Developing a service can be complicated, knowing where to begin can be bewildering and many practitioners lack the skill set to solely undertake improvement initiatives (Lees, 2010). This article will illustrate how a group of professionals worked together as a team and used improvement methodology in a project to radically change the operating of community nursing services. The author is a professional lead in district nursing who was sponsored by the Head of Service and Professional Head of Community Nursing to join a project team formed to design, create and implement a centralised referrals system for community nursing. This article concentrates on the system created by the author, although learning from participating in an improvement project team will be explored, focusing on the value of shared expertise for successful outcomes.
Over the years, the NHS organisation involved in this project had explored ideas around creating a centralised community nursing referrals system, although no attempts were made at a system-wide level. This changed following a serious incident, which concluded that the community nursing communications systems were impacting on the responsiveness of the service to patients needing care and, therefore, needed to be improved, as a matter of priority.
Jones et al (2019) claimed that no one person has the skills or knowledge to devise a solution to a problem on their own, and improvement work should be a team activity. A project group was formed with the aim to design a system that would improve service responsiveness and patient safety by ensuring that all referrals are received, logged and actioned consistently through a central point in each locality, thereby greatly reducing the risk of referrals being lost in the system.
Team development
The first step in quality improvement work is to establish a team that shares a common vision for improvement and to define the roles of those within the improvement team (Swanson and Pearlman, 2017). Creating the right team for any project involves careful consideration, in order to ensure successful outcomes. Furthermore, Lees (2010) argued that clinicians should be involved if the change is going to affect delivery of frontline NHS services and pointed out that leading the development of new services can be a privilege and an exciting part of a clinician's role. It was important to ensure that the right people were around the table, as a blend of skills and perspectives is beneficial to any quality improvement work, and inter-professional collaboration is the foundation for improving patient safety (Rice et al, 2010). The project team consisted of two senior managers with operational experience of managing community nursing services, a project manager and a district nurse professional lead. Lees (2010) noted that management and clinical expertise must coexist to support governance, which supports the team composition for this improvement project. On reflection, this varied expertise alongside a significant level of enthusiasm from all team members generated a joint determination to create a revised system that safely supports patient care.
Importance of data to inform planning
The project team started its journey with the author (professional lead) performing a literature search to see if any similar work had been undertaken in other areas around a centralised community nursing communications system, while the senior managers explored any other similar initiatives in the organisation. Additionally, the author contacted colleagues in a selection of other areas to understand how telephone enquiries were managed. The literature search provided disappointing results and, even if there were comparable schemes running elsewhere, very little evidence was available that may have assisted with this initiative. Similarly, no other internal system encompassed referrals and enquiries from both members of the public and professionals. Therefore, the project group considered what information would be necessary in order to progress the work. Subsequently, it was decided that audits would be required for baseline information gathering, combined with key stakeholder engagement about potential opportunities. Wilkinson et al (2011) identified audits as being a key part of an improvement strategy and a vital tool to support quality-improvement work.
Data collection was undertaken by administrative support services, which manually gathered information about calls coming in to the community nursing service. The project group hypothesised that a proportion of calls were often administrative in nature, and the audit results supported this assumption (an example of results from 9 days’ worth of data can be seen in Figure 1).
Grainger (2010) cautioned how audits can be very time-consuming (especially when data is collected manually), but the professional lead learned that, on this occasion, the value of undertaking this activity was justified, as it confirmed the project group's hypotheses.
Designing the system
The professional lead presented an idea to the project group of creating clinical algorithms that would support decision-making for those initially handling community nursing referrals and enquiries from service users or professionals. Call handlers would receive telephone calls related to the community nursing service and use the algorithms to gather information, while being supported by an experienced community nurse, who would clinically appraise and triage incoming referrals. By combining knowledge gained through experience of community nursing with evidence-based practice, the professional lead could create a system that would enable call handlers to consistently manage community nursing enquiries so the community nurse could then clinically triage and efficiently prioritise. According to Storhaug et al (2017), decision-support systems are widely used in telephone services to assist the process of determining the priority of needs. Draft plans were shared with the project team, which showed how each algorithm would screen for signs of deterioration using ‘red flags’. The project team supported the aim of creating a detailed system, although they requested that the professional lead explore a system that would be functional even for non-clinicians. Therefore, a holistic approach was used to build the clinical algorithms, looking at basic information required from the caller to process the request. The algorithm aimed to answer the hypothetical question: ‘If I am a nurse visiting this patient, what information would be useful to help me prepare for the visit?’ Jackson et al (2015) advocated such a holistic approach to service improvement, because it ensures that a wide knowledge base is used to make changes. By considering different views, it was anticipated that a system could be designed that would facilitate more efficient service delivery. When creating the algorithms, the clinical systems change and configuration lead was an invaluable source of expertise and continually worked directly with the professional lead to turn draft plans into a useful system for call handlers while capturing all essential clinical information. The details in this new system would establish consistency, reduce risk, improve service responsiveness and enhance patient and service user experience. An example of the algorithm process can be seen in Figure 2.
Initially, the professional lead developed 14 clinical pathways, which increased to 20 pathways following quality improvement ‘plan, do, study, act’ (PDSA) cycles. Each clinical pathway was individually appraised by the most senior clinicians in the organisation, in order to provide rigour for the new service before it went live. Even though the importance of improvement work is well recognised, there is still concern that the demands of the NHS may be a barrier to embedding a culture of continuous improvement (Burgess and Radnor, 2012). The project team kept in mind that the service revision was a priority, and the protected time for this quality improvement work was, therefore, fully justified.
