Streamlining the patient discharge experience : a multidisciplinary approach using an improvement science framework

An exploration of hospital discharge planning from the viewpoint of a multidisciplinary team (MDT) working in an interdisciplinary manner is presented in this thesis. Differing perspectives regarding discharge planning are unpacked from registered nurses, visiting medical officers (VMOs), physiotherapists and occupational therapists. These clinicians provide an in depth understanding of the factors affecting the MDT working collaboratively to improve preparing patients for discharge home (Jeffers 2021). The uniqueness of the research stems from using an Improvement Science Framework to explore and answer the research question: How can the MDT work collaboratively to streamline patients discharge in a private hospital? The research provides an example of nurses taking the lead to facilitate and conduct quality improvement research as indicated by Flynn et al. (2017). The impetus for the research came from the study hospital's Press Ganey Patient Experience Surveys which demonstrated a decline in patient satisfaction with the discharge planning process, predominantly linked to; (i) instructions regarding care at home (ii) help arranging home care services and (iii) preparation for discharge throughout patients stay. The research is based on the premise that the MDT coordinate, collaborate and communicate effectively to address as many aspects of care as possible to provide the best discharge experience for patients. The circumstances of patients can change at any time so flexibility of the MDT when approaching patients care is vital. Previous research suggests the discharge experience of patients is impacted negatively when the MDT fail to collaborate effectively to meet their discharge planning needs (Armor, Wight & Carter 2016; Flacker, Park & Sims 2007; Nosbusch, Weiss & Bobay 2011; Oh 2017; Okoniewska et al. 2015; Olson & Bialocerkowski 2014). To examine which factors, inhibit the MDT working collaboratively to streamline patients discharge a two-phase study was adopted. The Exploratory Phase and the Improvement Phase provided the best opportunity to address the research question methodically and systematically. A mixed-methods study design was adopted underpinned by an Improvement Science Framework, utilising Plan-Do-Study-Act (PDSA) cycles (Langley et al. 2009). Qualitative and quantitative data were obtained through surveys, a focus group and PDSA cycles. Descriptive statistics (Cohen, Manion & Morrison 2017) were used to analyse the quantitative data and thematic analysis (Braun, Clarke & Rance 2014; Joffe 2012; Riger & Sigurvinsdottir 2016) was used to analyse the qualitative data. This research was approved by the Tasmania Human Research Ethics Committee and a clear governance structure was put in place to assist with mitigating risk and to ensure that the most appropriate people were available to support the research. The project governance consisted of a Guidance Team, Project Team, and the Multidisciplinary Team (MDT) and were purposely recruited. Four themes were derived from the data obtained from the online survey and focus group and these were: communication breakdown, discharge date, medication list, and resources. The theme communication breakdown‚ÄövÑvp involves the MDT not providing timely and appropriate written and verbal information to each other, to patients and their family/carer, and to GP's. The theme discharge date‚ÄövÑvp relates to a lack of documentation and minimal discussion of estimated discharge dates with patients by the MDT. The theme medication list‚ÄövÑvp involved issues relating to documenting of discharge medications in an appropriate timeframe and format. The theme resources‚ÄövÑvp was derived from the MDT identifying a lack of supplies and hospital processes which impacted their efficiency. The MDT expressed that a lack of education and poor understanding of the discharge planning process impacted their ability to work collaboratively to streamline patients discharge effectively. Furthermore, hierarchical, and occupational boundaries were found to impede their clinical practice. For example, the RNs and physiotherapists perceived that the action of preparing patients for discharge home was beyond their control. Hence they were unable to optimise the discharge process for patients. The factors that contributed to placing the RNs and physiotherapists into this vulnerable postion include the actions of VMOs, the activities of patients and hospital processes. For example, to involve the discharge planning team to assist with the discharge preparation of complex patients, members of the MDT had to seek permission from VMOs prior to making a referral. The Project Team focused on strategies to enhance communication using a communication board as a tool and these were developed over five PDSA cycles. The communication board facilitated a discussion about discharge planning between the MDT and patients and their family and/or carer regarding decisions about patients discharge plans. This in turn was found to influence patient outcomes and empower the MDT to create an environment of quality improvement that linked to everyday clinical practice. The findings validate the need to continue to focus on rigorous methods that create MDT improvements in clinical practice and patient safety related to discharge planning. A key recommendation is that prior to initiating quality improvement research in healthcare solid partnerships between MDTs, academics and consumers are established. This step will assist to breakdown silos and promote mutual respect and equilibrium. It is recommended that hospitals implement discharge protocols and policies to support MDTs in the discharge planning process. Policies and protocols must clearly define roles for MDTs so that there is no ambiguity around decision-making around streamlining patients discharge. Exploration of the efficacy of the information captured on the communication board by the MDT is recommended as the MDT did not capture all discharge planning information required. Finally, an evaluation of the MDT using teach back techniques with patients, as well as the study hospital's Planning for Your Discharge‚ÄövÑvp tool when preparing patients for discharge home. A focus on the MDT using the tool will provide an opportunity to test the effectiveness of the MDT teaching skills and the validity and reliability of the hospital's discharge tool. This research has contributed to creating new knowledge using an Improvement Science Framework. Establishing authentic partnerships to design, undertake and interpret improvement science research focused on MDTs working collaboratively to streamline patients discharge is crucial. Consideration of how each professional role interacts will provide the foundations to promote cohesiveness and accountability by the MDT when preparing patients for discharge.