seven day services transformational improvement programme community of practice

Seven Day Services Transformational Improvement Programme: Community of Practice

14th January 2015, 11:30-13:00

Improving health outcomes across England by providing improvement and change expertise

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Seven Day Services Improvement Programme in partnership with NHS England

Agenda National overview and update • Jo James Programme Delivery Lead, Seven Day Services Improvement Programme, NHSIQ

Overview of CD&D 7 day service preparation • Mike Brierley, Head of Customer Programme Manager, North of England Commissioning

Support Unit

Developing improved multi-disciplinary working on hospital wards • Ian Briggs, Associate Director for Business Development, County Durham and Darlington NHS

FT

Taking an integrated locality approach to 7 day delivery • Dr Andrea Jones, Chair, NHS Darlington CCG • Jane Haywood, Clinical Director, Adult and Integrated Services, County Durham and

Darlington NHS FT

Information governance and data sharing • Lisa Wilson, Head of Information Governance and IT Security, Health Informatics, County

Durham and Darlington NHS FT • Eileen Carbro, Commissioning Manager, Service Planning and Reform, North of England

Commissioning Support Unit

Information governance - National perspective • Rhuari Pike, Locality Delivery Manager, Seven Day Services Improvement Programme , NHSIQ


Jo James Programme Delivery Lead Seven Day Services Improvement Programme



Time to Change • Five day service model not

meeting patient needs or expectations.

• Increasing evidence of poor outcomes for patients admitted at weekends - mortality rates - re-admission rates - length of stay - patient experience

“This change will be difficult - but it is the right thing to do.”

Sir Bruce Keogh, National Medical Director


Mortality rates • Significantly greater risk of dying (up to 16%)

for weekend admissions

• Multi-factorial, likely to be result of: Variable staffing levels Absence of senior decision-makers /

consultant level skill and experience Lack of specialist services (eg diagnostics) Lack of specialist community and primary care

services to support patients to die at home


Other outcomes

Length of stay • Factors contributing to unnecessarily longer stays

more pronounced at weekends

• Waiting for senior assessment equates to longer LoS

Readmission rates • Working between different parts of system more

difficult, impacting on readmissions

Patient Experience • Lack of senior decision makers hinders

communication


The journey so far…..

• Everyone Counts: Planning for Patients 2013/14 - “The NHS will move towards routine services being available seven days a week.”

• Seven Day Services Forum established - urgent and emergency services, supporting diagnostics.

• Forum’s recommendations approved by NHS England – including adoption of 10 clinical standards.


The journey so far… (cont’d)

• Forum scope widened - consideration of a fully integrated seven day service.

• Five Year Forward View: key part of system transformation “…we will develop a framework for how seven day services can be implemented affordably and sustainably…”


The clinical standards

Patient Experience

Time to first consultant

review

MDT Review

Shift Handovers

Transfer to community and Primary

and social care

Mental Health

Quality Improvement Diagnostics

On-going review

Intervention /Key services

Patient Experience

Time to first consultant

review

MDT Review

Shift Handovers

Transfer to community and Primary

and social care

Mental Health

Quality Improvement Diagnostics

On-going review

Intervention /Key services


The timescale

• Local contracts to include action plan for delivering the clinical standards.

Year one

2014/15

• 5 out of the 10 standards to be implemented by end of March 2016.

Year two

2015/16

• Full implementation of all 10 clinical standards by March 2017

Year three

2016/17


Seven Day Services Partners

NHS England

Health Education England


NHS Improving Quality’s role

• Spread change, foster collaboration and build momentum • Help with the ‘how to’: - spreading learning and knowledge

- advice and support

- resources to support delivery

- connecting people

• Build capacity and capability - service improvement.

• Champion patient and public involvement.

• Evaluation and measurement of impact.

• Shape future policy - identify barriers/challenges.


Seven Day Services Improvement Programme

1. Diagnostics - spreading evidence-based models

2. Engaging all healthcare communities in moving towards services that meet the clinical standards and identifying the top interventions

3. Designing new models of seven day services


Early Adopters


Challenges

“There are numerous plans and strategies in place but little

positive action and achievement.”

“Stakeholders are

finding it difficult to ‘see outside their

own front door’ due to operational

pressures and cost reduction.”

“Everyone thinks that the CCGs should be driving the agenda…but in some areas leaders are questioning whether they have the courage to be radical.”

“We were slow to realise that it not about additional funding or simply adding to our workforce, we were not thinking laterally across the whole health economy.”

“Patients want 7 day services but react when we need to relocate services to offer a 7 day service."

