A&E Remedial Action Plan (RAP) The Hillingdon Hospital NHSFT (THH) and Hillingdon Clinical Commissioning roup (HCC) LAST UPDATED 28 th October 2016 VERSION NUMBER 1 RAP CRO Dr Abbas Khakoo, Medical Director, THH RAP SRO Shane Degaris, Chief Executive, THH CORE TEAM Mark Edward, Clinical Director, THH Joe Smyth, Chief Operating Officer, THH Melissa Mellett, Operations Director, THH Claire Sheppard, ADO Medicine, THH Lee Taylor, A&E Transformation Lead, THH Trevor Mayhew, Director of Finance, THH Sue Petrovic, Emergency Directorate Finance Manager, THH Dr Mitch arsin, Chair of Hillingdon A&E Delivery Board, P and HCC overning Body Member Caroline Morison, Chief Operating Officer, HCC Alex Faulkes, Director of Delivery & Performance, Brent, Harrow and Hillingdon (BHH) CCs Jonathan Tymms, Deputy Chief Finance Officer, HCC Stephen Dixon, Deputy Director for Contracts, HCC Rashesh Mehta, Senior Commissioner for Urgent Care, HCC Key: On Track and/or delivering some results White Delivery s yet to be realised A At risk of not delivering on time C Completed R Delayed 1
FOCUS AREA Diverting Patients with Unplanned Care Need away from UCC and/or ED where appropriate Empowering Patients to Self- Care CRO & SRO Dr M arsin R Mehta Dr N Bharakhada W Rabin REDUCIN DEMAND AT THE FRONT DOOR OF A&E (BOX 1) CRO Dr Mitch arsin & SRO Caroline Morison EXPECTED IMPACT/DELIVERY TASKS & TIMELINES PRORESS RA STATUS Reduce UCC attendances by 900 in 16/17 Reduce UCC Attendances by 300 and ED Attendances by 265 in 16/17 1. Commission Health connectors and agree pathway 2. Link HCs with Empowered Patient Programme (EPP) to promote self-care 1. Deliver the Empowered Patient Programme (EPP) for 16/17 (On-oing) 2. To work with HCs to reduce UCC attendances 3. Develop plans for EPP for 17/18 to increase scope and impact (Dec 16) 1. As of Q1 there have been 621 redirections into services outside of hospital 1. EPP currently underway. 2. EPP workshop for 17/18 to be worked up. Primary Care Model of Care (Care Home Support & Primary Care Contracts Elements) Dr S Shapiro R Pizarro Coordinated support to Care Homes reducing demand at ED by ~10/day 1. Agree model with CC Member Practices (Oct 16) 2. Redesign Primary Care Contracts and LISs into Single Contract Structure with Outcomes (Mar 17) 3. Explore joint commissioning of Care Home support with Local Authority (Oct 16) 4. Implement new Model of Care for Care Homes (Jul 17) 1. Workshop planned for Member Practices to design new model. 2. Discussions with Local Authority underway. Increase effectiveness of London Ambulance Service (LAS) in diverting patients Dr M arsin R Mehta Increase the number of Patients who are seen and treated or heard and treated by 10% Reduce conveyances from top 50 frequent callers by 40% 1. Programme on See & Treat and Hear & Treat to be in place (Jan 17) 2. Joint project with THH, UCC, Care UK (111), LAS and CC to be in place for people who frequently attend (Jan 17) 3. Implement increased Ambulance Diversion to UCC (Dec 16) 1. Programme for See/Hear and Treat in development. 2. Complex Patient data being collated and meeting to be organised. 3. Ambulance Diversion trial to commence in September. 4. Current figures show for Q1 469 ambulances offloaded to UCC an 2
FOCUS AREA Integrated Support for Patients with Long Term Conditions Improve Support for Patients at End of Life Improve Support for Patients with CRO & SRO Dr N Bharakhada R Pizzaro Dr K Johal V raziani Dr S Vaughan- Smith Divert 30% more ambulances to the UCC REDUCIN DEMAND AT THE FRONT DOOR OF A&E (BOX 1) increase of 109 offloads to the previous quarter. CRO Dr Mitch arsin & SRO Caroline Morison EXPECTED IMPACT/DELIVERY TASKS & TIMELINES PRORESS RA STATUS 1. Diabetes model now operational and ramping up. 2. On-going concerns about 1. Progress Integrated Service Models (On-oing) the Respiratory model are Reduce Attendances a. Diabetes being addressed. by 500+ and b. Respiratory 3. Existing Cardiology Model Admissions by 180 in c. Cardiology operational but behind. 16/17 2. Extend models for 17/18 and significantly increase 4. New models to be impact developed 5. Review LAS/CNWL and THH joint meeting for frequent attenders management Reduce Attendances by 60 and Admissions by 30+ in 16/17 Reduce A&E attendances from people with a Mental 1. Monitor Joint End of Life Strategy with Local Authority (On-oing) 2. Provide improved access to Night sitting Support 3. Deliver 10 Palliative Care Beds in the Community 4. Implement integrated End of Life Model (Mar 17) 5. Increase use and access to Coordinate My Care (CMC) (Dec 16) 1. Review effectiveness of Mental Health Assessment Lounge (Oct 16) 1. Strategy monitoring occurring via End of Life Forum 2. Night sitting Service delivering to plan. 3. Hayes Cottage (Palliative Care Beds) in place. 4. Business case for Integrated Model to be presented in Oct 16 and model for contracting with providers resolved. 1. Review of MH Lounge and plans for people with 3
