4 Hour Improvement Plan - Royal United Hospitals Bath NHS ...€¦ · robustness of CCG QIPP plans....

Author : Clare O’Farrell Divisional Manager Medicine, Sarah Hudson Urgent Care Programme Manager Document Approved by: Francesca Thompson, Chief Operating Officer

Date: 22nd

September 2014 Version: 6

Agenda Item: of 34

Delivery of the Emergency 4 Hour Operational Standard V6 22

nd September 2014

4 Hour Improvement Plan

1. Overview of the Plan and Purpose .............................................. 2

2. 4 Hour Performance Diagnostic ................................................... 4

3. 4 Hour Recovery Plan (immediate actions) .............................. 11

4. 4 Hour Recovery Oversight and Assurance ............................ 20

5. Trajectory for Recovery of Emergency 4 hour Standard ....... 20

6. Operational Resilience and Capacity Planning 2014/15 ........ 20

Appendix A– RUH 4 Hour Recovery Operational Plan ..................... 21

Appendix B– RUH 4 Hour Recovery Daily Scorecard ...................... 22

Appendix C – RUH 4 Hour Recovery Trajectory ................................ 22

Appendix D – RUH Urgent Care Improvement Programme ............ 24

Appendix E – RUH Urgent Care Strategic Overview ........................ 34


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September Version: 6

Agenda Item: of 34

Executive Summary

1. Overview of the Plan and Purpose

1.1 The RUH is currently failing to deliver the operational 4 hour standard in 2014/15, which is also having a detrimental effect on the quality of care that the Trust is able to deliver for both emergency and elective patients. Management Board has approved the implementation of this 4 hour recovery plan which will be daily performance managed throughout September and October 2014. The recovery plan has three work streams, front door, flow and backdoor and twenty immediate recovery actions have been identified. The plan is intended to deliver 5 key strategic outcomes:

Front Door Ambulatory care pathway activity recovery Flow Optimise Medical and Surgical elective capacity

Introduce speciality medical take in Medicine, with increased medical engagement in bed allocation

Back door Reduced Delay Transfers of Care

Drive improvement in LOS across all specialities 1.2 The RUH will lead the production of the recovery plan and coordinate its implementation through the local SRG meetings. The Area Team has requested SRG’s to provide confidence levels and assurance about 4 hour performance for 2014/15 during September. This plan can be used to provide assurance. 1.3 In light of the continued performance pressures the RUH has co-ordinated the production of local recovery and improvement plans for urgent care working through the BANES System Resilience Group (SRG). 1.4 The plan includes three stages. This paper is principally concerned with the development of the first stage, the 4 Hour Urgent Recovery Programme, with a focus of actions to be undertaken by the RUH. The second and third stages focus on both medium and longer term actions which will require the full support of the community; these will be managed by the RUH through the Urgent Care Improvement Programme.

First stage: A 4 Hour Urgent Recovery period will help regain performance, including daily performance management approach through September and October.

Second stage: A medium term approach to support delivery from November 2014 which will also coincide with the winter sit rep reporting. This will include care system planning, such as the Wiltshire 100 Day Challenge and review of CCG Health and Wellbeing boards approach to improvements in urgent care. Delivery of the BaNES and Somerset CCG Operational Resilience and Capacity plans to provide the necessary capacity to support ED admission avoidance and earlier supportive discharge.

Third stage: A longer term implementation of a community wide urgent care strategy across the four CCGs in order to deliver safe and sustainable service for the future.


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1.5 It is proposed that the RUH urgent recovery programme should focus on key immediate actions to recover 4 hour performance. The content of the individual projects and a more ambitious improvement trajectory set for the Urgent Care Improvement Programme is detailed by project in Appendix D. 1.6 The immediate 4 hour recovery plan for September and October 2014 for RUH will lead into a broader community plan as part of the Urgent Care System Resilience Planning for the medium term. The plan includes;

An agreed RUH and local plan to bring the performance back on track, with delivery of 4 hour standard in September 2014 and a trajectory for Q3 which will be managed on a daily and weekly basis. The RUH will work to identify targets for community providers e.g. daily/weekly discharge targets, daily reporting of DTOCs as we continue to focus the whole community on key actions to deliver sustainable performance.

Preparation for implementing the operational capacity and operational resilience and capacity plans, confirmation when 2014/15 winter schemes will be implemented. RUH to have reviewed the plan and anticipated contribution to recovery plan for meeting on the 9th October 2014.

RUH to review all best practice from the Emergency Care Intensive Support Team (ECIST). National best practice has been incorporated into the RUH Urgent Care Programme’s ‘sustain’ work stream, all projects have been reviewed, see appendix D and actions to regain performance incorporated into the Trusts recovery plan. ECIST will be once again invited to assist in our recovery planning.

Launch a trust wide initiative to coincide with the start of C³ and other discharge focused schemes “Space for Tomorrow”.


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2. 4 Hour Performance Diagnostic

2.1 Year to date 4 hour performance has been achieved for only 2 of the first 5 months of the year. This sets the scale of the challenge and the recovery trajectory will be mapped against the expected periods of increased demand for the last 6 months of 2014/15, which includes the winter period with the highest demand for both ED attendance and non-elective admissions. The RUH will need to be responsive in its approach to operational planning to achieve the balance required to attain all key performance indicators.

Table 1: 2014/15 ED 4 Hour Performance

Financial Year Quarter Month Attendances

4 Hour Breaches Performance

2014/2015

1

April 5769 420 92.7%

May 6325 237 96.3%

June 6136 465 92.4%

2 July 6181 242 96.1%

August 5828 552 90.5%

2.2 Analysis of breach reasons. The majority of 4 hour breaches are attributable to bed

availability. Review of ED flow metrics also supports the evidence that ED during this period has continued to function well; there have been minimal ambulance handover delays and time to treatment has improved. In conclusion flow and back door factors for poor performance.

2.3 ED attendance by arrival hour. Further analysis is required with respect to increases in non-elective admissions out of hours, which has been a continuing trend through 2014/15. This work needs to link intelligence from South West Ambulance Service Foundation Trust (SWASFT) with regard to ambulance conveyance and “batching” of medically expected patients. To be reviewed with SWASFT as part of SRG diagnostic, to be completed by the end of September. Expected batching during periods of peak demand is to be tested during daily performance review during the six week recovery period.

2.4 ED attendance by CCG. 2014/15 financial year to date there have been 1,122 more

ED attendances compared to the same period in 2013/14, representing a 13.5% increase against the CCG contracted level. Table 2 shows the CCG monthly breakdown of the variance against 2013/14. The BaNES Strategic Resilience Group (SRG) meeting, held on 4th September, agreed a joint RUH and CCG analysis of current emergency and urgent activity. This will be completed before the October SRG meeting with a report to be completed by the end of September.

Table 2: CCG monthly breakdown of the variance against 2013/14 is set out below;

Periods of significant variance against 2013/14 activity levels have been highlighted.

April May June July August Total

NHS Wiltshire 20 384 122 -22 17 521

NHS BaNES -157 134 173 -84 -124 -58

NHS Somerset -58 96 33 38 -10 99

NHS South Glos 16 63 176 187 106 548


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2.5 ED attendances and non elective admissions trend. Across the first 5 months of the year we have seen a 4.7% growth on the same period last year (Table 3). Whilst the early part of the year saw a large increase on 2013/14, August has seen a reduction on historic levels, although this still represents an increase against contracted plan. This reduction in activity could in part be due to patients remaining within the Trust into September. This possibility is explored further in the length of stay diagnostic. There has been a consistent increase every month in 2014/15, with July showing the biggest increase, despite the ED over-performance reducing slightly in July. The growth in 2014/15 months 1-5 is 11.1% above the contracted level, which again questions the robustness of CCG QIPP plans.

