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Organisation in partnership develops an integrated single-access portal for patient data, reducing delayed transfers of care and improving patient experience


    • Reported 7.1% rate of delayed transfers of care (DOTC) with patient information spread across individual systems
    • Ineffective care transition between partners and inefficient data gathering, sharing and storing practices
    • Lack of visibility, long-paper driven methods of reporting and multiple sequential assessments over discharge
    • Decrease the time patients spend waiting to be released from hospitals and enable data integration


    • Formed a D2A (discharge to assess) group to digitally share an assessment system, permitting single access to public/private sectors
    • Developed a web-based app with feeds from core operations, providing real time data on patient status, need, performance etc.
    • Developed a simple user-interface to reduce dual keying and maintain data quality
    • Facilitated live patient management and secured access via multi-web devices


    • Achieved the 3.5% national target for DOTC and improved discharge planning processes
    • Ensured complete transparency, improved referral quality and avoided unnecessary hospital admissions
    • 9% reduction in low harm complaints and zero serious incidents relating to discharge
    • 90% users found the system easy to use and 50% rated the service as good/excellent


In July 2017 the Central Cheshire system reported a Delayed Transfer of Care (DTOC) rate of 7.1%, indicating poor patient experiences, specifically:

  • Multiple sequential assessments in the hospital to discharge patients
  • Patient information spread across several independent systems and paper records
  • Distrust between partners due to lack of visibility
  • Frustration for service users and providers
  • Lengthy paper-driven methods of reporting and keeping partners informed about progress

Partners within Central Cheshire formed a D2A Group and created a shared vision to decrease the amount of time patients spent waiting in hospital for discharge and to improve the patient experience, which was achieved by:

  • Establishing a shared commitment to the vision helping integration to flourish
  • Agreeing to a shared trusted assessment to access community services
  • Ensuring that real-time patient information was available to all
  • Reporting and working from the same information

A new technological system has been developed meaning partners in both the public and the private sector can use consistent detailed information to begin planning as soon as a patient needing support to facilitate a timely discharge is identified. The DTOC rate has now sustained below 3.5%.


The barrier to effective care transition was inconsistent gathering, sharing and storing of information between partners. Partners held a piece of the jigsaw but a single view was not available meaning that patients told their story more than once. Partners maintained their own records which affected trust between partners and wasted resources and time.

The intention was for one story, one record and one storage place. Solutions were considered including providing reciprocal access to systems, integration, interoperability messaging. However, the development of a web-based app hosted in the cloud with feeds from core systems and accessible by all was selected, providing real-time information:

  • Patient status
  • Patient need
  • Performance
  • Required actions
  • Capacity information

An agile development approach fostered:

  • Functionality driven by staff from partner organisations
  • Simple user-interface designed by staff to efficiently assess the patient, using information from other systems to reduce dual keying and maintain data quality
  • Real-time information sharing ensuring complete transparency
  • Personalised access ensuring patient data was visible on a need to know basis
  • Accessible operational reporting alongside rich data feeds for Data Warehouse purposes
  • Multi-Device Web Development enabled access from computers, tablets and smartphones

Governance was robust with operational levels providing development and implementation support and strategic levels supporting innovation and finance. Information Sharing Agreements strengthened partner engagement and ensured joint ownership of a co-developed system between public and private organisations.


The investment of £40K has provided one data set accessible across public and private sectors to facilitate effective discharge planning, whilst streamlining DTOC monitoring and reporting.

  • The system has improved discharge planning processes and reduced the time it takes to discharge patients. (Ref OE1)
  • The aim of providing one trusted data-set that is used to monitor and report DTOC performance through the Urgent Care Steering Group was achieved
  • The number of low harm complaints decreased by 9% in 2018-19 when compared to 2017-18 and no harm complaints increased by 10% in 2018-19
  • There were no serious incidents relating to discharge in 2018/19
  • National 3.5% DTOC target was achieved in 2017 and has been maintained. (Ref OE2)
  • A user’s survey has been completed and an illustration of feedback is attached as evidence. From the survey, 90% of users found the system easy to use and 50% rated it as Very Good or Excellent. (Ref OE3)
  • Some care home managers have commented positively about how the system provides more relevant patient-based information to assist in the admission process

Having the shared system enable partners to continually define how they worked providing more rapid discharges which resulted in a bed day-saving equivalent to one ward. As the culture of continuous improvement continues partners expect the volume of patient time remaining unnecessarily in hospital to continue to reduce.


Initially designed to provide a shared assessment for hospital discharges this system has grown to support admission avoidance from the Emergency Department by the frailty and therapy teams. By developing a single, shared platform patients can now avoid an unnecessary hospital admission by accessing community services from ED through completion of a shared “safe to transfer form”.

Growing the project scope to include live performance information provides partners with a central point to access at times of escalation.

The shared reporting suite highlights peaks in demand as well as positive outcomes.

Training has been provided to ward staff and opportunities of shared learning are highlighted and cascaded.

The details of the project have been shared at “Action on A&E” events (north) and two Trusts have expressed an interest in a live demonstration of the new system. The system has been demonstrated to a small number of care homes to remove the need for pre-assessments for none complex patients.

Future developments in the system will enable commissioning decisions to be made based on live and retrospective capacity and demand information.


In preparation for MDT triage 6 weeks of trained nurse time was utilised in one year. The system has negated the need for this. Other staff time savings have been achieved by:

  • A single electronic record negates printing or faxing to stakeholders
  • A single record across partners; reducing the need for multiple phone calls, and inconsistent messages between wards and discharge teams
  • Live system capacity information available
  • Actual cost saving of £6000 per year on printer toner (for the Trust alone)

This single, integrated discharge system has enabled live patient management and timelier referrals, creating:

  • Multi-agency simultaneous assessment, reducing waiting times in the acute hospital and improving patient communication
  • Proactive management of patient needs
  • Improved referral quality

Overall the system has enabled a more efficient approach to manage complex discharge arrangements across a range of professionals

The virtual environment facilitates health and social care partners working together in a joined-up manner

Process changes enabled by the system delivered bed day savings equivalent to 3 beds per month within the first 6 months of operation. This was one of the contributing factors to not opening as many escalation beds over winter 18/19.

As the system and processes embed further, this figure is expected to increase due to the continuous improvement journey we are on.


The Project Group facilitated a range of engagement events to obtain stakeholder contributions including:

  • Patient Representative and Patient Groups - helped partners to understand the current system’s complexity
  • Social Care and CHC professionals - provided the legal contexts of ongoing care assessment
  • Community professionals - aided understanding of the information required to ensure safe hospital transfers
  • Integrated Discharge and Ward staff - helped make the system practical
  • IT professionals – helped understanding of the possibilities a web-based system would deliver
  • System development – unlocked innovation solutions
  • System Executives - removed barriers and let us “get on with it”
  • Ward Discharge Coordinators – were early adopters, testers and advocates
  • Information Services - helping to seamlessly continue national reporting requirements whilst monitoring systems were changed
  • Commissioners- unblocking financial constraints
  • Transformation Management - provided OD support and project drive
  • Partners – supported User Acceptance Testing (UAT)

The inclusive approach meant:

  • All parties shared an understanding of what the new system needed to deliver
  • Shared language was agreed to aid understanding
  • Developing the system encouraged positive debate and disagreement leading to the ethos of shared problem-solving
  • Feedback is continually used to develop the system and a user survey has recently been completed
  • Where once an “us and them” culture had been nurtured a shared vision and equitable access to data promoted a patient-centred integrated approach that we are proud of.