Stroke Services Improvement Programme. Stroke Project Initiation Document

Stroke Services Improvement Programme Authors: Date: 24/04/08 Project Initiation Document Dr Cerilan Rogers, National Director, NPHS & Interim Chief Executive, Wales Centre for Health Mark Dickinson, Director of Operations, NPHS, Specialist Trainee, NPHS Status: For Project Board Purpose and Summary of Document: This Project Initiation Document (PID): Version: 0p summarises the background to the project sets out the project objectives describes the project structure contains an outline project plan and associated material Version: 0p Page: 1 of 20

1 Background 1.1 Recent Documents Relating to Stroke Services in Wales 1.1.1 National Service Framework for Older People The National Service Framework for Older People, published in March 2006, stated that integrated stroke care pathways be developed and implemented to support the prevention of stroke and the effective treatment, care and rehabilitation of those who have suffered a stroke. The NSF specified short term actions in relation to: the design and implementation of local care pathways for stroke care, by March 2007 action by local health and social care communities to improve stroke services continuously 1.1.2 Royal College of Physicians National Sentinel Audit 2006 The 2006 RCP National Sentinel Audit, published in May 2007, stated that stroke services in Wales require urgent attention and concluded that rates of mortality and morbidity from stroke in Wales are unnecessarily high. The Audit contains recommendations for improving stroke services in Wales, with the highest priority being given to the development of specialist stroke units and services in the community. 1.1.3 Welsh Medical Committee Report on Stroke Services in Wales In June 2007, the Welsh Medical Committee received a report on Stroke Services in Wales that they had commissioned from the Welsh Stroke Special Interest Group. This report identified that: stroke is an important clinical problem in Wales there are evidence based preventative and therapeutic interventions available that are proven to reduce mortality and morbidity caused by stroke there are problems with accessing the benefits of such services in Wales, despite previous national recommendations there have been delays in the development of specialist stroke services in Wales there are service deficiencies in relation to other UK countries The report made a number of specific recommendations aimed at addressing the identified deficiencies, through changes to the provision and commissioning of services and improvements in training. Version: 0p Page: 2 of 20

1.2 Welsh Health Circular WHC (2007) 058 on Implementation of National Standards for Stroke Services in Wales On 1 August 2007, the Welsh Assembly Government issued Welsh Health Circular WHC (2007) 058 on Implementation of National Standards for Stroke Services in Wales action for Commissioners and Providers by March 2008. The purpose of WHC (2007) 058 is to: confirm that tackling stroke is now one of the Welsh Assembly Government s top priorities for the NHS and social services announce that a formal programme of work for 2008-11 to guide and direct the progressive implementation of the standards for stroke care set out in the National Service Framework for Older People will be published in the Autumn 2007 set out the Welsh Assembly Government s specific requirements of the NHS, Social Services and other organisations up to March 2008 Amongst other defined action, the WHC instructs that: By 30 September 2007, the Wales Centre for Health, the National Public Health Service and the National Leadership and Innovations Agency for Healthcare must establish a formal partnership. The purpose of this partnership is to inform and support action at a national, regional and local level in implementing the NSF Standards for Stroke. This partnership must actively promote strong clinical leadership to champion the necessary change by sharing best practice across Wales. Its role will also be to develop initiatives which will directly inform the commissioning and delivery of services. Examples of practical outputs from this partnership include a template for the action plans required of the Local Health Boards and Social Services and a generic specification for stroke services that meet the NSF s requirements which Local Health Boards can use to underpin their commissioning requirements of NHS Trusts and other providers 1.3 Partnership between the Wales Centre for Health, National Public Health Service for Wales and the National Leadership and Innovations Agency for Healthcare As instructed by WHC (2007) 058 (see section 1.2 above), the Wales Centre for Health (WCfH), National Public Health Service for Wales (NPHS) and the National Leadership and Innovations Agency for Healthcare (NLIAH) have established a formal partnership to work on action in relation to the improvement of stroke services in Wales. The aim of the Partnership is to meet the requirements of the WHC, through: the most appropriate use of the resources, skills and expertise within the three organisations fostering and developing clinical leadership within stroke services Version: 0p Page: 3 of 20

