Assess readiness
In healthcare, where change fatigue is common due to numerous competing priorities, assessing environmental readiness is crucial for successful change management. A readiness assessment (see Appendix 6) can help teams prepare and create action plans for effective CLD implementation (ACI 2016
Create a team to champion change
Establishing a team to support the change is essential for success. This includes establishing clear decision-making processes and escalation pathways if any issues occur within the project. Securing financial and professional support is crucial for ensuring the required levels of staffing and resources needed for implementation are met. Engagement and Sponsorship at all levels is essential (Implementation Management Associates Inc 2008). Health services who have implemented CLD recommend including the following people:
| Steering Committee- Monthly meetings | Improvement team – Weekly meetings |
|---|---|
Executive sponsor
| Project lead
|
Clinical lead
| Multidisciplinary team
|
Area leaders
| Quality improvement support
|
Other members to consider for steering committee or improvement team depending on local needs:
- IT eg: electronic medical record (EMR) administrator to support the integration into EMR
- Data expert, support the team in collecting and analysing data
- Policy or forms owners/administrators. To support the required changes to policy and documentation
Appendix 7 provides an example terms of reference and Appendix includes business case tips and tricks to gain executive support
Understanding current state
To successfully introduce CLD, the first step is to understand your current state from different perspectives, the opportunities for change and to prioritise which procedures or patients are most suitable. A gap analysis (including process mapping and collecting baseline data) will help paint a picture of the current state and enable the team to identify areas for improvement. Appendix 9 provides a gap analysis template that can help your team conduct a gap analysis, plan and prioritise change ideas.
Process design
Integration with the usual discharge process is essential for long-term sustainability of CLD.
The CLD process will involve elements of the usual discharge process including:
- Patient information and involvement in their discharge planning.
- Estimated Discharge Date (EDD), including regular review of progress towards the EDD throughout the admission and adjusting as required.
- Completing all discharge documentation.
- Ordering discharge medications, ensuring they are adjusted and validated by a pharmacist.
- Confirming the correct details of the patient’s GP to ensure the discharge summaries are sent to the right person.
- Completing the discharge summary for the patient’s GP or other care provider in a timely manner ideally on discharge or within 48hrs; arranging follow-up, including outpatient appointments and further investigations.
- Arranging referrals and ongoing care at home or intermediate care
(NHS 2019b)
As you introduce CLD you may find you need to review some of the usual discharge practices to ensure they are efficient to support CLD. These improvements may also help streamline discharge processes for patients who are not deemed suitable for CLD.
Test changes
Testing is crucial for sustainable improvement as it allows for gradual adjustments based on real-time feedback, leading to refined processes and documentation over time.
- Start small: Test new processes on one ward, patient cohort, individual patient or specific procedure.
- Test and refine processes using, Plan, Do, Study, Act (PDSA) cycles to test changes systematically ensuring that new processes are effective. Demonstrating the success of CLD through PDSA cycles fosters belief and commitment among the Multidisciplinary Team.
Implementation scale and spread
Once you have tested changes and are happy changes are producing the desired outcomes it is time to make the changes business as usual.
- Have steering committee sign-off for formal implementation and scale of successful changes.
- Update local protocols to include new CLD processes.
- Spread CLD to other areas, little by little, using data and the story of your improvement to get others onboard.
- Celebrate your successes and keep momentum going. Tell others about what you are doing and spread the word of CLD.
Appendix 10 contains an introducing of CLD into your local area checklist with a step-by-step guide including tools and resources.
Assess outcomes
Monitoring and evaluation play a vital role in quality improvement initiatives. Collecting and monitoring data is essential to ensure that any change leads to improvement, and that these improvements are sustained while achieving the desired outcomes. Collecting baseline data is essential to accurately evaluate and measure change (ACI 2016). Alongside the family of measures, it is also important to collect demographic data such as gender and cultural background e.g. Aboriginal or Torres strait islander or CALD (culturally and linguistically diverse), to ensure health interventions are equitable. It allows health providers and policymakers to identify and address disparities that certain groups may face, ensuring that healthcare services are accessible and tailored to diverse needs. Appendix 11 provides a detailed measurement framework including measurement definitions and collection tips.
CLD recommended Family of Measures
Essential measures
| Outcome | Process | Balancing/check |
| Length of stay | % of patients discharged using CLD | Readmissions to hospital by any avenue (e.g. Via ED, direct admit, outpatients) at 48hrs and 28 days |
| Consumer experience (see example questions) | Representations to ED and why at 48hrs and 28 days | |
| Staff experience (for example questions) |
Optional measures: choose measures that are relevant to your local aim and objectives
| Outcome | Process | Balancing/check |
| Time of discharge (with the view of increasing to pre-10am discharges or pre-midday discharges) | Estimated date of discharge recorded in agreed place | % of patients who have a completed discharge summary on discharge or within 48hrs of discharge |
| Number or percentage of weekend discharges/transfers | GP satisfaction with information provided within the discharge summary and timeliness or receipt of discharge summary | |
| Other process measures defined by local health services/sites to measure the effectiveness of new processes |
Example staff experience questions
| No. | Question | Answer |
| 1 | I would feel safe being treated (at my hospital) as a patient using criteria led discharge | Agree Strongly Agree Slightly Neutral Disagree Slightly Disagree Strongly |
| 2 | I involve the patient/family in developing a care plan | |
| 3 | I update a patient’s estimated date of discharge on admission and throughout the hospital stay | |
| 4 | I know the proper channels to escalate concerns about a discharge plan | |
| 5 | I safely communicate the patient criteria-led discharge plan using the appropriate documentation | |
| 6 | I have the support and resources I need to safely discharge my patient using Criteria-led discharge |
Example consumer experience questions Adapted from ACI 2016
| No. | Question | Answer |
| Admission | ||
| 1 | I know the date I am expected to be discharge from hospital | Yes/Unsure/No |
| 2 | I am aware of the criteria I need to meet before I am discharged from hospital | |
| 3 | I know who to ask if I have questions about my plan of care | Always Mostly Sometimes Rarely Never |
| Discharge | ||
| 4 | I received daily updates about my progress (for multi day patients) | Always Mostly Sometimes Rarely Never |
| 5 | I was involved in the development of my discharge plan | |
| 6 | I know when and where I need to attend for further follow up | Yes/Unsure/No |
| 7 | I understand my medication plan e.g., knowing what medications to take and for how long | |
| 8 | I know what changes were made to my previous medications e.g. medications stopped or a dose changed | |
| Follow-up after discharge | ||
| 9 | I was readmitted to hospital for a complication or concern | Yes/Unsure/No |
| 10 | I presented to an emergency department for a complication or a concern | |
| 11 | I had to see my GP urgently after I was discharged for a complication or concern | |
| 12 | I was satisfied with my criteria led discharge experience | |
These are sample questions. Select questions that match existing patient surveys and organisational needs. Also consider a free text section for qualitative data e.g other comments
Reviewed 01 November 2024