Adult Community Services

Project

Improving respiratory patient access to digital health resources via Patient Portal

Lead: Della Thomas, Respiratory Advanced Clinical Practitioner

 

What was the problem?

A patient survey highlighted that the existing chronic obstructive pulmonary disease COPD action plan needed to be redesigned to better meet patients' needs, and the organisation's new patient portal offered an opportunity to give respiratory patients digital access to their action plan and health resources. The wider patient portal rollout was later put on hold as organisational priorities shifted to the Electronic Patient Record system (EPR).

 

Aim

To improve respiratory patient access to digital health resources via the patient portal, by redesigning a simplified COPD action plan to raise patient satisfaction from 69% to 89% and increasing patient registration and digital plan usage on the portal, by July 2023.

 

What did we do?

Used QI tools including Lewin's change theory, force field and fishbone analysis, and stakeholder engagement to plan the change. Worked with clinical, design and patient experience colleagues to redesign a simplified COPD action plan and make it available digitally through the portal.

 

What are the benefits for patients (and staff)?

Patients now have a clearer, more concise COPD action plan that better meets their needs and gives them more control over managing their condition, with registered patients also gaining digital access to their action plan and resources. Increasing use of the portal is also expected to improve patient flow and reduce pressure on the workforce.

 

Measures

Patient satisfaction with the COPD action plan rose from 69% to 92%. 30 patients registered to access the digital plan and resources via the portal by the end of June, exceeding the 15% registration target.

 

Qi Tools used

• SPIN model.
• Lewin's change theory.
• Force field analysis.
• Fishbone diagram.
• Stakeholder analysis.
• Gantt chart.
• RACI chart.

Project

Reducing Direct Diagnosis Spirometry West waiting list

Lead:  Luke Butler, Clinical Service Manager; Vicky Egere, Service Manager

 

What was the problem?

The West Direct Diagnostic Spirometry Service (DDS) clinic, which provides respiratory diagnosis through spirometry, FeNO testing and clinical history to support treatment planning, had a waiting list of around 26 weeks and 188 patients, delaying diagnosis and evidence-based treatment.

 

Aim

To assess and treat an additional 35 patients on the West DDS waiting list by December 2026, by implementing a short-term additional clinic over five months.

 

What did we do?

Discussed options at a QI Huddle and agreed to set up an additional Tuesday clinic at Soho Health Centre from 11 August 2026. Arranged staffing, set up a temporary clinic stream on RIO, and began transferring and booking patients from the West waiting list into the new clinic.

 

What are the benefits for patients (and staff)?

Patients on the West waiting list gain earlier access to diagnosis and an evidence-based treatment plan, helping improve health outcomes and reduce hospital admissions, while planning around room and staff availability protects capacity across the wider service.

 

Measures

• Reduction in the West DDS waiting list, targeting 35 additional patients assessed and treated.
• Reduction in waiting time, targeting around 20 weeks.
• Measured between 11 August and 1 December 2026.
• Ongoing data analysis to inform the next PDSA cycle.

Project

Family carer hoisting instructions and practice form.

Lead: Fran Lenton, Clinical Lead Occupational Therapist

 

What was the problem?

The existing Moving and Handling policy appendix form was mostly tick-boxes with insufficient space for detail, gave families nothing to refer back to, and only covered full hoisting rather than standing hoists or other transfer aids. Family carers needed to be able to safely use equipment prescribed for their relative, and in most of Birmingham there was no alternative way, such as Sandwell Red Cross, for them to gain these skills.

 

Aim

By June 2026, to have a fit-for-purpose instruction and practice slides document for all Therapy Hub clinicians to give to family carers.

 

What did we do?

Set up a multidisciplinary working group to design a single form covering hoists and transfer aids, with equipment details, instructions and space for session notes. The form was trialled and refined with clinicians and families through PDSA cycles, developed in electronic and printable versions, and approved through governance.

 

What are the benefits for patients (and staff)?

Family carers now have clear, comprehensive information and instructions for using hoists and transfer aids safely, replacing a previous process that duplicated documentation and gave families nothing to refer back to. Clinicians report the new form is a much-improved guide that reduces duplication, and the project received a Learning from Excellence award.

 

Measures

• Clinician and family carer feedback since roll-out.
• Outcome measures: form adoption, family access to information, reduced duplication.
• Process measures: PDSA cycles, stakeholder engagement, governance sign-off.
• Balancing measures: documentation time, staff satisfaction, usability.

 

Qi Tools used

• Plan, Do, Study, Act (PDSA) cycle.
• Driver diagram.
• QI Huddle.

