discharge programme board performance report april …
TRANSCRIPT
DISCHARGE PROGRAMME BOARD PERFORMANCE REPORT
April 2016
Table of Contents Page SECTION ONE: Governance Structure 3
SECTION TWO: Dashboard 4 - 12
SECTION THREE: Improving Discharge Workstream 13 - 18
a) Highlight Report b) Exception Report
SECTION FOUR: Discharge Hub Workstream 19 - 22
a) Highlight Report b) Exception Reports
SECTION FIVE: Discharge to Assess 23 - 25
a) Highlight Report
SECTION SIX: Issue Log 26 - 28 Risk Register 29 - 30
PMO Document v0.6: Y:\ERYCCG\Shared Report & Data\PMO 2\Programme Areas\Discharge\Governance
Delivering Effective Discharge Programme Governance Structure
EO Emma Owen MH Moira Harrison
JC Jo Cooper ER Ellen Ryabov
JH Jane Hawkard SH Stacy Healand
JM Julia Mizon SJ Steve Jessop
KR Karen Richardson TCo Theresa Cope
RJ Richard Johnson TC Tracey Craggs
DE Denise Everett YE Yvonne Elliot
Discharge Hub (Lead: YE
Discharge to Assess (D2A) (Lead: TC)
Delivering Effective Discharge Programme (Lead: JH)
Systems Resilience Group
Unplanned Care Programme
Planned Interventions
Programme (PIP)
Trusted Decision Makers Model Implementation
(Lead: MH/JC)
Implementation of D2A Model (Lead: EO)
Data Intelligence (Lead: RJ)
Improving Hub Processes (Lead: DE)
Community Beds Utilisation Management
(Lead: JM)
Reduced LoS for Complex discharge within 4 days of MFFD/EDD
(Lead: DE)
In-Hospital Programme
Non-Complex (Simple) Discharge
(Lead: ER)
Reducing Length of Stay (LoS) for Simple Discharges
(Lead: ER)
Roll-out of Exemplar Ward (Lead: DM/SH)
Process Improvement/Improving flow – Nurse Led Discharge
(Lead: SH)
Community Beds (Lead: TCo/YE)
Implementation Single Operating Model
(Lead: DE)
Community Hospital Discharge (Following final assessment /MFFD not >1
day post EDD (Lead: JM)
3
Section One
Baselined Daily Average 84 84 84 84 84 84 84 84 84 84 84 84 84 84
Target (baseline -10%) 50 50 50 50 50 50 50 50 50 50 50 50 50 50
Actual Daily Average 74 76 92 88 85 86 86 75 78 86 84 94 93 96
87 95 114 95 92 99 100 88 86 101 100 119 107 135
Win/Loss 24 26 42 38 35 36 36 25 28 36 34 44 43 46
Baselined Daily Average 40 40 40 40 40 40 40 40 40 40 40 40 40 40
Target (baseline -10%) 24 24 24 24 24 24 24 24 24 24 24 24 24 24
Actual Daily Average 28 34 32 30 29 35 41 29 27 35 28 29 34 28
Win/Loss 4 10 8 6 5 11 17 5 3 11 4 5 10 4
Data SourceData source is the progress to discharge summary report and only those that are identified as a formal delayed transfer of care (DTOC SITREP). Patients ready
for discharge with a length of stay greater than 7 days, daily average for the reported week.
Commentary
Against the national DTOC reporting, the system has seen a consistently high number of patients waiting over 7 days. Denise Everett from City Health Care
Partnership to report on the Root Cause Analysis (RCA) of patients waiting longer than 7 days for discharge. A process is in place where every patient with a
LOS > 7 days is reviewed Monday, Wednesday & Friday and blockages to discharge addressed.
Tota
l>7
day
sDischarge Board - Dashboard Headline Measures
Indicator 1 - Medically fit for discharge (10% reduction on baseline)
Indicator 2 - Length of stay, once medically fit for discharge
Commentary
Data Source
The number of patients waiting over 7 days continues to be above the trajectory. The threshold for total discharges has been reduced to 50 and those over 7 days to 24 in line
with the plan from September 2015. From the 3rd January 2016, the Safer Start to 2016 and the MADE events commenced. The number of MFFD on Cayder increased due to
the proactive identification of MFFD patients. In addition 27/12/15 and 3/1/16 were extended Christmas/New Year when there was reduced resources to support discharge.
Discharge hub; data manully extracted from Cayder at 1000 hours daily. Baseline is daily average of those MFFD during June and July 2015. Targets are a 10% reduction of the
baselined activity.
Highest no: MFFD in week
0
50
100
20/12/2015 27/12/2015 03/01/2016 10/01/2016 17/01/2016 24/01/2016 31/01/2016 07/02/2016 14/02/2016 21/02/2016 28/02/2016 06/03/2016 13/03/2016 20/03/2016
Total
<7 days
>7 days
Target Total
Target >7days
4
Section Two
Data Source Data is sourced from the weekly community beds data
Discharge Board - Dashboard Headline MeasuresIndicator 3 - Community bed capactity, utilisation (bed days)
CommentaryBed occupancy has dropped by 0.7% from the previous week but is just above the 90% threshold for week commencing 20th March 2016 at 90.3%.
* For week commencing 20th March 2016, data was not collated for the 26th March 2016, therefore only 6 days were reported.