Table 3: CCG Year on Year Growth in non-elective admissions (excluding maternity)

Apr May June July August YTD

NHS Wiltshire 95 134 41 47 -59 258

NHS BaNES 92 5 -5 2 8 102

NHS Somerset -12 18 53 39 2 194

NHS South Glos 13 28 42 77 37 165

2.6 ED attendances and non elective admissions seasonal trends. Both attendances

and admissions follow a similar bimodal seasonal pattern (Graph 1). ED attendance reaching maxima in September and March, admissions December and March. This must be taken into account when planning the 4 hour recovery trajectory and will be a daily metric. Graph 1: ED Attendance and Non-Elective Admissions Seasonal Trend

2.7 ED ambulance conveyances are a marker of both acuity and dependency. South

West Ambulance Service Foundation Trust (SWASFT) are reporting sustained high levels of activity across the Bath and Bristol areas throughout Q1 and now well into Q2. Graph 2 below shows the trend with a particularly significant spike at the beginning of September and an expected spike at the end of September 2014 and mid October which will be planned for in the recovery plan. There is no single reason for the increase and SWASFT are reviewing their demand prediction modelling and auditing activity. A new operations manager for BaNES and South Wiltshire has been appointed by SWASFT, the RUH will meet to discuss how this role can support the RUH in September; 1) understanding SWAST activity predictions, 2) how to obtain the most accurate update of SWASFT activity on the day to support prospective planning and 3)


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improving the timing of HCP conveyance. The graph below shows the sustained increase in activity in 2014/15. Graph 2: RUH ED Ambulance Conveyance Year to Date and Five Year Trend

2.8 Impact of prolonged escalation on Medical Ambulatory care and Emergency Surgical Ambulatory Care (ESAC). During periods of escalation both Medical Therapies Unit (MTU) and ESAC are used in order to provide an additional 8 beds. The impact of these beds being used in escalation has a detrimental effect on the functioning of MTU and both Medical and Surgical Ambulatory Care. The net effect is that the three areas are unable to function efficiently. MTU when occupied with in-patients is unable to manage the elective workload effectively, directly compromising RTT and necessitating the referral of routine elective infusions to Medical Ambulatory Care. Medical Ambulatory Care is also requested to respond to Haematology/Oncology requests as William Budd day care opens 4 days per week, this adds to the elective demand for routine treatments i.e. transfusion. Overall the percentage of the take through both Medical and Surgical Ambulatory care is greatly reduced and suitable ambulatory patients are then referred through the medical and surgical takes. There is evidence to support that the loss of activity through ambulatory care exceeds the 8 beds opened in escalation.

2.9 Review of August Parry closure plan and why mitigating actions failed to sustain

performance:

RNHRD, only 2 patients placed, against the anticipated 12 patients, due to the RNHRD patient criteria

Elective plan, Surgery activity was below planned delivering the planned mitigation

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Week Ending

RUH ED Ambulance Conveyances

5 Year Range Fy-13/14 Fy-14/15


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Cheselden ward length of stay (LoS) reduced in month by 6.4 days delivering full mitigation plan.

Escalation was all opened and in full use as per plan.

Bariatric bed spaces – plan fully delivered

Wiltshire community beds – 6 beds opened, but impact below expected due to significant increase in Delayed Transfers of Care (DTOC). This was a direct result of a local care home closure, following a Care Quality Commission inspection issues and the need to place 22 residents. This was formally confirmed by Wiltshire Social Services as reducing placement offers to hospital patients.

Sirona – 6 beds open and plan fully delivered.

The Parry Closure plan failed to mitigate performance and the RUH will review how essential ward upgrades are planned going forward.

2.10 Impact of NBT transfer. Daily monitoring continues to assess the impact of the

North Bristol NHS Trust closure of Frenchay Hospital. Attendances from Bristol and South Gloucestershire CCGs are within the Trusts “likely” modelled scenario of 5% increase equating to a maximum of 10 attendances and 2-3 admissions per day (Graph 3).Analysis by Bristol CSU on the impact of Frenchay Closure on the health community is expected by the end of September.

Graph 3: South Gloucestershire CCG ED Attendance Monitoring

2.11 We have been working with each CCG to reduce the daily DTOC number. There was

an increase in NHS Wiltshire DTOC in late April and during May 2014. There was also a significant spike from 15 June. The impact in August of the closure of community nursing home capacity and limited social placement saw a significant rise in DTOC for Wiltshire CCG. September to date DTOCs remain high. This is a focus area for action as part of the Wiltshire 100 day challenge. Graph 4 shows the DTOC trend for each CCG.


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Graph 4: Days lost in week due to DTOC by CCG

2.12 Green patients. Daily there are approximately 20% of adult inpatients classified as green are medically and therapeutically fit for discharge. Information is provided daily to the CCGs for appropriate actions to be taken to support early discharge. Longer term the aspiration is to move to the proactive review of Amber patients, however short term consideration must be given to set a daily trajectory for green patient reduction by CCG with an internal focus on simple discharge. This has been requested by the RUH as an additional objective of the Wiltshire CCG 100 day challenge. The request has also been made to Sirona, health and social care community provider, with support from BANES CCG.

2.13 Length of Stay (LoS). Average LoS remains consistent despite back door pressures

preventing discharge. Initial investigations via BIU suggest that this could be due to the volume of patients admitted in early August that were still inpatients into September, and are therefore not included in the summary. Whilst this occurs every month, the proportion of patients with a stay of over 20 days at the end of August was higher than in other months of the financial year (a 23.7% increase on July 2014, August to be reported at end of September). Graph 5 clearly demonstrates that total LoS has improved and reducing LoS continues to be a focus for the Trust.


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Graph 5: RUH Average Length of Stay

2.14 Bed Occupancy rates. Occupancy has been maintained at an average 95.8% Apr-July but has seen an increase to 97.7% in August, reflecting the reduced bed base internally and increased numbers of DTOCs. Occupancy continues to be high in September.

Table 4: Average Bed Occupancy

2.15 Medical Outliers. Despite the obvious pressure on flow the Trust maintained a

relatively stable level of medical outliers. Medical outliers increased at the beginning of August as planned mitigation for the closure of Parry Ward for essential works, but may also have been affected by reduced flow into Wiltshire community. Graph 6 below compares green patients, medical outliers and bed occupancy rates.

Average

April 2014 95.9%

May 2014 96.2%

June 214 95.7%

14/15 Q1 95.9%

July 2014 95.1%

August 2014 97.7%

Sept 2014 to date 97.3%

14/15 Q2 to date 96.5%

LoS Improvement last year

Sustained improvement in LoS


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Graph 6: Comparison of Green patients, medical outliers and bed occupancy rates

2.16 Overall conclusions

Recovery must primarily focus on backdoor and flow as all indications are that 4 hour performance is not due to any issues in ED processes.

Planning for expected peaks in demand as per the 5 year projections of ambulance conveyances is critical to success.

Geriatric LOS increased in August, impact from increase in DTOC affects OPU directly. The overall increase in patient acuity also appears to have affected OPU with ACE OPU not being able to discharge patients due to complex medical needs.

Ambulance activity is a measure of acuity; it appears that more acutely unwell patients were transferred to the RUH during August, although for total admission the activity remains similar to August 2013.

Continued engagement with Community partners to focus on driving down DTOC and Green to Go numbers

Review with each CCG, ED attendance and Non Elective Admissions rate above contract.


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3. 4 Hour Recovery Plan

3.1 The 4 hour recovery plan is detailed in Appendix B and includes the following elements:

An immediate RUH recovery plan to bring the performance back on track in September and October. This has been developed based on RUH internal diagnostic and a review of the Emergency Care Checklist – Urgent and Emergency Care: A review of NHS South of England (The Kings Fund, March 2013, based on ECIST best practice).

The plan is intended to deliver five key strategic outcomes;

Front Door Ambulatory care pathway activity recovery Flow Optimise Medical and Surgical elective capacity

Introduce speciality medical take in Medicine, with increased medical engagement in bed allocation

Back door Reduced Delayed Transfers of Care Drive improvement in LOS across all specialities

Actions that the RUH will request from CCG’s and community providers. These actions have been proposed based on the RUH diagnostic of 4 hour performance.

Agree implementation plans for the Operational Resilience and Capacity plan from November 2014, with clear plans by provider.

3.2 RUH 4 Hour Recovery Plan is designed to provide enhanced daily performance monitoring across 20 key actions, with clear operational and executive leadership. Short term priority actions identified have been split into:

Front Door 4 immediate actions

Flow 10 immediate actions

Backdoor 6 immediate actions An operational KPI has been agreed for each action with a daily target agreed, the daily score card can be seen in appendix B. 3.3 This reflects the RUH 4hr diagnostic with a requirement to focus on flow and improve discharge performance, working collaboratively with the community. 3.4 All actions have clear performance KPIs, which will be monitored on a daily basis, by the Chief Operating Officer, Divisional Manager of Medicine and Urgent Care Programme Manager. 3.5 The RUH diagnostic of 4 hour performance has identified a number of issues that will be raised with CCG and community providers. The recovery plan details these by CCG and community provider, with the supporting RUH analysis. Through the BANES SRG the RUH will request all issues are urgently reviewed and key actions agreed. 3.6 The short term recovery plan will complement the RUH current 2014/15 Urgent Care Improvement Programme that has the following 3 work streams:


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Integrated Co-create new ways to integrate primary community and social care with lower risk urgent care.

Responsive Lead the expansion of ambulatory care management, rapid diagnostics and treatment to avoid admission. Co-create the redesign of discharge services.

