Affiliated Teaching Hospital BOARD OF DIRECTORS 28 TH SEPTEMBER 2012 AGENDA ITEM: 11.1 TITLE: INTENSIVE SUPPORT TEAM REPORT PURPOSE: The Board of Directors is presented with the report from the Intensive Report team from their visit to the Trust in July 2012. The report will be monitored through the A & E Action plan The report has been shared with our Regulator, Monitor. Discussion Please tick Approval Information RECOMMENDATION: The Board of Directors are asked to note the content of the report. PREPARED BY: Sue Watkinson Chief Operating Officer PRESENTED BY: Jon Green Deputy Chief Operating Officer CQC Standard: (specify standard) Financial Implications: (Specify yes/no. If yes detail in the report) Assurance Framework: (specify risk the report is providing assurance for) Strategic Objective: (specify objective) Freedom of Information Exception: (if applicable) NHS Constitution: Outcome 4: Care and welfare of people who use services 1. Failure to deliver against A&E Performance Targets Trust would be escalated with Regulator 4. Has a reputation for safety and quality care No. In determining this matter, the Board should have regard to the Core principles contained in the Constitution of: Equality of treatment and access to services High Standards of excellence and professionalism Service user preferences Cross community working Best Value Accountability through local influence and scrutiny
Emergency Care Intensive Support Team 15 th August 2012 DRAFT Management in Confidence (By Email) Mrs Lorene Reed Chief Executive Officer Kettering General Hospital Foundation Trust Rothwell Road Kettering Northamptonshire NN16 8UZ Dear Lorene Emergency Care Intensive Support Team (ECIST): Assurance Visit: Thank you for inviting ECIST to visit Kettering NHS Foundation Trust to review the Trust s emergency and urgent care pathway and progress around our recommendations. We would like to thank in advance all staff we met for their openness, candour and hospitality. The ECIST review team comprised of Mark Ellis, Intensive Support Manager and Stephen Duncan, Head of Intensive Support. During our review, we found evidence of good practice and in addition opportunities for improvement, and in this context we have made the following observations and recommendations. Headline Messages The hospital pathway has several areas of good practice. We found clear evidence of a commitment to improving the patient pathway from the point of entry to discharge, along with emerging clarity of strategic vision for more integrated services. The challenge will now be for the Trust to make that vision a reality through a clear implementation programme and improvement culture. The Emergency Department now benefits from strong clinical leadership arrangements with the appointment of a new Clinical Director. Restricted outflow from the Emergency Department and Medical Assessment Unit is a key issue. The Trust will need to prioritise and demonstrate an enterprise wide commitment to pulling patients from the department as a matter of routine and not just in escalation. The Trust should accelerate the implementation of new internal professional standards to support patient flow. These should be supported through a performance framework that measures, manages and addresses shortfalls in performance at frequent and structured periods of review.
The Emergency Department (ED) We were informed that a new model of rapid assessment and treatment (or RAT) had been piloted and fully embedded into the department. The model, based in the previous observation bay area, aims to rapidly assess all ambulance arrivals through seven trolleys. Whilst we commend the department on its ambition to introduce RAT, we still believe there are still outstanding issues around implementation of the model. During our visit, we witnessed long delays in hand-over of ambulance patients at certain times. From those we met, there remains concern that from time to time a queue of patients arriving by ambulance is inevitable and that there are not the necessary robust pathways required to minimise the clinical governance implications. We were told that the while the department aims to rapidly assess patients, those having completed their ED management, still remain on trolleys in the ED for significant periods of time awaiting inpatient beds. The ED staff are obliged to redirect resource to manage these patients and this leads to frustration within the clinical team and indeed with patients and relatives, as well as increasing the clinical risk for patients in a crowded department. The current RAT process should ensure that patients are seen by senior clinicians on arrival and an early decision made as to diagnosis, treatment, discharge or onward referral to in taking specialities. We were told this can be highly variable, depending on the availability and calibre of senior clinician along with the response time from specialities. We would like to acknowledge however, the current shortfall in ED Consultants and use of locum clinical staff not familiar with the department. We recommend that any future consultant expansion is closely linked with the further development of RAT in the department. We recommend the use of rapid assessment models not only to improve patient flow but to assure clinical quality and good patient experience. A number of trusts across England have implemented RAT in a smaller number of trolleys and at set periods of the day in an attempt to match capacity with demand. Success of any RAT model is dependent on the availability of senior clinical