TRANSFER OF CARE AND DISCHARGE STEERING GROUP. Terms of Reference

Transcription

1 TRANSFER OF CARE AND DISCHARGE STEERING GROUP Terms of Reference 1. BACKGROUND It is recognised that improving patient flow is the highest priority for the UHB. While there is a shared commitment to developing a whole system capacity plan, it is recognised that this will not be a short term solution. It is therefore essential that actions are taken immediately to address constraints that are impacting on timely discharge and appropriate and effective transfers of care. Effective discharge planning and timely institution of the assessment, discharge and transfer of care process is critical to the UHB s strategy for delivering Right Care to the Right Patient at the Right Time and in the Right Place. Delays in hospital discharge and timely transfer of care to other secondary care providers, primary care and community care (hospital and home) have a significant impact on patients, their carers and indeed for those patients requiring admission to hospital. Owing to the priorities associated with the bed capacity plan and appropriate transfer of ongoing care, the Steering Group currently excludes the Dental and Children s and Women s Division. 2. PURPOSE Discharge and transfer of care planning and its effective implementation is everyone s business with the multi-disciplinary team critical to its successful delivery. Importantly early engagement with the patient and the patient s family/carer, General Practitioner and locality/ neighbourhood team/case manager is essential to ensure that the discharge and/or the transfer of care plan is both safe and effective. In support of the delivery of timely and effective discharge planning and assessment and transfer of care functions a number of operational groups have developed, principally the Discharge Steering Group and the Super Tuesday operational group. In order to co-ordinate the actions being taken and maintain an overview of performance improvement it is proposed that these two forums should be co-ordinated by an over-arching group: The Transfer of Care and Discharge (ToCaD) Steering Group whose aims include: To establish a culture where discharge planning and transfer of care is viewed as a process rather than an event. To ensure that patients and their carers are involved from the beginning and throughout the process. To improve communication and information sharing between professionals and patients/carers so that they know what to expect, and between professionals to facilitate smooth transition from hospital to community based care/home. To avoid delays and to discharge patients in a safe, effective and timely manner. This ensures that the patient is in the right place to get the care they need (physically, socially and emotionally), To ensure that there is a consistent standard of discharge practice across the organisation, which supports the principles of a fair and equitable service to all. To ensure that staff are better informed as to care options available, including more effective use of voluntary organisations. Terms of Reference DRAFT 1/12

2 The Steering Group will be sponsored by the Medical Director and will report directly and be accountable to the Operational Board of Directors. Partnership issues will be reported to the Operational Leads for Social Services, Mr, Mike Murphy and Mr. Phil Evans and to the Integrated Health and Social Care Board. 3. KEY PRINCIPLES UNDERPINNING THE DISCHARGE AND TRANSFER OF CARE PLANNING PROCESS In order to meet these objectives and facilitate the best use of hospital capacity and improve patient flow throughout the system the UHB s Acute Discharge Protocol advocates the following key principles: Discharge planning starts at the point of admission (Unscheduled) and at the preassessment stage for Scheduled admissions. A working diagnosis is established as quickly as possible, ideally within hours. Using the Simplicity Matrix, patients discharge needs will be assessed as either Simple or Complex and the discharge plan will be managed accordingly. Planned Discharge Date (PDD) is established within pre-admission in the scheduled pathway or on admission 48 hours maximum (unscheduled) and at the weekly multidisciplinary team (MDT) meeting on FRAME and Community inpatient and virtual wards and should be agreed with the patient and their family/carer. The Discharge planning process is owned by the ward team, the Consultant is clinically accountable for the discharge and transfer of care decision and the Ward Sister/Charge Nurse is responsible for its delivery. For patients with complex care needs the MDT is critical to the planning and delivery of the transfer of care pathway and responsible for the timely escalation of constraints Patients and their family/carer will be given clear information on the planned discharge date early on in their care pathway. Communication with the patients GP, Locality/Neighbourhood teams is essential ensuring that their knowledge and views are taken into consideration. The planned date of discharge will be proactively managed against the treatment plan on a daily basis and formally reviewed at each multi-disciplinary meeting and changes communicated to the patient and their family/carer. Discharge will take place 7 days a week and encompass: - ward rounds/care management plans will be scheduled to allow a senior review of all patients at least daily; - protocol led discharge according to agreed clinical parameters to be employed. Inpatient discharges/transfers (ideally 50%) should be planned to occur before 12 noon, and on any day of the week, including weekends. Timely completion and actioning of a discharge checklist (24 hours before the planned discharge date) to include TTH s; ongoing review and transfer of care management arrangements, timely booking of transport and EMS transport in particular. Timely notification of the discharge (within 15 minutes) on the ward clinical workstation to support effective patient flow. Terms of Reference DRAFT 2/12

