Day of Care Learning workshop 24th September 2019

1. Using Day-of-Care Surveys (DoCS) for improvement
across acute and community hospitals

2. Welcome & Housekeeping
Turn off your phone
If you can’t - please put it on silent
Please leave the room if you need to take a call
Your time to network
Use it well
Talk to everyone you can
If fire alarm sounds please leave by the nearest exit
Muster point is….
Refreshments served in Foyer
Lunch served in Dining Hall downstairs
Keep in touch notes
Unscheduledcareteam@gov.scot
#6EAScot

3. Session agenda
1. Background to the DoCS
2. Why we are here?
3. Pan-Scotland DoCS results
4.Review National DoCS agreed
actions/recommendations
5. Using the DoCS for Improvement

4. 1. Background to the DoCS

5. The Day-of-Care Survey (DoCS): What is it?
Methodology published : Identifying reasons for delays in acute hospitals using the day of care survey method.
Clinical Medicine. 2015; 15(2) 117-120 Reid, E., King, A., Mathieson, A., Woodcock, T & Watkin, S 11
http://www.qihub.scot.nhs.uk/quality-and-efficiency/whole-system-patient-flow/day-of-care-survey.aspx
• The purpose of the survey is to provide a “snapshot in time of the inpatients present
within your hospital using a toll based on the Appropriateness Evaluation Protocol
(AEP)”
• Provides a Scotland wide picture to understand capacity issues
• Provides opportunities for improvement to reduce delays in discharge - that can be
supported by the 6EA programme
• Provides platform for improved collaboration between primary and secondary
healthcare professional to work together and finding joint solutions to eradicate them

6. Patient Pathways
6
Communit
HospitalHome
+/-
Support
Care Home
Nursing
Home
GP
NHS
111
Ambulance
Pharmacy
Primary
Care
OOh
ED
Co-located
Primary
Care
ASU
AMU
Ambulatory
care
Discharge
lounge
Inpatient
downstream
wards
Home
+/-
Support
Care Home
Nursing
Home
Minor
Injury
Services

7. Scotland DoCS – how it was done
• Since April 2018, 3 National DoCS across Scotland,
approx. 30,000 patients
• Survey has been used nationally & internationally
• All adult inpatient beds excluding
ITU/HDU/Obstetrics/Mental Health
• Patients deemed inpatients if waiting more than 4
hours in ED
• Unfunded/surge capacity beds included in survey

8. Purpose of Today
• Form key basis of improvement approach around
delayed discharges through collaboration between acute
and HSCP
• Provide platform to network and share key challenges
and celebrate success
• Opportunities to discuss:
• What have we done well?
• What do we need to focus on?

9. 9
Day of Care Survey: Pan-Scotland Acute (29 Sites) Overview
1. Total number of patients surveyed on the days of DOCS.
2. Boarders are patients who are in a ward bed not related to their main specialty needs. This is the % of boarders out of the number of patients surveyed.
3. Excludes patients for discharge.
4. Weekly census data
BENCHMARKED DATA
Pan-Scotland
Acute (29
Sites) May
2019
Pan-Scotland
Acute (29
sites)
October 2018
Pan-Scotland
Acute (27
sites) April
2018
Medians & Ranges
Number of beds surveyed 10,485 10,483 10679 Range: 23 - 1436
Number of patients surveyed1 9,983 9,524 9935 Range: 20 - 1389
Bed Occupancy % 95% 91% 93% Median: 93% ------ Range: 45% - 106%
Boarders %2
4% (445
patients)
3% (254
patients)
4% Median: 3% ------ Range: 0% - 13%
Day of Care - criteria met %3 79% 79% 80% Median: 77% ------ Range: 30% - 88%
Day of Care - criteria not met %3 21% 21% 20% Median: 23% ------ Range: 12% - 70%
Of those not met - within hospital
control (%)
17% 29% 33% Median: 12% ------ Range: 0% - 32%
Of those not met - whole system issue
(%)
79% 59% 65% Median: 83% ------ Range: 61% - 100%
Of those not met - Home designated
as most appropiate alternative place
(%)
33% 44% 40% Median: 36% ------ Range: 0% - 60%
ED performance on the week of the
survey
88% 92% N/A N/A
Delayed Discharges4 1,514 1,507 N/A Median: 109 ------ Range: 4 - 276

10. 10
Excludes patients being discharged today
Pan-Scotland Acute (29 Sites)
Day of Care Survey results (May 2019)
72
1508
333
0 500 1000 1500
Other
Outwith
Within
Number of Patients
HospitalControl
Groups
Acute specific
System issue
Other
Reason not discharged within/outwith hospital control

