flow through from the emergency department.

On the Acute Medical Unit, average daily discharges out of hospital increased by 75%, representing an additional three people per day.
On the older persons assessment unit, there was a 36% increase in average weekly discharges out of hospital, representing an additional four people per week.

The team also supported the set up of a new intermediate care ward on the acute site, working with frontline staff, hospital and social care leaders to determine the optimum operating model, culture and behaviours required to best support patients, and enable safe and timely discharges.

IMPOWER quickly facilitated the integration of social workers onto the ward to support the reduction of patients being discharged to residential and nursing care and maximising patient independence. Within a few months, the newly integrated team, using strengths-based multi-disciplinary team meetings, taking a social care and therapy-led model, reduced discharges to long-term placements by 42%, which led to more people being discharged home and doubled the number of weekly discharges from seven to 14.

These successful pilots, alongside significant engagement with health and social care partners, instilled confidence in the hospital and wider system to design and launch the hospital-wide programme to improve patient outcomes and reduce length of stay – Let’s Get You Home.

Impact

The Let’s Get You Home programme launched in April. Improvement was evidenced within the first month and, by August, there was evidence of continued and sustainable improvement across the patient journey that delivered tangible benefits for the hospital, local authority and wider system. This included:

Better outcomes for people:

32% reduction in patients spending 14+ or 21+ days in hospital
88% increase in discharges home (on Pathway 1) rather than to bedded care (on Pathway 3)

Better outcomes for the acute:

16% increase in ambulance handovers in 30 minutes (to 96%) and a 13% rise in emergency dept 4-hour performance (to 74%)
Length of stay reduction of half a day across non-elective care equivalent to 21,245 annual bed days. That translates to caring for the same number of patients with 58 fewer non-elective beds (equivalent to 2 wards) a year, or maintaining the same number of beds and caring for an additional 3,744 inpatients annually
42% reduction in bed occupancy by those who do not meet criteria to reside, improving the Trust’s national position from third to first quartile on this metric.

Better outcomes for the council:

44% fall in referrals to the hospital adult social care team
39% reduction in discharges to long-term placements (Pathway 3)

Better outcomes for the place:

Better use of the care market, resources and intelligence
Aligned ambition across integrated care systems
Greater confidence in commissioning the right Discharge to Assess services based on local need

Creating a more resilient client organisation

Critical to the success of our work in East Surrey was the unwavering commitment to improving outcomes for patients as a partnership by all of those working at the frontline and system leaders.

Long-term change requires a focus on behaviour and culture. We embedded a Let’s Get You Home accreditation scheme that allocated Gold, Silver or Bronze to each ward depending on their implementation of the behaviours and interventions, and regularly reviewed this with them and their Executive Sponsor to maintain momentum.

The accreditation scheme highlights how quickly and successfully the LGYH approach has been embedded. In May, 12% of wards were gold, 80% silver and 8% bronze following the launch of LGYH. By August, 44% were gold and 56%, silver with no bronze wards. This has set the foundation for the Trust, and wider system, to confront future pressures with confidence and togetherness.