Sustain Lead the provision of high quality major and high risk urgent and emergency care. All of these projects where implemented in 2013/14 following ECIST best practice.

3.6 The RUH Urgent care Programme will continue, with monthly review and monitoring of current projects already established.


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3.2 RUH Priority Actions for Immediate and Short Term Delivery:

RUH Priority Actions 8th September – 31st October 2014

ID Workstream Overall Action and Outcome Critical to

Impact Sponsor Implementation

Date Detailed Actions Operational

Leads Progress

RAG

1.1 Front Door Neurology patients referred to ambulatory care – alternative pathways to be considered and implemented Outcome: ED attendance and admission avoidance

Low S Spencer 17/10/14 Neurology team capacity for front door – confirmation from clinical lead

Consultant Acute Physician has a sub speciality in neurology – plan to hold specialist clinics.

Learning from referrals to neurology from ambulatory care.

W Hubbard A Garg/ F Maggs Z Haines

1.2 Front Door MAU challenge to allocate and move patients to all available beds by 20:00. Outcome: Flow

High H Jeffcoat 15/09/14 MAU coordinators to be briefed

Clinical site team access to MAU bed board in site office

Daily review of performance and reasons for blocks to moves

All medical wards to be briefed on new performance target

H Jeffcoat S Spencer M Rumble/S Spencer J Miller

Started

1.3 Front Door Increase Ambulatory Care: Medical (Amb Care) Outcome: Admission avoidance

High A Garg

22/9/14 Daily meeting to review performance and plan for tomorrow

Weekly planning meeting with MTU and Oncology Day Care

Provide evidence that not escalating into MTU will remove equivalent/more patients from Medical Take.

S Spencer / M Rumble J Miller (Matrons) / S Spencer S Spencer


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ID Workstream Overall Action and Outcome Critical to Impact

Sponsor Implementation Date

Detailed Actions Operational Leads

Progress RAG

Work with site team to plan escalation for any overnight period with elective only patients.

S Spencer / M Rumble / L Warner-Holt

1.4 Front Door Increase Ambulatory Care: Surgical (ESAC) Outcome: Admission avoidance

High S Richards 6/10/14 Implement 5 day service, for daily ESAC clinics

Increase to 4 theatre lists per week (from 3 per week)

Work with site team and Acute Medicine to agree plan for SAU Trollies daily

S Richards S Richards/S Roberts L Warner-Holt

2.1 Flow Medical Elective actions Outcome: Capacity for emergency activity

Low C O’Farrell 30/9/14 Cardiac elective patients to Spire in Southampton, releasing lab capacity to maintain low inpatient waits to cath lab.

Escalate daily to Bristol for patients waiting for Bristol Heart Institute (BHI) Maintain transfer pathway to London and offer to all appropriate patients.

F Bird J Stevenson / F Bird

2.2 Flow ACE OPU ‘step down’ pathway to Charlotte. Bring forward plan Outcome: Flow

Low J Miller 30/9/14 Agree pathway and transfer criteria with Charlotte Ward

Confirm medical cover

Confirm transfer process with site team, offer of Charlotte beds daily to ACE. (Following Cheselden pathway)

B Boyd/ J Miller (Matron) W Hubbard J Miller / L Warner-Holt

2.3 Flow Acute Coronary Syndrome Service Update post launch early September 2014 Outcome: LOS

Medium R Lowe 10/9/14 Agree model with MAU

Identify MNP & Junior Doctor resource in Cardiology

Baseline audit results of ACS patients completed (June to August)

Agree KPI and link to C³

R Lowe R Lowe S Jones (MNP) R Lowe

Started


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Progress RAG

2.4 Flow Access to diagnostics (not radiology)

Low S Hudson 6/10/14 Review all non-radiology diagnostics, access times and link to blocks to discharge

S Hudson (working with heads of service)

2.7 Flow Analysis of previous year’s peak activity weeks over recovery plan period.

High Sarah Hudson

15/9/14 Include peak escalation days on daily dashboard.

Review KPIs daily to ensure mitigation in-place.

Weekly review linking KPIs to performance.

S Hudson C O’Farrell F Thompson

Started

2.8 Flow Clinical site team allocation of beds; consideration of the moves to be made on MAU to support speciality placement, reduction in PPTRW (escalation trigger) and overall LoS) Outcome: Flow and LoS

High Lee Warner-Holt Anu Garg Sophie Spencer

01/10/14 Site team manager to review PPTRW patients with Dr Garg daily basis (10 minute meeting)

MAU to manage all medical beds (agree pilot for 06/10/14)

L Warner Holt A Garg L Warner Holt H Jeffcoat

2.9 Flow 12:15 MAU white board meeting ensuring bed manager and clinical site manager attend. Outcome: LoS

High Lee Warner-Holt Anu Garg Sophie Spencer

12/09/14 Embed into timetable for key staff – clinical site manager, medicine bed manager and MAU Consultant

Acute oncology attending to support William Budd and outlier moves

Plan to involve other specialties i.e. ACE

Acute Cardiac Team to attend

L Warner Holt M Rumble A Garg L Medley A Garg/ S Spencer F Bird

2.10 Flow C³ Launch and Medical Division move to speciality take model (from zones) Outcome: Flow, LoS

High W Hubbard 22/09/14 Confirmed new go-live date of 13

th October

Clinical lead engagement in flow and patient placement

Establish C³ daily meetings in ED seminar room

W Hubbard L Warner Holt W Hubbard

Delayed launch to follow ‘Green’ week


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Progress RAG

3.1 Back Door Wiltshire 100 Day Challenge – Providing robust feedback on impact in the RUH RUH Wiltshire discharge group established Outcome: Discharge, LoS, admission avoidance

High F Thompson 01/09/14 Daily reporting of DTOC/ complex discharge numbers

Agree processes for clinical team feedback for each division

Meeting dates agreed review progress of all Wiltshire schemes

H Bennett C O’Farrell S Wills R Hills C O’Farrell R Fackrell

Started

3.2 Backdoor Green Patient Challenge focus on Somerset and BaNES CCG Outcome: Discharge, LoS

Medium G Sargeant 22/09/14 Agree green reporting process and Daily escalation actions

Speciality specific feedback via matrons

H Bennett/ G Sargeant J Miller

3.3 Backdoor Twice Daily Medicine Huddle focused on discharge planning for tomorrow (Space for Tomorrow) Outcome: Discharge, Flow

Medium J Miller 01/09/14 Twice daily meetings in place with medicine matrons, DLN, medicine bed manager and speciality manager

Increased number of confirmed discharges declared for 9am meeting

J Miller L Warner-Holt (with bed managers)

Started

3.4 Backdoor Repeat ECIST 7 day LOS patient snap shot audit Outcome: Discharge, flow

High S Hudson 11/9/14 Agree staff to support audit completion

Complete audit and provide analysis to CCG and Community Providers.

Follow up with Directors at SRG

S Hudson S Hudson F Thompson

Completed

3.5 Backdoor Pilot RUH Integrated Transfer Team (ITT) – 5 wards (Following DART model at GWH)

Medium H Bennett & G Sargeant

1/10/14 Agree staff for ITT team

Confirm community support for ITT pilot

Confirm operational staff to

H Bennett/ G Sargeant C O’Farrell H Bennett/ G


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Progress RAG

Outcome: Discharge, LOS

support daily ITT meeting

Agree clinical assessment form with ward managers

Sargeant J Miller / S Bonson

3.6 Backdoor Transport trust wide education on the use of non-emergency patient transport – ensuring appropriate use of stretcher, wheelchair, walking patients to support allocation of most appropriate transportation

Low S Dyson 22/9/14 Agree ward training programme with Heads of Nursing

Agree outpatient training programme with Division’s

Set training date for Radiology staff

Agree performance monitoring

S Jack S Jack S Jack S Jack/ S Dyson

Started

High Priority Actions September – October 2014 3.3 Urgent Care Programme Management Actions to Support Recovery Plan


Lead(s) Implementation Date

Detailed Actions Lead Progress RAG

4.1 Flow Daily recovery plan metrics (scorecard) Outcome: Improved performance management

Low C O’Farrell 15/09/14 Metrics for all immediate actions to be reported daily

Escalation to DM and COO as appropriate

Weekly recovery plan review meetings

S Hudson/BIU S Hudson C O’Farrell

Started

4.2 Flow Whole Trust Space for Tomorrow week Spring to Green methodology Outcome: Staff engagement

Medium Francesca Thompson

10/10/14 Plan to commence w/b 06/10/14

To run concurrently with formal launch of C³ (workstream 7)

L Lewis W Hubbard


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3.4 SRG High Priority Issues

SRG RUH High Priority Issues September – October 2014

Organisation: Summary of Issue: RUH Diagnostic Organisation Lead Delivery

RAG

BANES CCG Increase in non-elective admissions. The RUH will provide a senior clinical lead (Head of Medicine) to review data with each GP practice and CCG.

