PSIP Test submissions

Test submission 1
Initial ideas for improvement: using Model For Improvement
Questions
Q1: What are you trying to accomplish? i.e. What overall
improvement do you want?
N.B. Focus on what needs improving overall and NOT a solution or
intervention. Does NOT need to be quantifiable or target driven (i.e. how
much by when).
Overall I need to make the team work more efficiently to meet the
demands upon it. I would like ultimately to be able to roster time for ward
work, emergencies and administration related to clinics. The overall
improvement I want to see will only be achieved by one smaller
improvement at a time (1000 lives). REF

Q2. How will you know that a change is an improvement?

N.B. What would it be like, what could you evidence as improvement?
Leads on to how you might be able to measure or evaluate that.
I hope to demonstrate that the change is an improvement by
measuring the increase in time available to trained staff, which
can then be utilised to enable further improvements. Efficiency
could also be quantified in a lower cost per patient appointment.
Satisfaction with the new service could be measured by patients
completing the existing friends and family cards and perceived
quality could be measured by the opinions of colleagues,
managers and the relevant consultants. The safety of the change
will be examined by audit id datex reports.
Q3. What changes can be made that will result in improvement?
(May not be known yet of course, or just some basic ideas)
3a) What is wrong
It is necessary to understand the problem to understand the solution
(1000 lives)REF .The Nurse Practitioner team are not able to spend the
time which they would like with ward patients and emergencies. In order
to improve waiting times for urology patients it is vital to increase the
frequency of Nurse led clinics. There is increasing demand for further
elective appointments. Currently the Nurse Practitioner on call for
emergency admissions also has scheduled appointments at the same
time, meaning delays to both the emergency patient and the patient with

the routine appointment. The constraints concerning the availability of

facilities currently dictate when particular clinics can run e.g. the
availability of clinic rooms and other staff.
N.B. focus on the underlying problems or issues in relation to what needs
to be improved.
3b) What might work?
Restructuring our work pattern could work, but I feel that there are too
many conflicting requirements.
I feel that fully developing the Band 3 HCA role in our team, enabling her
to manage more patients independently, will liberate more time in the
team as a whole. I have previously improved other areas such as working
more efficiently together and fully utilising our volunteer. There are a few
areas of our elective work that I think could be taken on by a HCA
experienced in Urology with appropriate training. These areas include trial
without catheter for patients after radical prostatectomy, removal of a
tethered stent after ureteroscopic stone surgery, and possibly female
catheterisation to administer a bladder treatment. In order to simplify this
project I have chosen to concentrate on removal of tethered stents
( Appendix 2).
N.B. Focus on any changes that might work to bring about that
improvement.

Test submission 2
Initial ideas for improvement: using Model For Improvement Questions
Q1: What are you trying to accomplish? i.e. What overall improvement do you
want?
The purpose of my service improvement project is to try to improve the quality of
information / evidence in Guardianship reports in my local authority. I would like to
help make the gathering of information more focused, more relevant to welfare
issues, which Guardianship is all about and therefore to make the evidence in the
reports less open to potential legal challenge.

Q2. How will you know that a change is an improvement?

I am aware that improvement is a very subjective term. My view of an improvement
may be totally different from my colleagues or my managers views. So I am

approaching my SIP with this in mind and hopefully the end result will be seen as an
improvement by all stakeholders (or at least most of them).
Following a change in the way information is gathered and reports are written,
improvements in the Guardianship application process could be observed /
measured by workers feeling more confident about their guardianship applications;
by managers observing a high quality of report writing, by the local authority having
few challenges to Guardianship applications from tribunals or by Nearest Relatives
objecting to the orders. Finally, it will hopefully enable service users and carers to
have a greater understanding of the process which could lead to increased levels of
compliance with the orders.

Q3. What changes can be made that will result in improvement? (May not be
known yet of course, or just some basic ideas)
3a) Anecdotal evidence from colleagues in my own local authority and others indicate
that many AMHPs do not like completing Guardianship applications. They believe
the paperwork is not fit for purpose; they are not always certain whether
Guardianship is the most appropriate piece of legislation or whether the individual
needs a different framework (such as the Mental Capacity Act).
When writing AMHP reports for Guardianship applications the AMHPs in my local
authority use the same form that they use for Mental Health Act assessments. These
forms primarily focus on the risks to the person from their mental disorder rather than
their social situation. The problem many AMHPs find is that they can feel deskilled
when making Guardianship applications. There is also a risk of the work just
becoming a paper exercise with little room for evidencing the use of professional
judgement in these cases.
3b) Some possible options that may improve the Guardianship applications may include
specialist training for AMHPs, a checklist / aide memoir that AMHPs could refer to when
completing Guardianship assessments or changing the Guardianship reports themselves.

Test submission 3
Initial ideas for improvement: using Model For Improvement Questions
Q1: What are you trying to accomplish? i.e. What overall improvement do
you want?
N.B. Focus on what needs improving overall and NOT a solution or
intervention. Does NOT need to be quantifiable or target driven (i.e. how
much by when).