3 4. PERFORMANCE FRAMEWORK UNDERPINNING THE TRANSFER OF CARE AND DISCHARGE PROCESS. Over the past seven months the ward clinical workstation (WCW) and Business Intelligence System (BIS) have been developed to provide enhanced data collection and reporting functionality to support the patient flow programme. A Task and Finish Group is currently in the process of finalising the reporting suite of activities which will reflect and prioritise constraints, actions being taken to facilitate transfer of care/discharge and importantly inform a number of the underpinning processes. For example, inform local MDT meetings, the Assessment & Transfer of Care pull model and support any necessary escalation process via the Super Tuesday meetings with the ultimate aim of having a live bed management system in place by September 2011 and fully operational and functioning by December In order to facilitate an effective performance management framework two key definitions are required. 4.1 KEY DEFINITIONS The term medically fit is based on the Delayed Transfer of Care definition; however it is not conducive to an integrated partnership approach. In the revitalised Discharge protocol the Department of Health definition is proposed as follows: Fit for Discharge: is when the patient no longer has the capacity to benefit from ongoing hospital based inpatient services within a tertiary/secondary care setting and where: ongoing care and social needs have been agreed and can be met in another setting, home or through primary, community, intermediate care or social services. ongoing care and social needs can be met more appropriately in a secondary or community care setting closer to the patient s home i.e. referring LHB catchment area additional tests and interventions can be carried out in an outpatient or ambulatory setting. PDD (planned date of discharge): It is recognised that the planned date of discharge is a working definition and encompasses patients with simple and complex care needs. The planned date of discharge is therefore representative of the working date that the clinical team/mdt/patient and carer aim to have the patient discharged from a hospital inpatient bed or have their care transferred to primary, community, intermediate care services or in the case of non-cardiff & Vale residents to another LHB care provider. 5. TIMELY DISCHARGE AND ATOC STEERING GROUP CORE OBJECTIVES 1. To be a comprehensive, inclusive and cross-sectional forum for the development/progression of the discharge and ATOC model in line with the overarching principles. 2. To develop a comprehensive project plan and allocate responsibilities and tasks to individuals and groups with clear deliverables and accountabilities. Terms of Reference DRAFT 3/12

4 3. To drive the implementation of safe, effective and timely discharge and ATOC in line with the project implementation action plan. To ensure that work remains focused and supports the delivery of the project objectives 4. To support the development and application of improvement methodologies, tools and techniques to inform baseline assessment, confirm process change, measure and monitor performance to ensure sustainable process improvement. 5. To receive regular reports from the project sub-groups leads (Timely Discharge and Super Tuesday) on progress. 6. To establish an evaluation framework for monitoring performance and evaluation of the various work streams against the Transfer of Care and Discharge project plans. 7. To provide regular reports to the Operational Board of Directors (OBD) and Integrated Health and Social Care Board on project progress, risks and issues. 8. To ensure appropriate communication with and input from relevant stakeholders. 9. To establish appropriate links with IM&T developments and e-communication projects. 10. To understand organisational development (OD) and financial requirements 11. To identify, monitor and mitigate against risks to the project. 6. DELEGATED POWERS AND AUTHORITY The Transfer of Care and is authorised by the Operational Board of Directors. In order for the Steering Group to achieve its core objectives the Steering Group has the vested authority to: ask for any reports or actions by the Divisions to comply within its Terms of Reference. seek any relevant information from any of the Divisions and corporate departments and other committee, sub committee or Committee set up by the Board to assist it in the delivery of its functions. establish sub groups or task and finish groups to carry out on its behalf specific aspects of it s business The Steering Group will:- Oversee that the organisation, at all levels, (Division and Directorate/Locality) has the right systems, processes and controls in place to ensure effective practice to achieve safe, effective and timely assessment and transfer of care/discharge. Develop and action a framework to deliver sustainable improvement in the transfer of care and discharge planning process for patients on the scheduled and unscheduled pathway. Terms of Reference DRAFT 4/12