Mental Health Needs J Veysey Health need by 25% and breaches by 50% 2. Develop services to support people with Challenging Behaviours (Oct 16) 3. Improve access to and support from the Mental Health Single Point of Access (Nov 16) Challenging Behaviour underway. 2. Support from the SPA is increasing. FOCUS AREA Commissioning an Integrated Urgent Care (IUC) System Improving Support for Older People CRO & SRO Dr M arsin R Mehta Dr K Johal J Veysey REDUCIN DEMAND AT THE FRONT DOOR OF A&E (BOX 1) CRO Dr Mitch arsin & SRO Caroline Morison EXPECTED IMPACT/DELIVERY TASKS & TIMELINES PRORESS RA STATUS Increased Urgent Care 1. Define Specification for IUC System (Dec 16) 1. Model still in development. Support Provided via 2. Commission New 111 Service as part of IUC System Spec to be drafted. 111 and P Led (Mar 18) Clinical Hubs reducing 3. Commission Clinical Hubs as part of IUC System demand at ED by at (Mar 18) ~40 people/day Reduce Attendances by over 2000 and Admissions by 475 in 16/17 1. Deliver Existing 16/17 Programmes (On-oing) a. Integrated Care Programme (136 Admissions) b. Care Home Support via Community Matrons (75 Admissions) c. Intermediate Care (135 Admissions) d. Falls (80 Admissions) e. Health & Wellbeing ateway (50+ Admissions) 2. Implement new model for Intermediate Care to reduce demand further (Nov 16) 3. Implement COTE Consultant support in the Community & within ED (Sep 16) 4. Implement Care Connection Teams (Dec 16) 1. Existing programmes are running behind schedule particularly Intermediate Care 2. Health & Wellbeing ateway established and now ramping up 3. COTE Consultant recruitment successful with 1 starting post in ED in September 4. Model to be developed for 17/18 for Intermediate Care A 4
FOCUS AREA 1: Reduce Time To First Seen 1a: Reduce time triage and packaging of patients Improve Ambulance Flows CRO & SRO Dr Kostic Dr Kostic/KW KW and consultant to be identified ACHIEVIN THE A&E STANDARD & AVOIDIN ADMISSIONS (BOX 2) EXPECTED IMPACT/DELIVERY STATUS Time to First Decision Reduced To 90 Minutes in 95% of walk in Cases. Phased delivery as requires ambulatory pathwaysexpected to reach 75% by Jan 17 Reduction in triage delays, reduction in delays for bloods, EC phased approach. Triage delays to reduce to sustained less than 30 mins by mid October. Reduce Handover Time Black Breaches by 75%+ phased approach - focus to be on zero black breaches with reduction of 30 minute breaches to be reduced by 10% once the CDU is refurbished CRO Mark Edwards & SRO Joe Smyth TASKS & TIMELINES PRORESS RA 1. Implement Early First Assessment (EFA) (Consultant Led Triage) at the Front Door of ED (Aug 16) 2. 1a. Failed to deliver expected impacts with EFAMmoved to enhanced nurse lead triage with parallel phleb and consultant sifting see and treats, alongside using two triage rooms to manage surge. Agreed new process- dashboard indicates significant reduction in delays related to triage 1. Hold Joint Improvement Meetings with LAS (Dec 16) 2. Finalise Blue Light Review with LAS and Methods (Oct 16) 3. Meeting held with methods to discuss report findings waiting on methods to amend report to finalise. Expected 14/10/2016. 1. EFA at Front Door to commence from 15 th August. 2. 3. Enhanced nurse lead triage with parall phleb and consultant sifting see and treats, alongside using two triage rooms to manage surge. PD s under development 1. Joint Meeting to be established. 2. Blue Light audit underway. 3. Black breaches reduced by 50% since March- ongoing micro management of all offloads approaching 20mins delay successfully embedded as core practice. 4. Waiting finalisation of the methods review- overdue November. 5. Implement LAS/Methods Review Dec 17 C C 5