Through this service improvement project I aim to improve communication

between our team of ANPs, and older patients who have been discharged
home from our care. The purpose of this is too provide older patients with a
means of directly speaking with an ANP with specialist knowledge and skills,
should they encounter any problems or have any questions once they have
been been discharged from hospital. Due to our current job role and access to
community services we would then be able to signpost patients to community
services or bring them into our ambulatory emergency clinic to assess them. It
is hoped this will provide a better service for older patients and potentially
prevent inpatient admissions to hospital.
Q2. How will you know that a change is an improvement?
N.B. What would it be like, what could you evidence as improvement?
Leads on to how you might be able to measure or evaluate that.

If this change is an improvement I would expect to see an increase in

communication on discharge between ANPs and patients. I would hope there
to be increased patient satisfaction and reassurance for patients and relatives
alike on discharge. Statistical information and documenting communication
between ANPs and patients on discharge which shows the reason for
interaction between ANP and patient, and the outcome would aim to evidence
this improvement. Equally, this service improvement may may also lead to a
reduction in hospital admissions by signposting patients to primary and

secondary services as required, although this may be difficult to evidence as it

would be based on personal judgement.

Q3. What changes can be made that will result in improvement?

(May not be known yet of course, or just some basic ideas)
3a) What is wrong?
N.B. focus on the underlying problems or issues in relation to what
needs to be improved.
At present it is suggested there is a lack of access to specialist services, poor
care planning and communication for older patients who have been
discharged from hospital (Cornwell 2012). This is also reflected in my
personal experience of working as an ANP for older patients being discharged
from hospital, and on occasions the reasons they re-attend to the hospital.
Similarly Witherington et al. (2008) also suggest poor communication on
discharge is a problem and a likely reason for adverse events and readmission to hospital for older patients.

3b) What might work?

N.B. Focus on any changes that might work to bring about that
improvement.
A telephone service for older patients to contact myself and the other ANPs
with any concerns or queries on discharge, may address the problem of
communication and access to specialist service and improve this problem.
However, older patients represent a large cohort of patients within the
hospital, therefore initially limiting the telephone service to a select group of
patients to test the service improvement idea would be my preferred
approach. I would then envisage the telephone service to be rolled out to all
the older patients who are seen and treated in our Ambulatory Emergency
Clinic, depending on the success of the telephone service.

Test submission 4
Service improvement within the health sector, aims to improve patient care
through what Boyle (2003a, p.223 cited Ashworth et al, 2010. p.3) describes as
a closer correspondence between perceptions of actual and desired standards of
public services, of which the NHS is still a part. That is to say, the drive behind
my chosen service improvement project, the improving of the level of
information provided on the hospitals patient discharge summaries, could be
improved and, therefore, closer to what I would desire within my practice.
On occasions within the community, the presence of a hospital discharge
summary can provide reliable evidence in the clinical decision making process, in
providing an overview of the reason behind their last admission, the outcome of
relevant investigations, the treatments they underwent prior to their release
from hospital, a list of their medication, and a plan for onward care. These
letters have proved wholly invaluable at many times in my career, and in the
working lives of my colleagues and other health care professionals within the
out-of-hospital setting, as they provide a robust set of reference notes which can
help guide the current consultation.
A feature, however, of the discharge letter that has never been included, but
which would have proved invaluable in trying to better manage patients within
the community, is a copy of the 12 lead electrocardiogram (ECG); a recording of
the patients latest ECG. Whilst there are occasions when patients are
discharged from hospital inappropriately (Rayner 2015), it would generally be a
reasonable belief that when patients are discharged, their last set of clinical
observations, including their ECG, could be regarded as an accepted benchmark
finding for that specific patient.
Working as I do within the Out of Hospital setting, providing around the clock
care, the routine of my shift will place me in direct contact with patients with
varying ailments; shortness of breath, chest pains, dizziness, and many other
health concerns. In these instances, it would be pertinent to record a copy of
the electrical activity of their heart on an ECG, which Hampton (1992, p.v)

regards as an extension of the history and physical examination. That the ECG
is just one piece of the jigsaw of signs and symptoms of the presenting
complaint (ref ref), it can nonetheless, be a determining factor in onward care
decisions. At present in most instances, the clinician on scene when evaluating
the ECG is comparing the patients rhythm and the electrical waveform against a
predetermined set of ECG parameters dating in their origins to the work of
Waller and Einthoven in the 19th century (Hurst 1998). For patients with preexisting cardiac disease, who may be older in life and, or, may have been the
subject of cardiac surgery, or have a congenital cardiac defect, their accepted
norm is a deviation from the accepted standard.
The benefit of an ECG for comparison becomes clear, as the clinician evaluating
the patient with shortness of breath or chest pain, can gauge whether there has
been any acute changes to the electrical waveform which would warrant
immediate admission into hospital.