Analysis RUH non-elective admissions by GP Practice, selecting the practices with the some significant emergency admission growth form 2013/14.

Temple House Practice

Rush Hill Surgery

Fairfield park Health Centre

Combe Down Surgery

St Chards Surgery

Tracey Cox Acting Chief Accountable Officer

Increase in DTOC, Green to Go and Complex Discharge patients

August and September have seen DTOC increase for BANES patients, with a corresponding increase in Green to Go patients and Complex Discharge patients. Further diagnostic for BANES CCG patients to highlight changes in performance.

Tracey Cox Acting Chief Accountable Officer Janet Rowse Chief Executive SIRONA

Wiltshire CCG Increase in non-elective admissions. The RUH will provide a senior clinical lead (Head of Medicine) to review data with each GP practice and CCG

Analysis RUH non-elective admissions by GP Practice, selecting the practices with the some significant emergency admission growth form 2013/14.

Lovemead group practice

Porch Surgery

Bradford-On-Avon and Melksham Health

Widbrook Medical Practice

White Horse Health Centre

Debbie Fielding Accountable Officer

Significant Increase in DTOC, Green to Go and Complex Discharge patients

August and September have seen DTOC increase for BANES patients, with a

Debbie Fielding Accountable Officer


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Organisation: Summary of Issue: RUH Diagnostic Organisation Lead Delivery RAG

corresponding increase in Green to Go patients and Complex Discharge patients. Peak in social care delays in August, due to closure of Wiltshire Care Home. Daily reporting of Green to Go and Complex discharge patients established in September 2014, with daily escalation calls to Integration Director for Wiltshire CCG. Key action as part of Wiltshire 100 day challenge.

Carolynn Hamblett Acting Associate Director Adult Care Operations James Roach Integration Director

SWAST 2014/15 has seen a sustained increase in Ambulance Arrivals at the RUH. All months seeing activity above the 5 year average for ambulance arrivals. This is impacting on the RUH with significant pressure at the Front Door.

RUH Ambulance conveyance activity in Q1 and Q2. SWAST have been asked to review:

Ambulance conveyance by reason

Ambulance arrivals for Bath and Wiltshire Community

Time of day of arrival and day of arrival variation

Ken Wenman Chief Executive Nick Wilson, Operations Manager BANES and South Wiltshire

AWP Increase in admissions requiring mental health support. Increased use of RMN across RUH, due to higher acuity of patients and identification of clear mental health needs. HRG analysis of RUH admissions, looking at mental health HRG codes. Assessment by CCG for these codes.

Kirsten Dominy Operations Director Jason Everett, Operational Manager


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4. 4 Hour Recovery Oversight and Assurance

4.1 Oversight of the programme and the local plan to remedy immediate performance pressures will be provided through:

RUH Urgent Care Improvement Board, chaired by the Chief Operating Officer

System Resilience Group Meeting, chaired by BANES CCG Acting Accountable Officer. Wiltshire and Somerset SRG meetings will also provide assurance on the recovery plan.

4.2 Representatives of the Area Team will attend the Board, both as a stakeholder and in order to provide assurance of, and support to, the process. They will be requested to support the CCG in performance managing primary care following completion of the SRG diagnostic, including increase in non-elective admissions by GP practice. 4.3 The RUH Urgent Care Board will continue to review the plan and incorporate actions as agreed at SRG meetings. The RUH urgent & emergency care strategic overview has also been updated to include the 4 hour recovery and implementation of SRG ORCP from Q3, refer to Appendix E. 4.4 SRG’s have been asked to describe their high priority actions to support the Urgent Care System to reduce ED attendance, non-elective admissions and increase daily complex discharges as mitigation to support the recovery trajectory for ED performance and quality. The aim is to ensure that performance and quality is back to constitution standards by the end of October 2014.

5. Trajectory for Recovery of Emergency 4 hour Standard

5.1 The graph in Appendix C shows the planned trajectory for 4 hour recovery for the last six months of 2014/15. Actual performance will be mapped daily to ensure that the mitigation is supporting delivering in line with the anticipated trajectory and to take appropriate and immediate actions to address any deterioration from plan.

To date the RUH is within 0.3% of the trajectory. The trajectory will be refreshed at the end of October 2014. 5.2 The RUH will continue to review 4hr performance daily, linking performance to delivery of the recovery plan operational metrics recorded on the score card. This will confirm that the actions taken are supporting 4hour recovery.

6. Operational Resilience and Capacity Planning 2014/15

6.1 Preparation for the winter period 2014/15. The health community, through the relevant SRG’s need to give consideration to the early finalisation of the operational Resilience and Capacity plans for 2014/15 to provide the necessary mitigation to support RUH recovery.


Date:22nd


Agenda Item: of 34

Appendix A – RUH 4 Hour Recovery Operational Plan

Meetings

Delivery

Action to be Taken

Action Completed and On Track

Slippage

Missed / Off track

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

8-Sep

-14

9-Sep

-14

10-Se

p-14

11-Se

p-14

12-Se

p-14

13-Se

p-14

14-Se

p-14

15-Se

p-14

16-Se

p-14

17-Se

p-14

18-Se

p-14

19-Se

p-14

20-Se

p-14

21-Se

p-14

22-Se

p-14

23-Se

p-14

24-Se

p-14

25-Se

p-14

26-Se

p-14

27-Se

p-14

28-Se

p-14

29-Se

p-14

30-Se

p-14

1-Oct-

14

2-Oct-

14

3-Oct-

14

4-Oct-

14

5-Oct-

14

6-Oct-

14

7-Oct-

14

8-Oct-

14

9-Oct-

14

10-O

ct-14

11-O

ct-14

12-O

ct-14

13-O

ct-14

14-O

ct-14

15-O

ct-14

16-O

ct-14

17-O

ct-14

18-O

ct-14

19-O

ct-14

20-O

ct-14

21-O

ct-14

22-O

ct-14

23-O

ct-14

24-O

ct-14

25-O

ct-14

26-O

ct-14

27-O

ct-14

28-O

ct-14

29-O

ct-14

30-O

ct-14

31-O

ct-14

ActionAction

AssignedStatus

Delivery

Deadline

Daily Performance Review Huddle SH Dai ly

Report to Urgent Care Improvement Board CoF Monthly

Report to Management Board FT/CoF Monthly

Metrics for all immediate actions to be reported daily SH 14/09/2014

Escalation to DM and COO as appropriate SH/SpecMg 15/09/2014

Planning for expected increases in Ambulance Conveyance (5 year average data) SH 15/09/2014

Weekly recovery plan review meetings SH/COF 19/09/2014

Spring to green methodology to be used - focus on discharge LL 19/09/2014

Plan to commence w/b 06/10/14 To run concurrently with formal launch of C³ (work stream 7)LL 06/10/2014

Identification of specific KPI/Discharge focused KPI including quality SD/LL/SH 03/10/2014

Neurology team capacity for front door – confirmation from clinical lead CC 22/09/2014

Learning from Ambulatory Care referrals to Neurology - education/training, alternative

pathways/GP CommunicationZH 31/10/2014

Consultant Acute Physician has a sub specialty in neurology – plan to hold specialist clinics in

Am CareSS/AG/FM 17/10/2014

All medical wards to be briefed on new performance target JM 12/09/2014

MAU coordinators to be briefed NHJ 15/09/2014

Clinical site team access to MAU board in site office (medium term aspiration to develop new

bed board)SH/LWH 22/09/2014

Daily meeting to review performance and plan for tomorrow SS/JM 22/09/2014

Weekly planning meeting with MTU and Oncology Day careJM/Matron

s22/09/2014

Provide evidence that not escalating into MTU will remove equivalent/more patients from

Medical Take.JM/Matron

s22/09/2014

Work with site team to plan escalation for any overnight period with elective only patients.JM/Matron

s22/09/2014

Implement 5 day service, for daily ESAC clinics SR/SR 06/10/2014

Increase to 4 theatre l ists per week (from 3 per week) SR/SR 13/10/2014

Work with site team and Acute Medicine to agree plan for SAU Trolleys daily LWH 19/09/2014

Cardiac elective patients to Spire in Southampton, releasing lab capacity to maintain low

inpatient waits to cath lab.FB 30/09/2014

Escalate daily to Bristol for patients waiting for Bristol Heart Institute (BHI) Maintain transfer

pathway to London and offer to all appropriate patients.FB/JS 17/09/2014

Agree pathway and transfer criteria with Charlotte Ward BB/JM 30/09/2014

Confirm medical cover WH 30/09/2014

Confirm transfer process with site team, offer of Charlotte beds daily to ACE. (Following

