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Discharge from Care at Queen
Alexandra Hospital
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Research Report
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Portsmouth LINk Transition Group
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April 2013
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Contents
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Introduction
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Page 3
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Methodology
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Page 7
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Results
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Page 11
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Conclusion
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Page 17
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References
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Page 20
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Appendix A: Question Scheme
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Page 21
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Appendix B: Information Sheet
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Page 22
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Appendix C: Consent Form
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Page 23
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Introduction
This report focuses on research conducted by the Portsmouth Local
Involvement Network (LINk) Transition Group in relation to patient experiences
of discharge from Queen Alexandra Hospital (QAH). The following chapter will
provide an introduction to the role and activities of the Portsmouth LINk and
the rationale for this research project.
1.1 Local
Involvement Networks (LINks)
The Local Government & Public Involvement in Health Act 2007 created
Local Involvement Networks (LINks) for each local authority area in England.
The aim of Local Involvement Networks (LINks) is to influence the way health
and social care services are provided in local areas. The main functions of
Local Involvement Networks are to:
•
Give people the chance to say what they think
about local health and social care services, including what is working well and
what needs improvement.
•
Give people the chance to check how services are
planned and run.
•
Provide feedback to health and social care
services on what people are saying.
In order to fulfil these main functions, LINks have a number of key
responsibilities including:
•
Encouraging and supporting people's involvement
in the commissioning, provision and scrutiny of health and social care
services.
•
Enabling people to monitor and review the
commissioning and provision of health and social care services.
•
Obtaining people's views about their needs and
experiences.
•
Making reports and recommendations to service
providers, commissioning organisations and the regulator regarding existing
services procured and other services where the LINk has identified a need.
The work of each LINk is supported by a Host organisation, whose role is
to assist the LINk with administrative, governance, accountability, membership,
publicity and research support and guidance.
1.2 The Portsmouth LINk
The LINk has been a community-based network of organisations and
individuals committed to widening the influence of users of health and social
care services in the planning, development and improvement process. Those who
participate as members have been given the opportunity to comment on the
development of the LINk and to get involved in the work of the LINk through
activities such as working groups and visits to health and social care
premises.
In the early stages of the Portsmouth LINk, Portsmouth City Council (PCC)
officers organised local networking meetings with other voluntary
organisations. The purpose of these meetings was to introduce the LINk and
discuss the remit of the organisation to a wide range of individuals so as to
engage with as many people as possible. These meetings allowed for an early
‘mapping’ exercise of local organisations who could be involved in the Portsmouth
LINk.
The numbers and types of members of the Portsmouth LINk has been a
priority for both the Host organisations (HAP UK, then Portsmouth City Council)
and were also considered in the initially stages of the Portsmouth LINk. The
balance between group and individual members was considered and the decision
was made by the central committee that a majority of individual members should
be created. This was decided to ensure a range of opinions, issues and ‘voices’
would be heard by the LINk.
The Portsmouth LINk has previously operated with a main Steering Group
and two Sub Committees. However due to extreme difficulty in recruiting Chair
and Vice Chairs for the Steering Group and Sub Committees the Portsmouth LINk
now operates as a single Transition Committee preparing for the end of LINk
organisations and transition to HealthWatch.
1.3 Discharges from Care Topic
The Portsmouth LINk has conducted a number of ‘Question Time’ meetings (modelled
on the BBC programme) and ‘Focused Meetings’ (presentation to and questions from
existing groups) which have allowed local people to ask questions and speak
about health and social care issues. Over the last three years and across a
variety of locations in the city, discharge from inpatient care was raised at LINk
meetings. Comments regarding the discharge from care process came from
individuals, carers and care home organisations. The variety of comments has
led to two research projects being conducted by the Portsmouth LINk. The first
focuses on the discharge process from one health and social care provider to
another and was published with the support of HAP UK. The second is the focus
of this report and focuses on the comments related to the discharge process at
Queen Alexandra Hospital. A further area of investigation of the discharge
process and community support provision after discharge from St James’ has also
been highlighted by anecdotal evidence. This further area of investigation will
be highlighted to HealthWatch during the transition.
1.4 Discharges to Other Health and Social Care Providers
Previous research by the Portsmouth LINk had focused on the discharge
process from one organisation to another. Over the 3-year period of meetings,
the Portsmouth LINk became increasingly aware of a perceived lack of
coordination amongst Service Providers for the provision and implementation of
support in the community after discharge from the care of one organisation into
the care of another. Much of the information was, initially, anecdotal but
sufficient information was being received from a variety of sources, both
organisations and individuals, for the then LINk Steering Group to establish a
project to attempt to identify the extent of any problem and to gather data
through observation and information requests.
