def Agenda item: 8 (i) TRUST BOARD SEPTEMBER 2011 Surgical Services Reconfiguration PURPOSE: PREVIOUSLY CONSIDERED BY: To provide the Trust Board with an update on plans to reconfigure the Trust s surgical services. These changes are a direct result of the implementation of the Lister Surgicentre project which becomes operational in September 2011. N/A IMPLICATIONS: Objective(s) to which issue relates: Risk Issues: Financial: HR: Healthcare/ National Policy: Patient safety and clinical efficiency: To consolidate acute services on to a single site To improve the quality of all aspects of our service A comprehensive Trust Risk Register is in place for the Surgicentre project to identify and manage the project risks. Key risks of this proposal are identified in the paper. This proposal is consistent with previous updates to the Board in terms of the financial consequences of the Lister surgicentre. Over 180 wte (current figures) Trust staff are to be seconded to Clinicenta using the Retention of Employment model. ISTC reflects national policy. Legal Issues: Equality Issues: All legal contracts signed at Financial Close remain intact. None identified. RECOMMENDATIONS: The Trust Board is asked to note the progress with implementation of the plans previously agreed. DIRECTOR: Director of Operations PRESENTED BY: Director of Operations AUTHOR: Director of Operations & Divisional Director, Surgery DATE: 21 September 2011 Page 1 of 10
Surgical Services Reconfiguration 1. Introduction As a direct result of the transfer of part of the Trust s current elective workload to the Lister Surgicentre, there was an opportunity to review the configuration of the remaining surgical services. This review was undertaken by the Operational Work stream of the Lister Surgicentre project and led by the Divisional Director, Surgery, in 2010. The objectives of the review were to ensure that the remaining services are efficient, safe and maintain quality standards, where possible seeking to improve these. It also sought to use the best accommodation available within the Trust and utilise these in the most effective way possible, whilst meeting the financial savings outlined in previous papers to the Board. The Operational Work stream developed a number of initial options that were then appraised on both a financial and non financial basis. There was wide clinical involvement, through membership of the operational group, cascade to Directorate team meetings, numerous informal conversations with key clinicians and finally a meeting with the vast majority of Orthopaedic consultants, nurses, theatre staff, Divisional management and Executives to collectively take the final decision on the preferred option. The outcome of these discussions were outlined within a paper which was agreed through the RAQC and the Trust Board in October 2010. This paper provides an update on the progress and plans to implement these proposals and the Trust Board is asked to note the progress. 2. Background The ISTC would fragment the remaining elective activity in the Trust. For example, within Orthopaedics the elective work remaining on each site would have equated to 7 beds at QEII and 5 at Lister. Managing small volumes across two sites becomes particularly inefficient and potentially reduces safety. The speciality that is the most affected by the Lister Surgicentre transfer is orthopaedics so there was significant focus on the configuration options of the remaining Orthopaedic services, particularly with regard to the configuration of the fractured neck of femur service and the need to improve outcomes for patients. The other most significant issue was the need to centralise General Surgery emergency surgery at the Lister site to address concerns over mortality and the availability of consultant staff when on-call. Additional considerations were that all day surgery work not going into ISTC would need to relocate to QEII as the Day Surgery Unit at the Lister has to close to allow for the planned development of the Lister A&E department. Also, Gynaecology has to relocate to Lister in October 2011, when the women s and children s unit opens, so provision had to be made for the beds and theatre capacity to support this. The elective inpatient orthopaedic work remaining in the Trust post Lister Surgicentre is largely spinal surgery, revision hip and knee surgery and surgery for patients with significant comorbidities. The Trust currently has 3 laminar flow theatres, 2 of which are at QEII in Princes Wing. Transferring all elective work to Lister would have made the Trust very dependent on the single laminar flow theatre (theatre 7) and failed to make use of the two best theatres in the Trust at Princes Wing. The remaining elective activity is the more complex and higher risk surgery which is best suited to Laminar flow facilities to reduce infection risk. The Trust has three Laminar flow theatres, two of these being within Princes Wing at QEII. Logic dictated we centralise the elective Orthopaedic activity at QEII in Princes Wing. The other priority was to make provision to centralise General Surgery emergency surgery at Lister due to patient safety risks. The Trust has had an above average HSMR for general Page 2 of 10
