Presentation delivered as part of the NHS Improvement 150 day End of Life Care Improvement Collaborative. Nottingham University Hospital's project was to improve the sharing of the patients’ end of life plan of care between secondary and primary care settings.

1. Improving the sharing of the patients’ end of life plan of
care between secondary and primary care settings.
Project Team –
Sim Lan Koon, Consultant in Palliative
Medicine,
Daljit Athwal, Deputy Chief Nurse,
Katie Moore, HOS for PPI,
Roz Bexon, Macmillan CNS Palliative Care,
Nicola Jones, Macmillan CNS Palliative
Care,
Jeremy Lewis, Consultant Acute Medicine
and Trust Caldicott Guardian,
Sandra Minich, Better for You Programme
Manager
1

2. National Strategy - End of Life Care (EoLC)
The Six Ambitions
2

3. National Drivers - End of Life Care (EoLC)
3

4. NUH Strategy - End of Life Care (EoLC)
To provide care of the
highest quality
To provide the best
experience for patients
and their loved ones
To have confident and
supported staff
Roll out of improved EOL
care plan documentation
across NUH
Participation in the National
Audit of the care of the dying
Electronic palliative care
notes ‘EPaCCS’, a national
system to be implemented in
key clinical areas within
acute care at NUH
NUH EoLC Strategy
4

5. To improve
care for
patients and
their loved
ones at the
end of their
life
Each person is
seen as an
Individual
Care is
coordinated
Each community
is prepared to
help
Each person gets
fair access to
care
Maximizing
comfort &
wellbeing
All staff are
prepared to care
Use Individual plan of care on EPaCCS
to recognise patients at Hayward
House who are eligible for Fast Track
Standardise information &
procedures
80% of Nottinghamshire GP
registered patients who are
fast tracked/end of life care
and discharged from
Hayward House have a
shared end of life plan of
care on EPaCCS on the day
of discharge (Source – local
audit of EPaCCS )
Time to assess holistic needs of
patients & then communicate with
wider healthcare team regarding
treatment plan for medical, physical
& psychological needs
Seamless communication of
care plan between primary &
secondary healthcare
Communication of plan to
create awareness of
importance of end of life care
in primary & secondary care
Implement education programme of
end of life care to ward & medical
staff:
EPaCCS Training
Engagement of primary &
secondary stakeholders to
optimise this operational
change programme for
improving discharge
Contact / involve primary
stakeholders:
Loraine Parker –EOL In Reach Matron
Rushcliffe
Christina Sharkey – Macmillan GP
Conversations of preferred
treatment, place of care & death
with all eligible patients
Implementing plan of care according to
patient wishes & preferences
Consider appropriateness of
prescribing anticipatory
medication more quickly
Primary Drivers Secondary Drivers InterventionsAim Measurable Benefit
1. Set end of life plan in
place
2. Confirm technical
requirements are in place
80% of Fast Track
eligible patients at
Hayward House will
be identified via the
Nerve Centre (Source
– local audit)
80% of staff have
received appropriate
training to demonstrate
competence on using
EPaCCS (Source local
audit)
NUH Drivers - EoLC
5

6. NUH Leading Change – EoLC Improvement Collaborative
Rapid improvement cycle
The aim of this programme
is to:
• Improve the experience
and quality of care
received by patients at
end of life
• Learn about quality
improvement tools and
techniques and put into
practice
• Share best practice
• Improve our CQC rating
for EoLC
What have we done PDSA’s:
Established how many patients were discharged from Hayward House in a
2 month period (April & May 2017.) 22 patients.
Manual process to establish number of Fast Track eligible patients
11 on Fast Track with Nottinghamshire GP’s.
Identified need to train staff to use the Nerve Centre to identify Fast Track
patients – IT team visited Hayward House to update staff during August
2017. Aiming to ensure all staff are aware of Nerve Centre facilities by
updating Nerve Centre during evening board round.
Plan in place to train staff to use the Nerve Centre with a new Standard
Operating Procedure in place – not required as there is a hospital SOP
Trial the use of a discharge information guide to aid the discharge process
- incorporate information needed for EPaCCS and e-discharge.
Commenced on 1st September 2017.
6

7. E Discharge information guide
H
History of diagnosis/admission
E
End of life register, EPaCCS
A
Advance care planning, anticipatory medications
R
Resuscitation status
T
Treatment plan, escalation of treatments
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8. Patient Discharge Information Audit (Hayward House)
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Summary of Patient Discharge Information Audit (Hayward House)
Jul-17 Jul-17 Sept 2017 (so far)Sep-17
Number of patients discharged on Fast Track 8 3
Question
Preferred place of care documented 2 patients 25% 3 patients 100%
DNA CPR status recorded 1 patient 12% 3 patients 100%
Anticipatory drugs prescribed 3 patients 37% 3 patients 100%
End of life register documented 0 patients 0% 3 patients 100%

