Achieving Change Through Diagnostic Analysis: Introduction

Introduction

The purpose of this paper is to complete a diagnostic assessment and analysis to determine organisational readiness for an evidence-based service change linked to an action plan within Outer North East London Community Services (ONEL CS) Inpatient Unit within the London Borough of Havering. This paper will discuss how change can be achieved through completion of a diagnostic analysis. The evidence based change to be implemented and discussed in the paper, is the introduction of a Dementia Care bundle to improve dementia nursing care on the inpatient wards within Havering – ONELCS. Through the use of a service improvement audit conducted within the Inpatient Unit; this paper will reflect upon the application of research methodologies that can support the diagnostic analysis; and the development and implementation of the action plan developed to achieve service innovation.

The paper begins by giving the background information on the area of health care selected for review and service innovation. This will include the rationale for choosing this area, it importance and the explanation and definition of the key terms that will be used throughout the paper. The process by which the literature review was conducted will be detailed so that it could be replicated by the reader where necessary. Following on from this, the evidence pertaining to the chosen area of improvement will be critically appraised to identify its merit in informing the diagnostic analysis assessment.

Diagnostic analysis is the process of gathering information prior to the implementation of change, and is designed to identify the barriers and facilitators for change within an organisation; assessing organisational readiness for change (Hamilton, McLaren and Hamilton 2007). Theories and models relating to organisational change will be discussed; with the aim to informing and developing a strategy or action plan tailored to the local context for implementation.

Background

Dementia care is generally often overlooked on the acute inpatient hospital wards (Leung and Todd 2010). Up to 70% of acute hospital beds are occupied by older people (Department of Health (DOH) 2001; Alzheimer’s Society 2009). It is estimated that up to a of these patients, up to half of these patients in general acute care at any one time may have cognitive impairment including delirium and dementia (Royal College of Psychiatrists 2005). The unacceptable variation in the quality of dementia care provided on general wards in hospitals across England is well documented in numerous reports such as the ‘Counting the Cost: Caring for people with Dementia on Hospital Wards’ report(Alzheimer’s Society 2009). The ‘Healthcare for London: A framework for Action’ document (2007) and the National Audit Office report ‘Improving services and support for people with dementia’ (2007), highlight the fact that services were not provided consistently well across London for people with dementia and their carers; that people with dementia in general hospitals have worst outcomes in terms of length of stay, mortality and institutionalisation. In fact, the National Audit Office (NAO 2007)mentioned earlier- which is responsible for scrutinising the use of public money note in their report that dementia care is as poor as cancer care was in the 1950s.

Patients with dementia and their carers experience, have confirmed the above reports: patient feedback has highlighted an urgent need for research into care for older persons in general hospitals as is recently reported in media reports and Parliamentary and Health Service Ombudsman(2011) report investigating ten complaints into National Health Service(NHS) care of older people. Furthermore the National Audit Office(NOA) report (NOA 2007) provides potent evidence of the current costs of care for those with dementia diagnosis in the hospital setting; and highlights that acute general hospitals are not delivering a ‘value for money’ service.

As a result of this evidence the National Dementia Strategy(DOH 2009) was developed by the Department of Health. The policy document sets out a five year transformation plan for dementia under four themes: raising awareness and understanding; early diagnosis and support; living well with dementia and making the change(DOH 2009). Dementia has been included in the NHS Operating Framework for 2009/10 as one of the areas where the Department of Health will expect to see and monitor progress(DOH 2008). Following on from this, Dementia is one of only five areas where specific world class commissioning guidance has been produced(Commissioning Support for London 2009, DOH 2009). Given the significant numbers of people with dementia using health and social care services, transforming services for people with dementia will be fundamental to Commissioners in achieving world class commissioning, personalisation and the recommendations of the Darzi review (DOH 2008). This meant for St George’s Hospital as provider services for NHS Havering Commissioners, the inpatient service need to align themselves strategically with commissioning priorities for dementia services within Havering(see appendix one). The aims of this paper sit well with Objective 8 and 13 of the National Dementia Strategy (DOH 2009). It was against this backdrop that this paper was developed; to focus on the improving dementia nursing care provided on the inpatient wards by implementing a dementia nursing care bundle.

Definition of key terms:

For the purpose of this paper key terms have been defined in particular the meaning of Dementia and the concept of Care Bundles.

What is Dementia?

The term dementia is used to describe a collection of symptoms, a syndrome which includes changes in memory, reasoning and communication skills, with a gradual loss of ability to carry out daily activities (Alzheimer’s Society 2009, Commissioning Support for London 2009; DOH 2009 NDS-a/b). There are a number of different types of dementia; with the most common being Alzheimer’s disease that accounts for about 60% of cases (Gupta, Fiertag and Warner 2009).

