Specific:

Improve patient satisfaction by delivering care through PKB, with the use of secure messaging, a care plan to track symptoms (which is regularly reviewed) and access to a library of resources.

Measurable:

Baseline medical satisfaction questionnaire sent at registration and again sent at discharge; results compared against satisfaction when discharged.

The team aims to achieve a significant improvement (%) in patient satisfaction scores by the end of the PKB pathway. (How Much?)

Achievable:

All HF nurses must be trained on PKB to effectively use care plans and messaging with each patient. Prior to and post-live comms to the patient regarding the new service and its inclusions, ensure the entire department is informed about patient pathway changes and the commencement date. Nurses are responsible for sending the questionnaire at both registration and discharge.

Relevant:

Better self-management of patients with HF by number of symptoms tracked and care plans viewed

Better patient experience by using the satisfaction questionnaire.

Patients feel more in control of their health and hospital care with the use of a condition-specific care plan.

Time-Bound:

Care plan and workflow to be ready for the Team go-live. Patient questionnaire and clinical engagement stats review at 3 months (has all patients sent/completed questionnaires), 6 months, and 9 months post go live.

Specific:

To reduce the total number of F2F appointments with each patient during the pathway (all patients will have their initial f2f Appointment). Patients given a symptom tracking care plan to complete (enter time), nurse reviews care plan before 2nd apt to see if they cross the threshold and need a f2f apt. Need the average number of appts and what the threshold is going to be, is it the same for all patients, men/women/age ect At what point is a nurse checking the `CP? In time to change appointments?

Measurable:

Measurable by how many virtual appointments are used as currently Pathway is 100% f2f

Team wishes to see a reduction (%) in patient F2F appointments.

Measure cost saving for not having to run a f2f appointment (currently?)

Achievable:

All HF nurses to be trained on PKB. Prior to and post-live communications to the patient about the new service and its inclusions, ensure the entire department is informed about patient pathway changes. Nurses should offer virtual calls whenever possible and document the virtual appointments.

Relevant:

Better self-management of patients with HF by the number of symptoms tracked and care plans.

By freeing up nurses and patient time, they can determine the actual journey times from the patient’s home addresses.

Time-Bound:

Care plan and workflow to be ready for the Team go-live. Clinical engagement statistics will be reviewed at 3, 6, and 9 months post-go-live.

Specific:

Clinicians and patients can communicate more effectively and in a more streamlined fashion through the use of PKB care plans and messaging functions. This feeds into goal number one as patients’ satisfaction scores will be higher.

Measurable:

Measurable by the number of care plans created, comparable to those edited.

Measurable by the number of messages sent and threads within that message and the period of time it took to read the messages. All non-urgent communication is to be done through PKB instead of calls and emails. 50% of all patient communication is to be done through PKB.

Achievable:

All HF nurses to be trained on PKB. Pre and post live comms to the patient regarding new service and what’s included, make the whole department aware of patient pathway changes, nurses to make sure messages and care plans are actioned asap, timeframe suggested to patient.

Relevant:

Better self-management of patients with HF by the number of messages sent/received and care plans created and edited. Freeing up nurses’ time by using PKB messaging instead of calls (convenience, improvement of workload/time), freeing up patient time and being cost-effective.

Time-Bound:

Expect to reduce call numbers by 50% after 6 months with the use of PKB messaging. Nurses/coord to record every three months, on the first Tuesday of the month, the number of calls they have and their duration. Care plan and message engagement are reviewed every three months.

Specific:

A reduction in the overall ECHO DNA Rate. By patients taking an active part in their own self-care of HF and also having access to their appointments within PKB.

Measurable:

Measurable by the number of DNA pre-PKB and the Number 3 months post-live and 6 months post-live.

Achievable:

All HF nurses to be trained on PKB. Patient comms inform patients about their PKB patient portal. Patients are encouraged to add an ECHO Care plan to their record. Team send out ECHO questionnaires within PKB to patients every six months.

Relevant:

Better self-management of patients with HF by number of attendances to ECHO compared to previous. Cost effective

Specific:

Provide all patients in the team (currently 750) with a PKB record and have a process for patients to register with their record via Trust email registration.

Measurable:

Baseline, when the heart failure team goes live, PKB registration stats will show how many of the 750 patients have registered through email registration. Every week PKB sends the team registration stats for review. One month post go live, 25% patient registrations achieved. Two months post go live 50% patient registration achieved. Three months post go live, 70% registered.

Achievable:

All patients are invited to register, aiming for 70% registration rate.

Heart failure team trained on PKB and to check if the patient is registered with PKB at each interaction. Team trained on how to add an email address and carers. Hospital integration is completed for patients to get an email to register and reminders to register with each interaction.

Relevant:

• Providing patients with a digital record.

• Improve access to patient data.

• Patients having access to their heart failure care plan.

• Cost saving for the trust. Receiving results and letters digitally.

Time-Bound:

One month post go live, review if 25% patient registrations achieved. Two months post go live review if 50% patient registration achieved. Three months post golive review if 70% has been achieved.