The Portsmouth LINk observed that a number of health and social care
organisations focused on their individual internal discharge processes and, in
consequence, the holistic needs of the service user were being overlooked. As
such, a more efficient and ‘joined-up’ care approach to discharges would
potentially lead to a better service user experience. In the initial stages of
this research, the focus was on the discharge of patients from QAH. However,
this was expanded to cover the discharge from any health and social care
service to another organisation or into the community. The LINk was concerned
that whilst a satisfactory service was being provided by individual
organisations, this service was often withdrawn before another organisation was
in place to provide further support. Anecdotal information was being received
relating to mental health services, drug and alcohol rehabilitation as well as
acute care.
Based on this anecdotal evidence, the objectives of the project were to
engage with local stakeholders to examine whether service users discharged from
health and social care providers have the best possible support and experience
during the process of becoming as independent as possible in the community. Procedures,
processes and pathways for discharge were therefore explored through a survey
of service users and information gathering within health and social care
providers.
1.5 Discharges
from Queen Alexandra Hospital
Following on from previous investigations of discharges from care, the
Portsmouth LINk initiated a project to investigate Discharges from Queen
Alexandra Hospital. The group initially considered a single discharge from care
project to investigate all inpatient discharge processes; however, it was
established that this would be a vast undertaking. The focus of the research
needed to be limited to discharges from a single health or social care
provider. Due to anecdotal evidence collected by the Portsmouth LINk, QAH was
chosen as the focus of the investigation. A number of research methodologies
were considered for the research and a qualitative focus-group-based
methodology was agreed upon.
Based upon the
anecdotal evidence collected by the LINk a number of research topics were
utilised for the focus groups. These included:
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Discharge times;
·
Information provide to next of kin and/or carers;
·
Aftercare packages and follow-up appointments,
e.g. care packages in the home, physiotherapy, etc.;
·
Aftercare provisions and equipment, e.g. an
additional stair rail, raised mattress, etc.; and
·
Delays to discharge and underlying causes.
1.7 Secondary
Data
As part of this investigation and normal group responsibilities, the
Portsmouth LINk Transition group met with representatives of QAH. During the
course of these meetings, the progress of the research project was discussed
and the QAH discharge process was explained. Additional information was
provided by the hospital in order to help frame our investigation and in order
to provide secondary evidence. The Portsmouth LINk has previously collaborated
with the hospital to review the discharge leaflet provided to patients on
leaving the hospital; the current version of this document was provided to the
group. Secondary data relating to the
dispensing of medicines to QAH wards was also made available to the LINk. As a
direct result of discussions relating to this research, the LINk was provided
with the Discharge from Care Planning Policy Document, the Five Day Nursing
Care Plan and descriptive statistics relating to discharge times from hospital
departments.
Methodology
2.1 Qualitative
Research
Qualitative research designs were deemed the most appropriate because
they are interpretive and suited to exploratory studies such as this one.
Qualitative research, unlike quantitative research, allows for a personalised
and in-depth investigation of services users’ experiences of discharge. However,
the quantitative method of questionnaires was considered as a complementary
method for this investigation. Questionnaires could have been used as a second
line of investigation after focus groups or interviews. This could have been
used to confirm the findings of focus groups with a large number of respondents,
thereby creating a large data set (Saunders, Lewis and Thornhill, 2009, p.361).
However, the correct design of questionnaires is complex and inadequate
question design can affect the validity and reliability of the research (ibid., p. 362). As a voluntary
organisation, it was decided that this extension to the research was not viable
at the time of investigation.
2.2 Focus
Groups
Focus groups are a well established research method and are widely used
in marketing, healthcare and social science research. Unlike interviews, focus
groups bring together a group of previously unconnected participants to discuss
a ‘focused’ topic. This method allows the researcher to collect in-depth
information from a group of participants who represent the wider population of
interest (The Health Communication Unit, 2002). Through this relaxed and
flexible research method, participants can share their individual stories
through dynamic discussion allowing a variety of themes to emerge. As such,
focus groups have the advantage of providing a diverse range of responses
(Onwuegbuzie, Dickinson, Leech, & Zoran, 2009, p.3). However, exploring
people’s views in a group context can lead to dominant voices inhibiting others
(Saunders, et al., 2009, p.346). The flexibility of the focus group structure
allows for probing of narratives and clarifying questions that are not always
possible in other methods. The interaction between participants can generate
further discussion, greater insight and new areas of investigation. The large
amount of information generated by focus groups provides a rich data set for
analysis.
