'A hospital bed is a parked taxi with the meter running,' Groucho Marx once said.
The only difference in the UK is that the NHS, not the patient, foots the bill. It is estimated that each day a patient spends in hospital costs the NHS between £200 and £250.
But money is only part of the problem of a delayed patient journey. The longer treatment takes, the more prone a patient will become to complications such as infection or loss of mobility.
More importantly, the longer the delay in discharge, the longer the next patient must wait for their treatment to begin. Thus, discharge planning has a huge impact on waiting times.
To tackle waiting times, the Department of Health has set its 18-week patient pathway target.
By the end of 2008, no patient should be waiting longer than 18 weeks from GP referral to start of treatment.
For a large teaching organisation such as King’s College Hospital NHS Foundation Trust in London, this is a tough target to meet.
'We knew we had to reduce length of stay’
In 2005, patients at the trust had a 25% chance of their elective surgery being cancelled after pre-admission; half of patients were waiting more than 40 weeks for treatment, and patients ready for discharge could experience delays of hours or sometimes even several days.
This situation was one shared by many trusts around the UK.
Meeting the 18-week target: project outline
To help the trust modernise and streamline services in order to meet targets like the 18-week patient pathway, the King’s First Choice Organisational Transformation Programme was launched in 2005.
Critical care and surgery were among the first care groups in the trust to participate in the project.
'We wanted a really practical solution to help patients, nurses, doctors and AHPs know where patients were at any given time in their hospital journey,' says Zoe Packman, head of nursing for critical care & surgery.
'We knew we had to get better and that we had to reduce length of stay,’ she said.
'We looked at the time of patients' discharge and set a goal of 11am. For transfers from HDU and ICU, we set a goal of 3pm.'
This was quite a challenge considering that, at the time, 94% of patients being discharged were going home in the late afternoon and many transfers were taking place between 6 and 7pm.
However, two years on, average length of stay has been reduced from 3.6 days to 2.9 days (a 23% improvement), and 80% of patients for discharge now go home before midday.
In addition, transfers from HDU and ITU are happening before 3pm. 'Now if patients are not transferred before 3pm it is not because of a lack of beds but for a medical reason,' Ms Packman insists.
'We wanted to work towards having all elective patients admitted on their day of surgery, and now we have. We have only got to this point because our discharge planning is so successful that we can feel confident about bringing patients in,' she says.
So what is it that has changed over the last two years? A budget increase? A bigger discharge planning team? More beds?
Visual management system the key to improvement
In fact, all improvements have been achieved via a simple visual management system consisting of information boards above each patient's bed and at the nurses' station.
The boards use a 'traffic light' system of coloured dots to denote where a patient is in their journey; that is, how close they are to their planned discharge date.
The 'bed boards' also display the patient's name and consultant.
The 'big board' at the nurses' station also displays information under four categories:
• Patient satisfaction
• Financial & operational efficiency
• Staff development
Ms Packman says that this has created a visual reminder of discharge planning. To solidify this, team briefings have also been introduced at the start and end of each shift, taking place in addition to handover.
These briefings consist of a five-minute discussion, led by the nurse in charge.
The team stands by the big board and discusses what worked well during the last shift, what didn't, and what the team needs to do to meet the targets on the board.
'The briefings differ from handover as they are not about clinical information, but all the other elements that are important to keep things moving for the patient journey,' explains Phil Steen, matron in surgery.
'There is also a debrief halfway through the day, particularly if staff are really busy, to provide a 'refresher' and a moment to take stock,' she said.
Improving inter-departmental communication has also been vital, including making the nurse handover a multidisciplinary affair. 'Everyone is at handover at 7.30am including the OTs and physios,’ she added.
‘It is like the Holiday Inn. Staff know that 11am is checkout time’
‘This means there is no breakdown in communication: everybody hears it, everyone is there. This continuity of communication has been very beneficial,' she admits.
Getting staff uptake
Ms Steen adds that the simplicity of the system has been key in staff uptake. 'Any nurse can come on duty and see where each patient is in their journey.
‘A nurse changes the boards every morning and in fact, the patients themselves also make sure it is up to date. It has become like clockwork – people do it now without thinking,' she says.
'It is like the Holiday Inn,' adds Ms Packman. 'Staff know that 11am is 'checkout time'. This has prevented the afternoon rush that existed before, with staff trying to finish their admissions at the end of their shift. Patients know what is going on now and everyone is telling them the same things.'
'Paediatrics now have bed boards and the liver care group have duplicated both systems. 'It shows it is a replicable system'
The trust held a celebration day on 8 October 2007 to mark the successes of the First Choice project, including the visual management system.
But the real mark of the system's success is how other care groups have picked up on what is being done.
'Paediatrics now have bed boards and the liver care group have duplicated both systems. It shows it is a replicable system,' says Ms Packman.
Each care group has adapted the system to suit their own requirements.
For example, paediatrics must display patients' first names only on the bed boards and the liver care group have adjusted the time of discharge.
'It has had a huge impact in terms of team-building and working together,' says Ms Packman. 'The length of stay has been reduced and staff know they have been part of it and can own the achievement. Above all, it means we are treating more patients.'
THE VISUAL MANAGEMENT SYSTEM - SHORTENING PATIENT STAY
• Critical care and surgical staff at King's College Hospital NHS Foundation Trust have reduced patients' average length of stay by 25%
• Over 90% of patients for discharge go home before midday
• Transfers from HDU and ITU are usually completed before 3pm
• All elective patients are admitted on their procedure day, rather than the day before
• The system consists of information 'bed boards' above patients' beds and one 'big board' at the nurses' station, as well as twice-daily team briefings and a multidisciplinary morning handover.
THE BOARD SYSTEM
The bed boards detail name, consultant and status defined by a colour:
• White – ongoing
• Blue – theatre
• Green - ready for discharge
• Yellow - day before discharge
• Red - discharge is delayed
The big board displayed in the nursing station with magnetic coloured dots replicates information on each patient’s status, plus performance information under four categories:
Q – Quality: quality ward round score (what the ward has achieved)
P – Patients: the trust's patient survey results
F – Financial and operational efficiency
S – Staff development: training and skills progression