“Competition between Trusts and lack of trust

between us is one hurdle.”


How we can help

• Help develop system-wide approach, including coproduction of local events.

• Knowledge and learning sharing – connecting to others.

• Quality improvement and service redesign advice and support.

• Support with baseline, gap analysis and planning.


Self-assessment tool • Developed to help plan for seven day services and

national clinical standards.

• Provides baseline against standards, helps identify gaps and local needs.

• Considers patient involvement, barriers and drivers, and potential benefits.

• Use to stimulate discussion across local health community.

• Register at www.7daysat.nhs.uk

http://www.7daysat.nhs.uk/


Contact us

[email protected]

@NHSIQ #7dayservices

mailto:[email protected]

https://twitter.com/NHSIQ

https://twitter.com/NHSIQ

https://twitter.com/hashtag/7dayservices

https://twitter.com/hashtag/7dayservices

7 Day Services – Beyond

Assessment

County Durham and

Darlington

County Durham and Darlington

Health and Social Care 7 Day Services Overview

County Durham and

Darlington

“Beyond Assessment”

Mike Brierley

Head of Customer Programme Manager

North of England Commissioning Support Unit (NECS)


County Durham and

Darlington County Durham & Darlington Profile

• Population base served: – 610,000 approximately

• 3 Clinical Commissioning Groups – North Durham, DDES &Darlington – 82 GP practices

• County Durham and Darlington NHS Foundation Trust – integrated acute / community health care provider

– 2 Acute hospitals – Access to six community hospitals

• Tees, Esk and Wear Valley NHS Foundation Trust

– Provides inpatient and community services

• Two local authorities – Darlington Borough Council – Durham County Council

• North East Ambulance Service (NEAS)


County Durham and

Darlington Approach to 7 Day Services

• Whole economy integrated approach • Health • Social Care • Third Sector • Patient groups

• Service Transformation • Integrated governance and planning across all partners • Align with locality strategies such as ‘Better Care Fund’.

• Programme Methodology for delivery with three priority areas • Frail elderly • Urgent Care • Diagnostics


County Durham and

Darlington Programme Methodology

Establish The programme

Mobilise Breakthrough

System re-design

Review Evaluate & Plan

• Agree key 7 day principles

• Define point B & understand point A

• 7 day working gap analysis & change agenda

• Programme Plan • Business case • Create steering

group, change support team & key pathway teams

• Preparing key clinicians & mangers to lead change

• Establish the case for change

• Stakeholder analysis & comms strategy

• Creating a shared 7DS vision

• External visits\

benchmark • Staff input

into 7DS change agenda

• Simple wins

3 Key pathfinder areas • Frail Elderly • Diagnostics • Urgent care • Cascade vision

into pathfinder areas

• Early Wins

• Re-designing work process and systems

• Social systems design • Service configuration • Governance &

Infrastructure design • Define capability

needs • Performance mgt

design • HR\Workforce

systems design

* Red Text – Areas of Progress

• Review & evaluate pathfinders

• Finalise 7 day working system & design

• Consultation • Develop

phased full roll-out business case & Plan


County Durham and

Darlington Areas of Progress

• County Durham and Darlington Foundation Trust acute baseline assessment

• Multi-disciplinary team development: • Acute based • Community based

• Analysis of key barriers to change

• Integrated planning documentation including vision, principles and service blueprints

• Information sharing Agreements (ISA)

• Template and populated ISAs

• Case study on information sharing

Developing improved multi-disciplinary working

on hospital wards

County Durham and

Darlington


Kelly Bentham

Head of Business and Performance: Acute and Long Term Conditions

County Durham and Darlington NHS Foundation Trust

Ian Briggs

Associate Director Business Development

County Durham and Darlington NHS Foundation Trust


County Durham and

Darlington Standard 3 - Multi-disciplinary Team (MDT) review

“All emergency inpatients must be assessed for complex or on-going needs within 14 hours by a multi-professional team, overseen by a competent decision-maker, unless deemed unnecessary by the responsible consultant. An integrated management plan with estimated discharge date and physiological and functional criteria for discharge

must be in place along with completed medicines reconciliation within 24 hours.”

Supporting information: • The MDT will vary by specialty but as a minimum will include Nursing, Medicine, Pharmacy, Physiotherapy and for medical patients, Occupational Therapy. • Other professionals that may be required include but are not limited to: dieticians, podiatrists, speech and language therapy and psychologists and consultants in other specialist areas such as geriatrics. • Reviews should be informed by patients existing primary and community • Appropriate staff must be available for the treatment/management plan to be carried out


County Durham and

Darlington PERFORM is a people-focussed management system that changes behaviours

A management system that drives

new behaviours to achieve a step change in

operational effectiveness and efficiency.