5
Section Two
Discharge Board - Dashboard Headline MeasuresIndicator 4 - Morning Discharges by week
CommentaryThe data continues to demonstrates significant underachievment of this target. For week commencing 20th March 2016, 17.5% of patients were discharged
during the morning across the trust, 19.4% for medicine and 14.2% for surgery. HEY continue to provide ward level data for morning discharge.
Data SourceData sourced from Hull and East Yorkshire Hospitals NHS Trust. Daily data converted to a weekly average. No retrospective data available. Target set to 30%
of morning discharges on each ward base.
283 215 262 242 304 249 264 270 274 283 287 271 281 272
1278 1156
1311 1297 1321 1351 1265 1355 1300 1284 1323 1392 1290 1280
0%
10%
20%
30%
40%
0
500
1000
1500
2000
20/12/2015 27/12/2015 03/01/2016 10/01/2016 17/01/2016 24/01/2016 31/01/2016 07/02/2016 14/02/2016 21/02/2016 28/02/2016 06/03/2016 13/03/2016 20/03/2016
All wards
AM PM % AM Target
113 96 111 102 130 99 93 113 123 113 127 110 109 104
479
381 440 443 446 456
389 466 460 441 465 462 421 433
0%
10%
20%
30%
40%
0
200
400
600
800
20/12/2015 27/12/2015 03/01/2016 10/01/2016 17/01/2016 24/01/2016 31/01/2016 07/02/2016 14/02/2016 21/02/2016 28/02/2016 06/03/2016 13/03/2016 20/03/2016
Medical wards
AM PM % AM Target
6
Section Two
Data Source Unify2 Data Collection - MSitDT. February 2016 data available on 14th April 2016.
Discharge Board - Dashboard Headline MeasuresIndicator 5 - Delayed Transfers of Care at HEYHT (Delayed Days)
CommentaryFor June 15 and subsequent months the data may be incomplete, due to the implementation of Lorenzo (patient record system) at Hull and East Yorkshire
Hospitals Trust. The split where the delay occured by Social Care and both (i.e. Social Care and NHS) was not recorded prior to June 15.
819 880 880
711 713 589
756
582
756
242 161
75 152 103
237 260
539 18 94
65 66
21
62
263
197
98 62
51
98
95
35
89
49
358 317
191
316
219
334
612
785
0
200
400
600
800
1,000
Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16
NHS Social Care Both
7
Section Two
Total Total Total Total Total Total
138 22 15.9% 168 12 7.1% 36 12 33.3% 180 2 1.1% 206 4 1.9% 225 5 2.2% 8.8%
124 31 25.0% 112 10 8.9% 121 2 1.7% 150 3 2.0% 145 4 2.8% 145 56 38.6% 8.5%
246 22 8.9% 224 50 22.3% 232 16 6.9% 240 14 5.8% 232 19 8.2% 232 14 6.0% 9.3%
554 29 5.2% 504 19 3.8% 522 42 8.0% 540 27 5.0% 510 31 6.1% 522 90 17.2% 4.2%
948 13 1.4% 868 6 0.7% 899 5 0.6% 900 0 0.0% 899 0 0.0% 899 6 0.7% 0.7%
527 12 2.3% 476 14 2.9% 493 18 3.7% 510 0 0.0% 476 5 1.1% 493 10 2.0% 2.2%
372 87 23.4% 332 128 38.6% 348 99 28.4% 360 50 13.9% 348 97 27.9% 348 73 21.0% 22.2%
930 111 11.9% 840 34 4.0% 840 24 2.9% 900 0 0.0% 870 7 0.8% 870 4 0.5% 4.8%
368 143 38.9% 336 38 11.3% 348 62 17.8% 360 9 2.5% 348 39 11.2% 348 105 30.2% 17.2%
4207 470 11.2% 3860 311 8.1% 3839 280 7.3% 4140 105 2.5% 4034 206 5.1% 4082 363 8.9% 6.6%
ICT Hull Health Beds Bridlington
YTD
ICT Hull Health Beds Rose Villa
ICT Hull Health Beds Highfield
Hull CCG : Social Care Use Thornton Court
Hull CCG : Social Care Use Castle Rise
Provider
Hull CCG : Social Care Use Rossmore
Hull CCG : Social Care Use St Mary'
Feb-16
Improved Discharge Board - Dashboard Headline Measures
KPI1 - Community Bed Utilisation
Oct-15 Nov-15 Dec-15 Jan-16
Unoccupied
Mar-16
Unoccupied
IHT Humber Health Beds East Riding Community Hospital
Unoccupied Unoccupied Unoccupied Unoccupied
IHT Humber Health Beds Withernsea
Totals
Data is taken from the Discharge Summary report. Total bed days available across 11 providers vs those that are unoccupied each month.Data Source
Commentary For the month of February 2016, 6.3% of beds were unoccupied, year to date 9.4%
Improved Discharge Board - Dashboard Headline Measures
Commentary
KPI5 - Checklist to Home in less than 10 days KPI3 - Proportion of morning discharges (monthly)
BI Team, CHCP & BI Team HEY
Checklist to home in less than 10 days has increased to 87.9% in December 2015.The proportion of AM discharges has dropped slightly to 17.3% in February 2016.
BI Team, HEY Data Source
Commentary
Data Source
0.00%
10.00%
20.00%
30.00%
40.00%
Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16
% AM % AM Target
30 29 36
14 29
5 8 11
2
4
85.7% 78.4% 76.6% 87.5% 87.9%
0%
20%
40%
60%
80%
100%
0
20
40
60
80
Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16
=< 10days >10 days %=<10 days
8
Section Two
Improved Discharge Board - Dashboard Headline Measures
Data Source
CommentaryChecklist to DST has continued to achieve the threshold in January 2016 with all 19 completed within
48 hours achieving 100% of the 95% target.