Engaging with stakeholders
The project team consulted with key stakeholders to understand if the proposed system would meet the requirements of those requesting the service, recognising that stakeholder engagement can have a significant effect on any project and, if not managed effectively, can have negative outcomes. However, it was also recognised that engagement can be a balancing act, and it is unlikely that all stakeholders’ demands can be satisfied, as pointed out by Shirley (2012).
The two main groups of stakeholders who regularly use the service were identified as GP surgeries and local hospitals. Engagement with a selection of GPs revealed that many prefer electronic-based referral systems for simple requests (such as repeat blood tests). An electronic pathway system was created using the questions from the clinical algorithms as templates. The project team then decided to test both the call-handling algorithms and electronic pathway system in a particular area in which stakeholder were engaged. Due to the relationships built during the engagement, real-time feedback could be collated, and PDSA methodology was used to support necessary amendments to the algorithms and templates following analysis and review in the testing phase (an example of this can be seen in Figure 3). This reiterated the value of stakeholder engagement throughout the project.
Summary
Multidisciplinary working is well documented as a beneficial approach to explore problems outside of normal boundaries, drawing appropriately from multiple disciplines to reach solutions (NHS England, 2014). Throughout this project, various services were involved to help co-design the new system, and the author believes that this additional expertise strengthened the system. Alongside the use of a structured method, the importance of collaborative working is considered essential for effective quality improvement (Lees, 2010; Rice et al, 2010; Jones et al, 2019). This was notable in the roles that each member of the project team fulfilled. The project manager kept the team focused and on track; the managers led on operational elements, for example, accuracy of job descriptions, correct staffing levels and service continuity; and the professional lead maintained a focus on governance and quality.
Introducing the new system was not without it challenges, largely due to fears from some colleagues that data from the new system would encourage a reduction in the community nursing workforce, to ultimately save money. Various subject experts who assisted during the planning stage were brought back into the project team to support a smooth transition (such as telephony and IT support), particularly during the first few weeks of implementation. Change is perhaps one of the most challenging concepts to manage in any workplace (Curtis et al, 2018). Therefore, time was invested to explain how the new system would improve responsiveness and patient safety, with a clear message that NHS services ‘should not tolerate systems which pose risks to patients’ (Francis, 2013).
It was acknowledged that communicating all aspects of planned changes, irrespective of grade or level, is important because this can reduce the risk of resistance to change and avoid a top-down change process (Curtis et al, 2018). To this end, project plans were shared with frontline staff, to demonstrate the wider aspects of the new service and the amount of planning and consideration put into its development. The feedback from colleagues was overwhelmingly positive, particularly from some colleagues who had previously resisted change (especially when a loss of control was perceived). Again, this demonstrated the benefits of joint working with those who would be using the system.
There were distinct key points that led to the success of this project:
Evaluation, outcomes and learning
The main outcomes of this new service are release of nursing time to focus on clinical care delivery. This time was previously spent on telephone-based, administrative activity. Additionally, each local referral team has real-time oversight of activity levels and can liaise with frontline staff to adjust visits accordingly, particularly when priority calls come in. Previous multiple routes in made it almost impossible to govern activity and demand or assure that referrals were always received, registered and scheduled accordingly. The new system supports the organisation's ability to effectively capacity plan by improving the ability to the monitor volumes and types of referrals over agreed planning periods.
One of the challenges faced is county-wide consistency balanced with knowledge of additional support services that may be available in certain areas. Some areas may have additional services available (such as voluntary services), which could support patient's needs, but the call handling system needs to be suitable for the entire county and may not include such detailed local information. This is an area for resource development. However, the system emphasises the value of consistent clinical triage, and this is an area of development for all community nurses who support the referral centre to deliver consistent clinical triage and prioritisation.
At present, a planned review is being undertaken to examine how the service has developed since its introduction. It is known that local areas have developed the service in different ways, as was expected. The review will determine whether the implementation principles are retained, need refreshing or require alternative approaches to assure safe delivery. The review will ensure that call handlers engage referrers in information exchange and create a narrative within the referral record. The decision-making element of referral handling will be more closely aligned to the expectations of the community nurse working in triage.
Real-time data collection and multiple audits have provided valuable information about the service since introduction; very few incidents have been recorded, and most are mainly of administrative origin. The clinical algorithms have been reviewed and updated twice since implementation, and additional call handling staff have been recruited to support the community nursing service. The review is scheduled to start in spring 2020, with the report published in autumn, and the view is to implement any proposed developments through winter 2020/21.
Conclusion
Over a year on from introduction, the new call-handling system for community nursing referrals demonstrates not only how many contacts and referrals are received into the service, but also the nature and acuteness of the demands placed on the service. Referrers and users of the service (public and professional) have been contacted to provide feedback on the service, and subsequent PDSA cycles have continued. While this article has focused primarily on the introduction of the system within a specified service, the principles behind collaborative working, alongside the use of quality improvement methodology tools are applicable to other initiatives.
Ultimately, the combination of collaborative working, quality improvement methodology and co-designing with subject matter experts resulted in the successful delivery of an innovative method for the management of communication in a community nursing service. The project team members remained the same throughout early implementation, but the review team will include colleagues informed by knowledge now gained about the service. A further consideration would be how patients, families and carers could be involved in service review.
The time required for improvement projects such as this cannot be underestimated and may discourage some managers and leaders from making changes. However, the NHS Long Term Plan (NHSE, 2019) clearly states how important it is to proactively tackle the pressures faced upfront, and this will require redesigning services in order to future-proof the NHS. Arguably, the challenge that lies ahead is future analysis of the system, understanding how patient safety and experience can be enhanced through robust triage and prioritisation and data being used to inform real-time demand and capacity, as well as resource management.