SAFE-MOFD: A Quality Improvement to Restructure Ward Rounds and Improve Safety, Focus and Efficiency of Care for MOFD Patients

Introduction
Patients who are Medically Optimised for Discharge (MOFD) on Care of the Elderly (COTE) wards frequently receive unstructured review, falling into either cursory, poorly documented ward rounds or unnecessary over-medicalisation; both risk functional decline and prolonged admission. We aimed to improve the focus, efficiency and safety of inpatient care for MOFD patients across our COTE wards by implementing a structured MOFD checklist, targeting >90% compliance within six months.

Method
A quality improvement project used sequential Plan-Do-Study-Act (PDSA) cycles across four COTE wards. PDSA1 introduced a SAFE-MOFD standard operating procedure with weekly/daily MOFD checklists and "Tea Trolley Teaching"; PDSA2 introduced a patient information leaflet; PDSA3 introduced ward-based MOFD champions and an updated SOP. Outcomes included checklist compliance, discharge/TTO timeliness, staff/patient experience, and escalation/deterioration as balancing measures.

Results
Checklist compliance varied by ward rather than declining uniformly: full daily completion improved in two of four wards across three cycles (Guiting 59%→74%; GWW2 50%→65%), while weekly checklist completion within 24 hours fell in three of four wards (36–38% to 0–12%); one ward (GWW1) showed a marked fall in daily documentation (82%→8%). Safety measures remained reassuring, with deterioration events falling from 1.4% to 0% across cycles. Looking at efficiency, All three discharge-timeliness measures improved after the QI start (day-before-discharge requests: ~65%→79%; by 1pm: ~39%→50%; by 4pm: ~50%→69%) in the most compliant ward. Staff surveys showed residents perceived improved ward-round focus and manageable workload; consultants reported improved patient flow and proportionate review time, with mixed views on efficiency and MDT communication.

Conclusion
Structured MOFD processes are deliverable across COTE wards, although checklist compliance remain inconsistent but there is no evidence of compromised patient safety by using the checklists. Efficiency data clearly suggests improvement in timings for TTOs which is a benchmark for early discharge. Next steps include EPR integration and planned embedding of this framework trust-wide.