5 7. MEMBERSHIP The Steering Group will comprise: 1. Medical Director (Chair) 2. Clinical Leads for Surgery, Specialist, Medicine and IM&T 3. Programme Lead, Assistant Director I&I 4. Divisional Nurse for PCIC; Medicine, Surgery, Mental Health and Specialist 5. Patient Access Manager 6. Allied Health Professional Leads 7. LA representatives 8. Pharmacy Lead 9. Programme Leads e-discharge; ward clinical workstation (operational lead) 10. Locality Lead 11. IM&T Lead 12. HR Modernisation Lead 13. Finance Lead All Group Members/Representatives will be expected to ensure effective links are established within their Division/Department/Locality to support this work and to manage risks and issues as appropriate. The Chair may extend invitations to attend Steering Group meetings as required, taking account of the matters under consideration at each meeting. 7.1 Quorum At least 3 members must be present to ensure the quorum of the Steering Group, one should be the Chair or Vice chair, Divisional Nurse and Allied Health Professional Lead. 7.2 Frequency The meetings will be held on a six-weekly basis. 8. REPORTING AND ASSURANCE ARRANGEMENTS The Steering Group is directly accountable to the Operational Board of Directors for its performance in exercising the functions set out in the Terms of Reference. The Steering Group through its Chair and members will work with the operational groups to provide advice and assurance to the OBD through: Joint planning and co-ordination of the Steering Group s business (action plans) Sharing of information In so doing, contribute to the integration and partnership working within and across the organisation. The proposed accountability and reporting mechanisms are described in Figure 1 below. Terms of Reference DRAFT 5/12

6 Figure 1. Reporting arrangements Timely Discharge Operational Project Groups Super Tuesday Operational Meeting Timely Discharge & Assessment & Transfer of Care Steering Group Operational Board of Directors Integrated Health & Social Care Board Reports to/accountable to Reports to 9. TRANSFER OF CARE & DISCHARGE IMPROVEMENT PROGRAMME The Steering Group work programme sets out proposals to support the immediate operational priorities to support improved discharge planning and timely transfer of care and is based on the care bundle approach. The Model for Improvement methodology has been adopted to support sustainable improvement across a number of discharge/transfer of care metrics outlined in the driver diagrams overleaf with associated action plans. Table 1 below contains the reference guide with the nominated leads for the action plans. Table 1: Action Plan: Key reference guide Key Name Key Name Key Name Key Name MW Matt Wyatt JR Joanne Roach CC Cheryl Chambers LW Linda Walker CF Carys Fox PZ Paul Zirker JW Jan Walker KA Kerry Ashmore DN s Divisional Nurses JP John Peters JM John Martin RJ Ruth Jordan MF Maureen Fallon AH Ann Hiscocks CH Cath Heath CB Claire Bevan SF Sarah Follows VW Vicky Warner NH Nicky Hughes AM Anna Mogie AHPs Allied Health LT Lynne Topham LC Lance Carver RL Rachel Lewis DM s Professional Directorate Managers KJ Kay Jeynes LA Leads Local Authority Leads TB Tanya Balch Terms of Reference DRAFT 6/12

7 Utilising a bundle approach, each individual work stream lead(s) is responsible for developing and implementing negotiated actions and reporting on progress to the Steering Group on a 6-weekly basis. The outputs of the Steering Group meeting will be reported to and performance managed by the Operational Board of Directors and relevant partnership issues will be reported to the Integrated Health & Social Care Board. 9.1 PERFORMANCE MANAGEMENT PROCESS Compliance will be monitored as part of the UHB s operational performance management processes to include: PDD completion on CWS Discharges achieved before noon Utilisation of the Simplicity Matrix tool Outputs of MDT meetings and response times Adherence to the transfer of care pathway Readmission rates and response times Assessment and Transfer of Care function response times Response times to escalation issues and out of area transfer and the other metrics outlined in the driver diagrams. The census information to include patient transfer of care requirements will be updated by mid-day on Monday to inform the Super Tuesday meeting. Agreed actions from the Super Tuesday meeting which should include a revision to the PDD will be documented live on to the ward clinical workstation. A summary report confirming the transfer of care patient pathway to include the numbers of patients by division and their status in terms of what the patient requires to effect their transfer of care will by provided from the Business Intelligence System to inform the weekly meeting with the Chief Executive. A summary of the key metrics and trends together with a status report on the action plan will be provided to OBD on a bi-monthly basis. Terms of Reference DRAFT 7/12