surgery for some time and analysis previously reported to the Board by the Medical Director, has confirmed that this mainly relates to non-elective pathways. The Trust is one of the few remaining Trust s in the region in which general surgery consultant staff have elective commitments when on call. Due to the need to provide emergency on call rotas on two acute sites, it is not possible to release consultant staff from these commitments until emergency services are centralised. 3. Proposed Service Configuration It was agreed through RAQC and Trust Board in October 2010 that, elective orthopaedics and fractured neck of femur services would be centralised within Princes Wing at QE II Hospital and Orthopaedic trauma surgery centralised at Lister. Furthermore, emergency general surgical services would be consolidated at the Lister Hospital and all day surgery services provided from Queens Wing at QE II Hospital. This scheme had the particular benefits of: 1) #NOF services enhanced through centralisation, dedicated laminar flow theatre, proximity to a physio gym and x-ray facilities, and dedicated ortho-geriatrician pathway. 2) All remaining elective services on one site and via a laminar flow theatre. 3) Poly trauma and paediatric trauma better supported from Lister site 4) A&E consultant available 24hrs to support Trauma arrivals 5) The movement of Trauma to Lister was in line with to the trusts strategic direction. 6) Use of more modern estate for day surgery services 7) Improved outcomes for general surgery emergency patients through increased consultant availability. 4. Progress with Implementation Project Structure, Accountability & Clinical Engagement Surgical Reconfiguration and ISTC Please see chart on the next page. Page 3 of 10
Stephen Posey / Neil Dardis Executive Leads PCT led Project Board Our Changing Hospital Programme Board Construction/ Site Management (Chris King) Lara Waywell Project Director Wendy Scarr Project Manager Hospital Project Team support (APM s, Risk and Programme management) Financial (Tim Pearce) Clinical (Tim Walker) Workforce (Mariejke Maciejewski) Communications (Peter Gibson) IM&T (Keith Cunningham) Service Level Agreements (Wendy Scarr) Page 4 of 10
The Operational Group meets twice a week and is Chaired by the Director of Operations or Divisional Director, Surgery. It has representation from all Divisions and relevant corporate departments. The group have worked to a detailed project plan that details actions that required to be completed each day. There is Clinician representation on all project groups. Within the Surgical Division the reconfigurations are an agenda item at the weekly Senior Manager Meeting, all Departmental meetings and at the monthly Divisional Board. Beds The proposed changes have a significant effect on all surgical wards in terms of capacity and casemix. The extent of these changes are summarised in the table below. Site Ward Current Configuration Future configuration Change 11b 8a 8b ENT and Plastics 15 beds General Surgery- Colorectal (emergency and elective) 30 beds Vascular and Urology 30 beds ENT and Plastics 15 beds Emergency General Surgery 30 beds Emergency General Surgery (inc. some urology emergencies and high dependency vascular patients) None Speciality change Speciality change LISTER 24 beds New Acute Surgical Care Unit (ASCU) New Acute Surgical Care Unit 7b 5a Elective 23 hour stayall specialties 15 beds Trauma & Fractured Neck of Femurs 30 beds 6 beds Urology (emergency and electives) 15 beds Trauma (emergencies) 24 beds Speciality change Fractured Neck of Femurs centralised at QE2 QEII 5b Codicote Princess Orthopaedics (15 beds) Short stay surgery (14 beds) 29 beds General Surgery and Colorectal 28 beds Elective Orthopaedics (including day surgery) General Surgery (GI, Colorectal and some vascular) 29 beds General Surgery and Gastroenterology 28 beds Fractured Neck of Femurs Reduction of 6 beds Speciality change Specialty change to include elective Colorectal & Gastroenterology Dedicated Neck of Femur beds Page 5 of 10