KPIs, performance boards, performance reviews, competitions, recognition, vision, coaching, training

Director visibility and presence, Team leader driving team performance, Team member control and responsibility

Understanding the quality of the work that is done, getting things right first time to reduce the number of errors

Managing capacity and removing the unnecessary parts of the process to reduce the time taken to respond to clients and improve service levels without compromising quality

PERFORM


County Durham and

Darlington PERFORM Seeks To Challenge Traditional Ways Of Working

Fire fighting

“I’m working long hours fixing the latest issues...it never seems to stop”

I am frustrated with social service

There is a high variation in clinical performance including discharge process and consumables used

Management by email

“I received 200 emails yesterday, how do you expect me to meet with my team”

The blame game “We cannot discharge patients on time because social service cannot accommodate

“Poor communication regarding clinic scheduling, working lists and clinic cancellations”

Sickness levels are high

The performance disconnection

“I’m not sure how I impact our department’s performance”

Active management

“I understand issues before they happen because of increased visibility of performance and more regular review”

From a traditional way of working... ...to the PERFORM way of working

Management by walking the floor

“I have a structured day that allows me time to understand problems and best practice in my team”

Working together

“When things go wrong we raise problems and work together with other teams to resolve them”

Connected performance

“I know what is required of me on a day-to-day basis and can see how it impacts my department”


County Durham and

Darlington MDT Team: Identifying EDD and Management Plan for Every Patient 7 Days a Week

Ward 11’s

Board

Team track daily

discharges 7

days a week

Team identify

issues that cause

delays for

patients

Team schedule

problem solving

sessions to

understand and

resolve issues

Team celebrates

success by

highlighting what

they are doing

well

MDT daily focus

is on EDD


County Durham and

Darlington Perform is Aligning The Strategic Goals To Operational Delivery

Matrons and Ward Managers

discuss ward performance daily,

number of discharges, set targets

and share best practice

Head of Nursing Services and

Business Manager discuss

weekly performance with Matrons

weekly

Divisional COO discusses weekly

divisional performance and impact

on bed capacity

Strategic level

Tactical level

Operational level

Perform alignment – people talking about the things

that they can control with the information

that they need


County Durham and

Darlington Challenges

• Winter

• Time

• Reconfiguration

• Strategic and operational leadership

• Sustainability

• Celebrating success


County Durham and

Darlington Achievements

7 DAY MDT

Average Discharge

Increase by 7%

Reduction in LOS 5%

Medical Boarders Per

Day

Reduction of 67%

AM discharges

Increase by 13% Non acute of

patients per week

Increase by 27%

ED Activity

Increase by 5%

Falls per week

Reduced by 25%


County Durham and

Darlington

What Trust Staff Are Saying About PERFORM

“Perform has given us daily communication

with key people such as Physiotherapists and

Occupational therapists. It has given us instant feedback from these

teams.” Ward Manager

“I was not enjoying my job before Perform and was thinking of leaving – now I look forward to

coming into work again”

OT Manager

“Multi disciplinary teams identifying opportunities to

improve quality and performance through

collaborate working to deliver change and share best practice

whilst not forgetting to celebrate achievements and

success.” Lead Business Manager

“Engagement from all the MDT is brilliant- decisions are being made quickly, efficiently and staff feel

empowered to make decisions.”

Ward Matron

“Perform has improved the efficiency of the team as a whole, given the scope for many members of the MDT to contribute collectively at the care of the patients. It has also allowed us to focus on which patients can be discharged, and the barriers to this.”

Medical Consultant

“Before Perform I was not enjoying my job – I did

not look forward to coming into work. Now

with improved communication I feel I can

do my job better. (paraphrased, anonymous)

“I have worked at 5 other Trusts and no where have I seen

effective working like this – I am now looking

to stay at Durham” Medical Registrar

“Perform has given the inpatient areas a daily platform for multi-disciplinary working. This

model gives the teams an opportunity to focus on actions that are needed to address areas of each

patient pathway in order that they have timely and appropriate interventions that leads to a safe

and effective discharge.” Head of Inpatient Services


County Durham and

Darlington Further 7 day Projects Which Have Stemmed From The Implementation Of Standard 3…

There are 4 key issues which are blocking medically fit patients from leaving the ward…

On average the information centres across the six wards are typically seeing 30 patients

per week who are now medically fit for discharge but are “blocked” in the system due to

problems which are being addressed.