Reduce Diagnostic Result Turnaround Times Increase The Available Cubicle Space MW/DW TEM/Surgical and medical Directorates Reduce Turnaround Time By 30 Minutes or More Increase Available Cubicle Space by 30% 4. Deliver changes to drive down turnaround time. 5. Pilot of staff member actively printing off ICE reports and ensuring medics view them to commence end of November. 1. Obtain short term funding from SaHF ( 500k) (Complete) 2. Obtain longer term funding from NHS England ( 7.5m) (Overdue) 3. Measures ED actively undertaking to reduce impact of crowding within current footprint. 6. Audit completed 7. Agreement with pathology for 1 hour maximum turnaround time, re-audit to occur end of September 8. Identified delay with results being available and staff being ad vised of this due to inability to interface between ICE and ED PAS. Pilot of staff member to print and physically provide the results to medics to be undertaken in November when existing staff member return 1. Short term funding confirmed. Longer Term funding needs to be secured. CDU remodel currently under construction. 2. Increased triage capacity and EFAM ability completed. EFAM area used to assist with crowding for transient patients, additional trolleys for blue area obtainedhowever this reduces transient space 3. Protocols under development for fast track to SAU and AMU, CDU from EFAM- reduction of duplication and time in ED. 6
Improve Support to Children Future Proof The Department DrJ/PT ED management team/ surgical Increase Medical Cover To Reduce Breaches & Reduce Admissions by 500+ in 16/17 Plan for 180/Day As The New Norm and 1. Implement Consultant Paediatric Model (Nov 16) 2. Increase Paediatric Ambulatory Activity to 40+/Month (Nov 16) 3. Implement Paediatric Assessment Unit and increase activity to 100+/Month (Oct 16) 1. Plan for 180/Day available (Oct 16) 2. Plan for 200/Day available (Jan 17) 4. Clear escalation plan with strategies for increasing flow and minimising impact of crowding for final consult expected November sign off. 5. Trolleys for transporting patients to ensure cubicles occupied fully and facilitate flow to be purchased November- interim trolleys sourced from endo at 16:00. 6. Without significant investment to create additional majors capacity, alongside designated ambulance offload area the trusts ability to reach and maintain consistent 95% performance is severely compromised due to sheer volume. Methods clearly demonstrated that the likelihood of failing to reach the target exponentially increases with minimal increase in patient attendees. 1. All elements progressing to plan with possible exception of Paediatric Ambulatory Activity 1. Increase activity through AEC & direct activity to 7
and medical directorates for 200/Day as the Trajectory for 2017/18 3. Reduce time patients who require admission assessment spend in majors 4. Streamline patients through ED minimising packaging of patients increasing through put- Jan 2017 other services where possible. 2. EFAM model underway August 15 th. 3. Monitoring and continual discussion with UCC re increased UCC uptake 4. Sept new ED cote consultants working with RR to quickly & safely turn round elderly patients. Pathways will be continually developed 5. Redevelopment of CDU and new model underway December 2016 6. Development of pathways and fast track of patients from ED to appropriate assessment units, CDU. 7. Referral rights criteria to be developed alongside pathways for admitting rights from ED 8. Significant capital investment required to future proof department and consistently meet increased demand as 12 bed majors is frequently overwhelmed due to sheer volume with resultant inefficiencies, and loss of productivity. 8
Develop seamless patient focused Emergency Care Develop Improved Escalation Process JS/AK/TM Dr MK Patient centric provision of emergency care from presentation to discharge. Remove barriers and silos Improved Response To Rising Demand 1. Funding for Deputy Director role finalised by September 22, 2016 2. Recruitment for DD post to commence October 3. Identification of impact and silos for top 3 presentations to be process mapped by end of October 4. Development of agreed pathways, removing false barriers and focussed on patient centric, shared goal model to be developed for identified conditions to be piloted December. 5. Removal of discipline protection around CDU/AMU/ED develop a culture of patient centric service with flexible workforce and pathways- initial phase to focus on particular conditions to gain success and empower staff to work in differing ways 6. 7. Develop effective internal to Ed and trust wide escalation plans for surges in demand in ED 1. Establish Deputy Medical Director Role with specific focus on patient centric pathways and transition between ED,AMU, and ambulatory for medical patients in first phase. 2. COTE model under development which aligns with ethos of patient centric as opposed to ED, admissions etc model 3. Development of ANP rolls and overall nursing capability to facilitate streaming from presentation alongside increased ambulatory capacity and conditions. 4. ED escalation plan under review October 2016 finalising 9