Lemsford 51 beds Trauma 30 beds 26 beds Elective complex Orthopaedics 25 beds Ward closure Ward closure Ward staffing The surgical wards have an establishment of 305 wte and following the reconfiguration reduces to 268 wte. The key changes to the surgical wards are: - 7b becomes a dedicated 15 bedded Urology Unit which is open 7 days a week - Creation of the Acute Surgical Care Unit (ASCU) this will take level 1 patients and provide more intense monitoring and observations for elective and emergency patients with an increased level of nurse / patient ratio 1:3 - Creation of a trauma ward on 5A at Lister - Creation of an emergency floor on level 8 at Lister - At QEII the key changes are a dedicated fractured neck of femur and orthopaedic ward and co location of gastro patients within general surgery - A total of 38 bed closures - 29 on Lemsford, 3 on Princes and 6 on 5a Trauma - 26 wte nurses transferred to Lister Surgicentre. All ward nursing staff undertook a preference and skills assessment. Over 85% of staff received their first choice and had the appropriate skill, 10% received their second choice and 5 % were asked to move to a ward where they had certain skills. Any gaps in skills needs have been addressed through additional training. Several team days have been undertaken on 5B where the ward speciality has changed from orthopaedics to general surgery, colorectal and gastroenterology. Several of the senior staff have been asked to work on level 8 to gain further surgical skills prior to the ward opening. Further work is planned in terms of team development within each of the wards. Theatres Staffing improvements Pre ISTC theatre establishment was 215.49wte Post ISTC the theatre establishment is 161.23wte The number of theatre staff who moved to Lister Surgicentre is 51wte The number of staff who have internally changed base on a permanent basis is 26 wte (ie lister to QEII and vice versa) - this excludes staff who are rotating on weekly and daily basis The number of staff recruited externally to the trust theatres is 11wte Historically the theatre staffing establishments had evolved on each site in a reactive manner as and when sessions were added or changed. As a consequence of the reconfiguration the opportunity arose with the timetable changes to review the theatre establishments on both sites and apply a standardised approach to staffing, using the models recommended by the Association for Peri-operative Practice and the British Association of Day Surgery. To assist staff with managing the change, study days were held to recognise the changes the staff would go through and to build new teams after colleagues had seconded to ISTC. Page 6 of 10
There is now increased flexibility within the theatre teams with staff working across site on both rotation and on an ad hoc basis. The patients benefit from having a flexible workforce that can be adjusted according to the care that needs to be delivered and build teams prior to full consolidation in the future. The inpatient theatre teams are working together to ensure that where services are centralised the staff with the knowledge and skills of the speciality support the transfer, such as orthopaedics and general surgery emergencies. Better planning for emergency cases through the introduction of staffed evening emergency sessions will mean operating through the night should not be necessary. Staff in urology day surgery theatres have had additional training to prepare them for the type of patient they will be caring for. Day Surgery has dedicated paediatric sessions as recommended by the Royal college of Surgeons, Royal College of Anaesthetists and Royal College of Nursing. These are supported by qualified paediatric nurses and the children benefit from being cared for in an environment that provides play areas and the distraction of other children. This service will be delivered two days per week that not only takes pressure off Bluebell ward and the inpatient theatres, but will also deliver a service that has been assessed as one of the best in region when compared with other district hospitals. The nurse led discharge team in day surgery has been expanded to ensure that patients are discharged in a safe, efficient and timely manner, with plans to role this methodology out to some of the in-patient areas, particularly for overnight stays of one or two days. Opportunity to improve quality aspects of the service through the provision of new roles and new ways of working was taken with a structure put in place for the development of staff at bands 1-4 and the use of assistant theatre practitioners for scrub duties in day surgery. The structure allows for further development at band 4 level through the associate practitioner programme, which will provide support to the qualified staff in both scrub and anaesthetics. Sterile Services Department (SSD) & Instrumentation SSD has supported the theatre teams in standardising the instruments sets from the two sites in readiness for the centralisation of services. The introduction of a Set Relocation Procedure and a loan instrument policy means that the management of the instrument stocks is now centralised with less unnecessary duplication. Many consignment sets have been returned to the companies and the loan policy brings tighter controls on the use of non standard instrument sets. SSD does not supply service to Lister Surgicentre and