Cheselden pathway)JM/LWH 30/09/2014

Agree model with MAU RL/AG 12/09/2014

Identify MNP & Junior Doctor resource in Cardiology RL/FB 12/09/2014

Baseline audit results of ACS patients completed (June to August) RL/SJ 12/09/2014

Agree KPI and link to C³ WH 30/09/2014

Review all non-radiology diagnostics, access times and link to blocks to dischargeSH/Cl in

Leads06/10/2014

Establish metric and KPI for each modality SH 06/10/014

Include peak escalation days on daily dashboard. SH 15/09/2014

Review KPIs daily to ensure mitigation in-place. CoF 15/09/2014

Weekly review linking KPIs to performance. FT/CoF 19/09/2014

Site team manager to review PPTRW patients with Dr Garg daily basis (10 minute meeting)

AG/LWH 15/09/2014

MAU to manage all medical beds (agree pilot for 06/10/14) LWH/HJ/M

R01/10/2014

Embed into timetable for key staff – clinical site manager, medicine bed manager and MAU

ConsultantLWH/AG/SS

/HJ08/09/2014

Acute oncology now to attending supporting Will iam Budd and outlier moves LM 08/09/2014

Plan to involve other specialties i.e. ACE SS 22/09/2014

Acute Cardiac Team to attend FB 15/09/2014

Clinical lead engagement in flow and patient placement WH/LWH 22/09/2014

Establish C³ daily meetings in ED seminar room WH 06/10/2014

2.9 Additional Bed Capacity Planning Additional bed capaci ty planning - Pulteney, Midford and Cheselden (plan to open in November

2014)WH 06/11/2014

Dai ly reporting of DTOC/ complex discharge numbers HB 08/09/2014

Agree processes for cl inica l team feedback for each divis ionCoF/SW/RH 08/09/2014

Meeting dates agreed review progress of a l l Wi l tshire schemesCoF/RF 08/09/2014

Agree green reporting process and Dai ly esca lation actions HB/GS 22/09/2014

Specia l ty speci fic feedback via matrons JM 09/08/2014Twice da i ly meetings in place with medicine matrons , DLN, medicine bed manager and

specia l ty manager JM 09/08/2014

Increased number of confi rmed discharges declared for 9am meeting JM 09/08/2014

Agree s taff to support audit completion SH 31/10/14

Complete audit and provide analys is to CCG and Community Providers . SH/CoF 31/10/14

Fol low up with Directors at SRG for each CCG CoF/FT 31/10/14

Identi fy 5 Wards to s tart pi lot HB/GS 01/10/2014

Agree s taff for ITT team HB/GS 01/10/2014

Agree cl inica l assessment form with ward managers SB/JM 01/10/2014

Confi rm community support for ITT pi lot HB/GS 01/10/2014

Confi rm operational s taff to support da i ly ITT meeting HB/GS 01/10/2014

Agree ward tra ining programme with Heads of Nurs ing SD/SJ 22/09/2014

Agree outpatient tra ining programme with Divis ion’s SD/SJ 22/09/2014

Set tra ining date for Radiology s taff SD/SJ 22/09/2014

Agree performance monitoringSJ/SH 22/09/2014

Increase in non-elective admiss ions . The RUH wi l l provide a senior cl inica l lead (Head of

Medicine) to review data with each GP practice and CCGTC TBC

Increase in DTOC, Green to Go and Complex Discharge patients TC/JR TBC

Increase in non-elective admiss ions . The RUH wi l l provide a senior cl inica l lead (Head of

Medicine) to review data with each GP practice and CCGDF TBC

Signi ficant Increase in DTOC, Green to Go and Complex Discharge patients CH/JR TBC

SWASFT2014/15 has seen a susta ined increase in Ambulance Arriva ls at the RUH. Al l months seeing

activi ty above the 5 year average for ambulance arriva lsNW TBC

AWP Increase in admiss ions requiring mental health support JE TBC

1.2 MAU challenge to allocate and move patients to

all available beds by 20:00

1.3 Increase Medical Ambulatory Care Activity

1.4 Increase Surgical Ambulatory Care Activity (ESAC)

2.1 Medical Elective Actions

Operational Recovery Management Actions

Urgent Care Programme Manager

Daily 4 Hour Performance Recovery Metrics

Whole Trust Space for Tomorrow Week

KEY

Backdoor

Robin

Fackrell

Sarah

Hudson

UCIB Lead

Operational Recovery Work streams

Front Door

Anu Garg

Day

Date

1.1 Ambulatory Care Neurology Referral

2.6 Clinical site team allocation of beds;

consideration of the moves to be made on MAU to

support specialty placement, reduction in PPTRW

(escalation trigger) and overall LoS)

2.7 12:15 MAU white board meeting ensuring bed

manager and clinical site manager attend.

Flow

William

Hubbard

2.3 Acute Coronary Syndrome Service

2.2 ACE OPU Step Down to Charlotte Ward

Task Group / Issue

2.4 Access to diagnostics (not radiology)

2.5 Analysis of previous year’s peak activity weeks

over recovery plan period.

SRG

Francesca

Thompson

3.1 Wiltshire 100 Day Challenge – Providing robust

feedback on impact in the RUH

RUH Wiltshire discharge group established

3.2 Green Patient Challenge focus on Somerset and

BaNES CCG

3.3 Twice Daily Medicine Huddle focused on

discharge planning for tomorrow (Space for

Tomorrow)

3.4 Repeat ECIST 7 day LOS patient snap shot audit

3.5 Pilot RUH Integrated Transfer Team (ITT) – 5

wards

3.6 Transport trust wide education on the use of

non-emergency patient transport – ensuring

appropriate use of stretcher, wheelchair, walking

patients to support allocation of most appropriate

transportation

BaNES CCG

Wiltshire CCG

2.8 C³ Launch and Medical Division move to specialty

take model (from zones)

Delivery SRG

schemes

DTOC

Strategic Focus

(KPI)

4 Hour

Am Care

Activity

LoS


Date:22nd


Agenda Item: of 34

Appendix B – RUH 4 Hour Recovery Daily Scorecard

Work Stream Performance Measure Target 10-

Sep

-14

11-

Sep

-14

12-

Sep

-14

13-

Sep

-14

14-

Sep

-14

15-

Sep

-14

16-

Sep

-14

17-

Sep

-14

18-

Sep

-14

19-

Sep

-14

20-

Sep

-14

21-

Sep

-14

22-

Sep

-14

23-

Sep

-14

24-

Sep

-14

25-

Sep

-14

26-

Sep

-14

27-

Sep

-14

28-

Sep

-14

29-

Sep

-14

30-

Sep

-14

1-O

ct-1

4

2-O

ct-1

4

3-O

ct-1

4

4-O

ct-1

4

5-O

ct-1

4

6-O

ct-1

4

7-O

ct-1

4

8-O

ct-1

4

9-O

ct-1

4

10-

Oct

-14

11-

Oct

-14

12-

Oct

-14

13-

Oct

-14

14-

Oct

-14

15-

Oct

-14

16-

Oct

-14

17-

Oct

-14

18-

Oct

-14

19-

Oct

-14

20-

Oct

-14

21-

Oct

-14

22-

Oct

-14

23-

Oct

-14

24-

Oct

-14

25-

Oct

-14

26-

Oct

-14

27-

Oct

-14

28-

Oct

-14

29-

Oct

-14

30-

Oct

-14

31-

Oct

-14

Tre

nd

Daily 4 Hour Performance 95% 96.8 97.9 94.3 96.1 89.6 96.6 97.0 97.3 96.0 95.0 95.9 93.9 95.4 99.5

Total Number of Attendances 190 187 195 211 207 212 205 197 183 205 183 220 216 196 199

Total Breach Number (detail at daily meeting) 0 6 4 12 9 22 7 6 5 8 6 10 14 9 1

Breach Variance to 4 Hour Recovery Trajectory 6 0 -2 6 3 16 1 0 -1 2 3 3 6 3 0

Front Door ED Time to Treatment 60 63 40 70 40 63 45 47 33.5 53 40.5 45 64 40 43.5