One focus group was conducted for this research, although an alternative
research strategy of three focus groups was considered. Three focus groups
would have had the potential to research data saturation; however recruitment
constraints prevented this strategy being implemented. As such the single focus
group strategy was implemented with a wide and diverse sampling framework.
2.3 Research
Sample
Due to methodological constraints previously discussed, it was important
that this research had a clearly defined research population of either organisations
or individuals. It was recognised early in the design of the research that it
would not be feasible to investigate both populations as questions and sampling
would need to be vastly different. This is due to the problems and needs of the
organisation being different from those of community discharges. Furthermore,
the response rate, as experienced during previous requests to care homes for
information, would potentially be vastly different.
The sample for this research was developed through a heterogeneous
design. Heterogeneous sampling allows for a range of individuals and therefore
a range of themes to be explored (Saunders et al., 2009, p.239) thereby
creating a diverse investigation. By including a range of participants, a wider
range of experiences and attitudes will be collected (The Health Communication
Unit, 2002). Heterogeneous sampling requires participants to be distinct from
one another in order to achieve diversity; as such, selection criteria were
developed. Participants were invited to the focus group based upon various
characteristics including ethnicity, gender, sexuality, disability, age and
health status. Existing community, voluntary and health groups were used as the
vehicle for invitations to take part in this research. A list of groups that
had been contacted by the Portsmouth LINk was used as a starting point for
email invitations, additional groups were identified through internet research
and contact with LINk members. Approximately fifty organisations were contacted
in order to invite their members to take part in this research.
There was, however, a low response rate to this research which can be
partially explained as an inability to commit the required time for the
research and apathy towards creating change. Both these reasons were given by
potential participants as reasons for not taking part. Some suggested that
similar investigations and individual contact with QAH had not resulted in any
changes and therefore taking part would be ‘a waste of time’. Despite the low
response rate, the sampling technique allowed for a wide range of individuals
to be invited to participate in this research.
Four participants representing a range of opinions and experiences took
part in the focus group conducted by the Portsmouth LINk Transition Group.
Participant 1: A carer who has experienced a range of family discharges
from QAH.
Participant 2: A carer who engages with health and social care services
and cares for family members and has experienced a range of discharges from
QAH.
Participant 3: A member of the Black and Ethnic Minority (BEM) community
who supports other BEM members who has experience of discharge from QAH.
Participant 4: A community member who has been discharged from QAH within
the last twelve months.
2.4 Research
questions and data collection
The research questions for the focus group (Appendix A) were developed as
a result of analysis of anecdotal evidence. The underlying themes were:
·
Discharge times;
·
Information provide to next of kin and/or carers;
·
Aftercare packages and follow-up appointments,
e.g. care packages in the home, physiotherapy, etc.;
·
Aftercare provisions and equipment, e.g. an
additional stair rail, raised mattress, etc.; and
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Delays to discharge and underlying causes.
The research
question scheme was adapted throughout the focus group in to take account of
discussion and allow participants to interact with one another.
2.5 Data
Analysis Method
The synchronous and face-to-face nature of the data collection provided
the opportunity to collect verbal and non verbal data (Opendenakker, 2006,
p.3). By analysing both verbal and non verbal data a deeper understanding of
participant’s views and opinions can be developed. In order to analyse the rich
material collected through the focus group an analysis scheme was developed.
A gradual and comparative coding framework was developed for content
analysis of the transcribed focus group narrative. This was a multi-step
process of analysis used to interpret participants’ interactions, opinions and
experiences. This method was developed for two main reasons, to ensure that the
whole transcript was used for analysis (Silverman, 2011, p. 66), and to create
an in depth understanding of the data (Hannon and Callaghan, 2011, p.879).
The first stage of analysis was the creation of a multi-faceted account
of the focus group, created through the combination of research notes,
behaviour records and transcript. Through careful scrutiny of this multi-faceted
account, initial codes based on themes, topics and participants’ opinions were
developed and applied. The codes and themes developed were then reviewed and examined
for homogeneity. Finally, the links and relationships between codes and themes
were identified and discussed.
