Biography
Biography: Laura Porro
Abstract
Statement of the Problem: North West London (NWL) has seen its demand on local services outstrip funding the past few years.
This led to variations in the accessibility and quality of care, duplication and inefficiencies in a fragmented commissioning landscape.
The project aimed at delivering a programme of systemic change, joint-funded by the local CCGs.
Methodology: We rolled out a single hospital discharge function across NWL, focused on improving patients’ outcomes and
experience, and reducing capacity pressures on local acute services. We mapped existing discharge processes, co-designed new
shared policies and protocols and co-located discharge teams at key hospital sites, implementing the ‘early identification’ model. We
supported the development of a shared IT process, to allow quick and accurate transfer of patient information. We co-designed a new
model of hospital discharge, tailored to suit each locality, which includes the new role of the key discharge worker. Social workers
are allocated to specific wards and attend their multi-disciplinary teams, which mean patients’ assessment is holistic from admission
through to discharge. We supported staff through the change with a bespoke training programme, focusing on the soft skills needed
to work collaboratively and effectively across professional and organizational boundaries, as well as across seniority levels. We made
these programme sustainable thanks to an effective handover to a cohort of internal facilitators, who can deliver the training again
in the future.
Conclusion & Significance: We engaged with over 200 staff and managers across eight organizations throughout design and
implementation process. We standardized over 100 existing and varying processes into four clearly defined pathways and one set
of principles for the choice policy. The evaluation shows that delayed transfers of care figures have almost halved since the launch
in Match 2016. Other outcomes include a 5-10% decrease in referrals into higher levels of care; improved patients’ experience of
discharge; and reduced length of stay.