four hours improvement plan november 2015 · ahsn flow coaching ahsn flow coaching programme...

Four Hours Improvement Plan November 2015

Executive Summary

Improvement Trajectory ■ Minimum of 90% standard is an internal expectation. Trajectory to year end

submitted to NHS England. AHSN Flow coaching ■ AHSN Flow coaching programme continued in month, focusing on:

■ Frailty pathway

■ Bilary colic

■ Non- elective Gynaecology

Key issues and root causes

■ Norovirus outbreak from 11.11.2015 significantly impacted on flow out of ED; up to 7 wards were closed during the month, with between 2 and 27 empty beds at any one time within the closed wards.

■ Non-elective admissions are slightly higher than last year

■ Non-elective length of stay increased during Q1 and Q2, and has now improved.

■ More patients are discharged than admitted Monday to Friday; this is reversed at the weekend. Most patients are discharged from late afternoon onwards.

■ Average DTOCs in November 2015; 3.6% of bed base. Improvement predominately relates to exclusion of patients on closed wards from reported DTOC figure.

■ A third of patients are not admitted to their first choice ward

■ The main reason for four hour performance is poor flow in to inpatient specialty beds.

Winter planning ■ BaNES System Resilience Group lead on urgent care improvement for the

community Whole System Winter Plan. Home for Christmas event to be held from 14.12.2015 to support occupancy reduction in advance of the Christmas/New Year period.

Improvement Plan ■ Urgent Care improvement plan developed in response to ECIST recommendations,

with three key work streams:

■ Front Door

■ Specialties

■ Back door

■ The three work streams are underpinned by two interdependencies:

■ Trust-wide work on site management and escalation processes

■ System-wide work, including Discharge to Assess, HomeFirst, Integrated Discharge Team and domically care.

■ Risks are identified to non-delivery

Current Performance Year to date, the Trust has not delivered the 95% standard for the four hour maximum wait in ED. Performance in November 2015 deteriorated to 87.7%, following a period of improved performance in October. Table 1: 4 hour performance, April 2015- November 2015

Governance and Assurance ■ First Urgent Care Collaborative Board held in November, attended by executive

leads from the three key work streams, chaired by Chief Operating Officer.

■ Revised RUH Urgent Care Transformation Board and PMO established. Focus in month on implementing PMO processes to drive delivery of the programme.

Month Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15Four hour maximum wait in ED (all types) 94.1% 90.8% 92.3% 87.2% 85.4% 85.5% 93.4% 87.7%

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DRAFT FOR DISCUSSION PURPOSES ONLY Emergency Care Intensive Support Team

ECIST Whole system review 14 - 16 September 2015

Final report received in November 2015, and presented to BaNES SRG on 26 November 2015.

Four key feedback points:

1. Supported vision for front door services

2 Accelerate work on:

Senior review

Integrated Discharge

Home First

3. Improve ownership by clinical teams throughout the Trust

4. BaNES SRG to take lead on urgent care improvement for the health community

Visit

BaNES System Resilience Group, at the request of the RUH, invited the Emergency Care Intensive Support Team (ECIST) to undertake a whole system review in September 2015. Previous ECIST visits have focussed on front door services at the RUH.

The review took place between 14 and 16 September, with one day focussed on RUH processes, both on wards and in assessment areas, and a second day undertaking focussed interviews with community and primary care teams to understand flow across the whole system.

Report and next steps

Final report received in November 2015, and presented to BaNES SRG on 26 November 2015. The Urgent Care Improvement Plan has been reviewed to ensure that all feedback from the report is captured within the plan.

RUH initiated involvement of ECIST collaborative learning event (cluster 3) early November.,

Feedback

Key feedback included:

1. Support for the vision for front door services, specifically ED and MAU, and recognition of the work achieved to date in changing the MAU operational model

2. Need to accelerate work on:

SAFER patient bundle, particularly senior review

Implementation of an Integrated Discharge Team and supporting processes

Expansion of discharge to assess services, e.g. Home First

3. Work required to improve ownership of non-elective flow through inpatient speciality beds by clinical teams throughout the Trust

4. BaNES SRG to take lead on urgent care improvement for the health community

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DRAFT FOR DISCUSSION PURPOSES ONLY Urgent Care Improvement Plan

An Urgent Care Improvement plan was initiated on the 7th September 2015 to improve performance, including a daily performance management approach.

The Improvement plan has three key work streams, front door, specialties and back door.

In addition, two interdependencies will support delivery of 4 hour performance:

- Trust wide

- System wide

Focus in November on implementing PMO processes to drive delivery of the programme and support oversight by the Urgent Care Collaborative Board.

