Information Capture Tool
The final developed tool was an information capture pro-forma that can be adapted and used in most existing information systems. The purpose of this tool is to standardise information capture upon admission. The pro-forma enables the healthcare professional that is responsible for liaising with external referral agencies to capture 10 domains of information which participants in this process deemed to be important to enable effective and efficient discharge. The proforma provides prompts and open-text boxes to enable flexibility. The information categories generally concerned personal and social circumstances of patients.
Box 1: Final Co-designed information capture tool
Please complete the following free text entry in relation to the admission. This needs to include the key information needed to commence the admission onto the ward. The following should be included, if the information is not available please state why. Please highlight any information that is missing, as it will need to be followed up and addressed by the inpatient team within 72 hours of the patient on the ward.
- Source of the referral (e.g. crisis, MHA)
- Purpose of admission
- Current presentation (e.g. symptoms)
- Current risks
- What is needed for discharge (e.g. what are unmet needs in the community)
- Social needs (e.g. accommodation, finances etc.)
- Caring responsibilities (e.g. children, elderly relatives, pets, other)
- Safeguarding issues (present or past)
- Physical healthcare (e.g. what monitoring is needed, appointments, equipment and resus status)
- Other services involvement (3.g. community team, police, social care)
- Intervention Characteristics
There were three broad relative advantages associated with using the tool as opposed to an alternative solution 1) facilitating confidence in junior staff to legitimately question the suitability of a patient for an acute ward 2) collecting and storing essential information in a single accessible place that can be used throughout the care pathway and 3) collecting information from the services/agencies that patients will eventually be discharged to that will speed up the discharge process.
‘But, I think, from what I’ve seen it’s empowering them…And, I’ve seen a bit of a change in them actually, in terms of stand…you know…sort of, asking the right questions, and challenging, should this person be admitted’ – Acute Service Manager
‘this is the information that you’re gathering, that you’re giving to your staff to say, this is the person that’s coming in, these are their risks, these are their needs, this is what we need to help them with, this is the time they’re coming in, this is extra support that they might need. And for me, that’s all part of clerking and introducing that person to the ward’– Lead nurse
Having the information collected as standard and in a single place had’ knock-on’ effects for practice of other staff groups on the acute ward, for example, a junior doctor interviewed was unaware of the tool but had noticed its beneficial implications exemplified in a difference in the quality of information she had access to. A similar experience was had by ward staff, who felt that the questions asked using the new tool had a positive effect on the appropriateness of admissions.
‘this patient got admitted and essentially all that information was there and I’ve not seen the checklist but I’ve seen all of this information on an admission… Yeah, so they may have used it and actually made life a lot simpler’ – Junior Doctor
It could be that the tool was most beneficial as it collected the information into one place and documentation format that the ward staff needed, were familiar with and involved in the process of design. One junior doctor described how all of the information is probably in the online system anyway, but it’s difficult to access and spread across multiple files that may be slow to open.
‘It was just on [information sharing system] and in different places in the different case notes.’ – Junior Doctor
There was a lack of knowledge amongst staff who did not attend the co-design events about the tool being internally developed. Despite all staff being invited to join in the development of the tool at co-design events, there was a general consensus particularly amongst lower-level staff that they were not involved in the development of the tool and that they did not know who was. There was a lack of communication between those who attended events and other staff members.
‘I don’t know who went to them. Or how often they used it on the other tool since they’ve done the co-production meetings’- nurse.
There was a perceived complexity in terms of the scope of the tool; which enabled staff to make their own decisions about when to use it. The data highlighted that there were inconsistencies amongst professionals about when the tool should be used. For example, many lead nurses that were responsible for using the tool to capture information, felt that it wasn’t necessary to use the tool if there was a transfer back to the ward (for example from an out of area bed or psychiatric intensive care units). Inconsistencies in definitions of what constitutes an admission and therefore use of the tool were also noted in the ethnographic field notes. However, by choosing what defines an admission (and subsequently when to use the tool), there is a risk of missing the opportunity to capture pertinent information.