BI Team, CHCP
KPI 6 - Checklist to DST – 48 hours
77.8% 88.9%
70.4%
100.0% 94.1%
100.0% 100.0%
0%
20%
40%
60%
80%
100%
0
10
20
30
40
50
Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16
Same/next day 2 - 3 days 4+ days %same/next Target
9
Section Two
20/12/2015 27/12/2015 03/01/2016 10/01/2016 17/01/2016 24/01/2016 31/01/2016 07/02/2016 14/02/2016 21/02/2016 28/02/2016 06/03/2016 13/03/2016 20/03/2016
113 96 111 102 130 99 93 113 123 113 127 110 109 104
479 381 440 443 446 456 389 466 460 441 465 462 421 433
19.1% 20.1% 20.1% 18.7% 22.6% 17.8% 19.3% 19.5% 21.1% 20.4% 21.5% 19.2% 20.6% 19.4%
67 30 55 53 63 65 67 56 63 57 63 56 67 68
374 322 394 409 413 387 377 413 358 390 389 403 402 412
15.2% 8.5% 12.2% 11.5% 13.2% 14.4% 15.1% 11.9% 15.0% 12.8% 13.9% 12.2% 14.3% 14.2%
95 79 91 72 104 80 93 92 84 89 80 99 100 96
363 394 394 378 407 448 431 400 415 386 412 466 394 361
20.7% 16.7% 18.8% 16.0% 20.4% 15.2% 17.7% 18.7% 16.8% 18.7% 16.3% 17.5% 20.2% 21.0%
8 10 5 15 7 5 11 9 4 24 17 6 5 4
62 59 83 67 55 60 68 76 67 67 57 61 73 74
11.4% 14.5% 5.7% 18.3% 11.3% 7.7% 13.9% 10.6% 5.6% 26.4% 23.0% 9.0% 6.4% 5.1%
20/12/2015 27/12/2015 03/01/2016 10/01/2016 17/01/2016 24/01/2016 31/01/2016 07/02/2016 14/02/2016 21/02/2016 28/02/2016 06/03/2016 13/03/2016 20/03/2016
226 185 225 169 245 200 199 207 217 194 222 215 221 201
962 907 971 949 976 1018 928 989 999 959 992 1031 927 942
19.0% 16.9% 18.8% 15.1% 20.1% 16.4% 17.7% 17.3% 17.8% 16.8% 18.3% 17.3% 19.3% 17.6%
57 30 37 73 59 49 65 63 57 89 65 56 60 71
316 249 340 348 345 333 337 366 301 325 331 361 363 338
15.3% 10.8% 9.8% 17.3% 14.6% 12.8% 16.2% 14.7% 15.9% 21.5% 16.4% 13.4% 14.2% 17.4%
283 215 262 242 304 249 264 270 274 283 287 271 281 272
1278 1156 1311 1297 1321 1351 1265 1355 1300 1284 1323 1392 1290 1280
18.1% 15.7% 16.7% 15.7% 18.7% 15.6% 17.3% 16.6% 17.4% 18.1% 17.8% 16.3% 17.9% 17.5%
% AM Discharges for Hull and East Yorkshire Hospitals NHS Trust by ward type (all wards)
Week commencing
% AM Discharges for Hull and East Yorkshire Hospitals NHS Trust by site and trust (all wards)
AM Discharge
PM Discharge
Hull Royal Infirmary
AM Discharge
AM Discharge
PM Discharge
Ward type
Site
% AM Discharge
% AM Discharge
Castle Hill Hospital
Hull & East Yorkshire Hospitals NHS
Trust
Family & Womens Health
PM Discharge
Medicine
AM Discharge
PM Discharge
% AM Discharge
Clinical Support Services
AM Discharge
PM Discharge
% AM Discharge
Surgery
AM Discharge
Week commencing
% AM Discharge
PM Discharge
AM Discharge
PM Discharge
% AM Discharge
% AM Discharge
10
Section Two
20/12/2015 27/12/2015 03/01/2016 10/01/2016 17/01/2016 24/01/2016 31/01/2016 07/02/2016 14/02/2016 21/02/2016 28/02/2016 06/03/2016 13/03/2016 20/03/2016
H1 Medicine General Medicine HRI 20.9% 21.1% 10.0% 9.7% 19.4% 14.5% 10.6% 14.9% 11.1% 14.3% 26.9% 13.1% 7.7% 2.5%
H10 Medicine General Medicine HRI 11.8% 18.9% 20.0% 5.6% 8.8% 21.4% 13.0% 20.5% 12.7% 9.1% 20.0% 23.1% 10.0% 12.0%
H11 Medicine Stroke Medicine HRI 11.1% 18.2% 13.6% 35.7% 26.3% 15.4% 4.5% 33.3% 22.2% 0.0% 28.6% 11.1% 12.5% 10.0%
H110 Medicine Stroke Medicine HRI 26.1% 15.8% 0.0% 16.7% 16.7% 11.1% 12.5% 6.7% 0.0% 5.3% 5.3% 23.5% 15.4% 11.1%
H12 Medicine General Medicine HRI 14.8% 17.6% 36.0% 8.3% 11.5% 19.0% 8.7% 8.3% 14.3% 24.0% 17.9% 8.7% 11.8% 33.3%
H120 Medicine General Medicine HRI 25.0% 23.8% 20.0% 15.8% 20.6% 40.9% 23.5% 21.2% 25.0% 9.1% 28.6% 5.0% 0.0% 5.9%
H200 Medicine General Medicine HRI No patients No patients No patients No patients No patients No patients No patients No patients No patients No patients No patients No patients No patients No patients
H5 Medicine Respiratory Medicine HRI 17.9% 34.6% 29.2% 35.7% 20.0% 0.0% 36.8% 21.1% 13.0% 17.6% 28.6% 10.0% 28.0% 28.6%
H50 Medicine Nephrology HRI 4.5% 7.7% 0.0% 22.2% 20.0% 0.0% 33.3% 36.8% 4.5% 16.7% 8.7% 14.3% 14.3% 15.4%
H500 Medicine Respiratory Medicine HRI 18.4% 18.2% 26.1% 35.0% 26.7% 18.2% 15.0% 15.4% 25.0% 21.9% 33.3% 21.9% 33.3% 26.1%
H70 Medicine Geriatric Medicine HRI 3.6% 22.7% 12.1% 16.7% 9.4% 4.3% 8.3% 12.9% 16.0% 20.7% 4.0% 10.0% 8.3% 25.8%