Project

Discharge advice care for palliative patients

Lead: Lisa Kennedy, Service Clinical Manager

 

What was the problem?

Large numbers of stable palliative patients remained on community nursing caseloads, often receiving only telephone support for months, raising concerns about assessment quality. Discharge safety-netting advice was previously vague (“call if anything changes”) and not measurable, and the response to palliative referrals varied depending on where and by whom they were received.

 

Aim

To provide discharge advice to stable palliative patients so they know what signs of deterioration to look for and when to re-contact the service, while giving community nursing a clearer understanding of the palliative needs across their caseload, by June 2026.

 

What did we do?

Developed the Supportive and Palliative Care Indicators Tool (SPICT) deterioration guide into an A5 discharge card for patients, and created a RAG (red, amber, green) rating tool, based on the Gold Standard Framework, to support triage of palliative referrals and rate the acuity of the current caseload, helping identify patient needs and next actions for nurses.

 

What are the benefits for patients (and staff)?

Patients receive clear, measurable safety-netting advice on when to seek help, and community nursing teams have a clearer, more consistent understanding of palliative needs across their caseload, supporting more appropriate discharge decisions and triage.

 

Measures

Impact on the number of palliative patients remaining on caseloads, and impact on incidents and complaints as a result of a clearer understanding of patient needs.

 

Qi Tools used

• SPICT deterioration tool.
• Gold Standard Framework (GSF).

Project

Standardising the use of the Rockwood Clinical Frailty Scale

Lead: Amy Crumpton, Occupational Therapy (OT) Group Manager

 

What was the problem?

There was no standardised way of ensuring patients in their last 12 months of life were identified and added to the end-of-life register, meaning patients did not consistently receive a full palliative offer of services within their end-of-life journey.

 

Aim

To standardise the use of the Rockwood Clinical Frailty Scale in West Locality Community Nursing assessments for frail patients by 1 September 2026, improving identification of patients in their last 12 months of life.

 

What did we do?

Tested two Plan, Do, Study, Act (PDSA) cycles: the first to standardise use of the Rockwood Clinical Frailty Scale in West Locality Community Nursing assessments, and the second to improve identification of patients in their last 12 months of life using the GFS framework, which has since been signed off. Next steps include meeting with Palliative leads to confirm a go-live date for using the framework to identify frailty patients in their last 12 months of life, triggering referral to the SWB connective palliative hub's end-of-life register.

 

What are the benefits for patients (and staff)?

Frail patients in their last 12 months of life are more likely to be identified and added to the end-of-life register, helping ensure they receive the full palliative offer of services within their end-of-life journey.

 

Measures

Pre- and post-project number of palliative schedules monthly from the nursing caseload, and number of referrals pre- and post-study to the connected palliative hub (SWB).

 

Qi Tools used

• Plan, Do, Study, Act (PDSA) cycle.

Project

Safety huddles.

Lead: Nicola Burridge, Early Intervention (Adult Community Services)

 

What was the problem?

The project was initiated from a change idea raised in a QI Huddle, in response to several problems the team felt a safety huddle could address ensuring high-risk or deteriorating patients were prioritised, maintaining clear communication across the multi-disciplinary team (MDT), escalating concerns promptly, and ensuring accurate, real-time documentation and compliance were monitored.

 

Aim

By June 2027, the Early Intervention Community (EICT) East Team will implement a structured daily Safety Huddle that supports safe, effective patient care through a collaborative review of workload, patient status and risk management.

 

What did we do?

Several PDSA cycles were used to test and refine the safety huddles, with observations and outcome measures informing improvements after each cycle. This streamlined delivery to focus on the most effective elements for MDT communication, patient review and caseload management, while documentation was also simplified to reduce duplication and administrative workload.

 

What are the benefits for patients (and staff)?

Benefits reported by the team so far include open and honest conversations occurring in the safety huddle, reduced duplication of documentation and administration, and team members feeling empowered and confident to lead on huddles irrespective of their banding or MDT profession.

 

Measures

A staff survey measured the impact of the safety huddle, comparing baseline and follow-up feedback on MDT communication, escalation of concerns, team oversight, CIF allocation and reduced duplication. Patient safety was monitored through measures including Rio documentation compliance and patient breach rates.

 

Qi Tools used

• Plan, Do, Study, Act (PDSA) cycle.
• Driver diagram.

Project

North Early Intervention Community Team (EICT) improvement journey

Lead: Luke Butler, Clinical Service Manager; Vicky Egere, Service Manager

 

What was the problem?

A serious incident occurred in the EICT North team, where a patient died unexpectedly. In response, a hot debrief and a full Patient Safety Incident Investigation (PSII) were conducted with full engagement from the team, in line with the Patient Safety Incident Response Framework (PSIRF).