The Different Types of Dementia

1. Alzheimer’s disease changes the chemistry and structure of the brain, causing brain cells to die (DOH 2009). Alongside this decline, the person will show symptoms including difficulty with eating, swallowing, continence and experience loss of communication skills such as speech, becoming increasingly dependent on others(Alzheimer’s Society 2009, DOH 2009).
2. Vascular dementia is as a result of strokes or small vessel disease, which affects the supply of oxygen to the brain(DOH 2009). Similar to Alzheimer’s disease but progression is often ‘stepped’ rather than gradual(DOH 2009).
3. Fronto-temporal dementia is a rare form of dementia affecting the front of the brain. It includes Pick’s disease and most commonly affects people under 65(DOH 2009). In the early stages the memory may remain intact while the person’s behaviours and personality change(DOH 2009).
4. Dementia with Lewy bodies is caused by tiny spherical protein deposits that develop inside nerve cells in the brain(DOH 2009). These interrupt the brain’s normal functioning, affecting the person’s memory, concentration and language skills(DOH 2009). This type of dementia has symptoms similar to those of Parkinson’s disease such as tremors and slowness of movement (DOH 2009).

Dementia in Havering - the local picture

Dementia presents a unique challenge for London; with estimates of around 65000 people over the age of 65 in London diagnosed with dementia(Commissioning Support for London 2009); projections suggest that the number of people over 80 in London with dementia can be expected to rise by almost 50 per cent to 96000 by 2030(POPPI 2010).

Dementia is an under-diagnosed condition in the London Borough of Havering. This paper focuses on improving inpatient nursing care delivered for dementia patients at St Georges Hospital. St Georges Hospital is a community hospital within Havering. Predominately for patients aged 65 and over it consists of a day hospital and 45 in-patient beds across two wards. There is one rehabilitation/assessment ward; and a stroke unit. In common with all members of the community, people with dementia can become physically unwell and require general hospital care. St Georges Hospital admits patients with dementia from the neighbouring acute hospital, Barking Havering and Redbridge University Hospital NHS Trust. Demographic changes and an ageing population in Havering mean there will be a disproportionate increase in the common conditions of old age, such as cancer, stroke, and dementia; therefore it is expected that the majority of patients admitted to St Georges Hospital inpatient wards may have or have a current diagnosis of dementia. A Freedom of Information (FOI) Request revealed that the estimated number of people with dementia is 1015. this represents 0.4% of all registered General Practitioner population and is below the national average of 1.1%. This figure is anticipated to rise and as is outlined by Appendix one. The evidenced based change to be introduced is a nursing dementia care bundle with the aim of improving the nursing care provided on the inpatient wards.

What Is A Care Bundle?

A “care bundle” is an evidence based protocol (Resar, Pronovost and Haraden, Simmonds, Rainey and Nolan 2005). Successfully used in Critical Care; it is a collection of interventions (usually three to five) that may be applied to the management of a particular condition (Fulbrook, and Mooney 2003, Resar, Pronovost Harden et al 2005; Belt 2006). The theory behind care bundles is that when several evidence-based interventions are grouped together in a single protocol, it will improve patient outcome (Resar, Pronovost and Haraden, et al 2005). The concept of care bundles was introduced by the NHS Modernisation Agency (DOH 2004) and continues to be fully supported by the Department of Health. A heavy reliance on the use of care bundles is evidenced the development and recent review of High Impact Interventions in reducing Healthcare Associated Infections by the Department of Health(DOH 2010).

Care bundles have a number of attractions. In particular they can be used as tools to improve the quality of patient care, and they sit comfortably with the NICE definition of clinical audit and the purpose of this paper:

‘Clinical audit is a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. Aspects of the structure, processes and outcomes of care are selected and systematically evaluated against explicit criteria. Where indicated changes are implemented at an individual team or service level and further monitoring is used to confirm improvement in health care delivery’ (NICE 2002)

Care bundles are a way of reducing the gap between research and practice in clinical areas and in theory they will improve clinical effectiveness. Although most specialities are using ‘care bundles’ for the dementia care they are relatively a new concept. It is expected that by grouping dementia related evidence based practices or interventions together, within a single protocol that guides patient management, the overall quality of care nursing care delivered to dementia patients will improve. A dementia nursing care bundle has been developed by the Royal Wolverhampton Hospitals NHS Trust, through a freedom of Information (FOI) Request (Appendix three); a copy was requested and was to be locally adapted for the inpatient unit at St Georges Hospital ONELCS-Havering.

Method of Searching for Literature

An electronic search of the literature was undertaken on dementia care on hospital wards on the 30th of January 2011. Using an Athens NHS Log in details and advanced search of healthcare databases using theCumulative Index to Nursing and Allied Health Literature (CINAHL) was completed. Appendix four outlines how literature was identified and selected for appraisal.