Total Ambulance Conveyances 79 87 89 76 91 73 70 79 84 87 88 82 59 83

Daily Take Predictor 81 86 86 77 71 90 79 88 84 95 73 79 88 80 89

Actual Take 64 69 69 71 61 75 63 62 73 78 56 63 71 56

Escalation Status at 09:00 RAG R R A R R R A R A A A R R A A

Escalation Status at 16:00 RAG R R A R R R A R A A R R R A

Closed Beds at 9am 2 4 4 4 4 3 3 3 2 3 3 2 2 2 2 3

Escalation Beds Open at 9am SSSU 0 10 10 10 10 10 10 10 10 8 10 10 10 10 4 9

Escalation Beds Open at 9am ACE 0 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0

Escalation Beds Open at 9am ASU 0 1 1 1 1 1 1 1 1 0 1 1 1 1 0 0

Escalation Beds Open at 9am Eye 0 0 0 0 0 0 0 0 5 3 0 0 0 0 0 0

Escalation Beds Open at 9am ESAC 0 4 4 4 4 2 0 0 2 0 2 2 2 2 1 0

Escalation Beds Open at 9am MTU 0 4 4 4 4 2 0 0 0 0 0 0 0 0 0 0

Escalation Beds Open at 9am Day Rooms 0 2 2 2 2 2 0 2 2 1 0 0 0 0 0 0

Admissions Minus Discharges (negative value discharge >admission) 0 10 -23 -4 -8 32 -5 28 -4 5 -6 22 16 10 -2

Total In-Patients Red 262 311 307 297 336 361 354 345 367 275 345 353 381 340

Flow Total In-Patients Amber 140 136 121 130 115 94 127 128 113 117 106 109 106 110

Total In-Patients Green 114 110 108 105 107 108 112 103 103 127 97 94 99 92

Total In-Patients Not Classified 146 118 113 124 127 105 105 120 122 186 157 156 120 102

Total In-Patients Green Wiltshire CCG 50 43 41 40 44 48 47 40 42 56 42 41 42 33

Total In-Patients Green BaNES CCG 46 44 46 43 41 42 42 40 39 44 34 33 34 40

Total In-Patients Green Somerset CCG 9 11 9 8 8 8 11 11 12 16 12 11 13 12

Total In-Patients Green Other CCG 9 12 12 13 13 12 12 12 10 11 9 9 10 7

Total Number Length of Stay > 7 days 224 291 258 258 267 283 275 270 271 265 287 254 269 271 249

Elective Cancellations on the day Surgery 0 0 0 0 0 0 1 0 6 0 0 0 0 0 0

Elective Cancellations on the day MTU 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Elective Cancellations on the day Haem/Onc 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

% Take through Medical Ambulatory care 20 19 27 33 19 15 9 28 8 15 15 #### #### #### #### #### #### #### #DIV/0! #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### ####

Medical take 42 45 58 47 39 46 54 50 48 33 0

Elective activity in Ambulatory Care (actual) 2 8 3 10 7 7 7 12 12 10 0

Non-elective work 8 12 19 9 6 4 15 4 7 5 0

Total medical ambulatory care 10 20 22 19 13 11 22 16 19 15 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

% Elective Activity in Ambulatory Care 20 40 14 53 54 64 32 75 63 67 #### #### #### #### #### #### #### #DIV/0! #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### ####

Surgical Ambulatory Care Activity 19 20 25 16 16 TBC TBC TBC TBC TBC TBC TBC TBC TBC

PPTWR at 9am <10 14 15 18 9 16 12 15 20 13 11 9 16 18 10

Number of Patients in ED with a bed request at 20:00 16 9 8 13 11 9 11 13 5

Number of unoccupied beds on MAU at 20:00 10 3 4 7 4 5 0 0 1 13

Allocated bed moves to be made (MAU to core wards) at 20:00 5 6 3 8 6 5 0 14 12

Number of unallocated beds at 20:00 11 4 8 4 5 0 0 3 4

Number of electives through MTU (activity to date cardiac only) 5 5 4 0 2 2 6 5 5 4 0 8 6 6

ACE OPU Step Down to Charlotte Ward at 16:00 3

Total Referrals to Acute Coronary Syndrome Service 1

In Patient Wait for Endoscopy >24 hours at 9am TBC

In Patient Wait for Echo >24 hours at 9am TBC 22 22

In Patient Wait for Other Acute Provider at 9am (cardiac) 3 8 8 8 8 8 8 3 3

Complex Delay Total Wiltshire <5 8 20 18 17 11 12

Complex Delay Total BaNES <5 9 2

Complex Delay Total Somerset <5 4 2

Complex Delay Total Other <5 3 2

DTOC Total <15 19 16 37 37 37 30 20 19 13 33 31 31 27 22 17

Back Door DTOC Wiltshire CCG 5 8 8 19 19 19 15 10 9 4 4 10 10 8 6 3

DTOC BaNES CCG 5 8 6 9 9 9 9 7 7 6 16 15 15 13 10 8

DTOC Somerset CCG 3 1 1 4 4 4 2 1 1 1 3 3 3 3 3 2

DTOC Other CCG 2 2 1 4 4 4 4 2 2 2 3 3 3 3 3 1

DLN Identified Discharge Declared for Next Day at 16:00 Huddle 6 6 0 8 0 0 0 NA NA 2 6

Potential Discharges Declared for Next Day at 16:00 Huddle 15 12 0 10 0 0 2 NA NA 8 15

Integrated Transfer Team Daily Meet (5 Wards)


Date:22nd


Agenda Item: of 34

Appendix C – RUH 4 Hour Recovery Trajectory


Date:22nd


Agenda Item: of 34

Appendix D – RUH Urgent Care Improvement Programme

1.0 Sustained ID Project/Action Impact Description and Key Action Start Date KPI and Lead

Target

1.1 Medical Ambulatory Care

- ED attendance avoidance

- Non-Elective admission avoidance

- 4 hour performance

Continue to develop the service offerings and increase service to open ambulatory care Monday to Friday until 8pm. Aim to review an additional 15 patients per week in the department and increase the number of primary care calls to the consultant led team. Funding to support the additional Consultant PA and nurse practitioners required - 2014/15 Operational Resilience and Capacity funding request.

Oct 2013 - Number of non-elective patients seen in ambulatory care, per month

- Number of patients discharged from MSSU with 0-3 days

Clinical Lead: Anu Garg Project Lead: Sarah Gillett

190

1.2 Emergency Surgical Ambulatory Care (ESAC)

- Admission

avoidance

- Reduced LoS

category C and

D

- ED attendance

avoidance

Continue to improve the emergency surgical pathway for category C/D (see NCEPOD classification) patients, thus reducing length of stay by;

Providing consultant led ring fenced emergency theatre lists

Providing consultant led daily urgent GP access clinic, with access to diagnostics, within the Surgical Assessment Unit (SAU)

Trajectory for 2014/15 based upon a two surgeon service, advertisement placed again in July to recruit substantively. Locum in place from June 2014 – able to provide a full five day service with no operational service gap due to leave etc. Plan to move to 6 day then seven day once substantive post holder in place. Benefits will be seen in Q2 as per trajectory with a continued improvement throughout Q3 and Q4.

May 2013 - Number of patients seen in urgent clinics

- Pre-op length of stay for cat C/D theatre list

- Number of patients

deteriorating from

C/D lists to A/B

Clinical Lead: Sarah

175


Date:22nd


Agenda Item: of 34

ID Project/Action Impact Description and Key Action Start Date KPI and Lead

Target

Richards Project Lead: Steven Roberts

1.3 Acute Oncology Service Expansion

- LoS reduction - ED attendance

and admission avoidance

- Patient flow and 4 hour performance

- Early

supportive

discharge

Continue the current service provision Monday to Friday; ensuring patients are booked appropriately into the admission avoidance clinics. 24/7 advice and guidance available at Consultant level. Aim to develop the service to be 7 days per week with Consultant and nurse specialist led input to the front door. Complete business case for October Management Board

Sept 2014 - Number of patients

seen per month in

AOS clinic

Clinical Lead: Louise Medley Project Lead: Ed Nicolle

75

1.4 Senior with a Team (SWAT)

- Reduce time to

treatment

- Unplanned

admission

avoidance

- Reduced LOS

- Increase ED

throughput

In 2013/14, 40% of patients from time of arrival had a decision to admit. This has improved in 2014/15 to 48.7% and increasing. Time to treatment also continues to reduce well below the target. This clearly demonstrates the impact of senior decision makers at the front door. And with the ED coordinator completing additional training as per the 2013/14 urgent care programme there are even more skilled decision makers within the ED department.

Oct 2013 - % of patients with time to treatment ≤60 minutes

- % of patients admitted

Clinical Lead: Dominic Williamson Project Lead: Mandy Rumble

60

1.5 Acute Diabetes - LoS reduction for patients with diabetes

- Medication error reduction and dosing

- Medicines compliance

- Access to senior decision makers

- Decrease LoS for patients with Diabetes on MAU/SAU

Supports MAU and SAU reduction in LoS for patients with a diagnosis of Diabetes. This reduction is also seen when patients are transferred to the appropriate specialty ward for their admission. Improved communication with primary care on discharge supporting a reduction in readmission with earlier senior specialty input.

