We put our service design skills to the test with a quality improvement challenge for Imperial College Healthcare NHS Trust, facilitated by the Royal College of Art Service Design department.
Reduce the amount of time a patient spends in hospital during the discharge process and minimise the risks involved for patients beginning Warfarin treatment.
A 6 strong team of doctors, consultants, patients and designers.
Key to our early success was the inclusion of a junior doctor whose intimate knowledge of Warfarin treatment immediately earned her Project Champion status.
The doctors on our team described a complex discharge process reliant on detailed dosages, continual monitoring and multiple stakeholders.
Going on Safari
However, to fully understand the real challenges of Warfarin treatment, we had to leave the safety of our our conference suite and get out into the real world (Imperial’s anticoagulation clinic.)
Speaking to patients exploded our understanding of the treatment. Their personal stories helped build a profile of the key service users.
The personal experiences of patients and clinic nurses helped us develop stakeholder personas; using them to build empathy and focus our attentions on real patient and doctor problems.
Creating a customer journey map helped us identify all the ways in which stakeholders interacted with the service. However, a physical mapping of the steps involved in a discharge opened our eyes to the unnecessary duplication throughout the process.
So what exactly is the problem?
The customer journey and discharge maps illustrated an overly long process. Stored in silos, information is duplicated and activity regularly hits roadblocks for reasons as basic as an unanswered fax.
Self care materials, not distributed in a timely manner finds patients experiencing unnecessary waits to get home.
Who is affected by this problem?
Patients play a central role in this process and are expected to take a great degree of responsibility for their treatment.
However, when information, such as the yellow anticoagulant book is delivered late into the discharge process, or missing, they lose vital time to clarify any confusing steps in their treatment.
The Problem In Greater Detail
Every patient requires a unique dosage of Warfarin which they’re not allowed to leave hospital without. Nor can a patient be discharged until a follow up appointment at their local anticoagulation clinic is confirmed. At present, these appointments are booked when a doctor receives confirmation of an appointment after faxing a patient referral form to the hospital clinic.
Much of the referral summary is then duplicated and manually entered into a discharge summary, inviting opportunity for clerical error.
Everyone in the warfarin supply chain is currently experiencing significant demands on their time. Faxes are missed and phones unanswered, causing significant and unnecessary discharge delays. Sometimes, it takes all day for a clinic to reply, only at which point can they confirm that the booking has been made to the most appropriate clinic for the patient’s location.
At some point during the discharge process, patients are informed of their responsibility to manage their treatment plan.
Earlier work has been done to produce a reference and usage guide and appointment log book, the ‘Yellow Anticoagulant Book.’ Limited supply of this important document means they aren’t always distributed in a timely manner, reducing the amount of time patients have to seek and clarify information about their treatment.
After two days of investigation and research, we identified a number of opportunities to improve the Warfarin discharge system.
Problem 1: The referral form and discharge summary require the same information yet are completed separately.
Solution: Merge these forms.
Problem 2: Doctors only realise Yellow anticoagulant books have run out when they go to take one from the filing cabinet.
Solution: Place the books in a clear bag outside the filing cabinet so ward doctors can see when they need replacing.
Problem 3: Yellow Anticoagulant books contain a great deal of information that required much clarification from time poor doctors.
Solution: Produce an FAQs intro card of most important information at the start of the book.
Problem: Doctors have to wait for clinic feedback to book an appointment.
Solution: Make the online clinics booking calendar available to the doctors on the hospital intranet system.
Problem: A Warfarin app exists but doesn’t prompt doctors to follow a prescribed discharge process
Solution: Update the capability to include a discharge checklist whereby discharge can only be granted once steps have been followed in the correct order.