Foundation trust adopts E-discharge standard
Cambridge University Hospitals Foundation NHS Trust is a global digital exemplar and early adopter for the use of the Professional Record Standards Body headings in their electronic discharge summaries. They have worked with the PRSB to embed the national standards in their inpatient and day-case units and plan to do the same for their emergency department patients.
The Trust has been implementing a new IT system and decided adopting the PRSB standards at the same time made sense so they have formed part of the whole digital change programme in the Trust. They believed that digitisation would improve quality, safety and efficiency of care and support integrated care through better information sharing in real time with GP and other partners. The trust started embedding use of the standards in inpatient areas and day-case units. They plan to do the same shortly for Emergency Department patients with the emergency care discharge summary standard.
A key success factor was having the commitment and support of senior leadership. Their Chief Executive, Medical Director and Director of Nursing gave their full support. This included making time and resources available, making engagement with training and learning a requirement for all staff and ensuring that, while listening to staff who had concerns, they had someone to refer to with any problems they had.
While the full impact of the new standards cannot be assessed properly yet, some of the benefits found include:
staff are saving significant amounts of time because records are readily available electronically and they spend about the same amount of time completing discharges.
Documentation is now consistently more standardised than before, so helping to avoid errors
GP colleagues are able to process the documents more effectively
Before the Introduction of the PRSB headings
The discharge summary using the historical system pre-2014 had no pre-populated fields and staff had to type more information than now but had fewer tasks to complete.
After the Introduction of the PRSB Headings
Some people complained about additional time taken to complete the record using the headings. However, the headings make sense and quickly became established practice. Once staff learned the new system they were able to complete the summaries in about the same time as before. Some of the information is pre- populated as well.
Based on a simple audit, junior doctors at Addenbrooke’s estimate it takes 3-4 minutes to fill in an e-discharge summary for a day case admission and a bit longer for a routine surgical admission (7 minutes) or a general medical admission (9 minutes). The question is perhaps more along the lines of, “How long should it take to complete a good discharge summary?” It may be that it takes people longer initially because previously they weren’t supplying a sufficient amount of information.
Although it was time-consuming, throughout the implementation, members of the project team spoke directly to every single clinical and administration team and department on numerous occasions, and in each area we identified local leads to work closely with us by helping to encourage involvement in development locally. As is true with all change projects, face to face communication with those involved is absolutely key.
We are using the same approach we took with delivering a new IT system to embedding the PRSB standards, deploying our leaders and local teams to explain the benefits of using the standards and we are talking about how they will make care safer, improve patients’ experience and help us work more effectively.
For clinical, financial and organisational reasons adopting the PRSB standards is the right thing to do. We are also reminding people that the record standards were developed by our peers through expert reference groups and agreed by all the medical royal colleges.
Understanding what local GPs want and need has been central to the Trust’s development of its electronic patient record and discharge summaries. The Trust appointed a Primary Care Liaison Manager and she has regularly visited the local practices, listening to their feedback, resolving queries and complaints, and sharing information, to build effective working relationships.
This has stood the Trust in good stead for its current work on refining the electronic record it uses and implementing the records standards, including e-discharge summary headings. Working with the Clinical Interface Group made up of Trust, CCG and GP representatives, two mock-up templates were designed and tested with a group of 12 GPs, and their feedback led to a revised template being agreed. This process of continual testing and review ensures that all parties are aware not only of the context for change, but also what compromise or improvement is possible and why.
Benefits and Business Case Justification
The full impact of the new standards cannot be assessed properly yet, but the Trust is confident that it is saving staff significant amounts of time, and errors avoided will be significant. The use of the agreed standard headings ensures that key information is captured reliably and is easily accessible. It estimates already that it avoided 8,500 medication issues (such as potential allergic reactions) and saved between 2,500 and 3,500 bed days in the first 18 months.
Challenges and Lessons Learned
As with many NHS organisations there was some resistance to change with the need to give up old IT systems that had been developed over time and which worked with varying degrees of success for them, however, the project knew that for the Trust to achieve this goal, they would need to bring people together and explain the clinical and other benefits, whilst at the same time recognising that the change itself would be incredibly disruptive.
Although it was time-consuming, throughout the implementation, members of the project team spoke directly to every single clinical and administration team and department on numerous occasions, and in each area identified local leads to work closely with by helping to encourage involvement in development locally.
The Trust made time and resources available and made engagement with training and learning a requirement for all staff. Members of the project team spoke directly to every team and department affected, and in each area identified local leads to work closely with the project by helping to encourage involvement in development locally. As is true with all change projects, face to face communication with those involved is absolutely key.
The Trust deployed leaders and local teams to explain the benefits of using the standards and how they will make care safer, improve patients’ experience and help staff work more effectively. For clinical, financial and organisational reasons
adopting the PRSB standards is the right thing to do. The Trust reminding people that the record standards were developed by our peers through expert reference groups and agreed by all the medical royal colleges.
The Trust also linked in the importance of coding more generally, with the project manager and the lead coder talking to every team about what is important to record for both the clinical complexity of patient care and for coding for other purposes. The CCIO provided coding sessions for individual consultant colleagues, one from each speciality at first and then in cycles, targeting new consultants to ensure that everyone was clear about what is important clinically and how this relates to other colleagues, the hospital as an organisation and to income.
The Trust also provides a session about this as part of all new staff induction programmes to ensure that everyone is clear right from day one about why this is so important. Addenbrooke’s continues to evaluate progress in using the PRSB discharge headings and is continuing to audit and ensure the discharge summaries are going out quickly and their quality is good.
Cambridge University Hospitals (CUH) NHS Foundation Trust comprises Addenbrooke’s Hospital and the Rosie Hospital in Cambridge. The Trust provides accessible high-quality healthcare for the local people of Cambridge, together with specialist services, dealing with rare or complex conditions, for a regional, national and international population. The Trust is recognised as a centre of excellence and innovation with many of the hospital specialists being leaders in their field.