Oct 2013 - Total Referrals to

Acute Diabetes Team

- Episodes of

hyperglycamia >15

- Total number of feet

checks

Clinical Lead: Marc Atkins Project Lead: Helen Griffiths

135

1.6 Discharge Coordinators

- Reduction in failed

As per 2013/14 programme roles support earlier supportive discharge and proactive management of a patients discharge – preempting all

Oct 2013 - Increase by 5% adult 35%


Date:22nd


Agenda Item: of 34

ID Project/Action Impact Description and Key Action Start Date KPI and Lead

Target

discharges due to TTAs, discharge summaries, timely booking of transport, communication with family to ensure all requirements are in place and liaison as required with the voluntary sector

- Patient flow - Early

supportive discharge


- Reduce readmission

requirements to ensure a smooth transference of care. These posts also support the work of the discharge liaison team and will also be part of the Discharge to Assess and reduction in DTOC work planned with the community. Focused on OPU, ACE-OPU and ASU.

discharges before

1pm

- Trust wide Adult non-

elective LoS

Clinical Lead: Jo Miller Project Lead: Helen Bennett

1.7 ACE-OPU - Reduction in adult geriatric non-elective LoS

- Reduction in ACE-OPU LoS

- Increased discharge at the weekend

- Early supportive discharge

- Patient flow

ACE facilitates rapid clinical assessment, investigation and interventions to support early discharge, reducing the length of time patients have to stay in hospital. Aim for a length of stay ≤ 72 hours. Very successful to date with the average number of discharges per week of 32, compared to 13 prior to the ACE service being developed. Daily MDT white board round continues to be attended by a range of health care professionals to support earlier discharge. In addition the OPU clinical lead will work on early supported discharge schemes to Warminster (Wiltshire Health and Well Being Project) and RNHRD.

Oct 2013 - Sustain ACE OPU Non Elective LoS

- Sustain Geriatric non-elective LoS

Clinical Lead: Robin Fackrell Project Lead: Anita West

14.7


Date:22nd


Agenda Item: of 34

2.0 Integrated

ID Project/Action Impact Description Start

Date KPI and Lead

2.1 Discharge to Assess - LoS reduction geriatric

adult non-elective

- Bed occupancy

reduction

- Increased discharge

rate (including at the

weekend)

- Reduced daily Green

to Go number

- Quality outcomes

The objective is to enable people to be discharged from a hospital setting in a timely manner and supported in their own home for as long as possible. Significant change in practice – the team has developed three levels of service which will be developed with the community who have expressed an interest in working in collaboration. This would significantly reduce the LoS for this patient group – audit planned w/c 28/07/14. The work is based upon the Sheffield model which has been very successful to date in reducing the acute phase of care. For those patients who require level 2 (re-ablement) exploration of an alliance with the RNHRD and access up to 8 beds is well underway, summer pilot commenced.

August 2014

KPI to be agreed for Pultney Ward pilot and KPIs agreed for Wiltshire 100 day challenge. Clinical Lead: Robin Fackrell Project Lead: Helen Bennett

2.2 Delayed Transfer of Care (DTOC) Reduction

- LoS reduction adult non-elective geriatric

- Bed Occupancy Rate - Increased discharge

rate (including at the weekend)

- Reduced daily Green to Go number

- Focus on Amber patients

- Early supportive discharge

-

Focus on Wiltshire CCG DTOC. Two meetings have already taken place – objective to radically change practice and to focus on time to assessment and placement. Bringing the key decision makers in earlier to support discharge. Aim to work on Green to Go patients then Amber patients – a move away from using DTOC as an indicator of patients waiting for transference of care. The number of green to go patients has remained relatively consistent over the past 12 months.

July 2014 Reduction to 1.9% DTOC patients trust wide (baseline 3.5%) Clinical Lead: Robin Fackrell Manager Lead: Clare O’Farrell Project Lead: Helen Bennett

2.3 Primary Care Communication, service


Improving primary care awareness of services available to support ED attendance and admission avoidance i.e.

July 2014 Clinical Lead: William Hubbard Manager Lead: Clare O’Farrell


Date:22nd


Agenda Item: of 34

ID Project/Action Impact Description Start Date

KPI and Lead

awareness and increased access

- Non-Elective admission avoidance

medical and surgical ambulatory care, acute oncology, acute diabetes, catheter care and availability of consultant mobile numbers for GP’s to discuss any new admission or admission over 14 days.

Project Lead: Sarah Hudson

2.4 Wiltshire Optimising Teams - More patients are looked after in their own home or in their community

- Patients will be encouraged and supported in prevention and self-management

- Reduced hospital admissions

- Reduce lengths of stay in secondary care

- Reduced readmissions to hospital

- Fewer admissions to residential and nursing care homes

- More people dying in their preferred place of death

Wiltshire CCGs 5 year plan for the delivery of integrated community services across Wiltshire of 20 Extended Primary Care Teams (ECPTs) across Wiltshire, based on populations of circa 20,000 people across a number of local GP Practices providing holistic and seamless care for their populations in a predominantly community setting. Care is planned with people who work together to understand the patient and their carers, to put them in control and to coordinate and deliver services to achieve the best outcomes. Recruitment started by GWH community to additional integrated primary care team posts. Trajectory to have teams working from December 2014.

May 2014 KPI’s to be agreed by the Wiltshire steering group when projects finalised Clinical Lead: William Hubbard Executive Lead: Francesca Thompson (RUH executive member of CCG steering group) Manager Lead: Clare O’Farrell

2.5 Urgent Care Centre – 24 hour nurse streaming


- Reduction in Minors attendance

- Quality improvements – senior decision makers

- 4 hour performance monitoring

Increasing the efficiencies of the Urgent Care Centre and the joint working with the Emergency team. Pilot requested to increase the Urgent Care Centre Streaming Nurse capacity to cover 24 hours as currently only provided until 1am. Increased admin support during twilight hours to support streaming at the point of the greatest demand to ensure patients are booked and processed as quickly as possible. This supports patient selection of appropriate place to seek and receive advice and treatment within the urgent care system.

November 2014

KPI’s to be agreed depending upon outcome of 2014/15 Operational Resilience and Capacity funding request.– joint project with BDUC Clinical Lead: Dominic Williamson Project Lead: Sophie Spencer


Date:22nd


Agenda Item: of 34


KPI and Lead

Funding to support the additional admin and nurse practitioners required - 2014/15 Operational Resilience and Capacity funding request. This proposal would be a good pilot to

3.0 Responsive


KPI and Lead

3.1 Elective Activity Reduction

- 4 hour performance - Medical outlier

reduction - LoS reduction in line

with trajectory in the LTFM

- RTT

Planned reduction in elective activity at the RUH during periods of escalation. Particular focus is required during Q4 2014/15 to ensure that the trust remains focused on 4 hour performance and the use of APO support this. Capacity available for the effective management of non-elective patients. Elective plan submitted as part of the 2014/15 Operational Resilience and Capacity planning. As approved by management board July 2014

Sept 2014 2014/15 Operational Resilience and Capacity funding request – KPIs as outlined in the elective plan per specialty. Clinical Lead: Monica Baird Manager Lead: Suzanne Wills

3.2 Flexible Bed Capacity - ED 4 hour performance (plan supports patient flow)

- Trust wide LoS reduction

- Medical outlier decrease (<10)

12 beds have been identified to be used during periods of escalation and 10 beds overnight, responding to the needs of the Urgent Care System. Bed modelling has been completed by the RUH BIU team, in addition to demand predictions (based upon 5 year averages) supporting flexible capacity during periods of highest demand. Flexible capacity supports the front door at the point of demand and more rapid step down from escalation.