decision making and the agreement of internal professional standards (IPS) that actively support patient flow before and beyond the doors of ED. We recommend that the department now reviews the existing model to ensure a more robust clinical governance framework that as a minimum considers and mitigates risk, ensures audit and evaluation and uses demand and capacity information to further develop the model. ECIST would be delighted to assist in developing this framework and we have attached some guidance that may be of assistance. Internal Professional Standards (IPS) During our review, we felt that the implementation of Internal Professional Standards (IPS) as recommended in our previous engagements and reports had yet to be achieved. Internal Professional Standards are response and practice standards that are set internally by clinicians and managers, as agreements or pledges to colleagues and patients. In an ED, these might typically include time standards, including the national CQIs, but with additional local standards, such as time from presentation to decision, time from referral to a specialty to that specialty arriving in the department, or response from imaging services. Despite the continued enthusiasm and commitment of those we met, there is still a need to fully embed standards that support patient flow and reduce variation in practice. This will now require an accelerated plan of implementation and full endorsement from the Medical Director and Chief Executive. Success will require greater ownership of the 4 hour standard and IPS by many of the speciality teams and support services outside the ED. We recommend that involvement of key Clinical Directors from other specialties at performance meetings should be helpful in achieving the desired changes. In summary, we have a number of recommendations for the Emergency Department:
1. Review the Rapid Assessment and Treatment (RAT) model to ensure it meets the need for both patients and staff that ensures rapid assessment and decision making. This should underpinned by a robust governance and clinical framework; 2. Review and strengthen procedures to deal with ambulance handover; 3. Further develop Internal Professional Standards around response times for rapid assessment and in taking specialities based on the first 120 minutes of arrival. This should be supported by a performance framework that regularly reviews performance against the standards and addresses shortfalls; 4. Involvement of key Clinical Directors in ED performance meetings. Medical Assessment Unit Since our last visit, there have been many changes to the acute assessment and short stay pathway at KGH. We were told that Clifford ward has now expanded its case mix beyond those with acute cardiorespiratory conditions, which we regard as good practice. Having had the opportunity to meet with lead clinicians and managers, we witnessed a continued enthusiasm and philosophy for short stay and a more integrated front door to the hospital. We were told however of the significant reduction in Ambulatory Emergency Care (AEC) pathways over recent months, which is disappointing. We were told that the clinical area (CDU) originally designated for AEC had now been closed and as such had led to an overall reduction in AEC. Development of the assessment units and short stay model should make good use of the existing ED and the MAU and Clifford ward to ensure the seamless transfer of patients throughout the hospital system. In our view, failure to identify patients at the assessment stage can often miss the potential for ambulatory emergency care and shorter lengths of stay. We recommend that you consider streaming patients through a degree of segmentation namely short stay, sick specialty, sick general and complex and a greater use of ambulatory care pathways. This will rely of course not only on internal diagnostic and therapies but on the alignment, availability and responsiveness of community based teams and seamless access to intermediate care facilities. To support patient flow, as with the Emergency Department, we would advocate the adoption of Internal Professional Standards for all Assessment Units that essentially mirror the ED fast tempo and ensure optimal patient flow. There should also be a commensurate approach in downstream wards. Many sites we support have now approached this through the introduction of flow bundles for each clinical area. A typical flow bundle would consist of five internal professional standards or improvement initiatives that would have a demonstrable impact on patient flow for example: Daily Consultant led board rounds at 08.00; Daily review of the patients expected date and time of discharge; A targeted discharge standard of all patients to be discharged by 1pm to be reviewed at the 0800 board round (anything beyond that would be regarded as a breach and attract the same route cause analysis as an ED breach); Standardised clerking documentation; Criteria led discharge by which clinical criteria are identified in patient s notes; Home for Lunch schemes, whereby the hospital gives patients written commitment to get them home for lunch on their day of discharge, and therefore to plan to move the patient from their bed to the discharge lounge early in the day; family members and carers are also