8 CONTENT AREA DRIVERS INTERVENTIONS MEASURES Safe Discharge Improve patient experience MDT decision captured Senior Review/ Protocol Led Discharge Capture and respond to failed discharges e-discharge % compliance with proforma % discharges with a PLD/ Snr review PDD % readmissions within 48 hours of discharge. % of GPs receiving e-communication within 24 hrs of discharge work with patient experience team to capture patient satisfaction metrics associate with discharge/transfer of care process PDD compliance and manage to PDD % compliance with PDD Programme aim: Safe, effective and timely discharge planning and processes Effective discharge Robust discharge processes Understand and minimise the variance between ADD and PDD PDD for electives according to AVLOS/preelective PDD Census to inform Escalation/ problemsolving process for 0-20 days and complex discharges (super Tues) 20% tolerance for ADD vs PDD % pts on PMS with a PDD for elective procedures % reduction in lost capacity due to internal constraints % reduction in DTOCs % reduction in DTOC beddays lost % reduction in LOS > 20 days (fit for discharge) % discharges b4 noon Discharge before noon Timely discharge Improve patient flow All patients to be discharged on WCW < 15 minutes of departure Demand and capacity will be known in real time i.e. live bed management Bed Turnaround time of 1 hour (exc IPC related constraints). Terms of Reference DRAFT 8/12

9 Content Area Safe Discharge Intervention MDT Decision Captured Snr Review Flag & Roll-out Protocol led discharge Failed Discharge capture and action MW Lead JR/CC/MF LW/CF/JW/PZ KA/DN's AToC function Complete By Comment Part of the CHC programme of work being led by CEO. MDT decision tool being piloted on B6 September currently. Electronic capture of the decision to be developed. Development completed, roll-out to be completed to support effective discharge planning in the OOH June periods. Protocols for relevant areas in Surgery & Specialities, Respiratory & Trauma to be reviewed. August I&I to develop an evaluation template to monitor effectiveness. JulyWCW flag development to capture failed discharges within 48hrs. Develop escalation and responsive action plan. E-discharge JP/RJ Dec Requires significant OD & Training programme for effective implementation. PDD Compliance MF/JR Maximum bed turnaround time JR/SF of 1 hour Minimise PDD/ SF ADD variation Elective PDD based on median PZ/AH/JM Effective LOS Discharge Escalation CH/CB pathway Electronic census KA/CC/JR Discharge before MF/JW Noon Timely E-bed Discharge Management SF/DNs/DMs/ MF/AHPs Ongoing August July Compliance c % at UHW and > 90% at UHL. Performance reviewed on a weekly basis. Baseline audit of turnaround times completed on C6 and A2 at the end of June. Process change to include a call remind service to be implemented by PAT, 45 mins post bed allocation to ensure patient flow. Process change to be evaluated for a 4-week period post implementation. Review ADD and PDD variance on daily basis and develop action plans to tackle poor performing areas. July Review of HRG admission codes and benchmarked LOS to be completed in general surgery. Roll-out to medical specialties to be taken forward by C.Bevan and D.Parry. Develop and implement proforma for escalation to support ward process and action at the Super Tues meeting. Roll out in surgery/specialist/opaic to be considered. June and Develop an escalation pathway for Out of Area Patients, Caerphilly residents in particular to ensure September that patients are repatriated once assessed as medically stable to transfer June June WCW development to be completed to include fit for discharge and locality information. Priority needs to more appropriately reflect constraints. DNs to ensure all relevant staff have received WCW training. Understand process issues on ward, develop appropriate actions and measure outcomes. Apply Pareto rule to focus on wards with high volume discharges and to the process issues. Focus currently is A2; B4 and medical wards. Dec All patients admissions/discharges to be recorded on the WCW within 15 mins of arrival/departures. Terms of Reference DRAFT 9/12