Just over one

third of the

patients ready to

move on are

under the Trust’s

control

By making problems visible on information centres, the teams have highlighted 4 key areas

of focus: CHC assessments, Nursing Home discharges, Diagnostics and community

hospitals.

Taking an integrated locality Approach to 7 Day

Delivery

County Durham and

Darlington


Dr Andrea Jones

Chair

Darlington Clinical Commissioning Group

Jane Haywood

Clinical Director Adult & Integrated Services County Durham and Darlington NHS Foundation Trust


County Durham and

Darlington What We Are Trying To Achieve

• Improve patient experience

• More effective care planning and packages centred on individual needs

• Care in the community or at home where preferred option

• Increase in self-management

• Increased involvement of Voluntary Care sector

• Prevent unnecessary acute admission/re-admission

• Reduce length of stay (e.g. through ‘in-reach’)

• Reduce number of patients transferred to long term care


County Durham and

Darlington Stakeholders Involved

• Darlington CCG & Associated Practices

• County Durham and Darlington FT

• Darlington Borough Council

• Tees, Esk and Wear Valley FT

• Voluntary Sector

• Care Home Sector

• Healthwatch

• NEAS

• North of England Commissioning Support

“Beyond the Assessment”

County Durham and

Darlington

Elderly in Acute Hospital bed

Rapid Assessment Base (request diagnostics) 8-8 x

7 days

MDT Community Rapid Response & case management

GP practices

Nursing Homes

Long Term Condition Case management/Care Planning/EOL

Self Management

Crises patient Ambulance 999

Life threatening

Diagnostic rapid access

pull

pull By-pass A&E


County Durham and

Darlington Progress since March 2014 – Primary Care

• Practice MDT’s take place monthly in place with attendance from

Social Workers, Community matrons and Voluntary Sector brokers

• Advanced care plans being developed for 2% of population at

highest risk of emergency admission

• Monthly meetings to discuss those who have had emergency

admission in previous month & agree how care plan/support

package needs to be amended to prevent re-occurrence

• Voluntary sector broker liaises with other VS organisations as

appropriate

• Referrals made to other teams as appropriate e.g. mental health

• Evolutionary development


County Durham and

Darlington Progress since March 2014 – Care Homes and initial feedback

• Community Matrons now working 9am – 5pm; 7 days a week

– linked to Top 10 Care Homes

• District Nurses pick up any referrals overnight

• Community Matrons attending all GP practices monthly MDT’s

• EHCP/Advanced Care Plans starting to be put in place for all

patients in care homes.

• NEAS aware of new ways of working and ring Matrons prior to

patients conveyance to hospital


County Durham and

Darlington Key Benefits and Value Added


County Durham and

Darlington Outcomes So Far: Emergency Admissions from Care Homes – April to November 2014

Local authority Location Name Apr-14

May-14 Jun-14 Jul-14 Aug-14 Sep-14

Oct-14

Nov-14

Current Total

Darlington Darlington Manor Care

Home 6 4 6 3 4 1 24

Darlington Eastbourne Care Home 6 8 1 8 6 8 4 2 43

Darlington Eden Cottage Care Home 6 8 1 8 6 8 4 2 43

Darlington Grosvenor Park Care Home 8 7 9 8 5 9 6 52

Darlington Rydal Care Home 3 2 2 4 2 10 2 25

Darlington St Georges Hall and Lodge 4 5 6 4 7 4 2 32

Darlington The Gardens Care Home 9 5 8 8 6 7 5 2 50

Darlington The Grange 8 17 16 5 7 6 6 2 67

Darlington Ventress Hall Care Home 4 5 7 11 8 4 4 2 45

Darlington Willow Green Care Home 14 9 8 7 5 3 3 1 50

Monthly total 68 65 63 68 49 66 38 14 431


County Durham and

Darlington Issues – Or Challenges And Opportunities

• Multi organisation working

• Aligning national strategies against challenging timelines

• Information sharing

• IM & T

• Communication


County Durham and

Darlington Future direction and next steps

• Community Rapid Assessment Service - Front of House

• Geriatrician telephone advice line 12:00 – 14:00 Monday to

Friday

• Hospital to Home

• Additional matrons/assistant practitioners to support

remaining care homes

• Identification of areas for future development/investment

Developing the Information Sharing Agreements

(ISAs)

County Durham and

Darlington


Lisa Wilson

Head of Information Governance & Trust Data Protection Officer County Durham and Darlington NHS Foundation Trust

Eileen Carbro

Commissioning Manager North of England Commissioning Support (NECS)


County Durham and

Darlington Barriers to sharing information?

