Home before dinner

Our project is making it quicker and easier for patients to get home after a hospital stay, by standardising team communication and involving patients in discharge planning.

A rapidly increasing population on the Central Coast is driving demand for health services. This is affecting staff retention and patient outcomes, and contributing to service capacity limitations and our ability to deliver best-practice care to the community. Gosford Hospital is facing significant challenges with prolonged hospital stays. In 2024, patients stayed longer than average for 8 of the 10 most common diagnoses (compared to peer hospitals).

Key contributing factors include:

• fragmented discharge planning
• ineffective multidisciplinary team communication
• low engagement with patients.

Hospital staff reported poor collaboration and low satisfaction with the discharge planning processes. Patients said they didn’t know their own discharge plan and date, and felt stressed and forgotten about because they were not involved in the process. To enhance discharge planning, our project implemented changes that standardised daily multidisciplinary team meetings, improved communication and increased patient involvement.

Making changes to relieve discharge pressures

Gosford Hospital is a tertiary referral hospital located between Newcastle and Sydney. It is one of two acute hospitals in Central Coast Local Health District (CCLHD), providing 24/7 emergency services and specialist inpatient care. A growing population with a higher-than-average number of older people, and a significant number of people who are socioeconomically disadvantaged, is increasing pressure on local health district services. For more than 2 years, Gosford Hospital has not met targets that recommend no more than 85 patients at any given time should be hospitalised for 9 days or longer.

During our project’s diagnostics phase, we found patients wanted to be more involved in their own discharge planning. Bureau of Health Information data indicates that 55% of patients definitely want to be involved in discharge planning.¹

Our patient interviews showed that only 43% of patients felt involved in their discharge planning, creating stress and dissatisfaction with the process. Our patients gave feedback including: “I felt like I had been forgotten”, “I just want to go home”, and “I’ve tried to be involved but it didn’t get me anywhere”.

Staff surveys also highlighted low satisfaction with communication, interdisciplinary collaboration (23% satisfied) and patient-centred care (24% satisfied).

Improving meetings and communication

Our diagnostics showed there were multiple issues contributing to fragmented discharge planning processes. Project stakeholders identified the key area to improve as ineffective daily ward meetings, which were impacting communication between  multidisciplinary team members and patients.

To explore and develop solutions, our project team facilitated a hospital-wide workshop, encouraged collaboration through an online whiteboard and conducted a literature review to identify evidence-based practices. We selected a ward to trial potential strategies, and established a working group to oversee the design, testing and refinement of our ideas.

We designed and tested 5 solutions through plan-do-study-act cycles on the trial ward:

• Improving attendance at multidisciplinary team meetings, and using high-level support from the executive sponsors to ensure engagement with the medical teams, allied health and nursing staff
• Standardising these meetings by developing a meeting script
• Documenting meeting outcomes electronically on the electronic patient journey board
• Using bedside patient communication boards to improve communication with patients and their families
• Assigning responsibility for updating the patient communication boards.

Following successful testing, the project entered its implementation phase. A high-level GANTT chart helped us plan the rollout, and we used tools such as the implementation history profile, implementation risk forecast and the CAST model (champions, agents, sponsors, targets) to assess risks and readiness across the hospital. We prioritised 2 key areas for support – addressing organisational stress and reinforcing confidence in the implementation process.

Throughout implementation, ongoing feedback from staff, patients and carers informed continuous improvements, refined our strategies and ensured that changes were acceptable and sustainable. Hospital-wide rollout of the solutions are now underway, supported by strong executive sponsorship and structured implementation planning.

Early signs of success

Multidisciplinary team meetings and communication processes with patients are currently being implemented across Gosford Hospital.

Our project team observed that patients and staff have a real need to feel the discharge planning process runs effectively, with communication being central to the solution. During the pilot phase of the project, meeting attendance improved significantly. Discharge planning information being updated on the electronic patient journey board was completed most days, and feedback from staff showed that having one access point for this information was beneficial.

Implementing the changes hospital-wide has required adapting the solutions to ensure there is a consistent and standardised approach across all wards. For example, evidence from the literature review highlighted that a daily 15-minute meeting at the electronic patient journey board effectively promoted consistent multidisciplinary team meeting attendance and communication.^2,3 We didn’t adopt this approach on the trial ward because it didn't align with their existing meeting structure. However, it was incorporated as a core component of the standardised approach for the hospital-wide rollout. Emphasis has also been placed on ensuring that all disciplines, particularly medical staff, attend the meetings to support more effective communication, shared decision making and improve discharge planning outcomes.

References