FOCUS AREA Increase the Number of People Ambulated Ensure Staffing Levels Meet The Demand Needs CRO & SRO Dr M Edward ED leadership team ACHIEVIN THE A&E STANDARD & AVOIDIN ADMISSIONS (BOX 2) CRO Dr Mark Edward & SRO Joe Smyth EXPECTED IMPACT/DELIVERY TASKS & TIMELINES PRORESS RA STATUS 1. Current ambulatory activity is being achieved (albeit with some paediatric 1. Delivery of the planned 16/17 activity for the activity counted within it). Ambulatory Emergency Care (AEC) Pathway and 2. Pathways currently under Emergency ynae Assessment Unit (EAU) (On- Increase The Number development for range of oing) of People Ambulated conditions. This will negate 2. Provide monthly updates to the CC on Conditions To 420/Month in need for condition Treated (Overdue) 16/17 and reporting 3. Develop plans for 17/18 and increase activity (Dec 500+/Month in 17/18 3. Development of pathways 16) with direct deflection and 4. Implement CDU Chairs to increase patients referral from ED- fast track supported to avoid admission (Jan 17) 4. CDU Tariff and process to be agreed between the CC and THH. Reduction in unnecessary ED deflections. Staffing levels meet surges in ED activity 1. Restructure management of Urgent Care to improve effectiveness (Oct 16) 2. Staffing aligns with activity- dashboard now in place that identifies predictable surges- work to commence end of October to realign staffing models 1. Database of UCC deflects commenced, agreed review of themes between THH and UCC service. 2. P herald patients direct access from UCC to be piloted October 2016. 3. Nursing staff reviewed using NICE guidelines- band 7 supernumerary roles established. 4. Review numbers and responsibilities of HCA, management of pts who require 1:1 needs developed with view to 10
Implement Daily Situation Reporting & Dashboard ST Daily Situation Reports and Dashboards in Place 1. ED activity report/dashboard complete 2. Dashboard for new CDU under development 3. Discussions to occur around a system wide SITREP having RMN to access. Discussion with CNWL to review intoxicated patients care. 5. Matthew Cooke employed for 1 day per week to support development of ED medical team and processes commenced November 2016. 6. Recruitment underway for Deputy Medical Director 7. Internal restructure completed with new ADO for Emergency Directorate to commence November 1. IT developing daily ED activity report complete view attached 2. Review of SITREP A Appendix A is the newly developed ED activity and performance dashboard that enables complete analysis and breakdown of patients journey from entry to exit through ED. This ensures rapid identification of impact of changes, areas to target and accountability. 11
FOCUS AREA Implement The Methods Recommendations CRO & SRO MM & ME ACHIEVIN THE A&E STANDARD & AVOIDIN ADMISSIONS (BOX 2) EXPECTED IMPACT/DELIVERY STATUS Deliver The Recommendations Identified by Methods Analytics CRO Dr??? & SRO Joe Smyth TASKS & TIMELINES PRORESS RA 1. Implement The Phase 1 Recommendations (Mar 16) a. Implement agreed portfolio approach for managing improvement opportunities b. Remove performance constraining practices associated with downstream (UCC/ P heralded) and interdepartmental flows, eliminate batch working eg discharges, transfers to reduce exit block. c. Specify and create additional substantive physical capacity. d. Speed flows in the ED to reduce dwell time, reorder tasks, defer tests, procedures and administrative tasks that can safely be delayed until after admission. e. Improve staff morale in the ED by communicating measures being taken to improve performance. f. Standardise escalation and remedial actions for managing ED flows. Major escalation steps reserved for disruptive situations. Phase 2 to commence upon completion of phase 1 priorities likely to be post December with a further 5-7 recommendations prioritised. 1: Development underway of Emergency Deputy Director role which will be responsible for brokering pathways and streaming from presentation to admission across all specialities. Job description underway and associated TME business case. B: Discussions underway with pathology regarding batching of tests. Completed C &D: Establishment of EFA (RAT model) to increase flow, decrease time to assessment by senior decision maker, ordering of tests earlier in the patient pathway. Wider hospital agreement being brokered to increase support for transfers when clusters occur. Establishing EFA model for front door alongside CDU redesign and increase in sizecompleted, development of pathways and ambulatory services 12