The investigation identified several key areas for improvement:

• Safeguarding: enhancing awareness and strengthening the referral process.
• Clinical knowledge: improving understanding of the deteriorating patient.
• Communication: creating structured opportunities for team discussions about patient care

 

Aim

By end of August 2024 , the aim is to have no further preventable serious incidents reported for the North Team.

 

What did we do?

• Bespoke National Early Warning Score (NEWS2) deteriorating patient training delivered to EICT citywide by Urgent Care Response (UCR) - since adopted across the Trust and other community services.
• Reintroduced Rehabilitation Assistants (RA) huddles and added to Standard Operating Procedures (SOP).
• Introduced daily multi-disciplinary team (MDT) discussions.
• Staff charter introduced to improve team culture.
• Introduced a team leader of the day rota, with a clear line of escalation, who sat with the team, being more visible.
• Safeguarding team delivered in house training with EICT North and across EICT.
• Triage nurse role trialled – was successful and looking at implementation across the city.

 

What are the benefits for patients (and staff)?

• Having a dedicated triage nurse significantly improved continuity of care and ensured patients were seen more promptly. This led to a reduction in the number of rescheduled visits.
  • The team reported increased opportunities to discuss patients and collaboratively problem-solve complex cases during MDT and RA huddles. This fostered deeper reflection and strengthened team cohesion.
  • As a result of enhanced multidisciplinary discussions, the team was better equipped to identify optimal care pathways for complex cases. This collaborative approach led to measurable improvements in patient safety and outcomes, ensuring that individuals received the most effective and personalised support.
  • Culture: it encouraged staff to embrace change with enthusiasm and provided a clear framework for how they could contribute meaningfully to service development and innovation.
  • Focused training initiatives enhanced staff confidence and competence in handling complex clinical scenarios. This was especially evident in safeguarding practices and the early identification and management of deteriorating patients, contributing to safer and more responsive care.
  • NEWS 2 training was adopted across the trust and added to bootcamp.

 

Measures

• ECIs, which turned green in July 2024 for first time since incident occurred in December 2023.
• Reduction in rescheduled visits.
• Surveys on knowledge of deteriorating patient before and after training - saw an improvement in knowledge and confidence of staff.
• Better safeguarding awareness through more reported incidents (datix) and more calls logged with BCHC Safeguarding Adults team.
• Staff feedback on handovers and the staff charter was positive, and they continued to shape how these discussions took place.

 

Qi Tools used

• Plan, Do, Study, Act (PDSA) cycle.
• Fishbone diagram.
• Driver diagram.

Project

You said, we did, appointment cards.

Leads: Sachin Kaddad, Clinical Team Leader.

 

What was the problem?

Potential misunderstanding and confusion around follow-up appointments.

 

Aim

Improve the quality of how we communicate with our patients and relatives by revising non-utilised appointment card and included other useful service contact details.

 

What did we do?

We as a team also reflected on several possible improvements to our communication in engaging with relatives better in the future including being aware of staff choice of phrase, body language and tone, considering discussing with people, their family members and friends how they wish to be included in their therapy input prior to starting rehabilitation and discuss how best to communicate with them.

• Reflection on improvements in communication.
• Review how patients and relatives are informed about follow-up  appointments.
• Revise non-utilised appointment card and included other useful service contact detail.
• Include QR code for patient or relative to provide feedback via ‘iWantGreatCare’.
• Monitor the increase in the number of FFT per month for each team.
• Staff and Patient survey to collect wider feedback, and any updates required on current appointment card.
• Monitor DNA rate and changes since the Appointment Card is introduced.
• Team feedback on improved appointment.
• Liaison with patient experience team.
• Piloted with small number of patient and collected opinion and feedback.
• Fully Implementation within Therapy HUB from January 2025.
• Regular reminder to utilise appointment card.
• Improvement in the very good responses after appointment card has been introduced.
• No similar concern received so far or negative feedback about appointment card.

 

What are the benefits for patients and staff)?

• Less confusion for patients around appointments.
• Better communication between patients and staff.
• Time saved for staff by not having to answer queries around appointment confusion.

Measures used

• Undertake audit to understand reduction in number of calls in office to chase follow-up appointment.
• Monitor monthly data to understand if there is increased number of FFT for the team.
• Undertake wider audit to know if there is reduction in did not attend’s (DNAs) on follow-up appointments post introduction of appointment card.

 

Qi tools used

• Plan, Do, Study, Act (PDSA) Cycle.
• Audit.
• Feedback.