H8 Medicine Geriatric Medicine HRI 26.1% 28.6% 21.4% 0.0% 9.1% 31.6% 20.0% 13.0% 18.5% 22.7% 18.8% 11.8% 33.3% 28.6%
20/12/2015 27/12/2015 03/01/2016 10/01/2016 17/01/2016 24/01/2016 31/01/2016 07/02/2016 14/02/2016 21/02/2016 28/02/2016 06/03/2016 13/03/2016 20/03/2016
H80 Medicine Geriatric Medicine HRI 11.8% 28.6% 18.2% 38.1% 16.7% 26.3% 11.8% 10.5% 22.2% 14.3% 18.2% 17.6% 20.0% 23.1%
19.5% 28.0% 20.8% 21.0% 20.4% 19.4% 17.1% 21.5% 18.1% 19.6% 26.1% 16.7% 18.9% 20.3%
H100 Surgery Gastroenterology HRI 16.7% 4.3% 0.0% 3.6% 14.3% 14.3% 14.3% 5.0% 8.7% 5.0% 9.5% 24.1% 11.8% 15.8%
H4 Surgery Neurosurgery HRI 0.0% 5.7% 11.8% 6.8% 7.3% 9.5% 9.7% 7.7% 2.7% 0.0% 0.0% 2.4% 11.9% 0.0%
H6 Surgery General Surgery HRI 4.3% 7.8% 14.0% 7.4% 7.3% 5.3% 14.6% 13.2% 12.5% 5.1% 22.0% 11.1% 7.7% 9.1%
H60 Surgery General Surgery HRI 21.4% 3.8% 13.3% 2.4% 17.9% 10.3% 17.1% 6.3% 8.7% 5.8% 6.8% 15.8% 15.6% 3.2%
H7 Surgery Vascular Surgery HRI 16.7% 9.1% 3.0% 11.1% 3.0% 13.0% 6.7% 0.0% 9.4% 20.7% 0.0% 4.2% 6.3% 10.0%
H9 Surgery Trauma & Orthopaedics HRI 33.3% 33.3% 36.8% 20.0% 41.2% 10.0% 46.2% 25.0% 0.0% 27.3% 25.0% 30.8% 46.7% 30.8%
H90 Surgery Trauma & Orthopaedics HRI 31.6% 23.1% 25.0% 28.6% 30.8% 16.7% 22.2% 42.9% 58.8% 33.3% 23.5% 0.0% 28.6% 25.0%
17.1% 9.3% 15.1% 9.8% 15.8% 11.5% 18.9% 13.4% 13.9% 9.9% 12.2% 13.5% 16.7% 11.0%
C29 Clinical Support Services Rehabilitation CHH 100.0% 100.0% 0.0% 50.0% 16.7% 33.3% 0.0% 66.7% 8.7% 0.0% 33.3% 0.0% 100.0% 0.0%
C30 Clinical Support Services Clinical Oncology CHH 10.0% 8.3% 5.3% 13.3% 0.0% 0.0% 0.0% 0.0% 0.0% 6.3% 21.1% 7.1% 6.7% 6.7%
C31 Clinical Support Services Clinical Oncology CHH 11.1% 15.4% 13.3% 7.7% 25.0% 13.3% 0.0% 14.3% 11.1% 12.5% 22.2% 14.3% 8.3% 0.0%
C32 Clinical Support Services Clinical Oncology CHH 0.0% 5.9% 6.3% 33.3% 0.0% 0.0% 12.5% 4.5% 7.1% 7.1%
11.6% 13.2% 8.3% 20.8% 8.8% 7.3% 4.1% 10.2% 6.8% 9.6% 27.3% 10.0% 7.5% 4.7%
Selected medicine wards (Total)
Selected surgery wards (Total)
Selected clinical support services wards (Total)
% AM Discharges for Hull and East Yorkshire Hospitals NHS Trust (all wards)
Ward Type Speciality Site
% AM Discharges for Hull and East Yorkshire Hospitals NHS Trust (selected wards)Week commencing
0.0%
20.0%
40.0%
20/12/2015 27/12/2015 03/01/2016 10/01/2016 17/01/2016 24/01/2016 31/01/2016 07/02/2016 14/02/2016 21/02/2016 28/02/2016 06/03/2016 13/03/2016 20/03/2016
Medicine Surgery Family and Womens Health Clinical Support Services HRI CHH HEY Target
11
Section Two
12
Section Two
IMPROVING DISCHARGE WORKSTREAM
Lead: Ellen Ryabov
13
Section Three
HIGHLIGHT REPORT - Improving Discharge Project
FOR IMPROVING DISCHARGE BOARD:
26 April 2016
LEAD: Ellen Ryabov OVERALL PROGRESS Vs PLAN: Under Control Risks identified with a recovery
plan in place
Summary of achievements in reporting period Key actions for progress in coming calendar month
Plan refined with proposed KPIs and key Milestones drafted, which incorporates and aligns to the SRG deliverables
5 wards per month Rollout Plan drafted – to align with other PMO internal activities
SAFER Bundle and supporting products under development to ensure consistent offering to all wards; will include standard bundle with additional tools to address specific areas for improvement where needed
Monthly Steering Group meetings established
MADE Event held (wards H5, H500, H12, H120) – 23rd
March 2016
Working with Commissioners to align activity reporting
Project 4: Delivery plan to be finalised
Project Rollout Plan to be agreed and commenced
SAFER Bundle and supporting products to be agreed and standardised
Monthly Steering Group monitoring project delivery against plan
Review feedback from MADE Event 23rd
March 2016
SPMs to visit Ipswich to review their red/green working in practice and how this links
to board rounds, SAFER principles and trigger tools for escalation
Progress against KPIs
KPI This month’s achievement Recovery actions (if required) Included in Exception Report to Board? (Y/N)
KPI 1: Reduction in medical outliers
Aligned KPIs to U&ECP P4: Reducing Waits and Improving Discharge