11. 11
Excludes patients being discharged today
Pan-Scotland Acute (29 Sites)
Day of Care Survey results (May 2019)
103
102
71
57
282
262
230
223
119
62
57
54
53
39
32
28
27
22
9
8
1
72
0 100 200 300
Awaiting final multi-disciplinary team decision
Awaiting consultant decision/review
Waiting for AHP assessment
Awaiting procedure / investigation / results and
not meeting criteria for acute care
AHP treatment ongoing – could be provided out of
hospital if alternative place of care available
Home care support availability / funding
Awaiting social work allocation / assessment /
completion of assessment
Awaiting community hospital bed
Making choices/awaiting place in care home
Alteration to/or equipment for home / re-housing
Vacancy in home of choice/funding
available/discharge planning in progress
Waiting funding for placement, vacancy in care
home
Legal / financial
Awaiting hospice bed / palliative care services
community
Delay due to relatives
Awaiting / planned repatriation to other board
Disagreement between family / patient / NHS / LA
Awaiting tertiary care (is within own board
area?)
Health care assessment arrangements
Delay due to transport
Ward / care home / facility closed – patient well
but cannot be discharged
Other
Number of Patients
Reasonnotdischarged
Reason not discharged

12. DoCS – reasons for discharge delays
Wider system issuesAcute
specific
• Awaiting final multi-
disciplinary team
decision
• Awaiting consultant
decision/review
• Waiting for AHP
assessment
• Awaiting
procedure/investigatio
n/results and not
meeting criteria for
acute care
• AHP treatment ongoing – could be provided out of
hospital if alternative place of care available
• Home care support availability/funding
• Awaiting social work
allocation/assessment/completion of assessment
• Awaiting community hospital bed
• Making choices/awaiting place in care home
• Alteration to/equipment for home/re-housing
1 2 Other
• Unspecified
3
223 patients were identified in the acute report as waiting for a community bed

13. 13
• The national survey shows 21% of patients do not meet criteria for ongoing acute care. This is similar
to previous surveys.
• Requires an agreed integrated Health and Social Care response
• Develop an action plan to address the top 6 cause of delay and systematically reduce aim to reduce this
• Action plans will be monitored through PMAP and should be on agenda of monthly local partnership/UC meeting
• The balance of cause of delay has shifted from acute based cause of delay to wider whole system
• Complete footprint of capacity to include community services that support discharge, reduce attendances and admission
• Develop whole system approach to delay reasons through a clearer understanding of provision of community referral criteria
• Review national and local community report as benchmark – engage with colleagues with similar issues
• Align provision of community bed against demand supported by Basic Building Blocks
• Delays are greatest in older age groups
• Review current, and agree appropriate, referral criteria for community/PC services
• Engage in activity to reduce effects of deconditioning – e.g. Move it campaign, #endPJparalysis
• Over half (57%) of patients not meeting criteria have a Length of Stay >14 days
• Aim to reduce length of stay through early discharge planning – utilise Daily Dynamic Discharge process
• A high proportion (4%) of patients are boarded out of specialty – this is an outcome of system failure
• Explore specialty and inter-specialty boarding to understand full extent
• Set specialty based daily and weekly in/out balance measures, and monitor against predictions
• Aim to eradicate all boarding – this results in better outcomes for patients, shorter length of stay, no “safari” ward rounds and
better staff experience
Recommendations: Pan-Scotland Acute (May 2019)
The following recommendations are designed to prioritise areas of potential need to expedite the patient
journey for the specific patient(s), but also to focus on themes which could improve overall system flow by
shifting the discharge time curve to the left and reducing overall LOS
Day of Care Survey May 2019 Recommendations