Management Board has approved the implementation of this Urgent Care Improvement plan which will be daily performance managed throughout 2015. The plan has three work streams, Front door, Specialties and Back door, with clear operational, clinical and executive leadership in place for each work stream. This reflects the RUH 4hr diagnostic with a requirement to focus on flow and improve discharge performance, working collaboratively with the community. The RUH is also working closely with community providers to deliver system-wide actions including Discharge to Assess/Home First and the Integrated Discharge Team. Area Strategic Initiatives Executive Leader

Work stream 1 - Front Door • ED internal working • Development of Ambulatory Care services- medical, surgical and

orthopaedic • Revised operational models on both MAU and SAU • Admission avoidance pathways, in conjunction with community services

Chief Operating Officer

Work stream 2 - Specialties • Embedding the SAFER patient bundle across all wards • Implementing an ‘identify and pull’ process to improve the flow of patients

out of the assessment areas • Understand opportunity to lower the threshold of clinical risk for patients

who could potentially be discharged.

Medical Director

Work stream 3 - Back Door • Implementing improved discharges processes including consistent standards for ward and board rounds, across the Trust to achieve 33% of discharges before midday.

Director of Nursing & Midwifery

Trust interdependencies • Site team review, including site meeting function • Trust-wide escalation plan • 2015/16 Winter Plan


System interdependencies • Working with community providers to implement Discharge to Assess models in BaNES and Wiltshire, and to develop an Integrated Discharge Team at the RUH, pooling discharge resource from the RUH and community providers.


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DRAFT FOR DISCUSSION PURPOSES ONLY Urgent Care Improvement Plan – progress in November 2015

The three internal workstreams commenced in October 2015; this summary provides an overview of progress in the Front Door work stream, and key areas of focus in December 2015.

The Front Door work stream, led by the Chief Operating Officer, includes all three AHSN Flow Coaching projects (frailty, ESAC and non-elective gynaeclogy), with a focus on supporting teams to deliver sustainable transformation.

November delivery The Front Door team, supported by PMO, is developing a range of indicators to monitor delivery against plan and impact of changes made.

Direct admits After significant improvement during September and October 2015 as a result of changes in the operational model, the number of GP referred patients directly admitted to MAU in November 2015 fell sharply. The main causes identified are; 1. reduction in flow out of the unit as a consequence of the norovirus outbreak. Focus in December on

reinstating pathway as flow improves with wards reopening. 2. Early identification of specialty beds and discharges before midday not sufficient to support the holding

of MAU assessment capacity for GP expected patients. The early morning discharges from MAU, MSS and ACE were used in month to prevent 12 hour and reduce 4 hour breach number.

Breaches due to ED delays Indicator continued to improve in November, despite poor flow out of ED resulting in periods of high escalation within the department. Improvement relates to changes in staffing model for ENPs, EDAs and the Flow Assistant role. Further improvement anticipated in December as a consequence of further planned changes to match staffing with demand.

Work stream Actions completed in November 2015 Actions planned for December 2015 and January 2016

Seven sub-groups established to drive change at a local level; ED, ACE, Ambulatory Care, ESAC, SAU, Medical Short Stay, MAU.

Priority in December to reinstate direct admit model in MAU, as wards reopen post-norovirus outbreak.

MAU Operational Model continued to be embedded with the MAU team; flow out impacted by ward closures.

Focus on time to assessment, total LoS in Unit, Standardisation and transformation to support CQC preparation

Action plans for ACE operational models completed following model walk-throughs in October.

Plan to develop HOT clinic service for Cardiac to be completed and frailty to be developed.

EDA and ENP rotas reviewed with additional resource moved to evenings in month; reduction in ED delays.

ED consultant rota review to conclude, ceasing ED OP clinics in line with ECIST recommendations. Review of junior cover and trial of additional registrar OOH at the weekend.

Fron

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Sub-groups to develop local action plans, adopting the FLOW approach to identify and drive change. Flow Coaching training session hosted by Sheffield planned for all work stream leads on 20 January 2016 to support roll out.

First meeting of the Front Door team on 24 November 2015, chaired by Dr Anu Garg as Front Door Clinical Lead. AHSN Flow Coaching approach to transformation and service improvement has been adopted by the group. Pre-evaluation phase for the Front Door Programme has commenced, initial focus on standardisation.

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The three internal workstreams commenced in October 2015; this summary provides an overview of progress in the Specialty work stream, and key areas of focus in December 2015.

The Specialties work stream, led by the Medical Director, focusses on changing clinical practice within the core medical teams to improve flow through the hospital.

November delivery The Specialty team, supported by PMO, is developing a range of indicators to monitor delivery against plan and impact of changes made. PMO support during December will be focussed on developing a set of indicators to support the Geriatrician of the Day pilot.