Trajectories to be set once baseline data agreed for KPIs listed and risks to be identified – Project Steering Group meeting on 11.04.16
N
KPI 2: Reductions in stranded patients
Aligned KPIs to U&ECP P4: Reducing Waits and Improving Discharge
Trajectories to be set once baseline data agreed for KPIs listed and risks to be identified – Project Steering Group meeting on 11.04.16
N
KPI 3: Robust clinical plan and EDD within 24 hours
Aligned KPIs to U&ECP P4: Reducing Waits and Improving Discharge
Trajectories to be set once baseline data agreed for KPIs listed and risks to be identified – Project Steering Group meeting on 11.04.16
N
KPI 4: Delivering flow through demand and capacity modelling
Aligned KPIs to U&ECP P4: Reducing Waits and Improving Discharge
Trajectories to be set once baseline data agreed for KPIs listed and risks to be identified – Project Steering Group meeting on 11.04.16
N
KPI 5: Reduction in LoS Aligned KPIs to U&ECP P4: Reducing Waits and Improving Discharge
Trajectories to be set once baseline data agreed for KPIs listed and risks to be identified – Project Steering Group meeting on 11.04.16
N
KPI 6: Facilitating early morning flow - 30% increase in morning discharges (monthly) in medicine bed base
Aligned KPIs to U&ECP P4: Reducing Waits and Improving Discharge
Trajectories to be set once baseline data agreed for KPIs listed and risks to be identified – Project Steering Group meeting on 11.04.16
N
14
Section Three
KPI 7: Patients who are medically optimized for discharge should make up less than 3% of the total acute bed base (22 patients)
Aligned KPIs to U&ECP P4: Reducing Waits and Improving Discharge
Trajectories to be set once baseline data agreed for KPIs listed and risks to be identified – Project Steering Group meeting on 11.04.16
N
KPI 8: No patient on the delayed list for more than 7 days
Aligned KPIs to U&ECP P4: Reducing Waits and Improving Discharge
Trajectories to be set once baseline data agreed for KPIs listed and risks to be identified – Project Steering Group meeting on 11.04.16
N
KPI 9: 95% achievement of agreed standards across all modalities
Aligned KPIs to U&ECP P4: Reducing Waits and Improving Discharge
Trajectories to be set once baseline data agreed for KPIs listed and risks to be identified – Project Steering Group meeting on 11.04.16
N
KPI 10: Implementation of the SAGER Patient Flow Bundle
Aligned KPIs to U&ECP P4: Reducing Waits and Improving Discharge
Trajectories to be set once baseline data agreed for KPIs listed and risks to be identified – Project Steering Group meeting on 11.04.16
N
Key Risks (Score 12 or over) Recommended Actions Probability/ Likelihood score
Impact/Severity score
Overall Risk score Included in Exception Report to
Board? (Y/N)
To be agreed
Description of Issue Recommended Actions
Completed by: Rachel Craven / Donna Dudding Signed off by: Agreed with Rachel Craven at meeting on 07.04.16
Organisation: HEYHT Organisation: HEYHT
Date: 07.04.16 Date: 07.04.16
15
Section Three
Programme Name: Priority Measure: Morning DischargesProgramme Lead: Reporting Date: Apr-16Dashboard Summary of Performance: Recovery Action Plan/Options: No update for April 2016
KPI Target Latest PeriodLatest
PositionRAG KPI Target Latest Period
Latest
PositionRAG
Proportion of morning
discharges (monthly)
Specific Wards
30% Jan-16 13.5% 0KPI3 - Proportion of morning
discharges (monthly)
All wards
30% Jan-16 15.7%
Improving Discharge ProjectEllen Ryabov
CHART GOES HERE CHART GOES HERE
Data Source: AM discharges (showing only non-elective admissions),ERY patients only. Exclusions : pateints marked as deceased are excluded from the dataset
Data Source: AM discharges (showing only non-elective admissions) ,ERY patients only. All Wards Exclusions: patients marked as deceased are excluded from the dataset
16
Section Three
Recover Action/Options Expected Impacts Impact Date RAG
MADE Events and 'Safer Start 2016 currently underway. Piloting new
processes on Wards H5, H9 and H12 until end January to identify and
remove barriers to discharge with all partner agencies; potential to roll
out wider across Trust if outcome is positive.
