TRUST BOARD 27 JUNE 2013 Public Section Report of Paper prepared by Subject/Title Background papers Purpose of Paper Action/Decision required Mark Smith, Chief Operating Officer, Urgent Care Clinical Service Unit Emergency Care Standard None To provide the board with an update on progress towards the sustainable delivery of the Emergency Care Standard. 95% patients seen, treated and discharged from the Emergency department. The board is asked to: 1. Note the content of the paper 2. Support the requirement to change the improvement work as part of Transforming Unplanned Care work to deliver on external recommendations to support sustainable achievement. 3. Agree to consider the impact of any proposed change or service review by other CSU s upon the Trust ability to deliver the ECS. Link to: Trust s Strategic Direction Corporate objectives Becoming a Foundation Trust To be the hospital of choice for patients and staff To be a consistently high performing influential healthcare provider To achieve the best possible clinical outcomes for every patient, every time Resource impact Consideration of legal issues Acronyms and abbreviations ECS - Emergency Care Standard ED - Emergency Department TDA - Trust Development Authority ECIST - Emergency Care Intensive Support Team 1
1. Introduction The purpose of this paper is to provide background and assurance for the Trust s actions to sustainably deliver the Emergency Care Standard (ECS) from the end of. LTHT performance against the 95% required standard was 93.32% in 2012/13. The key reasons for the failure to deliver have been identified as: Long waits for patients to see a clinician within the ED Significant middle grade staffing vacancies Waits for beds during 4 months (winter) of the year Lack of flow 2. Improvement Trajectory An improvement trajectory has been agreed with our commissioners and the Trust Development Authority. Table 1 - LTHT performance against the ECS - TDA agreed improvement trajectory 100.0% 98.0% 96.0% 94.0% 92.0% 90.0% 88.0% 86.0% 84.0% 82.0% 80.0% 07/04/2013 14/04/2013 21/04/2013 28/04/2013 05/05/2013 12/05/2013 19/05/2013 26/05/2013 02/06/2013 09/06/2013 16/06/2013 23/06/2013 30/06/2013 07/07/2013 14/07/2013 21/07/2013 28/07/2013 04/08/2013 11/08/2013 18/08/2013 25/08/2013 01/09/2013 Trajectory Actual Performance Standard Performance against the emergency care standard has now improved on a continuous basis for 8-weeks. LTHT have delivered the ECS of 95% for 3-weeks consistently. 3. External Support and Scrutiny LTHT invited the Emergency Care Intensive Support Team (ECIST) to visit and review systems, processes and pathways in order to ensure that our improvement plans are robust. This visit took place on Wednesday 22nd. The initial feedback indicates that local diagnostics and improvement plans are accurate and appropriate. There are a number of additional areas for consideration within the acute pathway that will be actioned and incorporated into the overall recovery plan. 2
In addition, key senior managers and clinicians were invited to attend a workshop hosted by the Trust Development Authority to gain further insight and understanding of solutions that have been adopted elsewhere in the country. A key recommendation from both events is the requirement to implement a Rapid Assessment and Treatment (RATs) model of care within both of our emergency departments. The clinical and management team within Urgent Care fully support this recommendation and intend to adopt the model during summer 2013. There are multiple steps to take to embed this model within the departments and there is a requirement for some system and process changes to be adopted in key speciality teams to allow patients to be rapidly transferred to in-patient or assessment facilities if on-going care needs are identified. These actions are incorporated into the overall improvement plan. The model is expected to be fully implemented by the end of September 2013 in preparation for Winter 2013/14. 