Medicine Non-Elective Length of Stay A key indicator of efficiency is non-elective length of stay across the Medicine Division, with many of the key projects within this work stream - including Respiratory value review, OPU Therapy pilot, Cheselden and the work with the Cardiology team – focussing on moving patients through the inpatient bed base quickly and efficiently. Length of stay in month remained slightly above the internal target (which represents a 3% reduction in LOS from 2014/15). All specialties have been set individual LOS targets, with more detailed monitoring in place for each project, supported by PMO. Length of stay was impacted in month by the norovirus outbreak, limiting flow in to community provision from closed wards. Cardiology elective activity Monitoring now in place to support development of day case cardiology pathways for PCI patients. At present the majority of angioplasty (PCI) and Permanent Pacemaker (PPM) patients are admitted overnight, using on average one bed per day. The cardiology team are developing revised pathways for both procedures to move to day case treatment as the norm, improving patient experience and reducing the impact on the non-elective bed base. Monitoring to continue throughout Q4 2015/16 when day case PCI pathway planned to go live. Pathway for PPM remains under review.


'Value' review agreed, focussing on understanding the value of an inpatient stay; Respiratory to pilot new approach in January 2016.

New process for 14+ day LOS reviews as part of Silver daily meetings.

Visit to Barking to be arranged to review Flow model

Review of OPU Therapies pilot completed; to be considered as part of Therapies review.

Spec

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Geriatrician of the Day pilot from 1 December 2015. Consultant Geriatrician support to ED/MAU in the afternoon, providing early assessment of frail elderly patient, improve flow to ACE/OPU wards, link to DAT/community providers to advoid admission.

Cardiac deep dive commenced; support from the specialty to enact daycase PCI now in place. Cardiac team job plan to be completed in December for launch in February 2016.

Revised staffing model for Cheselden agreed and recruitment underway; Medical Nurse Practicioner and Therapy staff replacing existing SHO posts to improve the model of care for patients waiting to move in to community placements. Full go-live January 2016.

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The three internal workstreams commenced in October 2015; this summary provides an overview of progress in the Back Door work stream, and key areas of focus in December 2015.

The Back Door work stream, encompasses the work of the Discharge Programme Board, chaired by the Director of Nursing. Work streams within the Board include Safe and Proactive Discharge “Fit to Leave”, End of Life Care and Patient Experience.

The Integrated Discharge Service also reports in to the Discharge Programme Board to ensure strong links between community and ward discharge processes.

November delivery The Discharge Programme Board has a Programme Manager who, with PMO and BIU, has developed a range of indicators to monitor delivery against plan and the impact of changes made. Each work stream has three KPIs, with ten overall programme metrics

Discharges declared by midday A key driver of the Discharge Programme Board is the national SAFER inpatient care bundle, which includes a target of 35% of discharges by midday, to support flow out of front door assessment areas. The Discharge Programme Board is currently monitoring discharges declared by midday to support progress towards SAFER bundle implementation. Performance for November not yet available, but expected to show improvement following Discharge Week. Social History completion within 24 hours This indicator identifies the completion of millennium discharge information by ward nursing teams; a key element of the Trust’s revised discharge standards. Improvement in performance seen in November following Discharge Week, reflecting the emphasis on early assessment of every patient’s needs at the point of discharge so referrals for community support can be made in advance of a patient becoming medically fit.


Millennium-based Departure Board to be developed and launched; Silver meetings to be re-established in December to support roll-out.Focus on raising awareness of Integrated Discharge Service (IDS) across wards during December.

Standards for MDTs, ward rounds and discharge planning presented at Medical Grand Round, Professional Nurse Forum.

Pharmacy workplan developed; key focus for next two months.

Following pilot on ACE and Forrester Brown, new Discharge Status agreed, with Amber status removed, rolled out to all wards.

Launch of Integrated Discharge Service, co-locating all community in-reach teams and simplifying referrals processes.

Discharge passport pilot underway on four wards to understand improvement in patient experience.

Focus on clinically-led discharge processes - sub-group established.

Back

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Discharge Week held 2 November 2015; all wards visited by the discharge roadshow, DLN ward teaching, stall in the Lansdown foyer to promote good discharge practice.

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DRAFT FOR DISCUSSION PURPOSES ONLY 4 hour performance trajectory – planning assumptions

4 hour performance trajectory developed.

Trajectory reflects planned recovery of 4 hour performance to the three year average, as a result of the Urgent Care Improvement Programme.

Key milestones in the programme are noted within the trajectory.

Performance in November and early December significantly impacted by norovirus outbreak. All wards reopened by 8 December 2015.

Planning assumptions:

- Trajectory set based on 3 year (2011/12 - 2014/15) average performance.