2.6 Research
Ethics
The focus group was audio-recorded, permission having been obtained from
all participants; the resulting recording was transcribed and participant
behaviour recorded in order to ensure that a complete account of the focus
group was used in analysis. As such, non response, agreement and dissent were
analysed in conjunction with transcripts to gain additional depth of
understanding and increase validity (Onwuegbuzie et al., 2009, p.5).
All primary data collection was approved by the Portsmouth LINk
Transition Group before commencing and research best practice and ethics were
considered at all times. Before beginning data collection, a document detailing
the nature of the research, data disposal and anonymity arrangements was
provided. A copy can be found at Appendix B. An ethics form (Appendix C)
recorded that the information sheet had been read and consent given for
involvement in the research, audio recording and use of anonymised quotes. All data has been
stored securely both electronically and in hard copy. All information will be
shredded and electronic data destroyed at the end of the research process.
Results
In the initial stages of the focus group, participants’ most recent discharge
experience was explored and the result suggested that this had been negative.
Each participant explored their reasoning for suggesting this. The table below
shows the score each participant gave their most recent experience and the
reasons they gave for this scoring. (See Appendix A, paragraph 1 for scoring
methodology*.)
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Participant
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Score*
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Reason
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1
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2
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Timescale issue; and discharge at 10pm.
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2
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1
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Lack of communication between staff relating to discharge; broken
promise relating to discharge time; Some positive communication.
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3
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1.5
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Assumptions by staff; patients categorised into ‘boxes’; mis-understandings;
assumption that information is understood by patients and family.
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4
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1
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Delay to discharge; told at 10am ready for discharge; discharged at 9pm;
asked to stay another night because they couldn’t get discharge signature.
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These initial discussions of patient discharges from QAH highlighted a
number of themes such as delays to discharge, time of discharge and
communication with next of kin. These themes have previously been raised at
LINk events; therefore the previous anecdotal evidence collected could be deemed
consistent with the initial findings of this research. These previously
established themes will be explored later in this section; first, however, a
number of general themes will be discussed.
3.1 General Discharge Experience at QAH
Participants were asked if the discharge lounge was used in the most
recent experience of discharge from hospital. One of the four participants had
an experienced a discharge that incorporated the discharge lounge, the other
three had experienced discharges straight from the ward.
Participant 2 described their relative’s experience of being moved from
the ward to the discharge lounge.
“ ...we were told to go some place, and we
went there, and there were no signs and we were told - try there [somewhere
else], and there was no one there on the desk”
(Participant 2)
This participant described
how they felt the process of going to the discharge lounge wasn’t ‘joined up’.
The lack of effective communication and direction left them to go back and
forth between two possible discharge locations.
“It seemed as though...
where she was or where she should have been wasn’t quite connected.”
(Participant 2)
This participant’s description of discharge was not unique in describing
a lack of communication and a confusing discharge process. Participant 1 illustrated
how their relative had been moved from their ward into an empty 4-bed ward
instead of using the discharge lounge. They went on to say that their relative
was left waiting alone, without explanation, in the empty 4-bed ward for
several hours.
Communication was identified as a key problem for participants,
especially Participant 3, who described a number of negative experiences by
black and ethnic minority service users. This participant suggested that these
experiences were a result of patients being categorised in a ‘tick box’
exercise leading to cultural misunderstandings.
During the group discussion of the general discharge process, the
connected issue of collecting discharged patients was raised by Participant 2,
“…there is no place to park to pick someone up...” They described their
frustration at having to use the car park for a few minutes in order to pick
someone up from the discharge lounge. They suggested that a 20-minute pick-up
bay by the nearest exit would allow for a better discharge process in such
circumstances. They also described a separate experience where they were
sitting in traffic for five minutes because the car park was full and there was
nowhere for queuing traffic to go. This comment was met with general agreement and
it was suggested that the hospital is too big and has too many patients, and
that parking and traffic issues are a manifestation of this problem. All
participants commented on their perception that QAH was too busy and that staff
appear overstretched.
There was a further discussion regarding the services and staffing at
QAH. It was suggested by two participants that specialist services and wards were
able to provide better care and discharge than the general services at the
hospital. Participant 2 attributed the difference in care between specialist
and general services to a culture of caring and a greater amount of time for
each patient as a result of SMART working.
“They create the time
because they do their jobs properly ... they seem to be staffed by the right
people, with the right attitude.”