alerted. An alternative is the Ticket Home approach of other Trusts that provides the EDD and summary treatment goals in writing to patients and carers. As in previous reports, we have also recommended the adoption of one stop ward rounds to improve patient flow. The development of a Consultant first review sheet with a section for case management plan, observation frequency, clinical criteria for discharge and expected date of discharge would assist in monitoring delivery against these standards. Inpatient Wards The necessity of improving patient flow through wards is, in our view, a key challenge in enhancing patient experience and outcomes at KGH. There are some examples of positive initiatives within the Trust to tackle this issue, rightly prioritising internal delays, which are within the Trust s complete control, as opposed to the external interface with partner agencies. We were pleased to note that is now supported through the Discharge JONAH project piloted across five wards at KGH. We were told that this initiative enjoyed regular senior clinical engagement across the trust and there has already been significant improvements made from information shared at buffer meetings and cross buffer meetings with multi agencies. We were also told of the systematic review of the top 20 patients delayed and common themes every Tuesday and Thursday, which again we regard as good practice. A key message from our ward visits and discussion with clinical leads however is that there remains too much variability in key clinical processes supporting discharge on downstream wards, including between individual consultants, which risks promoting a slower tempo of discharge, and thus prolongs stay. We recommend that more universal processes linked to discharge are defined and promoted across the organisation. Other Trusts we are working with are increasingly defining and actively leading implementation of more standardised clinical processes. These include short focussed morning board rounds for every patient every day, and consultant-defined expected discharge dates, underpinned by written clinical criteria for discharge. From our review, we felt these could be more strongly defined within the Trust to expedite discharge. We felt the full implementation of standards around Expected Dates of Discharge (EDD) still yet to be achieved through an enterprise wide approach. Using EDDs, ideally underpinned by clinical discharge criteria, is increasingly commonplace across NHS Trusts, with benefits in setting clear expectations and potential to drive a high discharge tempo. This requires clear expectations on the part of the Trust about more standardised clinical processes and how these will be introduced, and we can share the work we have done elsewhere on this issue if helpful. Other Trusts where we have worked have strengthened the use of EDDs based around some simple rules, notably: Every patient should have an EDD completed within 12 hours of admission; EDD should be reviewed each day by the consultant or senior daily at board ward rounds; Any non-clinical change to the EDD should be captured separately and reviewed; All EDDs should stipulate a time and date of discharge (a number of trusts have found by specifying a morning discharge helps improve bed availability earlier). We were told that there was still a uniformity to be achieved in the roll out of daily ward rounds across the hospital. Infrequent ward rounds reduce the opportunities to steer patient journeys, and thereby inevitably affect flow. We were advised that while some specialists carry out daily board reviews and board rounds of their patients, a significant number still provide twice weekly ward rounds, supplemented in some cases by less formal ward visits.
Good practice is daily board rounds (ideally first thing in the morning), where every patients care plan and progress against clear objectives is reviewed every day by a senior doctor. This approach creates an appropriate focus on discharge that leads to prompt discharge and more empty beds. We recommend that physicians carry out a short focussed morning board review of all their patients in every bed, every day, and that all patients have EDDs and criteria for discharge. From those we met there was felt to be an inconsistent pattern of morning discharges. Staff we met highlighted the challenges of securing routine medical review of patients before 11am, and securing timely transport, suggesting the potential to strengthen morning discharges. We would also acknowledge the work being undertaken around length of stay review.the 14 day threshold is a useful indicator, as reduced numbers of these patient stays indicates an increasingly effective frailty/complex elderly flow stream. We also recommend the Trust considers measures to strengthen awareness of and accountability for improving flow amongst ward managers and matrons. Many other Trusts now review, at a short weekly meeting with individual ward managers chaired by the discharge lead, all non-short stay inpatients (some look at all stays >5 days) - in addition to prolonged stays - to identify and address obstacles to discharge. Ward managers are expected to come briefed to talk about each patient. In addition, for extended stays (however defined locally; for example, over 50 days initially), at some Trusts the consultant and ward manager are asked to report jointly on the circumstances and actions to expedite discharge. We also recommend trying to identify patients at risk of prolonged stay at an early stage using simple tools like ALICE and Blaylock. In summary, for specialty wards we recommend: 1. The Trust should promote a more standardised clinical processes including consultant led EDDs and clinical criteria for discharge recorded in each patient s notes; 2. There should be daily board rounds