- Key milestones noted within the trajectory support recover y to 3 year average

- Incremental improvement in performance expected to be seen in advance of milestones being achieved

- The trajectory does not reflect potential impact on performance of infection control outbreaks.

- The trajectory does not assume any improvement in DTOCs.

- 95% performance standard for 4 hours will not be achieved until May 2016.

Scenario performance summary

The table below summarises the quarterly and year-end performance outlined in the trajectory:

Trajectory

Milestones and deliverables associated with the front door workstream are marked in red text on the trajectory; specialities is represented by blue text and the back door in green.

The trajectory will be reviewed in light of the impact of norovirus and ward closures through into December.

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DRAFT FOR DISCUSSION PURPOSES ONLY National target 95%

RUH 4 hour performance trajectory (type 1)

– Q1 95.1%

– Q2 96.2%

– Q3 95.0%

– Q4 91.7%

The graphs and table to the right shows the current trajectory performance which are updated daily with actual performance.

Key action to continue to review 4hr performance daily linking performance to ongoing delivery of the Urgent Care Improvement Programme

Daily monitoring of the Medically Expected and Medical and Surgical Direct GP admission pathways in place – undergoing a review to reflect the performance improvement plans and focus on ambulatory care.

Ongoing metric review will confirm that the actions taken are supporting delivery. Reportable through the Urgent Care Improvement Board.

Clarification and confirmation of SRG ORCP plans and delivery in line with the expected trajectory improvements is required.

Current Trajectory – Type 1 Activity

Date Range / Week Ending

Week Number

Target Trajectory

Performance

01-05/04/2015 14 90.3% 97.1%12/04/2015 15 86.6% 90.0%19/04/2015 16 93.1% 93.0%26/04/2015 17 95.3% 94.5%03/05/2015 18 97.6% 96.3%10/05/2015 19 97.9% 88.7%17/05/2015 20 97.1% 88.7%24/05/2015 21 97.0% 91.4%31/05/2015 22 95.8% 84.9%07/06/2015 23 95.9% 91.8%14/06/2015 24 95.7% 92.3%21/06/2015 25 95.5% 91.7%28/06/2015 26 97.0% 88.7%05/07/2015 27 97.1% 84.1%12/07/2015 28 97.1% 85.6%19/07/2015 29 97.3% 80.0%26/07/2015 30 97.2% 91.7%02/08/2015 31 96.3% 87.5%09/08/2015 32 96.6% 82.9%16/08/2015 33 96.3% 82.6%23/08/2015 34 95.6% 87.4%30/08/2015 35 95.3% 75.0%06/09/2015 36 96.0% 83.9%13/09/2015 37 94.7% 77.1%20/09/2015 38 95.6% 80.3%27/09/2015 39 95.9% 89.6%

70.0%75.0%80.0%85.0%90.0%95.0%

100.0%

RUH ED 4 Hour Performance Vs Target Trajectory

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DRAFT FOR DISCUSSION PURPOSES ONLY Risks

The Trust has identified a number of risks to achieving the improvement plan both internal and system wide.

These are being managed through the RUH Urgent Care Collaborative Board.

A system-wide risk register is held by BaNES SRG.

Risk Risk Description Mitigation

Lack of staff engagement Lack of engagement from staff results in organisation inertia, and the change programme set out in this document is not successfully embedded and sustained.

Communications plan and 4 hour narrative developed to build consensus across the Trust. Clear structure of responsibility for delivery of plan in place.

Lack of skills to deliver transformation programme.

Lack of quality improvement skillset prohibits a test, spread, sustain approach.

AHSN flow project commencing October 2015. Internal targeted Quality Improvement training programme.

Capacity to deliver transformation programme

Lack of capacity to deliver significant organisational change results in change not being successfully delivered and sustained.

Develop PMO approach for delivery of the programme. Executive leads allocated to each work stream

System demand and capacity

Insufficient level of bedded or holding capacity to address capacity impacting events, such as high demand, loss of beds and significant increase in LOS driven by increased complexity. The impact of this is reduced patient flow, increased level of patient dissatisfaction, clinical risk to patients and risk of system failure through gridlock.

Internal Provider Demand, Capacity & Escalation plans. Operational performance management framework for the urgent care system

Assessment capacity Loss of assessment capacity during periods of high escalation impacting on operational models, potentially requiring direct admit patients to be diverted to ED. This will cause additional pressure on 4 hour performance and have a significant impact on patient flow.

To be addressed in operational models.

Impact of infection Trust resilience to the impact of ward closures as a consequence of norovirus outbreaks.

Focus on good infection control practices, both within in the RUH and in the wider health-community, to minimise outbreaks.

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