(Participant 2)
Participant 1 suggested that services such as stroke care were better at
providing care and holistic discharge than more general services as a result of
better leadership and an ability to focus on core issues. It was generally
acknowledged within the group that there was increasing pressure on the
hospital to provide more services to a wider population and that this is
impacting on patient care and discharges. For Participant 2, this was
identified as a major issue with the hospital’s discharge process and they
suggested that the hospital should re-focus.
3.2 Discharge Times
The time at which a patient is discharged from QAH has been a recurring
theme within anecdotal evidence received by the Portsmouth LINk. As such, this
issue was explored within the focus group. When providing a score for their
previous discharge, participants also gave reasons for their scores.
Two participants suggested that the time of their most recent discharge
was inappropriately late. Participant 1 described how their elderly relative
was discharged at 10pm and suggested that this was not appropriate for that
patient. Participant 4 described how, after a significant delay, they were
discharged at approximately 9pm. This participant suggested that the delay was
the most significant reason for their low score; however, the lateness of the discharge
also influenced them.
One participant described a connected issue relating to the ability of
carers to arrange a suitable time for discharge. Participant 2 described how
they were informed that their relative would be discharged on the following day;
this participant talked at length with their relative’s nurse regarding their
ability to provide care for their relative the next day. They described how the
nurse listened to their circumstances and made arrangements for the relative to
be discharged in the afternoon when they would be able to take over the care.
However, the patient was discharged the next morning as the message regarding
the discharge time had not been passed to the next shift. This participant was
left feeling that staff “…end up promising and under-delivering”, but also said
that the “most important thing about that particular interaction was ... she
actually listened and then tried to help”.
3.3 Delays to Discharge
All the focus group participants talked about experiences where they
experienced delays to discharge. For Participant 4, the delay experienced
significantly impacted on their perception of the hospital and their rating of
the discharge experience. This participant described how they were informed at
10 o’clock in the morning that the patient was ready for discharge, but left
the ward at 9 o’clock that night. This participant described how they were
informed that the cause of the delay was a missing doctor’s signature on their
discharge papers.
“There was a lot of
effort and promises ... I had this constant, ‘Yeah you’re ready to go but…”
(Participant 4)
This participant described their frustration at being unable to leave the
hospital when they were medically fit. They described how, after waiting almost
ten hours to be discharged, they were asked to stay another night in hospital.
“...to be asked to stay
another night when there are stories of bed blocking going around is just
criminal.”
(Participant 4)
This participant described how they were informed that the only person
who could sign the papers was in theatre and therefore discharge would have to
wait. Once the doctor arrived, however, Participant 4 was unhappy with the
treatment received: “When he did arrive, he was rude, abrupt, poking me around.”
This participant’s frustration at their experience was clear when, at the
conclusion of the group session, they suggested that the key element they would
change was: “The person who says you’re fit to go should be able to sign to say
you can go, not to have to wait for some other person who’s just there to sign
a bit of paper.”
Participant 1 suggested that they were “…ready to go a long time before
we went…”. They went on to describe how, in a variety of their discharge
experiences, they were delayed. In one experience, they described being sent
back to a waiting area to await prescribed medication prior to leaving the
hospital. Others, such as Participant 3, identified the shift change as a cause
of their delay. They had experienced a three-and-a-half-hour wait due to the
shift change. Although a number of excuses were provided, they felt that
communication was poor. Poor communication regarding delay to discharge was identified
by three of the participants (1, 2, 4). Participant 2 described an experience
where their relative was left waiting to be discharge and they had to seek
information.
“... there was nobody at
all there, it was empty there and I had to go into the corridors to find
someone.”
(Participant 2)
Whilst Participant 3 did not directly comment on communication
difficulties, they did comment more generally during further discussion that
they felt communication with patients was being rushed during discharge. They
suggested that this was a result of the staff being consistently busy, leading
to reduced time to evaluate and engage with patients.
3.4 After Care Packages
As part of the focus group agenda, participants were asked about the
aftercare arrangements they have encountered after discharge from QAH. None of
the participants described situations where community care or provision had
been required. Whilst this element has not been captured as part of this
research, it has been a prominent theme within anecdotal evidence received by
the Portsmouth LINk.
Participant 1 described how they had mostly positive experiences of
follow up care at QAH, they suggested that the follow-up appointment was made
quickly but that they didn’t received aftercare advice. They did describe how there was discussion
with hospital staff to ensure that there would be someone available to look
after the patient after discharge. Participant 3 then suggested that they had
experience of aftercare appointments not being arranged. The appointment with
the surgical consultant was meant to be arranged within a few weeks but wasn’t
made, resulting in the patient losing their place in the queue and therefore
having an increased wait time for a replacement appointment. This participant
also suggested that, on occasions where aftercare advice and instructions had
been given, it was often too much information and difficult to absorb.