If pilot successful, a multi-agency approach will speed up discharges by:
• All agencies working to same EDD (Med Fit date)
• No rejection of Section 2s
• Therapies to list rehab goals and not rehab ‘potential’
• Social Care pre planning for discharge and not waiting until discharge date
• Social Care to advise patients of appropriate package of care following assessment and not
Medics to pre-determine. Following completion of pilot, H9 reported initiative made a
positive impact on ward efficiencies to discharge. Need to consider agreeing formal process
to continue this arrangement and roll out across Trust.
To commence
February 2016a
a
Using Service Improvement and Lean methodologies to develop a
standard set of tools and processes (Board Rounds, The SAFER Bundle,
EDD, PREDICT, Ticket Home)
The 'Safer Start 2016' documentation mirrors those developed in conjunction with the IDP
and Improvement Academy work; therefore ensuring a standard approach across the Trust.
As project progresses, need to continuously audit to ensure that improved practices are
maintained and sustained.
Ongoing a
Develop the ‘exemplar discharge ward’ so that the new processes can be
spread across the Trust to ensure there is a consistent effective approach
to discharge practice across the organisation utilising the SAFER Bundle
and ‘Predict’ tool.
Improving Discharge Project : The key KPIs are:
o 0.5 day reduction in baseline ward average Length of stay (50% reduction on >14 day
stays, 20% reduction in >7 day stays)
o 30% morning discharge rate
o 20% weekend discharge rate
• Current workstreams on H9 and H80 have not yet achieved the desired improvements and
therefore, plan is behind schedule but PMOs continue to investigate further improvements.
Ongoing
17
Section Three
18
Section Three
DISCHARGE HUB WORKSTREAM
Lead: Yvonne Elliott/Denise Everett
19
Section Four
HIGHLIGHT REPORT - Discharge Hub FOR DISCHARGE BOARD: April 2016
LEAD: Denise Everett OVERALL PROGRESS Vs PLAN: AMBER
Summary of achievements in reporting period Key actions for progress in coming calendar month
1. SOP finalised for HUB partners in line with Cayder changes. 2. SOP embedding commenced and consolidation for all patient flow charts at
10am morning meeting. 3. DTOC action plan will be progressed. 4. Task & Finish group commences for Escalation & Choice Policy review 5. Task & Finish group commences for System wide single assessment. 6. Daily DTOC reporting will be progressed.
Progress against KPIs
KPI This month’s achievement Recovery actions (if required) Included in Exception Report to
Board? (Y/N)
Key Risks (Score 12 or over) Recommended Actions Probability/Likelihood score
Impact/Severity score
Overall Risk Score Included in Exception report to
Board? (Y/N)
Potential risk to the effectiveness of single operating procedure due to organisations not following process
Nominated key lead for each organisation in the HUB who will be responsible for embedding the SOP in their teams Embedding of the cascade of key pathway at ward level so no confusion as to role and function of hub with regards to complex discharge for patients
3 3 9 N
Description of Issue
Recommended Actions
None Identified
Completed by: Denise Everett Signed off by: Yvonne Elliott
Organisation: CHCP
Date: Date:
20
Section Four
Programme Name: Priority Measure: Indicator 2 - Length of stay, once medically fit for dischargeProgramme Lead: Reporting Date: April 2016
Dashboard Summary of Performance: Recovery Action Plan/Options:
KPI TargetLatest
PeriodLatest Position RAG Recover Action/Options Expected Impacts Impact Date RAG
Indicator 2 - Length of
stay, once medically fit
for discharge (complex
discharges)
0 patients
> 7 days
w/c
20/03/2016
17 (> 7 days) 9
(14-29 days)
2 (> 30 days)R
Deviation Description
Discharge HubDenise Everett
See Chart Below
21
Section Four
Programme Name: Priority Measure: Medically fit for discharge (10% reduction on baseline)Programme Lead: Reporting Date: April 2016
Dashboard Summary of Performance: Recovery Action Plan/Options:
KPI TargetLatest
Period
Latest
PositionRAG Recover Action/Options Expected Impacts Impact Date RAG
Medically fit for
discharge (10%
reduction on baseline) of
complex discharges
24 patients
> 7 days
w/c
20/03/201628 R
Deviation Description
Discharge HubDenise Everett
22
Section Four
DISCHARGE TO ASSESS WORKSTREAM
Lead: Tracey Craggs
23
Section Five
HIGHLIGHT REPORT - Discharge to Assess Programme FOR DELIVERING EFFECTIVE DISCHARGE BOARD:
April 2016
LEAD: Tracey Craggs
OVERALL PROGRESS Vs PLAN: Off-Track
Summary of achievements in reporting period
Key actions for progress in coming calendar month
1. Evaluation from PDSA of first D2A patient commenced, data still being gathered verbal report to D2A/Hub work group 06/04/16
2. Innovation workshop for D2A Implementation planned on hold until outcome of options appraisal received
3. Development of Pathway 2 for first patient for D2A to be discharged completed 4. Commenced PDSA on second patient for D2A discharged on Pathway 2 planned
identification of patient for Pathway 2 pilot was for w/c 04/04/16 currently delayed due to suitable community bed availability
5. Patient feedback received from Pathway 1 to be added to evaluation
1. Options appraisal to be completed and presented to Discharge Board for extra capacity/resources to deliver full model roll-out
2. Decision for progression to Business Case or closure of project from Discharge Board following options appraisal presentation
3. Evaluation report 4. Separated project plans for each pathway to be developed in more detail for
development and service leads to be identified once outcome of options appraisal is clear
5. Testing of patient satisfaction questionnaire and information leaflet, and further development of these based on feedback received through Pathway 2 testing
Progress against KPIs
KPI This month’s achievement Recovery actions (if required) Included in Exception Report to
Board? (Y/N)
Key Risks (Score 12 or over) Recommended Actions Probability/Likelihood
score Impact/Severity
score Overall Risk
Score Included in
Exception report to Board? (Y/N)
Non identified
Description of Issue
Recommended Actions
Capacity and resources for outreach ‘wrap around’ services to deliver D2A model in full identified by stakeholders
Report presented to Discharge Board in March an Options Appraisal to be developed and presented to Discharge Board in April with view to full business case if continuation of project agreed.
