Oxleas NHS Foundation Trust case study

Oxleas NHS Foundation Trust decided to implement the Academy of Medical Royal Colleges (AoMRC) headings into their eDischarge summaries to ensure consistent recording of information, improve the quality of information shared with GPs and meet the NHS Standard Contract requirements December 2016 deadlines.

The implementation was fairly straightforward as electronic editable letters were already in use. The introduction of the new discharge letters improved productivity for clinicians as information was prepopulated from the Electronic Care Record (ECR) using the AoMRC headings.

Oxleas NHS FT provides community and mental health services to three boroughs in South East London. The services comprise of several specialist teams that serve children, young people, working age adults and older people in collaboration with several partner agencies. They are committed to providing services which are well managed, patient centred and efficient.

They have a workforce of around 3,500 people including many highly skilled health and social care professionals. There are over 125 sites in a variety of locations across the London Boroughs of Bexley, Bromley and Greenwich.

They also provide specialist forensic mental health care across South East London and in Kent prisons as well as adult learning disability services in Bexley, Bromley and Greenwich.

The project was started because the NHS Standard Contract requires the AoMRC headings to be included in discharge summaries. A small working group was formed with representatives from clinical, IT and the RiO transformation team. The group reviewed the old discharge summaries and the requirements for the new discharge summaries. All the headings recorded in the ECR, irrespective of whether they were Mandatory, Required or Optional, were identified and a new editable template developed to flow this information into a new eDischarge summary.

At the same time a review of the form used in RiO on ward rounds was also done. This form includes items such as medication and risks to self and is completed on an ongoing basis with a new one being created each week. Information from this form flows straight into the new discharge summaries.

Once the new discharge summary template was developed in RiO, it was tested, reviewed and then a go live date was agreed with all the adult mental health wards, seven in total. During this initial implementation, feedback was gathered and the quality of the discharge summaries was reviewed before roll out to other areas was considered.

Before the introduction of the Academy of Medical Royal College's headings

An electronic editable letter template already existed, with some of the wards using this and others creating them manually. Even using the template, discharge summaries were predominantly done manually and included some information that GPs wanted, but didn’t include all the AoMRC headings.

After the introduction of the Academy of Medical Royal College's headings

After the introduction of the new discharge summary using the AoMRC headings, about two thirds of the discharge summary is completed automatically for adult mental health. The discharges now take about 20-30 minutes less to complete compared to previously. 

A small working group consisting of representatives from clinical, IT and the RiO transformation team was formed. The group undertook two pieces of work, one to review the old discharge summary and look at the requirements for the new discharge summary and the other to review the ward round form used in RiO which feeds into the discharge summary. The reviews looked at what information could be included automatically in the discharge summary and what would still need to be done manually.

The project was greatly facilitated by another project that was implemented to improve the standards and practice of note keeping in the weekly ward rounds. The notes were taken as free text entries in the ECR using templates that varied between different hospital teams. Using the outcome of a wide consultation a new form was created in the ECR to support the note keeping in the ward round in a semi-structured format. The eDischarge summary project enabled flowing of key information from this ward round form into the editable letter template that automatically creates the first draft of the eDischarge summary.

Once the review was completed the new editable template for the eDischarge summary was developed in RiO. The first draft went through two revisions after initial tests with the final version being audited for two weeks. Junior doctors who traditionally prepare discharge summaries used the new eDischarge summary template in three hospital wards to measure the time taken to prepare them. This small group of doctors was trained in the use of the new ward round form, how information from this form flowed into the new eDischarge summary template and how they were expected to review, edit and finalise the first draft generated by the ECR.

This small audit showed average savings of 30 minutes for each discharge summary. An acute admissions ward of 20 beds typically has to prepare between four and six discharge summaries each week, so the new eDischarge summary showed potential for considerable time savings for the junior doctors.

During the initial testing and training with different ward teams, there was feedback regarding the diagnosis section and changes were made to improve the clarity and consistency of contents in this section. The clinical coding team also fed back about the information entered into the diagnosis field and this was changed into a table rather than free text.

Approximately six weeks after go live the quality of the discharges was reviewed and a newsletter was written to the doctors informing them of what went well and what didn’t go so well. Feedback also determined a few other minor tweaks to the template to show that the doctors were being listened to.

Once that was complete work then started on community and the older adults and adult learning disability team and prisons. None of these have currently gone live, however, community and older adults are working with the manual template which although it doesn’t pre-populate with fields, does use the AoMRC headings. When the new discharge template is implemented it will drastically improve the production of eDischarge summaries in these areas as they will have information pre-populated which they haven’t had before.

1. Standardising the implementation of AoMRC headings across the organisation has reduced the time spent producing the final eDischarge summary by approximately 30 minutes per discharge.
2. Collaboration with GPs to make the action plan section clearer so that it is obvious who is responsible for what - the clinician, the patient or the GP.
3. From a safety point of view, using the AoMRC headings means less opportunity for the omission of key information.
4. Reduces the time spent by GPs contacting the trust to ask for potential missing information. 

The electronic care records system requires further enhancements to ensure that structured/coded information is populated automatically into the discharge summary template. Currently this needs to be done manually which has created considerable variation in practice. We have addressed this through training and guidance materials and plan to follow this up through audit cycles to ensure that the practice standards are embedded.

Demonstrations were carried out in doctors’ meetings to show how things would change and guidance documentation was available for them to refer to. A recorded webinar was also made available for viewing to remind them of how to complete things, including completion of the ward round form which feeds into the discharge summary.

Due to the fact that the clinicians were already used to using the editable letters, it was felt that the guidance would be enough as the new discharge template is very similar, just with more information included automatically.

There is now only one editable adult mental health discharge template which they all use.

Find out more about the AoMRC headings.

The eDischarge summary is one of the Transfer of Care Initiative projects.

If you have any questions please email: [email protected] (mark it for the attention of the Integration Projects Team).