9. Information in discharge summaries from Hayward
House
BEFORE USE OF DISCHARGE GUIDE
Information regarding discharge
“ She was assessed by physiotherapy and OT teams and the
impression is that she will need to be nursed in bed at home. Both
she and her husband seem to understand”
AFTER USE OF DISCHARGE GUIDE
Information regarding discharge
“We have completed the EPaCCS template on the following-
P has been a fast track discharge.
She has been prescribed anticipatory medications.
She has a DNACPR in place.
Her preferred place of care has been home & she has been keen to
attend her grandson's marriage in November.
I would be grateful if you could put her on the end of life register.
It would be appropriate to treat her reversible causes, for example
infections with oral antibiotics”
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10. NUH Leading Change – EoLC Improvement Collaborative
Rapid improvement cycle
The aim of this programme
is to:
• Improve the experience
and quality of care
received by patients at
end of life
• Learn about quality
improvement tools and
techniques and put into
practice
• Share best practice
• Improve our CQC rating
for EoLC
What have we done PDSA’s:
Plan and schedule training of all relevant staff to use the EPaCCS system.
The 5 current ward doctors (SHO’s and SpR’s) were trained on 31.8.17.
3 senior ward nurses to be trained, therefore at present we have
achieved 62% compliance.
There is a cost for each person to have a licence, but this is transferable.
Sept – so far 2 out of 3 Fast Track patients had EPaCCS completed before
discharge and entries reviewed by SK and NJ.
EPaCCS - Write a Standard Operating Procedure for staff to follow - outline
roles, responsibilities and expectations of staff for the discharge process to
include e-discharge and EPaCCS discharge
Rather than an SOP, Dr Sarah Awan is amending the current Hayward
House junior doctors handbook, and feedback can be provided to the
medical team at the Hayward House Quality, Risk & Safety meeting.
Formulate a communication plan with all primary and secondary care
stakeholders
Plan to communicate within NUH, to GP’s and DN’s via Communications
Teams
Re evaluated the PDSA’s using the sustainability tool
Sustainability scores much improved
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11. A short working definition of sustainability can be described as ‘when new
ways of working and improved outcomes become the norm’.
For our EoLC Project, we chose to use a Sustainability Model and not only have
the process and outcome changed, but the thinking and attitudes behind them
are fundamentally altered and the systems surrounding them are transformed
in support.
In other words it is becoming integrated or mainstream way of working rather
than something ‘added on’. As a result, when you look at the process or
outcome above; you can see that at a minimum it has not reverted to the old
way or old level of performance. Further, it has been able to withstand
challenge and variation; it has evolved alongside other changes in the context
and perhaps has continued to improve over time. Sustainability means holding
the gains and evolving as required, definitely not going back.
Our Jar has moved from being almost empty to full.
Sustainability
Jar
Sustainability
Jar
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12. What are we most proud of? Lessons Learned
Collaborative
working - working
together to make
changes from 2
separate sites &
balancing clinical
caseloads.
Leading Change
- step forward
in achieving
EoLC goals
within the NUH
strategy
Rapid
improvement
in quality of
information
provided on
discharge
summaries
Development of e-
discharge guide for
fast track patients
Clinical, PPI &
improvement
team support
helped drive
project forward
Able to drive
other changes
forward within
the group
Advantages of
collaborative
everyone working
together with same
goal
Keep the project
small
Need to test, embed
then sustain the
change before moving
on to next test area
Share the work
Listen to each other
and share ideas
Learn – change and
adapt
Measure
Need to audit
and re-evaluate
each step
Collect evidence
to support
project
Consider using the
sustainability model
earlier
Earlier consideration of
stakeholder inclusion
and engagement
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13. 13
Hi I am Daljit Athwal, Deputy Chief Nurse, I’m really proud
that Nottingham University Hospital was a part of the
NHSI Collaborative, which I was involved in setting up. The
thing that I’m really proud of, however is working with the
most fantastic clinical team in a way that’s very different
from the way I would usually work and my role in just
supporting the team to achieve their vision to improve
patient care. The thing that I have learnt the most is about
persistence and never give up. There were times in our
project where I thought are we really going to achieve this,
but with the strength and the courage of the team and
their belief we carried on and all those people that didn’t
want to listen to us at the beginning have now started to
come on board so I’m very excited.
Hello my name Sim Koon , consultant in
palliative medicine with the Nottingham
University Hospital. The thing I was most
proud of with this project is that within 150
days we have been able to come up with a
sustainable project and implement changes
in clinical settings. The lesson I have learnt
is the early engagement with the right
stakeholder can make a great deal of
progress to our project.
Hello, I’m Katie Moore, head of patient
public involvement, I’m most proud of the
way we involved and got support from our
patient group and welcomed their support
from the beginning. The lesson that I
learned was the value of the different
perspectives and knowledge the different
team members gave and also the
importance of medical engagement.

14. 14
Hi, I’m Nicola, a Palliative Care CNS, If you
get a chance to be part of an NHS
Improvement project please go for it, I’ve
had the opportunity to develop a greater
understanding of our improvement and PPI
teams and work alongside highly motivated
colleagues to make a change for patients
and I’m most proud of the fact that we have
managed to meet weekly with phone in’s if
needed.
Hello my name is Trish Cargill and I chair the
patient partnership group, what I’m most
proud of is that patients and carers have
been involved and helped develop the
project from the beginning and are
genuinely listened to, lessons learnt is the
importance of involving patients and carers
and the patient partnership group are very
keen to support the project in the future
I’m Jeremy Lewis, I’m the clinical lead for ICT at
NUH, it has been an exciting project to be involved
with and for me I think the best bit has been to see
the benefits of bringing clinicians in ICT together
with clinicians on the ground to work towards the
best solution for our patients. One lesson learned
from my point of view would be to make sure that
we always include sustainability in the initial
project plans to make sure that we have a clear
idea of how we are going to make it work in the
long term.

15. Next steps
• New discharge summary- continue to review
effectiveness
• Nerve Centre- review need for discharge plan
• EPaCCS- audit completion of template and timescale
from September onwards
• Progress report to NUH EOLC steering group & PPI
group
• Further communication of project to colleagues &
primary care
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