‘Yeah, I think admissions that you would use that tool for ’cause you don’t sort of use it for transfers’ – lead nurse acute ward
‘Most of the calls that have been received today have been for transfers rather than what staff would constitute as ‘new admissions’ therefore the bleepholder today, as well as yesterday, has chosen not to use the tool for transfers for potential mental health act assessments that are not yet definitive admissions. They used scrap paper instead to collect skeletal information.’- researcher field notes, day 3 of implementation.
There were also many instances when the typical process would not be followed, as individuals chose to ‘by-pass’ the system, and therefore using a standardised format for information capture might be difficult.
‘Yeah, there’s lots of occasions when it might just get by-passed. So it might be that the mental health liaison team at A&E just ring the bleep-over themselves, and get the bed themselves.’ – crisis team lead nurse
- Outer setting
External Policies and Incentives
The tool was co-designed with staff to fit into the current systems, processes and policies; which are amenable to change at any time. The implementation process also promoted a deeper engagement with transition quality and safety, by facilitating meaningful discussions on a frontline and management level.
I think, it’s a bigger picture, I think, the whole idea of the, kind of, assessment services being more responsible for the admission process, is something that is being discussed at quite a high level.- lead nurse
- Inner setting
Networks and communication
The implementation and co-design events highlighted the effect of weak communication between services, wards and professions, that potentially had an effect on ineffective information transfer. The interviews highlighted that staff are unaware of roles, associated documentation and intentions/capabilities of other teams. This was a particular barrier in gaining ‘buy in’ from other teams that felt that the tool was duplicating work or implicitly suggested that other teams were not performing. This was particularly problematic in a complex period, such care transitions, whereby inter-agency working is essential. Those interviewed from associated agencies other than the acute ward felt that they were already gathering this information from referral agencies (crisis team, bed management team). However, interviews with all of the ward staff highlighted that they did not feel they had access to the information they needed to improve safety and patient experience and accelerate discharge.
‘We gather it all anyway, I make sure that I’ve got it all anyway. I wouldn’t dare ring the bleep holder and say I want a bed and them say, well why and me saying, I don’t know.’- crisis nurse
‘I think that is absolute basic stuff that doesn’t get…I think that doesn’t get asked by anybody half the time.’ – Acute service manager
A similar misunderstanding of roles and tension was felt by the bleepholders, they felt that other agencies didn’t understand the pressures they faced trying to secure beds; which inevitably leads to inter-agency tension. Although staff from groups worked together in co-design events, there was a definite tension between ward staff and those from other associated services which was a barrier to implementation and changed the format of the tool after the co-design event 2.
‘‘‘Because I’m sure most people think we actually do hide beds up...but people still think we do, so they think they can threaten you or they’ll talk to your manager’ – Lead nurse
‘In the co-design event 2, there was evident tension between the crisis team and bleepholders. The crisis team felt that the tool was redundant and a duplication of existing process, whereas the bleepholders felt that they were missing vital information and would like a standardised tool to collect this. The crisis team refused to pilot the tool as they felt they did this anyway, however the bleepholders really favoured the tool, so we decided to pilot the tool with the bleepholders only’ – researcher field notes
Many staff felt one of the benefits of the tool was that it empowered more junior staff to be more confident in asking questions. However, there was also a sense that although the tool empowered staff to ask the right questions, it didn’t necessarily give them to power to change anything based on the responses they receive. Another unintended consequence was that some staff reported using the tool as vehicle to block admissions, by describing the tool as process of rejecting admissions. One interviewee (lead nurse) described the tool metaphorically as a way of depersonalising the rejection process ‘computer says no’. A beneficial unintended consequence, was that the work sparked changes in policy around the roles and processes associated with discharge on a local level.
‘why ask a question, if it doesn’t change anything? …But, I can also see that if you ask for information, and then you challenge it, and you basically get told to pipe down, I can see that you wouldn’t keep asking for stuff’ – Assistant head of nursing
‘It’s given us the evidence to really robustly challenge that and it’s made the referrers think, when we’ve said, well, have you got a safety plan on? Oh, well, no. Well, I’m not accepting them until we’ve got a safety plan. Because we’ve got the structure of the tool and because we appear to know what we’re talking about, and everybody’s saying the same thing, I think it’s been better’ – Lead nurse