1.4 Welsh Health Circular WHC (2007) 082 on Improving Stroke Services: A Programme of Work WHC (2007) 082 builds on the requirements of WHC (2007) 058, by setting out a formal programme of work to improve services for patients who are at risk of, or who have had, a stroke. Specific actions, with associated deadlines, within the programme of work are assigned to the Partnership. All of these actions are within the scope of this project. 2 Project Aim and Objectives The aim of the project is to deliver the contribution of the Partnership to the programme of work set out in WHC (2007) 058. The specific objectives of the project are to: 1. Develop a specification for a comprehensive stroke care pathway (and associated facilities) 2. Specify the indicators and outcomes that should be measured in order to monitor both progress with, and the effects of, the implementation of the care pathway 3. Carry out a gap analysis comparing current service provision with the care pathway 4. Develop and oversee the implementation of an action plan, based on the gap analysis (and informed by regional and local action plans) for the full implementation of the care pathway across Wales 5. Develop and implement a mechanism for assessing development proposals (in support of the action plan) from Trusts and LHBs and for advising WAG on the allocation of resources to such proposals 6. Develop a service improvement collaborative involving a range of professionals from across Wales to take forward the implementation of defined elements of the action plan 7. Provide a workforce development tool which identifies the competences required to enable clinical and non clinical staff within stroke services to: a. lead and participate in the implementation of the care pathway b. deliver the care pathway to a high standard 8. Develop and implement a symptom awareness campaign for professionals and the public, aimed at ensuring that individuals take appropriate and timely action in response to relevant symptoms 9. Identify where there are gaps in availability of local and national resources and services to support risk reduction and develop action plan to address gaps Version: 0p Page: 4 of 20

3 Project Structure 3.1 Overview The project will be overseen by a Project Board, chaired by a Welsh Assembly Government sponsor (see section 3.2). The project will be managed and coordinated by a Project Management Team, led by Dr Cerilan Rogers as Project Director, supported by a Project Manager (Mark Dickinson) and Deputy Project Manager () and also including the Work Stream Leads (see below) a Lead Clinician (Dr Anne Freeman), Deputy Lead Clinician (Dr Mushtaq Wani) and representatives from the Stroke Association (Leighton Veale and Trish Hughes). The objectives will each be delivered by separate Work Streams (with the first Work Stream meeting several objectives). Each Work Stream will be led by a senior member of staff from the most appropriate participating organisation: Work Stream Objective(s) Lead A 1. Care Pathway; 2. Indicators and Nigel Monaghan, NPHS Outcomes; 3. Gap Analysis; 4a Action Plan (development); 4b Action Plan (overseeing of implementation); 5 Mechanism for Assessing Development Proposals B 6. Service Improvement Collaborative (to Alan Willson, NLIAH implement defined elements of the Action Plan) C 7. Workforce Development Tool Stephen Griffiths, NLIAH D 8. Symptom Awareness Campaign Chris Lines, WCfH E 9. Action Plan to address gaps in resources and services to support risk reduction TBC, NPHS Each Work Stream Lead will be responsible for establishing and leading a Work Stream Team to undertake the required work. Work Stream Teams will include relevant staff from the participating organisations, together with individuals from within the stroke services. Project products will be quality assured by one or more Clinical Reference Groups, consisting of relevant professionals from Wales and beyond, who are not directly involved in the work of the project (i.e. who are not members of the Project Management Team or Work Stream Teams). The Project Board will also be advised by a Policy Reference Group made up of all relevant Welsh Assembly Government policy leads together with LHB and Trust representatives. Version: 0p Page: 5 of 20

3.2 Project Board The Project Board will be responsible for the overall delivery of the project and will formally approve (or reject) all project products. The membership of the Project Board is: Name Job Title Organisation Mike Harmer (Chair) Deputy Chief Medical Officer WAG Cathy White Community, Primary Care and Health WAG Services Policy Division Chris Tudor-Smith Head, Public Health Improvement Division WAG Other members to be identified by the Chair 3.3 Project Management Team The Project Management Team will be responsible for the day to day management of the project and for ensuring that all project products are completed for approval by the Project Board as set out in the Project Plan. The membership of the Project Management Team is: Name Project Role Organisation Dr Cerilan Rogers Project Director NPHS/WCfH Mark Dickinson Project Manager Deputy Project Manager NPHS Dr Anne Freeman Clinical Lead Gwent NHS Trust Dr Mushtaq Wani Deputy Clinical Lead Swansea NHS Trust Leighton Veale Stroke Association Trish Hughes Representatives Stroke Association Version: 0p Page: 6 of 20