24
Section Five
Completed by:
Emma Owen Signed off by: Tracey Craggs
Organisation:
ERYCCG ERYCCG
Date:
04/04/16 Date: 06/04/16
25
Section Five
Produced by NYHCSU on behalf of East Riding of Yorkshire CCG
Work Stream Name: Discharge Hub
Ref Description of Issue Comments (to include
Originator and date raised)
Priority* Assigned To (who is responsible)
Target Date
Action/Outcome/Decision Category**
Status***
1DH Discharge Hub Coordinators role- The job description and person specification has been to the panel for banding and has come back as an 8A and not an 8B. The board have advised that there needs to be an interim staff member in post before LWa leaves.
14/09/15 Christy Francis
P2 Christy Francis 01/10/15 CF is to relook at the job description and person specification. An interim to backfill LWa’s post needs to be in place.
13/10/15 Update: Job advertised and interim in place.
Scope/Quality Closed
Work Stream Name: Improving Discharge Group
Define process for project as now reporting to two boards (Closed 10.03.16)
Ellen Ryabov 10/3/2016 Action to be undertaken: Revise project realigning to Urgent and Emergency Care
Closed
Project is 5 weeks behind schedule for rollout die to SPM leave and resource, reallocation to establish U&ECP. Project will be superseded by U&ECP for at least 10 months. Agree new date to handover H9 and H80in light of U&EC Programme Board and new governance structure
Ellen Ryabov 10/3/2016 Project 4 reducing waits and Improving Discharge. H5 Respiratory and H90 Department of Elderly Medicine to commence from 14/03/2016 in line with ECIP Concordat. H9 and H80 to be handed over to service as business as usual 1
st April 2016.
Being reviewed
2IDG Lorenzo Therapy referral protracted (24 clicks vs. 3 click)
15/09/15 Ruth Colville
P3 Ellen Ryabov 20/10/15 Software patch currently in development and in testing stage.
09/10/15 Update: Deployment now expected 20/10/15
Update 06/11/15 Lorenzo 3-step Therapies referral extension (delayed due to failure)/ ongoing testing and development. Associated ‘Risk’ removed as not being managed within the project
Time Being reviewed
Improving Discharge Programme Issues Log February 2016
26
Section Six
Produced by NYHCSU on behalf of East Riding of Yorkshire CCG
being managed within Information Services.
4IDG Launch of CAYDER virtual wards
delayed
13/11/15 P3 Ellen Ryabov TBC I believe this may have been addressed by Steve Jessop and implemented but can’t be 100% sure.
Scope/Quality Being reviewed
3IDG Staffing Shortfalls 15/09/15 Ruth Colville
P3 Ellen Ryabov All posts are actively reviewed and must pass through Trust Vacancy Control Panel. Active overseas recruiting efforts for Nursing posts. OT and Physiotherapy services have a cross competency training programme to make more flexible use of resource within existing staff. Radiology, SLT actively attempting to recruit subject to controls.
Scope/Quality Closed
1IDG Lorenzo reporting insufficient 15/09/15 Ruth Colville
P3 Ellen Ryabov Manual snapshot audits being conducted to from baseline in therapy response times.
13/10/15 Update: Risk Closed
Scope/Quality Closed
Work Stream Name: Discharge to Assess
Capacity and resources for outreach ‘wrap around’ services to deliver D2A model in full identified by stakeholders
15/02/2016 Tracey Craggs Report and business case to be developed and presented to Discharge Board on 22
nd March.
3D2A The scope of the sub programme is to be redefined. Some of the projects that had been allocated to the D2A sub programme originally have now been reviewed and identified as needing to sit either in the Discharge Hub or In-hospital programme or are discharge related matters to be managed via the contract management process.
03/11/15 P3 Tracey Craggs 24/11/15 Agreement is required from the programme board lead and the SRG Director of the projects now contained within the sub programme.
Scope/Quality Closed
1D2A Change in required model of beds from spot purchase to block contract identified week commencing 02/09/15. Has required changed specification and engagement agreement of wrap
07/09/15 Tracey Craggs
P2 Claire Strawbridge 30/11/15 Specification has been changed resulting in delayed implementation
Time Closed
27
Section Six
Produced by NYHCSU on behalf of East Riding of Yorkshire CCG
around services from key stakeholders and will put the implementation back.