Participant 4 had a mixed view of the aftercare advice and appointment they
received, stating that they were given advice and dressings and received an
appointment for specialist testing but that it was seventeen weeks later. This
participant highlighted the issue of communication with their GP: “They sent my
papers to the wrong GP.” This was something other participants identified and
agreed with. Participant 2 described a discharge experience where the letter to
their GP wasn’t sent; this resulted in their relative having a prolonged wait
for follow up care. This participant felt that the problem was compounded by a
lack of acknowledgement of the problem by the administrative staff spoken to.
3.5 Next of Kin
The final theme explored in the focus group related to communication with
next of kin, something that has been highlighted to the LINk on a number of occasions.
Most participants suggested that they had experienced no problems with next of
kin being contacted about, or informed of, discharge decisions. However,
Participants 1, 2 and 4 made note of the fact that the next of kin were
informed as a result of their presence in the ward during the discharge
process. Participant 3 suggested that, whilst next of kin were informed of
discharges and aftercare, it was sometimes difficult for them to understand
what was being said as a result of cultural and language differences.
Participant 2 highlighted that they had experienced difficulties when they were
not present during healthcare discussions with their relative; they stated that
it was inappropriate as their relative had dementia and wouldn’t remember what
was said. They also suggested that there was a cost to carers, often ignored by
the hospital, when there was a delay to discharge and that the effect on carers
was not considered.
3.6 Influence of discharge
over perception of QA
The influence of experiences of discharge on the overall perception of
QAH was also explored within the focus group. Participant 1 suggested that the
process of leaving hospital was very important and greatly influenced
perceptions and, as such, they had a negative view of QAH. Participant 3 agreed
with this assertion and suggested that the process was full of too much form
filling by the staff and not enough communication. Participant 4 suggested that
their opinion of QAH was influenced by their whole experience. They stated that
it was:
“…not just the discharge
experience, but the whole thing was a nightmare. So yeah I did come out with a [negative]
view and I’ve actually joined the Portsmouth Hospitals NHS Trust, mainly to try
and get a voice in.”
(Participant 4)
This participants’ opinion of the hospital was also influenced by their
interactions with the nursing staff.
“I was in ... E ward, a
surgical ward, a small one, about 8 people in it, the nurses’ station was just
outside. Within the ward the alarms were going off because people’s drips had
run out and I said to the two nurses at the nurse’s station ‘shouldn’t you do
something about these alarms’ and they said ‘that the ward wasn’t their
responsibility’.”
(Participant 4)
Others talked of their experiences with staff when trying to communicate
negative views, complaints or problems. Participant 3 suggested that there is a
culture amongst patients and carers not to complain about the care they receive
at QAH but, if complaints are made, there is a general tendency to blame a lack
of staff and to make excuses. Participant 2 also described negative experiences
of making complaints to staff, suggesting that assertiveness is often labelled
as aggressiveness. This participant suggested that if staff said “I am sorry,
I’ll do the best I can to sort it out”, this would make situations much better
and would improve the overall experience.
Conclusion
This research was conducted by the Portsmouth LINk to investigate a
number of themes relating to the discharge experience from QAH as a result of
anecdotal evidence. A qualitative investigation of patient and carer experience
of leaving QAH after receiving inpatient treatment was conducted through a
focus group. The investigation focused on a number of previously highlighted
themes:
·
Discharge times;
·
Information provided to next of kin/carers;
·
Aftercare packages and follow up appointments;
·
Aftercare provision and equipment; and
·
Delays to discharge and underlying causes.
The participants in this research have suggested that the discharge
experiences they had at QAH directly impacted their perception of the hospital.
As such, the negative discharge experiences relating to communication, delays,
night discharges and administrative errors created a negative view of the
hospital overall. Communication was a key theme established from the
transcripts of the focus group; many of the participants described their
frustration at being left without information for long periods of time. This
lack of communication can be seen to have compounded any discharge problems, leading
to increased negativity about the overall experience. Therefore, accurate and
simple communication about the discharge problem, the solution to it and the course
of action intended should be communicated to the patient and next of kin or
carer at the earliest possible opportunity.