4. Recovery Plan The ECS recovery plan identifies the key steps and actions required to sustain performance. (See appendix 1) This plan requires some minor adjustment in light of the feedback received from key external agencies and the Urgent Care CSU intends to review w/c 17.6.13 the objectives, outcomes timetable and allocation of work to comply with delivery of the ECS. 5. Performance Management The Urgent Care CSU management team attends a performance management review on a weekly basis chaired by either the for the CSU or the Managing Director for the Women s and Children s Hospital who has been given oversight and responsibility for assurance to the Chief Operating Officer. Performance against the standard is continuously monitored and any breeches of the standard reviewed on a daily basis with speciality teams from within the organisation informed of any problems occurring in relation to their service. On-call managers are briefed on the requirement to deliver and on site teams have clear instructions to escalate any risk of non delivery of the ECS in real time. They have been provided with instructions and actions to take if problems occur. The ECS recovery plan is monitored and reviewed in this forum to ensure the timely delivery of objectives is maintained. As per the requirement outlined by national teams in a letter from Dame Barbara Hakin (9th - see appendix 2), LTHT have complied fully with commissioning partners in establishing and attending stakeholder management groups, developing local improvement and recovery plans and have contributed to the establishment of an urgent care board to review and determine the strategic vision for urgent care in Leeds. 3
6. Summary In summary, there has been a significant improvement in performance against the ECS within LTHT during May and June 2013. Sustained improvement is dependent upon on-going recruitment in line with the workforce strategy and the implementation of a Rapid Assessment and Treatment Model of care delivery within the Emergency Departments. 7. Actions Required: The board is asked to note the improvements in performance delivered over the last 8 weeks. Review and endorse the Recovery Plan. Support the requirement to change the improvement work as part of Transforming Unplanned Care work to deliver on external recommendations to support sustainable achievement. TD/SH 12/06/13 In addition, the board is asked to consider the impact of any future service change or remodelling by other CSU supon the delivery of the emergency care standard before agreeing to proceed. 4
Appendix 1 LEEDS TEACHING HOSPITALS NHS TRUST Emergency Care Standard: Recovery Plan 2013/14 Objectives: 1. Performance management arrangements in place to monitor Emergency Department (ED) Performance, national KPIs and measures appropriate to improvement, within LTHT and with external partners. Measurable Outcome Qualitative /Quantitative Weekly performance meeting with Director in place, robust agenda and risk management process in place. Clinical Service Unit (CSU) management team mandated to attend. Daily review of breeches, data analyses, with appropriate escalation within LTHT and to external partners Monthly Urgent Care Stakeholder Group with external partners (LTHT representation) 111 review with commissioners Lead person(s) Stacey Hunter, Managing Director Iain MacBrairdy, Business Target Date: Identify when each objective will be completed End June 2013 Progress : Date: May14th&28th 2013 June 4th 2013 Standard agenda in place and performance framework according to TDA tracker. Daily review Weekly review of trends Consultants prepare shift report CD/GM instigates detailed investigations as reqd. Additional actions agreed and monitored by UC CSU SB meeting with Bal Leighton 29.5.13 Barriers / Escalation 12/6/13 - SH leaving in July. To confirm future responsible officer. 5
2.Deliver relevant, timely, accurate data re Performance Activity/demand Inpatient capacity Monitor and respond to findings as appropriate Winter Planning event (cross agency debrief and planning for 2013/14) Emergency Care Intensive Support Team Visit Daily and weekly monitoring of activity data related to performance and patient flow Predict and monitor implications of changes to service delivery/ reconfiguration / workforce on activity and performance. David Berridge, Medical Director (Operations) Stacey Hunter, Managing Director Iain MacBrairdy, Business 24.5.13 Output to be circulated to Facilitators for reviewcompleted Local winter delivery event arranged 23/7/13 22.5.13 Balanced verbal feedback received the majority of which is consistent with what we have identified as the key issues and recognised with the current recovery plan. Draft written report received 4.6.13 - for comments to COO from TD by 17/6/13 Once the final written report is received any additional actions that are required will be added to the Recovery Plan Report to the weekly performance meeting of the CSU. Interventions made as appropriate Report to the weekly performance meeting of the CSU. Interventions made as appropriate 6