10 CONTENT AREA DRIVERS INTERVENTIONS MEASURES Safe Transfer of Care Improve patient experience Community services directory MDT decision to support effective pull model captured on workstation/locality Capture and respond to failed discharges Directory of locality services to inform appropriate pull model % patients readmitted with 7 days of transfer of care and effective management plan implemented % response to Community based MDT decisions to effect pull by ATOC function Work with patient experience team to develop metrics Unified Assessment Escalation/super Tues metrics: Programme aim: Safe, effective and timely transfer of care Effective Transfer of Care Robust ATOC processes Patient Choice Directive Census to inform Escalation/ problemsolving process (super Tues) Timely Community Assessment Services (TCU); Community Teams/Beds and Out of Area repatriation % reduction in following: LOS > 20 days DTOC numbers DTOC bed days lost Choice delays UA delays Social worker delays Completed assessment: 1 day max Mental Health 3 day max Community 7-day turnaround time to effect out of area transfer Timely Transfer of Care Improve patient flow Nursing Home Capacity Real time community capacity Weekly Nursing Home Capacity (places and type) Twice daily community capacity reports (places and type) Terms of Reference DRAFT 10/12

11 Content Area Safe Transfer of Care Effective Transfer of Care Timely Transfer of Care Intervention Lead Community Services directory RL/LC/LT Capture and respond to MDT decision Respond to Failed Discharges Unified Assessment Tool Choice Protocol Complete By October NH/AM/KJ/CD/KA October NH/AM/KJ/CD VW/LA leads End VW Escalation process to inform Super DNs Tuesday Timely Assessment and Transfer of Care Out of Area Repatriation Nursing Home Capacity Community Capacity LM s/ln s/atoc function VW/CB TB LN s/lms September of July August July August Comment Develop and implement a community services directory to capture type and capacity of service available and contact details. On completion of MDT tool and Activities development on the WCW, the Locality Divisional Nurses will be provided with a daily report of the patients requiring a community based service/community and Mental Health bed. Locality DN s required to direct community resource to effect a safe transfer of care. WCW flag development to capture failed discharges within 48hrs. Develop escalation and responsive action plan to arrange appropriate services for the patient within 7 days (as appropriate to the individual patient) to ensure that the patient s needs are met in the right place. Develop and implement a uniform UA tool which will meet both health and social service requirements. On completion and sign-off arrange for the UA tool to be incorporated on to PARIS and the Ward Clinical Workstation to better co-ordinate patient care across the health community Protocol completed. Sign-off by the Local Authorities outstanding. Protocol to be available on the intranet and official launch required to ensure compliance. I&I to complete the super Tuesday performance management framework. Census development completed, and once the activities WCW development is completed constraint metrics will be captured. Complete IM&T feasibility study to ascertain whether the response to constraint escalation can be captured live at the Super Tuesday meetings. In response to the ward clinical notification of complex cases the ATOC function will review the case by day 6 and support the transfer of care plan as appropriate to the individual patient. Referrals to Community Services to be completed <3 days and outcome recorded on the activities section of the WCW. Referrals to Mental Health Services to be completed <24 hours. WCW currently captures patients fit for discharge destination. Director of Planning receives the report on a weekly basis and escalates to appropriate Executive Colleague. Database to capture the outputs of the escalation process to be developed to include days lost. SeptemberClaire Bevan has arranged for Caerphilly locality team to present the profile of their services to include a turnaround service (within 4 hours of referral to the emergency unit) and a directory of available services and contact details. August July Directory of nursing home capacity to include bed type, location and waiting list information to be made available to the Patient Access Team and Divisional Nurses on a weekly basis (Super Tues) Schedule of bed and community service capacity (to include bed type/service type) by locality to patient access twice a day to flexibly respond to the requirements for timely transfer from the acute sector. Terms of Reference DRAFT 11/12

12 Terms of Reference DRAFT 12/12