The time of discharge was an existing theme that was explored in the
course of this research. For some participants the time at which patient
discharge occurred was thought inappropriate. Whilst it may not be possible always
to plan an exact time of discharge due to capacity management issues, there
needs to be a holistic appraisal of whether a discharge is being conducted at
an appropriate hour. Previous anecdotal evidence has suggested that discharges
that occur at night (after 8pm) have left patients with no arrangements for
next of kin or carers to provide support and aftercare. This research has
highlighted that the circumstances of the patient and ability of the carer to
provide aftercare are being considered by some staff in the initial
conversations regarding discharge. This is a positive and encouraging practice
that has been highlighted by this research. However, as described in the
previous section, plans put in place are not always communicated to the next
shift resulting in rushed arrangements, misconceptions and disappointment.
Delays to discharge were highlighted by all the participants in this
research. For some, delays impacted significantly on their perception of the
hospital. Within discussion of this theme, most participants highlighted the obstacle
to discharge which was identified to them or they perceived to be delaying the
discharge. These difficulties included medication, change of shift, a doctor’s
signature and the responsible person being unavailable. This discussion
regarding delays and obstacles highlighted issues of communication and
responsibility. It suggested that, in these participants’ experiences of QAH
discharge, there has been a delay between being medically fit for discharge and
completing the discharge process and paperwork. Often, delay has been
compounded by poor communication to the patient and next of kin or carer.
Aftercare arrangements post-discharge from QAH has been a recurring theme
in the anecdotal evidence provided to the Portsmouth LINk. However, in the
sample of participants for this research, no one with previous requirements for
care packages or equipment was captured. However, the focus group was able to
capture data relating to the provision of follow up appointments and aftercare
advice as part of this wider theme. This
research captured both negative and positive experiences of these elements,
especially relating to the provision of follow-up appointments. This element
was a contentious issue for three of the participants who described long waits
and administrative errors leading to delays. These discussions alluded to an
issue with the arrangement of aftercare or follow up appointments. Another
aspect of this section was the provision of advice at the point of discharge. One
participant described how, as part of their discharge process, they received
aftercare advice. However, another suggested that they had been given too much
information too rapidly. Another stated they had received none. Within this small
sample, it can therefore be seen that there is a lack of consistency in
provision of aftercare advice.
The issue of communication with next of kin and carers, a returning theme
in anecdotal comment to the Portsmouth LINk, was examined within the focus
group. Whilst this previous anecdotal evidence highlighted a lack of
communication, this research did not find that next of kin or carers were
excluded from discharge discussions or planning. Nevertheless, it was
highlighted during the focus group that this may have been a result of next of
kin or carers being present at the hospital during the discharge process and
therefore being included directly in any discussion. As highlighted previously,
however, communication regarding the discharge process in this sample was found
to be insufficient and unclear, especially once a delay was underway.
Within the focus group two core themes were presented as key to improving
discharge process, communication and reducing delay. As such, the concerns,
issues and problems which emerged from the focus group confirmed aspects of previous
LINk anecdotal evidence and probably contributes to wider perceptions of QAH.
Staff at QAH understand that early and effective planning for the
Transfer of Care of all patients leaving hospital is key to ensuring patients
are safely discharged in a timely manner. In the event of unforeseen problems
arising, immediate and clear communication with the patient and carer about a
solution and course of action is vital for both patient wellbeing and
experience, as well as for the reputation of the hospital.
Good communication amongst staff, between staff shifts, between ward
staff and clinicians and administrators and, above all, between ward staff and
patients and carers is fundamental to the provision of timely transfer of care
and to resolving issues about any delays to this process.
This research suggests that experience of the discharge process could be
an influential factor in patient, relative and carer perception of the
inpatient experience, and general perception of the hospital. As such
appropriate, prompt and well communicated patient discharge needs to be a
priority for the continued improvement and development of Queen Alexandra Hospital.
References
Hannon, A., & Callaghan, E. G.
(2011). Definitions and organizational practice of sustainability in the
for-profit sector of Nova Scotia. Journal of Cleaner Production, 19(8),
877–884. doi:10.1016/j.jclepro.2010.11.003
Onwuegbuzie, A. J., Dickinson, W.
B., Leech, N. L., & Zoran, A. G. (2009). Toward more rigor in focus group
research: A new framework for collecting and analyzing focus group data. International
Journal of Qualitative Methods, 8(3), 1-21. Retrieved from http://ejournals.library.ualberta.ca/index.php/IJQM/issue/view/459
Opdenakker, R. (2006). Advantages
and disadvantages of four interview techniques in qualitative research. Forum:
Qualitative Social Research, 7(4), 1-13. Retrieved from
http://www.qualitative-research.net/index.php/fqs/article/view/175/392
Saunders, M., Lewis, P., &
Thornhill, A. (2009). Research methods for business students. Harlow:
Pearson Education.