Name Project Role Organisation Nigel Monaghan Work Stream A Lead NPHS Alan Willson Work Stream B Lead Stephen Griffiths Work Stream C Lead NLIAH Chris Lines Work Stream D Lead WCfH TBC Work Stream E Lead NPHS 3.4 Project Assurance The role of Project Assurance is to provide external advice to the Project Management Team and to the Project Board. 3.4.1 Clinical Reference Group(s) Members of the Stroke Alliance, consisting of relevant professionals from Wales, who are not directly involved in the work of the project (i.e. who are not members of the Project Management Team or Work Stream Teams) will form a Clinical Reference Group to advise the Project Management Team. The Clinical Reference Group will: provide a mechanism for the project teams to obtain rapid feedback on clinical issues from a range of experts, during the development of project products subject all project products to scrutiny before they are finalised and submitted to the Project Board for approval. The initial membership of the Clinical Reference Group is: Name Discipline Organisation Sue Lambert OPAN Swansea University Shawn Halpin Radiology Cardiff University Caroline Adams Radiology North West Wales Trust Tom Hughes Neurology Cardiff and the Vale NHS Trust Gareth Llewellyn Neurology Gwent NHS Trust Louis Fligelstone Vascular Surgery Swansea NHS Trust Phil Thomas Cardiac Network Swansea NHS Trust Richard Hatfield Neurosurgery Cardiff University Jo Mower Accident and Emergency Medicine Cardiff and the Vale NHS Trust Andy McCann Stroke survivor / vocational support for stroke survivors of working age Jonathan Pearce Stroke survivor Jon Hollies Carer Antony Bayer Psychiatry Cardiff University Simon Noble Palliative Care Gwent NHS Trust This list is not exhaustive. It is intended to be broadly indicative of membership and demonstrate the range of professions that will be consulted. Where necessary, other professions will be drawn in to the clinical reference group. Version: 0p Page: 7 of 20

3.4.2 Policy Reference Group The Project Board will be advised by a Policy Reference Group made up of all relevant Welsh Assembly Government policy leads together with LHB and Trust representation. The Policy Reference Group will provide advice on the compatibility of project products with Welsh Assembly Government policy, priorities and the performance management framework and on relevant service interfaces (see section 6.2). The membership of the Policy Reference Group is: Name Job Title Policy Lead for: Dr Sarah Watkins WAG Professional advisor Acute Stroke services Jan Smith WAG Professional advisor Rehabilitation services Denise Richards WAG Professional advisor Nursing Other members to be confirmed by Chair of the Project Board 4 Outline Project Plan 4.1 Overview 4.1.1 Project Products The primary products of the project are as specified in the project objectives (see section 2). 4.1.2 Project Timetable The project is to be completed by May 2009. Within the overall project the phasing of the delivery of each of the above products is as follows: Work Stream Product Start Date End Date A. 1. Care Pathway 11/07 03/08 A. 2. Indicators and Outcomes 11/07 03/08 A. 3. Gap Analysis 11/07 03/08 A. 4a. Action Plan (development) 02/08 04/08 A. 4b. Action Plan (overseeing of implementation) 05/08 05/09 5. Mechanism for Assessing Development Proposals 03/08 04/08 (defined) B. 6. Service Improvement Collaborative 03/08 05/09 C. 7. Workforce Development Tool 03/08 09/08 D. 8. Symptom Awareness Campaign 03/08 12/08 (proposals) E. 9. Action Plan to address gaps in resources and services to support risk reduction 04/08 12/08 Note that the delivery of Product 4b will require the development of a detailed subsidiary project plan and possible subsidiary work streams. Version: 0p Page: 8 of 20