Phase 3 to commence upon completion of phase 3 priorities likely to be post April 2017 for the remaining recommendations. Feasibility study being undertaken specifically looking at establishment of a ambulance offload area and resus reconfiguration E: Matron role appointed too. Staff newsletter established, staff forums underway and suggestion box. Staff meetings under review with particular focus on developing regular meeting for nursing staff. F: Developed ED escalation plan alongside trust escalation plan and ensure consistent and collaborative models, establish formal step downs and debriefs following escalation ensuring areas escalation plan is functional and adds value 13
FOCUS AREA Early & Effective Discharge Planning Establish Frailty Services CRO & SRO MM/ME JW/ SAFELY REDUCIN LENTH OF STAY & DISCHARIN PATIENTS (BOX 3) CRO Mark Edwards & Dr Mitch arsin EXPECTED IMPACT/DELIVERY STATUS Discharge Planning to occur within 48 hours of Admission in 95%+ of cases System wide integrated frailty service- patient centric service provision with expectd reduction in ALOS and admissions alongside reduce readmissions SRO Joe Smyth & Caroline Morison TASKS & TIMELINES PRORESS RA 1. Establish effective Integrated Discharge Team (IDT) (Overdue) 2. EDD to be available with Discharge Plan within 48 Hours of Admission (Oct 16) 3. 1. IDT plan required. 2. Discharge focus group established with pending priorities for pilots. 3. COTE role will link in with reducing LOS and CDU for discharge planning/ reducing conversion rate- December 2016 1. Care of the Elderly (COTE) ED in reach post established November 2016. Establishment of remodelled CDU in January will further enhance COTE in reach and rapid response support from cross sector MDT. Rapid response trial from mid November 2016 increased hours of ED support. Cross sector clinical design and model steering group and associated task and finish group established to support an integrated system wide frailty pathway, frailty unit tbc and single point of access for patients fitting frailty A 14
definition. Specific focus on admission avoidance, fast tracked discharge and support in the home, cross sector communication and support. Reducing Length of Stay Following a Non-Elective Admission Supporting Complex Patients Effectively MM/ME Achieve 7+/Day Patients Taken Home Via Home Safe Reduce Overall Length of Stay by 1 Day Reduce DTOCs and Medically Fit for Discharge (MFFD) Patients by 50% Reduce Excess Bed Days Associated with 1. THH to deliver Home Safe Service to support 7+/Day patients per day home (On-oing) 2. CC to commission CNWL and Age UK elements of Home Safe (Complete) 3. Deliver Reduction in average LoS by 1 Day (Jan 17) 1. Improve DTOC & MFFD Planning Processes (Oct 16) 2. Develop Challenging Behaviour Programme and support for Care Homes (Dec 16) 1. Delivery of programme on track. 2. Blended tariff for Rapid Response and Home Safe for Zero Length of Stay (ZLOS) patients required. 3. Task & Finish roup in place to look at LoS but progress needs to accelerate. 4. Pilot of extended hours of rapid response to facilitate earlier time of discharges to commence on 31 October 2016. 5. Development of pathways alongside redesign of ambulatory, CDU and new model and COTE role with focus on reducing conversion, deflection and ambulatory utilisation. 1. DTOC Plan to be produced and agreed. 2. CNWL to provide proposal for Challenging Behaviour Programme. R R 15
Managing Bed Capacity Effectively Patients with Challenging Behaviour by 50% Reduce Escalation Bed Usage By 50% A FOCUS AREA Providing Support in the Community Reducing number of MFFD in acute hospital Utilising Resilience & Readmission Funding To Best Effect CC CRO & SRO THH/CC SAFELY REDUCIN LENTH OF STAY & DISCHARIN PATIENTS (BOX 3) CRO Dr Mark Edward & Dr Mitch arsin EXPECTED IMPACT/DELIVERY STATUS CC to Provide 5 Step Down Beds, Bridging Care Support & Additional Spot Purchase Beds Reduction in number of MFFD patients in acute sector Demonstration of Effective Use of Funding SRO Joe Smyth & Caroline Morison TASKS & TIMELINES PRORESS RA 1. Commission Step Down Beds & Monitor Activity (On-oing) 2. Commission 1,400 Days of Bridging Care Support & Monitor Activity (On-oing) 3. Agree budget for Spot Purchase beds and manage within Budget (On-oing) 1. THH developing business case for cross sector approval looking at a shared funding agreement to access beds for patients deemed MFFD but requiring none acute interventions e.g social care, allied health input 2. Provide update on Resilience Funded Schemes (Monthly) 3. Provide plan for residual 950k of funding (Overdue) 1. Step Down Beds in place. 2. Bridging Care packages in place. 3. Spot Purchase budget being exceeded. 1. THH business case and proposed model under development. Potential provider identified. Business case to be completed end of November. 2. Submissions to be finalised November 2016 3. Plan for residual funding now overdue. C 16