3.Implementation of agreed workforce strategy 4 x Advanced Practitioners (APs) to commence in post 4 x Consultants to commence in post June 2013 June 2013 3 practitioners in post during May/June. Further advert to be placed for the 4 th as 1 recruited applicant has withdrawn Posts advertised. Current staff applying for AP posts. Backfill required if successful. Further Consultant recruitment/interviews Potential start date Nov/Dec 2013 Recruit to Band 5 Staff Nurse posts July 2013 Recruitment on-going Lack of trainees available to employ. June 2013 Currently 10 posts recruited, interviews w/c 21/6/13 for a further 5 posts International medical trainees commence on 2 year secondment (1st post 2 April) August 2013 Currently 2 in post. Further 2 in August working ST1-2 level. One leaves in June. Aim for 4 by year end. Visas/training transition Increase senior nursing presence to deliver floor manager role at SJUH and LGI Clinical Site s (CSMs) to be based in ED at SJUH to ensure that flow is maintained. Approach to be trialled Either non clinical or clinical background would be appropriate. To be trialled for 3 weeks commencing 4/6/13 - TD/BC The CSMs will take a handover at 5pm from the Matron and Nurse in Charge in ED and ensure a Identification of funding source. Current staff applying for AP posts. Backfill required if successful as reduced pool for floor manager role Current vacancy within CSM - on-going recruitment 7
Training programme for Advanced Practitioners to commence Sept 2013 minimum of hourly checks to manage flow out of the ED. As recruitment completed - they will base in ED Linked to recruitment of APs above. Introduce new ED Ward Clerks Iain MacBrairdy, Business Introduce new Phlebotomy process. Clinical Support Worker (CSW) roles in SJUH ED to be reviewed. Process trialled. Sustained role requires a trained workforce available to undertake regular and reliable shifts KM&T to provide outcome data/analysis from previous trial of Phlebotomists in ED Phlebotomy staffing. CSW vacancies. Resource implications To review recommendation with KM&T 17/6/13 4.Deliver safe and effective patient flow through ED exit from ED Open medical assessment area 24/7 July 2013 (open until 2am from 1/6/13) On-target. Some recruitment outstanding but this will be managed by the use of temporary staff. On target Medical patient flow review Review completed. New process agreed. Delivery dependent upon completion of HR consultation with staff. Contingency plan in 8
place for the interim. Establish model for Ambulatory Care / virtual ward Further enhance clinical engagement in delivery of Emergency Care Standard Sam Khan Lead Clinician Helen Christodoulides David Berridge, Medical Director (Operations) July/August 2013 Principles agreed for delivery of additional ambulatory pathways and management of patients via virtual ward set up. Led within Acute Medicine CSU and on target. Communication sent as per proposal PID for Trust approach rejected - escalated to Jackie Green for further discussion 11/6/13 Awaiting final sign off. Collaboration with the Accelerated Inpatient Care project to improve timeliness of treatment planning, improved access to main bed base Improve Chronic Obstructive Pulmonary Disease (COPD) pathway Implement GP led minor illness stream at LGI Judith Lund, Service Andy Webster, Lead Clinician (ED) / Ian Clifton, Respiratory Consultant Andy Webster, Lead Clinician TBC Accelerating Inpatient Care project timeline is currently being developed. TBC April 2013 (start) Feedback to UC Performance Meeting on 11.6.13 Initial meeting of Accelerated Inpatient Care project re arranged to 28.6.13 Established as a priority workstream to link with CCGs MAJOR RECRUITMENT ISSUES, very little response from GPs. Raised at Operational Urgent Care Board 29.5.13 - TD a second GP has now 9
Introduce new Rapid Assessment and Treatment process to ensure that a Doctor is at the start of the assessment process. Interface geriatricians Nicola Turner, Lead Clinician May - September 2013 Sept 2013 expressed an interest D/W urgent care stakeholder group - further letter to be sent week commencing 17/6/13 - TD Principles agreed. To standardise way of working and introduce. This requires full implementation plan and engagement events within service. Trial completed and successful at reducing admissions. Substantive appointment approved and out to advert. Locum to be appointed in the interim. Meeting KM&T Monday 17/6/13 to reallocate work to deliver core action. Locum appointed pending substantive appointment for approved post. 11/6/13 Reconfiguration opportunities with ED and with other urgent care providers in Leeds August 2013 TD and NT to be asked to provide an update report by end June To assess as part of the enhanced remit of the Urgent Care Board - with partners 10
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