4.2 Work Stream A (Care Pathway, Action Plan etc.) 4.2.1 Work Stream Products Primary Product Subsidiary Product Definition 1. Care Pathway 1.1 Care pathway Care pathway describing patient journey from initial onset of symptoms through emergency stroke care / TIA care, acute care, rehabilitation, discharge and community care. 1.2 Workforce guidance by profession Guidance on the composition of the specialist stroke team and the amount of time provided by each member of 2. Indicators and Outcomes 3. Gap Analysis 4a. Action Plan (development) 4b. Action Plan (overseeing of implementation 1.3 Service outline - provision, specification and characteristics the team to each patient / bed Outline of a stroke service, based on guidance for service provision, detailed service specification outlining the structure of the service and key characteristics needed to provide a quality and value for money service 2.1 Improvement measures Measures for improvement for a high quality and value for money service 2.2 Key audit indictors Audit tools used in RCP sentinel audit (bi-annual, next due in 2008) and work force audit 2.3 Outcome measures Key outcome measures monitoring patient survival and recovery 2.4 Monitoring of new information Assessment of new information and evidence on an ongoing basis to inform products 4a and 4b 3.1 Review of local care Review of availability and content of pathways care pathways by hospital. 3.2 Workforce availability National summary of gaps in by profession workforce availability 3.3 Service organisation Review based on RCP and SSIG audits N/A Recommendations for action based on products 1-3 and identification of most appropriate leads for that action Detailed Project Plan Further products to be defined within the subsidiary Project Plan, derived from the Action Plan Description of the way in which the implementation of the Action Plan will be overseen, including consideration of potential resource allocation issues To be defined Version: 0p Page: 9 of 20

5. Mechanism for Assessing Development Proposals 5.1 Definition of mechanism Definition of mechanism and protocols and identification of expert panel 5.2 Implementation of mechanism Mechanism publicised and in operation 4.2.2 Work Stream Team Name Discipline Organisation Nigel Monaghan Public Health NPHS Public Health NPHS Anne Freeman Stroke Physician Gwent NHS Trust Rhiannon Williams Nutrition and Dietetics Cardiff and Vale NHS Trust Nicola Davies Consultant Nurse for Stroke Blaenau Gwent LHB Allison Cooper Physiotherapy Gwent NHS Trust Megan Douglas Dietetics Pontypridd and Rhondda NHS Trust Janet Ivey Neuro OT Pontypridd and Rhondda NHS Trust Julie Wilcox Neuro Psychology Cardiff and Vale NHS Trust Maggie Price Dietetics Cardiff and Vale NHS Trust Sian Burton Dietetics Bro-Morgannwg NHS Trust Trish Hughes Voluntary Organisation Stroke Association Russell Walker SALT Gwent NHS Trust Andy Williams Pre-hospital care - ambulance Welsh Ambulance Service Trust 4.2.3 Work Stream Timetable November 2007 December 2007 By end April 2008 To be agreed Identification of work stream team Introduction of project to work stream team Report containing products 1 4a Mechanism for Assessing Development Proposals defined Timetable for implementation of Action Plan Version: 0p Page: 10 of 20

4.3 Work Stream B (Service Improvement Collaborative) 4.3.1 Work Stream Products Primary Product Subsidiary Product Definition 6. Service Improvement 6.1 Definition of collaborative membership All members of the collaborative identified Collaborative 6.2 Appointment of Senior Service Development New temporary secondment to NLIAH Manager 6.3 Delivery of learning sessions involving Three two day learning session collaborative members 6.4 Agreement of Action Plan outcomes to be the focus of the Collaborative 6.5 Operation of Collaborative Specific outcomes in the Action Plan to be assigned to the Collaborative To support participating sites in achieving outcomes from the Action Plan This collaborative will be based on the model used previously by NLIAH in the Welsh Critical Care Improvement Programme (WCCIP), the format of which is adapted from the IHI Breakthrough Collaborative Methodology. All 8 established or formative Trusts in Wales working with their LHB, ambulance service, local authority and third sector partners will be invited to join an All Wales Breakthrough Collaborative and teams of up to 15 people per area will be invited to learning events and to form the local implementation teams. Events, monitoring and training for this project will also benefit from links with the 1000 Lives campaign that NLIAH is involved in as one of four partner organisations. 4.3.2 Work Stream Team Name Role Organisation TBA Senior Service Development Manager NLIAH TBA Lead Clinician, Stroke Improvement TBC Collaborative Alan Willson Director NLIAH Members of the Collaborative to be identified 4.3.3 Work Stream Timetable June 2008 Finalise work stream team members and recruit service teams July 2008 First two day learning session December 2008 Second two day learning session May 2009 Final two day learning session August 2009 End of Year report Version: 0p Page: 11 of 20