14. 14
Day of Care Survey- Pan-Scotland Community Overview
1) Total number of patients surveyed on the day of DOCS at site
2) Excludes patients for discharge
3) Weekly census data
4) NHS GGC and NHS Shetland have no community sites
BENCHMARKED DATA
Pan-Scotland
Community
(12 Health
Boards- May
2019)
Pan-Scotland
Community
(12 Health
Boards-
October
2018)
Pan-Scotland
Community
(11 Health
Boards- April
2018)
Scotland comparator (12 Health
Boards)
Number of beds surveyed 2,512 2,548 2031 Range: 14 - 494
Number of patients surveyed1 2,142 2,154 1789 Range: 13 - 418
Bed Occupancy % 85% 85% 86% Median: 87% - Range: 76% - 99%
Day of Care - criteria met %2 61% 61% 62% Median: 59% - Range: 43% - 76%
Day of Care - criteria not met %2 39% 39% 38% Median: 41% - Range: 24% - 57%
Of those not met - within hospital
control (%)
5% 9% 6% Median: 2% - Range: 0% - 20%
Of those not met - whole system issue
(%)
94% 89% 89% Median: 97% - Range: 80% - 100%
Of those not met - Home designated as
most appropiate alternative place (%)
42% 45% 52% Median: 47% - Range: 12% - 80%
Delayed Discharges-Scotland3 1,514 1,507 N/A Median: 109 ------ Range: 4 - 276

15. 15
Excludes patients being discharged today
Pan-Scotland Community (91 Sites)
Day of Care Survey results
9
764
38
0 250 500 750
Other
Outwith
Within
Number of Patients
HospitalControl
Groups
Hospital specific
System issue
Other
Reason not discharged within/outwith hospital control

16. 16
Excludes patients being discharged today
Pan-Scotland Community (91 Sites)
Day of Care Survey results
30
8
218
138
124
65
59
48
40
24
18
17
8
5
9
0 100 200
Awaiting GP/Consultant decision/review
Awaiting final multi-disciplinary team decision
Home care support availability/funding
Awaiting social work allocation/assessment/completion of assessment
Making choices/awaiting place in care home
Legal/financial
Alteration to/equipment for home/re-housing
Vacancy in home of choice/funding
available/discharge planning in progress
Waiting funding for placement, vacancy in care home
Ward/care home/facility closed – patient well but
cannot be discharged
Disagreement between family/patient/NHS/Local Authority
Delay due to relatives
Ongoing AHP assessment/treatment
Health care assessment arrangements
Other – please specify
Number of Patients
Reasonnotdischarged
Groups
Hospital specific
System issue
Other
Reason not discharged

17. DoCS – reasons for delayed discharge
Wider system issuesAcute specific
• Awaiting GP/
consultant
decision/review
• Awaiting final multi-
disciplinary team
decision
• Home care support availability/funding
• Awaiting social work
allocation/assessment/completion of assessment
• Making choices/awaiting place in care home
• Legal/financial
• Alteration to/equipment for home/re-housing
• Vacancy in home of choice/funding
available/discharge
1 2 Other
• Unspecified
3

18. 18
• The national survey shows 21% of patients do not meet criteria for ongoing acute care. This is
similar to previous surveys.
• Requires an agreed integrated Health and Social Care response
• Develop an action plan to address the top 6 cause of delay and systematically aim to reduce this
• Action plans will be monitored through PMAP and should be on agenda of monthly local partnership/UC meeting
• The balance of cause of delay has shifted from acute based cause of delay to wider whole system
• Complete footprint of capacity to include community services that support discharge, reduce attendances and
admission
• Develop whole system approach to delay reasons through a clearer understanding of provision of community referral
criteria
• Review national and local acute and community reports as benchmark – engage with colleagues with similar issues
• Align provision of community bed/virtual services against demand supported by Basic Building Blocks
• Delays are greatest in older age groups
• Review current, and agree appropriate, referral criteria for community/PC services
• Engage in activity to reduce effects of deconditioning – e.g. Move it campaign, #endPJparalysis
• 77% of patients not meeting criteria have a Length of Stay > 30 days
• Aim to reduce length of stay through early discharge planning – utilise Daily Dynamic Discharge process
• 42% of patients not meeting criteria identified home as alternative place of care
Recommendations- Pan-Scotland Community (91 Sites)
The following recommendations are designed to prioritise areas of potential need to expedite the patient journey
for the specific patient(s), but also to focus on themes which could improve overall system flow by shifting the
discharge time curve to the left and reducing overall LOS

19. Repeat DOCS
regularly
Results
Design change
Monitor
Change
Drive
improvement
DayofCare@gov.scot
19
Day of Care Survey: Next steps
• Develop Whole System Actions plans
agreed across Health and Social Care
Partnerships
• Incorporate findings into 6EA UC
Improvement plans monitored through
PMAP and Local meetings
• Examine individual themes and agree
recommendations to systematically
reduce delays
• Iterative DoCS have been shown to
lead to improvement
• Explore DoCS for mental health +
paediatrics.
• NHSScotland DoCS across all Acute
and community beds
• 29th, 30th 31st October 2019