to ensure that the care plan of every patient is reviewed every day by a senior clinician; 3. The Trust should develop further opportunities for peer review and constructive challenge in respect of managing length of stay and maintaining discharge tempo, such as involving medical staff to a greater degree in the review of prolonged stays. Interface with social services and NHS community services During our visit we only met staff working on-site at KGH. There were several issues of note, affecting patient flow out of KGH. We were told of the local procedure replacing conventional section 2 and 5 referral. The requirement to refer all appropriate patients through a Transfer of Care (TOC) form to the hospital discharge team did not appear to add value, but protract the referral process. We would recommend that the process is reviewed by the trust and partners. A recent development is the Rapid Discharge Team, co-locating key staff focussed on hospital discharge from the Trust, plus social services and NHS community services from Northamptonshire is positive practice. We had limited discussion with these staff during our visit, but Trust personnel highlighted good working relationships at operational level. Restart social care packages were reported as notable delays, with the requirement for a reassessment once a patient stays in hospital overnight. Delays were also reported around the Continuing Healthcare process, whereby patients remain in acute beds throughout the assessment and decision-making process. Based on our recent experience, increasingly health communities are routinely moving patients out of acute care during this process, and we recommend this is explored with partners.
As with the Emergency Department, Assessment Units and inpatient wards, we recommend that you work with community partners to adopt internal professional standards at key points across the whole system pathway. Summary We acknowledge that there has been much work undertaken and progress made against our original recommendations, which we would commend. Despite work to increase discharge activity in the morning there are still significant delays in discharging patients with the result that patients waiting admission continue to wait in the Emergency Department. We regard capacity as not beds but as the organisations capability and infrastructure to process patients in the most effective and safe way. This, as we have indicated, is best achieved through an intelligent service model, senior clinical decision making and the adoption of internal professional standards that improve flow and reduce non value adding steps in the patient pathway. Supported by a performance framework that has regular review and mechanisms to address shortfalls in performance, many organisations have found significant benefit in looking at capacity in this way. We agree with the focus at KGH on patient flow before and beyond the doors of the Emergency Department. Viewing adverse performance against the 4 hour standard as a symptom at a key point of the pathway of wider problem with demand and patient flow is, in our view, the correct starting point. During our review, we were informed that much of the reform around patient flow going forward was now fully embedded in the trust QIPP improvement programme. This we felt to be supported by strong governance arrangements, programme management and clinical leadership. However, we felt there remain too few clearly defined Trust standards for how emergency flow should be organised and variable practice where these exist (for example as illustrated by the use of EDDs). The success of other trusts where we have worked has been built on clear definition of these standards and their monitoring, coupled with clear leadership, both clinical and Executive. This needs to involve peer review and constructive challenge, highlighting areas of good practice within the Trust, making explicit links between emergency flow and patient safety and outcomes, and reinforced by clear metrics. This will require a continued and increased effort to address the flow problems throughout the pathway and to increase engagement from in-patient teams and widen ownership of the four hour standard and CQIs. There needs to be greater ownership of the 4 hour standard by many of the speciality teams outside the ED. Involvement of key Clinical Directors from other specialties at performance meetings should be helpful in achieving the desired changes. We hope that this short report is helpful and will be useful in providing a focus on priorities. Although there is a great deal to be done to improve processes, we feel confident that hospital staff are aware of the need for change and keen to provide the best of care to local people. The Trust has clearly made urgent and emergency care a major investment priority, both in terms of funding and management time. We will be happy to elaborate on the contents of this report when we return to the Trust, or before by telephone if that would be helpful. We can also provide written material to support improvement initiatives as necessary. In going forward, ECIST would be delighted to offer continued support over the next 2-3 months to support you in your internal programme of reform. Support will be offered through site visits, supplemented by telephone and e mail as required. We should aim to review this arrangement early September to ensure alignment with your organisational requirements. We hope this report is of some assistance. Please do not hesitate to contact us if you want to discuss.