4.4 Work Stream C (Workforce Development Tool) 4.4.1 Work Stream Products Primary Product Subsidiary Product Definition 7. Workforce Development Tool 7.1 Identify specific workforce planning tools for use in stroke care There are a range of workforce planning tools available, it is essential tools are identified which specifically address the needs of stroke care this may be 4.4.2 Work Stream Team 7.2 Identify core competences required to deliver care pathway 7.3 Identify the most appropriate member of the stroke team to deliver the various elements of the care pathway which may result in changed/extended or new roles more than one Provide the core competences required to deliver the agreed care pathway in order to enable service providers to determine how their local service will be best configured to deliver service Ensure that the most appropriate member of the stroke team delivers the required component of the stroke care pathway Name Role Discipline Organisation TBA Stroke Physician TBA Consultant Nurse TBA Physiotherapist TBA Occupational Therapist TBA Dietician TBA Senior Workforce NLIAH Planner TBA Senior Workforce NLIAH Modernisation Manager Stephen Workforce Development Director NLIAH Griffiths Stroke Services Improvement Project, Deputy Project Manager Public Health NPHS 4.4.3 Work Stream Timetable May 2008 Identification of work stream team Version: 0p Page: 12 of 20

June 2008 August 2008 August 2008 October 2008 December 2008 Introduction of project to work stream team Review workforce planning tools Map competencies to the care pathway /gap analysis Draft report of work stream Final report of work stream 4.5 Work Stream D (Symptom Awareness Campaign) 4.5.1 Work Stream Products Primary Product Subsidiary Product Definition 8. Symptom Awareness Campaign 8.1 Review of research of professionals and public awareness and attitudes Development of an understanding of current attitudes and awareness of stroke, its symptoms and 8.2 Review of existing information provided for professionals and the public; and of public awareness campaigns 8.3 Links to other relevant public health campaigns stroke services Development of an understanding of existing information materials and its effectiveness. Evaluation of Stroke Association Campaign. Linking in with other health campaigns (e.g. from the British Heart Foundation, Stroke Association, Food Standards Agency, Brain & Spine Foundation, WCfH Physical Activity /Nutrition /Mental Health Networks, Age Concern, hospital-based initiatives etc) to identify opportunities for joint communications work based on agreed messages. Version: 0p Page: 13 of 20

Primary Product Subsidiary Product Definition 8. Symptom Awareness Campaign (continued) 8.4 Proposal for a wideranging communications programme including community engagement, social marketing techniques and media relations Strategy, plan and budget for campaign to raise awareness of symptoms of TIA and stroke and the importance of health professionals acting quickly (e.g. GPs speeding up referral process, and paramedics calling ahead to alert hospital staff of cases of stroke). The proposal should cover key messages, communication routes and methods. This should follow the work of the other work streams to capitalise on the developments and service 4.5.2 Work Stream Team 8.5 Proposal for a multimedia campaign aimed at the public to raise awareness of symptoms of stroke clarity they achieve. Strategy, plan and budget covering the development of public messages, the preferred communication routes, methods and tools for different audiences. Social marketing techniques will be explored. Name Discipline Organisation Chris Lines Director of Communications WCfH/NPHS Jo Menzies Media Officer WCfH Leighton Veale Public Affairs Officer for Wales Stroke Association Julie Bishop Consultant Lead on Influencing NPHS Behaviour Stephen Allen Primary Care/Patient & Public Involvement Officer Cardiff Community Health Council TBA NHS Trust Communications Officer TBA Ann Davies Head of Communications Department of Health and Social Care, WAG TBA Stroke Professional 4.5.3 Work Stream Timetable This will be heavily dependant on the deadlines of the other Work Streams which will provide some of the content for the symptom awareness campaign. The evaluation of the Stroke Version: 0p Page: 14 of 20

Association s campaign to be launched in the spring will also inform and shape the timetable of this Work Stream. March 2008 April 2008 June 2008 June 2008 September 2008 December 2008 Finalise Work Stream Team Members. Finalise subsidiary products and timetables, informed by detail from other Work Streams. Complete review of awareness and attitudes Complete review of information materials Establish links with other campaigns and networks Complete Communications Plans and Strategies for health professionals and the public 4.6 Work Stream E (Resources and Services to Support Risk Reduction) 4.6.1 Work Stream Products Primary Product Subsidiary Product Definition 9. Action Plan to address gaps in resources and services to support risk reduction To be defined To be defined 4.6.2 Work Stream Team To be defined 4.6.3 Work Stream Timetable To be defined 5 Project Communications Plan 5.1 Communications Role and Tasks Clear channels of communication between the work streams and partner organisations are very important to the successful implementation of the stroke services improvement programme. The role of communications in this project is to: Facilitate engagement and understanding of the project amongst all audiences Develop an infrastructure to ensure clear channels of communication between partners Ensure all audiences are kept informed and keep others informed of developments in the work streams. Version: 0p Page: 15 of 20