• There shouldn’t be any.

• Ensuring we comply with the legal and regulatory

framework and various requirements (e.g. Caldicott 2

report)

• Professional/public attitudes to sharing information differ.


County Durham and

Darlington Overcoming the ‘Barriers’

• It’s not ‘we can’t share’ – its ‘how can we share’

• An Information Sharing Agreement (ISA) is a document

for all parties to agree :

• Assist compliance with information rights law and

practice.

• Set’s out standards and consistency that have to be met

by all signatories.

• Ensure patient consent is achieved in process


County Durham and

Darlington Approach

• North East Information Governance (IG) Managers

developed Multi Agency Information Sharing protocol –

ISA Template used is an appendix of this.

• Balance between legislation (e.g. consent) and best

interests of the patients for their healthcare

• Engagement between IG leads essential to understand

concept and agree way forward.


County Durham and

Darlington Why We Needed to Share Information

• Identified and agreed to develop two phases of

information sharing for specific parts of project:

1. Data analysis across health and social care

organisations to inform planning (e.g. identify

patient cohorts, team roles required, capacity)

2. Sharing of relevant client information across

partner organisations to support new ways of

working and processes across partners

* Examples used are for the Darlington MDT for frail elderly


County Durham and

Darlington Phase 1 – Data Analysis ISA

• Data Analysis ISA:

– Allow sharing of information to identify the cohort of patients we needed to target for the project.

– 3003 frail elderly patients identified

• 76% were in GP practice DES (direct enhanced services)

• Care homes – 12% of DES

• Assumption 88% care home population were included in the initial 3003 identified patients

– Data then shared across Social Services/Mental Health and Acute Trust to determine how many of Frail Elderly cohort already known to them

– Results surprising and very beneficial; informed planning of roles/capacity required


County Durham and

Darlington Phase 1 – Data Analysis ISA Challenges

• Question whether using NHS number for

planning/commissioning purposes met regulatory/legal

framework

– Issues with NHS number “used only for direct patient

care”

• After local and national review over several months –

NHS Number could be used if appropriate ISA was

agreed by all partners


County Durham and

Darlington Phase 2 - MDT Process ISA

• Can only start ISA when processes have been agreed by

staff involved.

• ISA detailed what information will be shared, how it will

be shared, how it will be transferred, stored and securely

disposed of, also covered a range of other areas e.g.

training, incident reporting etc.

• ISA for Third sector organisations were new, challenging

and surprising.

• Full Communication between all parties crucial.


County Durham and

Darlington Phases 1 and 2 - ISA lessons learnt

• Must be a single lead / facilitator

• Standards have to be met by all parties, discussions of

how these can be worked towards / met.

• Version control is a must to track different comments.

• Central point for all comments and signatories.


County Durham and

Darlington Future Challenges

• Identified a broader range of Voluntary Sector

Organisations who have not yet signed current ISA

• Lack of understanding - CCG’s for the need for this

protection (seen as red tape)

• Integrated working outside the public sector

• Shared / integrated electronic systems

• Acceptance of the learning and sharing across other

organisations - don’t reinvent the wheel


Information

Governance

Rhuari Pike

Locality Delivery Manager Seven Day Services

Improvement Programme


National actions: Progress.

• Background: SDSIP support to CDD 7DS team.

– two way conduit for information.

• Purpose:

1. Data analysis.

2. Sharing of relevant information.

• Escalated to NHSIC/NHS England IG to clarify. – A conference call allowed the process followed to date,

following local guidance, to be presented for clarification and support, and for debate to allow greater understanding both of the full extent of the issue, and the solutions recommended.


• Case study being written up. – Contains process followed, outcomes, copies of

documentation produced (inc’ Information Sharing Agreements).

– To be shared via NHSIQ/SDSIP website.

• Escalated to NHS England (7DS Implementation Board). • Recognition that the scale of the problem has not been

identified nationally. – Purpose of the EA sites is to identify these issues.

• Clear national guidance to be developed about how to overcome these problems.

• Assurance of how the NHS number can be used for these purposes.


• Further learning from 7 Day Services Early Adopters

• How Healthwatch have contributed to the 7 day services agenda

• Approaches and solutions to workforce issues and how Health Education England can support 7 Day services

• Sharing the learning of new models of care

Let us know if:

• there are other topics you are interested in • If you have work you would like to share

www.nhsiq.nhs.uk [email protected]

#7dayservices

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