Oct 2014 KPI’s to be agreed depending upon outcome of 2014/15 Operational Resilience and Capacity funding request – will include 4 hour performance, non-elective LoS, Number of Open Beds, Medical Outliers. Clinical Lead: William Hubbard Manager Lead: Clare O’Farrell

3.3 Increased radiology capacity CT/MRI/US to support ED, MAU, SAU, ESAC and Medical Ambulatory Care

- ED 4 hour performance (plan supports patient flow)

- 85% CT/MRI and US inpatients scanned and reported within 24 hours of request

- Sustain Length of Stay

Scheme A; increase CT/MRI/US capacity five days per

week; supporting rapid assessment, rapid reporting, supporting senior decision making, reduction in Length of stay, time to treatment in ED and improving patient outcomes and experience. Tested and evaluated as part of 2013/14 Urgent Care Programme, one of the most successful winters funded projects. Scheme B; New project to support CT scanning

Oct 2014 KPI’s to be agreed depending upon outcome of 2014/15 Operational Resilience and Capacity funding request - will include number of inpatient scans completed and reported within 24 hours and overnight scanning number. In the absence of funding being approved


Date:22nd


Agenda Item: of 34


KPI and Lead

in line with LTFM - 12 CT scans overnight

and reported

overnight (in addition to the existing on call emergency service); enabling the scanning and reporting of all ED, MAU and SAU patients overnight with results therefore available for the early morning rounds supporting senior decision makers and more efficient patient management. Outpatients will also be offered the opportunity to be scanned at night freeing capacity during the day for in-patients. Supports reduction in length of stay, patient outcomes, management and experience. Increased radiology capacity, critical to the effective management of in patients. Will also support cancer waiting times and RTT.

the teams will continue to develop services and develop proposals to support demand and non-elective activity. Clinical Lead: Stewart Redman and Richard Graham Manager Lead: Craig Forster

3.4 Seven Day Services - Support patient flow at the weekend Acute Oncology review within 24 hours of admission

- Increased % weekend medical discharges (2013/14 evaluation average 3 discharges and 10 reviews per day)


- Sustain Length of Stay

- Seven day working group in place called the RUH Keogh Group Chaired by Dr William Hubbard (Head of Medicine) KPI tbc

- Acute Oncology review within 24 hours of admission (90%)

Scheme A: Weekend discharge registrar (10am to 6pm

Saturday and Sunday). Work allocated by the Clinical Site Team in conjunction with the Discharge liaison team and in reach teams. To increase the number of medical discharges at the weekend, by 15 patients. Scheme piloted as part of the 2013/14 Urgent Care Programme; very successful. Ensuring senior decision makers are supporting flow; even if patients are not discharged there management plans are progressed supporting earlier discharge. Scheme B: Acute Oncology. Increase the service to 7

days per week - enabling the consultant and acute oncology nurse specialist to provide support to the front door and for all ward referred oncology patients. Consultant able to provide GP advice and guidance to prevent ED attendance and admission avoidance.

Oct 2014 2014/15 Operational Resilience and Capacity funding request. In the absence of funding being approved the teams will continue to develop services and develop proposals to support demand and non-elective activity. - Increased % weekend medical

discharges

- Acute Oncology review within

24 hours of admission (90%)

Scheme A: Clinical Lead: Anu Garg Manager Lead: Sophie Spencer

Scheme B: Clinical Lead: Louise Medley Manager Lead: Ed Nicolle

3.5 Consultant-led rapid assessment and treatment systems


- Increased % evening medical discharges

- ED 4 hour

Scheme A: Evening ward rounds MAU. The Unit would

have x3 daily ward rounds 7 days per week. Providing consultant led review of all patients; supporting their overall management and discharge as appropriate. Peak ED demand seen 2pm-8pm, this supports patient

Oct 2014 2014/15 Operational Resilience and Capacity funding request. In the absence of funding being approved the teams will continue to develop services and develop proposals to


Date:22nd


Agenda Item: of 34


KPI and Lead

performance (plan supports patient flow)

- Sustain Trust wide Length of Stay

- Increase medical ambulatory care activity (trajectory)

flow at the time of the greatest demand. Scheme piloted as part of the 2013/14 Urgent Care Programme; successful in ED avoidance and contributed to a 2.5% reduction in ED attendance growth as one of the three key avoidance schemes. Average of 6 patients reviewed per round and 2 discharged. Scheme B: Increasing Medical Ambulatory Care

Capacity until 8pm Monday to Friday. Equivalent of six Consultant Sessions per week to ensure complete coverage and advanced nurse practitioner and band 2 support secretary to aim for discharge letters typed and available within 24 hours of dictation. Supporting GP direct referrals from afternoon clinics for assessment and treatment, Consultant available for advice and guidance over the phone in addition to within the unit.

support demand and non-elective activity.


- Increased % evening medical

discharges

Scheme A: Clinical Lead: Anu Garg Manager Lead: Sophie Spencer

3.6 Additional capacity on core speciality wards to support flexible capacity modelling.


- LoS reduction adult

non-elective trust wide

Bed modelling has been completed by the RUH BIU team, in addition to demand predictions (based upon 5 year averages) supporting flexible capacity during periods of highest demand. To provide flexible capacity on three specialty medicine wards - representing the highest non-elective admission demand groups. Flexible capacity supports the front door at the point of demand and more rapid step down from escalation.

October 2014

2014/15 Operational Resilience and Capacity funding request - 4 hour performance

- LoS reduction adult non-

elective trust wide

In the absence of funding being approved the teams will continue to develop services and develop proposals to support demand and non-elective activity. Clinical Lead: William Hubbard Manager Lead: Clare O’Farrell

3.7 Additional non-emergency patient transport

- Failed discharges due

to transport

- Support patient flow


To support patient flow during periods of high discharges and if discharge needs to be less than the 4 hour NSL and Arriva contracted response times. Piloted in 2013/14 programme and very successful with x2 crews. Plan to use x1 crew 11:00-20:00 day seven days per week which will be managed by the RUH transport lead that will maximise activity (for 22 weeks). Additional non-emergency patient transport to support patient flow during periods of high discharges and if

October 2014

2014/15 Operational Resilience and Capacity funding request - 0 failed discharges due to

transport failure


In the absence of funding being


Date:22nd


Agenda Item: of 34


KPI and Lead

discharge needs to be less than the 4 hour NSL and Arriva contracted response times.

approved the teams will continue to develop services and develop proposals to support demand and non-elective activity. Manager Lead: Sian Dyson Project Lead: Simon Jack

3.8 Medicine Specialty Take - Medical outlier reduction

- LoS - Access to specialist

team earlier supporting LoS reduction against trajectory

- Patient flow and 4 hour

- Early supportive

discharge

Introduction in October 2014 of a Medicine Specialty Take to support patient flow, zoning, ward standards and early supportive discharge. Right patient, right bed, right time, first time. Plan to recruit to x4 SHO to support teams and patient management. There is a reasonable correlation between beds and occupancy. There is also a reasonable correlation between occupancy and outliers such that with high occupancy rates comes a high numbers of outliers.

October 2014

C³ project KPI’s to be agreed in September 2014 2014/15 Operational Resilience and Capacity funding request for x4 SHO Clinical Lead: William Hubbard Manager Lead: Clare O’Farrell

3.9 Seven day service – Keogh Working Group

- Senior decision

making

- Reduced length of

stay

- Reduced occupancy

- Access to diagnostics

A working group has been established Chaired by the Head of Medicine to review the 10 national clinical standards. Clinical leads have been assigned to each standard and have been tasked with reviewing and updating the gap analysis completed in March 2014 which was presented to Management Board. Aim to provide recommendations to Management Board with regard to the requirements to provide seven day services in line with the trusts operational delivery. This work is planning for 2015/16. For management board

June 2014

KPI’s to be agreed as part of the project in line with the 10 clinical Clinical Lead: William Hubbard Manager Lead: Clare O’Farrell Project Lead: Sarah Hudson


Date:22nd


Agenda Item: of 34


KPI and Lead

to review recommendations in March 2015. Review of the ten clinical standards and building upon the original RUH scoping of both the speciality teams and trust compliance. Group to meet monthly until December 2014. Aim to make recommendations to the July Urgent care Improvement Board (UCIB) following the first planned meeting in June 2014.

3.10 Working with the Urgent Care Providers - System Resilience

- Medicines optimisation

- Reduction in

admissions and ED

attendance due to

medicine

errors/compliance

- Communication

improvements

- NHS 111 patient

pathway

improvements

- Use of alternative

providers such as

Urgent Care Centres,

Pharmacists, MIU

Continuing to be a proactive member of the Urgent Care Provider Groups for all the CCG’s and System Resilience Groups. Supporting all urgent care initiatives in the community Daily Urgent Care escalation declaration and support to a dashboard to support the community response to high demand and escalation

April 2014 KPIs depending upon community projects to be agreed with the System Resilience Group allocation of funding 2014/15 Manager Lead: Clare O’Farrell Project lead: Sarah Hudson


Date:22nd


Agenda Item: of 34

Appendix E – RUH Urgent and Emergency Care Strategic Overview

4 Hour Improvement Plan - Royal United Hospitals Bath NHS ...€¦ · robustness of CCG QIPP plans....

Documents

Transcript of 4 Hour Improvement Plan - Royal United Hospitals Bath NHS ...€¦ · robustness of CCG QIPP plans....