5.2 Target Audiences and their Perspectives and Needs The project will interact and communicate with many audiences, divided into the following main groups: 5.2.1 Project partners and their staff The main project partners NLIAH, NPHS and the WCfH are the key audience for the project. They will have an obvious knowledge and interest in the project but this cannot be assumed for all their staff. Project updates should be shared with key staff e.g. NPHS Regional Directors, Local Public Health Directors and Board so they have knowledge of and can represent the project. 5.2.2 Stroke unit professionals A wide variety of hospital-based professionals contribute to the diagnosis, treatment, care and rehabilitation of stroke patients, including doctors, nurses, neurologists, radiologists, physiotherapists, occupational therapists, speech and language therapists, dieticians, psychologists, social services, and family/patient support workers. The above professionals are well represented in the Work Streams and Clinical Reference Group, having been involved in the development of the project, and have an obvious knowledge and interest in the improvement of stroke services. It cannot be assumed however that those professionals not engaged with the project will be aware of its work so project updates will need to be disseminated. 5.2.3 Other healthcare professionals in direct contact with stroke patients Healthcare professionals such as GPs, ambulance and Accident & Emergency staff are often the first point of contact with those experiencing a TIA or stroke. They have a vital role to play in the correct diagnosis and initial treatment of TIA or stroke, although research shows there is little knowledge or use of FAST amongst this group. This group should be kept informed of the stroke services improvement programme as it will be affected by the development of the care pathway, improvement collaborative and workforce development tool, and will also form a core audience for the symptom awareness campaign. This group are often the target of initiatives and information campaigns. Therefore, information disseminated should be relevant and appropriate to their needs and should not place too great a demand on their time. 5.2.4 Health professionals directly affected by the project NHS Trust managers, LHB Health Improvement Teams, specialist commissioning bodies (e.g. Health Commission Wales), and LHB/NHS Communication Officers will be affected by the implementation of the project and will need to understand its objectives in order to be Version: 0p Page: 16 of 20

supportive of it. They will also play an important part in the establishment of a dialogue on the implementation and progress of the project. 5.2.5 Professional and voluntary groups There are a number of professional and voluntary groups with a role to play in the improvement of stroke services in Wales. These include the Stroke Association, Community Health Councils, Wales Stroke Alliance, Welsh Stroke Interest Group, Welsh Medical Committee, British Geriatrics Society Wales, Royal College of Physicians, National Stroke Nursing Forum, British Association of Stroke Physicians, Association of Chartered Physiotherapists Interested in Neurology and the British Psychological Society. Some of this group is represented in the Clinical Reference Group and have been consulted throughout the development of the Work Streams. Senior members of the professional and voluntary groups will therefore have a good understanding of the objectives of the project which should be cascaded down to their wider membership. This group will also facilitate the sharing of best practice and learning from around the UK. 5.2.6 Government officials This project will be of interest to policy/decision makers including the Minister for Health and Social Services, the Chief Medical Officer for Wales and the Chief Executive of NHS Wales. This group will need to be kept informed as there is obvious public and political interest in the state and development of stroke services in Wales. 5.2.7 Those influencing opinions Though groups such Assembly Members, MPs, the media, academics, local authorities, the NHS Confederation, the Welsh Council for Voluntary Action and the Welsh Local Government Association will not be directly affected by the implementation of the project, it they have some influence on public perceptions and understanding of the project, and can publicly lend their support to it. 5.3 Issues to be Addressed A number of issues may arise which will need to be identified and addressed through the communications strategy in order to maximise the success of the project. The issues addressed here will be those surrounding the project itself, not the diagnosis and treatment of stroke as these should be addressed in more detail for each Work Stream. The following list is by no means exhaustive as new issues may emerge after completion of planning the Work Streams and throughout the duration of the project. Possible issues arising with the stroke services improvement programme are: Version: 0p Page: 17 of 20