2D2A The Business Intelligence support to the sub programme is leaving to take up another post in 4 weeks’ time. There is no identified replacement resource identified.
17/09/15 Tracey Craggs
P3 Richard Dodson 01/11/15 Escalation to Discharge Board 22/09/15 Scope/Quality Closed
*Priority: **Category: ***Status:
P1 = project work must stop until the problem is resolved P2 = project work will soon fall behind schedule if the problem is not resolved P3 = the project will continue without a disruption
Scope/Quality Time Budget
C=Closed O=Open D=Deferred
28
Section Six
Ref Date identified Risk Event
Probability
of Risk
Recommended
Action
Risk
Owner Status
(dd/mm/yy) (Description) (Likelihood)
(Accept/Transfer
/Reduce) (Closed/Open/Deferred)
IDG8 13/11/2015
Engagement of junior medics in
board rounds and early
completion of IDLs, identifying
discharge to location on IDLs /
communicating with Pharmacy
Improving
Discharge
Work Stream
failure to
deliver Possible 15
Clarify roles and responsibilities with Clinical Leads, work with
Pharmacy to explore improvements, training needs (Controlled
Drugs, Anticoagulation) (3/5=15). 27/11 Roles and
responsibilities drafted (Rco/RMC, W80 agreed. (Now links
with Risk IDG11) Reduce ER Same 14/12/2015 Being reviewed
IDG9 10/03/2016
Engagement of junior medics in
board rounds and timely
completion of IDSs Likely 12
In discussion with Pharmacy to understand barriers Drs face
when completing IDS and also new guidance re Lorenzo to be
rolled out w/c 11/01/16. Updated: extending due dates as
further meeting pending with Pharmacy (links with Risk IDG8) ER Same 10/03/2016 Being reviewed
IDG10 10/03/2016
MADE events highlighting
barriers to discharge by internal
culture - patients/families
refusing to leave hospital due to
social matters when they no
longer have an acute need and
should be discharged (bed
blocking) Likely 12
Consider assertiveness training for nursing staff to tackle
patients and families refusing to leave. SPM exploring options
with Alyson Newlove (Legal Dept) regarding effectively
managing 'bed blockers'. Escalation policy needs to be actively
implemented. ER Same 10/03/2016 Being reviewed
IDG11 10/03/2016
Urgent and emergency care
programme will draw on HIP
PMO resources in the short - mid
term
Almost
Certain 10
Agreement of mid-long term strategy for delivery per revisions
necessitated by ECIP Concordat ER Same 10/03/2016 Being reviewed
DH3 11/12/2015
Potential risk to the
effectiveness of single operating
procedure due to organisations
not following process
Discharge Hub
Work Stream
failure to
deliver Likely 9
Nominated key lead for each organisation in the HUB who will
be responsible for embedding the SOP in their teams.
Embedding of the cascade of key pathway at ward level so no
confusion as to role and function of hub with regards to
complex discharge for patients. Reduce DE New 11/12/2015 Open
Controls and Mitigation Movement Date Last Reviewed
PROJECT LEAD: Emma Owen
Risk Score
Catastrophic
Moderate
Moderate
Moderate
Minor
SPONSOR/SRO: Jane Hawkard
(Impact)
PROJECT START DATE: 01/04/2015PROJECT END DATE: 01/04/2016
Severity
Impact
Description
RISK LOGPROJECT NAME/REF: PMO Discharge ProgrammePROGRAMME AREA: Discharge Programme
29
Section Six
D2A1 09/10/2015
Implementation of Intermediate
Tier (Time to Think) beds not
completed by 1/10/15 for
ERYCCG.
Beds on line from 7/12/15 Risk
score reduced to reflect
Failure to
deliver within
agreed time
frames
Almost
Certain 9
Agree revised implementation date of 07/11/15. Confirmation
of funding for beds to enable procurement to progress. Accept CS Down 07/12/2015 Closed
IDG5 10/06/2015
Baseline data delayed due to
implementation of Lorenzo
Improving
Discharge
Work Stream
failure to
deliver Serious 20
Note high level LoS data available for H500 / H8 until HRG
breakdown is available. T Sowersby committed to providing
resource as soon as possible. Data may be another 3-4 weeks
(19/06/15) . 17/07/15 awaiting HRG data. Information Services
and Business Intelligence teams are now working to provide but
data not yet available. Lorenzo reporting may be delayed
further as not clinical priority. Corporate Information Teams
aware and will prioritise after issues with clinical impact fully
resolved. 11/9/15 HRG comparisons and LoS >7 >14 > 30 days
received and used to inform Exemplar Ward Rollout proposal.
Therapy referral to response reporting remains outstanding – Accept RC / TS Same 13/11/2015 Closed
IDG6 09/10/2015
Staffing shortfalls – across all
disciplines remain a risk.
Radiographers & Radiologists
compromising short and long
term plans.
Improving
Discharge
Work Stream
failure to
deliver Possible 15 Reduce SB Same 13/11/2015 Closed
IDG7 09/10/2015
Lorenzo referral process
protracted due to system issues
impacting national spine at
implementation. This is
impacting productivity on wards
due to time it takes to complete
referral process.
Failure to
deliver within
agreed time
frames Possible 15
Reverted to 24-click referral process while development
solution is pursued. Solution is in testing phase but has yet to be
deployed.
9/10/15 Deployment scheduled for 20/10/15
Reduce SB Same 13/11/2015 Closed
Almost Certain
Catastrophic
Catastrophic
Moderate
30
Section Six