Silverman, D. (2011). Interpreting
Qualitative Data (4th ed.). SAGE: London.
The Health Communication Unit.
(2002). Using Focus Groups. Canada: University of Toronto.
Appendix A
1. Thinking
of your most recent experience of the discharge process at QA hospital, where
either you or someone close to you left the hospital after inpatient treatment.
How would you rate the experience on a scale of 1 to 5, with 1 being terrible
and 5 being excellent? What is the major reason for you giving this score?
2. Was
this most recent experience of the discharge related to an overnight stay or a
day in patient treatment? Did the patient use the discharge lounge?
3. In
your most recent experience, what time was the hospital discharge? Were you
given any choice in relation to this time due to your circumstances?
4. If
you have had any other experiences of discharge from QA in the last 12 months
what times where the hospital discharges? Again were you given any choice in
relation to this time due to your circumstances?
5. Thinking
of all your experiences of discharge in the last 12 months, how long was it
from the time between being told of the discharge to leaving the hospital? Did
you think that length of time was appropriate?
Did any further treatment, care or discussion occur during this period?
6. Thinking
of all your experiences of discharge in the last 12 months, when preparing for
discharge were there discussions of any support or aftercare requirements? Were
there any requirements? Did you receive all the aftercare requirements agreed?
7. Thinking
of all your experiences of discharge in the last 12 months was the patients
chosen person or contact (like a next of kin) involved in the discussion about
the discharge?
8. Thinking
of all your experiences of discharge in the last 12 months, was the patients
chosen person asked to prepare for the patient leaving hospital?
9. Has
your experience of the discharge process influenced your opinion of Queen
Alexandra hospital?
10. Have
you had experienced the discharge process at other hospitals or in patient
services? Was this process different from QA?
Appendix B
Portsmouth Link
Discharge/Transfer of Care from Queen
Alexandra Hospital, Cosham.
Information Sheet
This Project
aims to investigate the extent of certain issues surrounding the
discharge/transfer of care, from the hospital.
You are
being invited to take part, as someone who has been discharged from the
hospital during the past year or because you know someone else who has been
discharged.
If you agree
to take part in this Project, you will be invited to take part in a ‘focus
group’ which will involve discussion of discharge/transfer of care from Queen
Alexandra hospital. The focus groups will last no more than two hours and
refreshments will be provided throughout the discussion.
Neither you
or any other person mentioned by you, will be identified by name in the Project
Report. All information will be kept in accordance with the Data Protection Act
(1998) No information will be given to third parties and will only be used for
the purposes of the Project.
The Project
Report will be made available to Portsmouth Hosp (Health Oversee and Scrutiny
Panel), Ship (Southampton, Hampshire, Isle of Wight and Portsmouth) Cluster –
formerly separate Primary Care Trusts, NHS Solent (Provider of Services), Adult
Social Care, Portsmouth and Portsmouth CCG (Clinical Commissioning Group). The
findings will also be made available to the Governing Body of Queen Alexandra
Hospital.
Should you
wish to contact an independent advocacy/support group during the Project please
contact the Samaritans on 08457 90 90 90.
Any
complaints concerning the conduct of the Project should be addressed to Ms
Noreen O’Leary, Portsmouth Link Support Officer, c/o, Portsmouth City Council
Community Engagement Team, Civic Offices, Portsmouth, PO1 2AL.The envelope
should be marked ‘Confidential’.
Yours
sincerely,
Terry Carter
Chair,
Portsmouth Link
Appendix C
PORTSMOUTH LINk DISCHARGE/TRANSFER OF CARE FROM QA HOSPITAL PROJECT
CONSENT FORM
Please tick box
I confirm that I have read and understood the
information sheet for the □
above project and have had the opportunity to ask
any questions.
I understand that my participation is voluntary and
that I can withdraw □
from the project at any point.
I agree to take part in the project. □
I agree to focus group to be audio recorded. □
I agree to the use of anonymised quotes being used
in the report. □
Contact details
Name ……………………………………………
Address ……………………………………………
……………………Post
code ………….
Telephone ……………………………………………
Email address ……………………………………………
These contact details will be destroyed once the
Project has been completed.