Issues Arising 1 In April/May 2008 the Royal College of Physicians (RCP) will be conducting a clinical audit of UK stroke services. Any improvements made to stroke services in Wales will be at too early a stage to show up in the audit, resulting in possible negative media surrounding its publication in 2009. This could possibly demotivate healthcare professionals and have a negative impact on their perception of the project. 2 Promotion of the project could lead to negative media on the current state of stroke services in Wales. 3 There is a risk that staff in the specialised stroke units will see the project and the associated work around the care pathway, improvement collaborative and workforce development tool as adding to their workload. 4 There are many healthcare improvement campaigns underway in Wales such as the SPI, 1000 Lives Campaign and Welsh Critical Care Programme which may overlap with the project and convey a sense of initiative-itis in some staff. 5 In a project with many partners, there may be breakdowns in communication between Work Streams if the meeting of the project board is the only designated place for updates on progress, challenges and learning exchanges. Solutions Keeping the RCP informed of the project from the early stages (such the care pathway being developed in Work Stream A) and working with them during their clinical audit will demonstrate the positive and joined up commitment Wales is making to improving stroke services. Emphasise the aims of the project and position it as a proactive response which cannot happen over night but will result in sustainable improvements in Welsh healthcare. Prepare briefings for project board in case of media attention. Staff should be consulted with and kept informed of all stages of development of the care pathway and associated facilities. Ministerial commitment to improving services and the important role stroke staff of all levels play should be emphasised. Comprehensive early-stage planning will ensure that any overlap is not seen as duplication of effort but duplication of the key messages (i.e. the need to improve healthcare services in Wales) which through repetition will be enhanced. Communication between Work Stream members should be facilitated regularly by the project team and communications team via an internal project e-bulletin. This will provide a platform to exchange learning, challenges and knowledge, whilst avoiding duplication of effort and maximising efficiency. 5.4 Communications Methods Individual Work Streams will develop their own methods and strategies for communication. The communication methods to be used for promoting knowledge of the project as a whole are: Version: 0p Page: 18 of 20

5.4.1 Project database A database needs to be built of the names and contact details of the target audiences identified in 5.2 to facilitate communication of the project. 5.4.2 Email and e-bulletin Through existing channels of communication (e.g. through WCfH, NPHS and NLIAH existing contacts databases), emails will be sent to the key players informing them of the project objectives to encourage proactive engagement. Communication will be tailored for professional and non-professional audiences, focusing on clinical processes and the patient experience respectively. Members of each Work Stream will contribute to an e-bulletin containing updates on progress, issues arising, areas of interest to other Work Streams and areas of collaboration. This will be produced and disseminated to the project board and members of the Work Streams by the Communications Team on a regular basis. 5.4.3 Representation at events Members of the project team will also make themselves available at established events such as the Joint Professional Forum, Welsh Health Professional Advisory Committees and Board Meetings in order to promote awareness of and engagement with the project, creating a twoway channel of communication with opinion-forming health professionals in Wales. The annual Welsh stroke conference is a key forum for communications. 5.4.4 Web Content The NPHS websites (intranet and internet) should be the agreed host and source of all web content for the project with sign posting from and use of the WCfH and NLIAH websites in support. A secure area (workplace should be established for sharing draft papers). The Communications Team will post information on the project including e-bulletins, regular updates, progress of Work Streams and any downloadable resources and contact details. 5.4.5 Media Briefings and holding statements on the implementation of the project will be prepared for use with the media at key milestones in the project (e.g. outcomes of gap analysis, launch of new service collaborative/ public awareness campaign), and a comprehensive briefing will be given to the media and relevant others (e.g. partner organisations, party political health spokespeople) once the project is completed. 5.5 Resources Required The lead staff resource for the Work Stream comes from the Wales Centre for Health. In addition to the team members identified to support their work, there will be a need for some Library and Knowledge Management support with the first subsidiary product of the Work Stream. Version: 0p Page: 19 of 20

6 Project Constraints and Interfaces 6.1 Constraints The project will be constrained by: a challenging timescale limited resources availability of Project Management Team members and members of Reference Groups multiple stakeholders interfaces with other work (see section 6.2) 6.2 Interfaces The project will need to interface with other work relating to stroke services, including other work triggered as a result of the NSF and WHC (2007) 058. The WHC specified a number of specific actions for LHBs, Trusts and Social Services, many of which have already commenced. Version: 0p Page: 20 of 20