the loss of this work equated to the loss of 8 wte's which has been managed through natural wastage, thereby maintaining the morale of the department. The change in type and quantity of work through this department gives an opportunity for appraisal of moving the decontamination of flexible endoscopes away from nursing staff in endoscopy to SSD staff. Timetable and sessions From 19 th September 2011 all theatres in the Trust have been running an entirely new timetable. This timetable has been developed over many months to deliver the remaining casemix, improve access to emergency and trauma theatres in preparation for the centralisation of services and to re-balance sessions between specialties to reflect their ongoing needs. In addition, children s surgery is now in line with national and regional standards. The timetables have had to balance the capacity with the availability of theatres and surgeons which has required a complete re-planning of all consultant job plans in all Surgical specialties. Page 7 of 10
The new timetable has resulted in changes to over a third of the elective theatre sessions at the Lister and three quarters of elective sessions at QEII as well as an increase of 9 emergency theatre sessions across the Trust, with 7 new evening and weekend sessions at the Lister and daily (7 days) #NOF sessions at QEII. Over 60% of the sessions in day surgery at QEII are in specialties / areas not previously delivered there which has only been made possible by the flexibility of the Queen s Wing staff over the past few months working between the two sites to acquire the new skills they require. The new timetable has allowed us to bring the number of urology sessions back to their original level prior to the introduction of IOG patients. They now have a theatre completely dedicated to Urology where the robot can be used every day of the week as well as additional theatre capacity at Lister and more day surgery capacity at QEII. The provision of offsite day surgery facilities at QEII for Urology, Plastic Surgery and Children s surgery is supported by detailed protocols as well as internal Trust ambulance provision (by St John Ambulance) to enable patients to be treated safely and transferred efficiently to inpatient beds at Lister if an unexpected admission is required. Fractured neck of femur The centralisation of fractured neck of femur patients into a separate unit at QEII (Princes) has allowed us to develop a dedicated service to #NOF patients which will aid improvements in care and outcomes. All patients who have a fractured neck of femur will be operated on in dedicated laminar flow theatres located within Princes which meets NICE guidelines. There is a dedicated half day session each day for that are primarily consultant led, this change will reduce the time from admission to theatre. The most acute patients will be cohorted together with the ward being modified to ensure work stations and nurses will be within these bays. The unit is self contained and has two laminar theatres, a physiotherapy gym is on the ward which will also aid rehabilitation. Overall this unit will ensure that there will be an increased presence from both Orthopaedic and Ortho-geriatric Consultants. With support from colleagues in nursing and therapies HSMR, quality and patient experience should improve as a direct result of these changes Pre-operative Assessment Unit As part of the reconfiguration of services across all sites, the Trust has improved its Preoperative Assessment (POA) process to align with the transfer of patient care to the Lister Surgicentre and to provide an improved service and experience to patients. At Lister a new POA hub has been established with waiting list staff working in conjunction with the POA team. At QEII the POA hub will be operate in a similar format to Lister from late October 2011 and a satellite service at Hertford County Hospital 3 days a week. For 80% of patients who are listed for an operation at outpatients, they will have the preoperative assessment the same day as there outpatient appointment and leave the hospital that day with their operation date. The remaining 20% of patients, will be booked into a structured appointment at a later date. 5. Benefits Realisation The following benefits have been identified through the deliberations undertaken to date and as were identified in the previous papers to the Board. A number of benefits would also relate to the fact that a do nothing option would result in the services being potentially fragmented and unsustainable. The benefits compared to that option have not been assessed overleaf. Page 8 of 10
Benefit Measure Expected Reduced mortality within General Surgery HMSR less than 100 6 months after implementation Reduced Mortality for HMSR less than 100 6 months after #NOF patients implementation 95% of #NOF patients Time from listing for 2 months after operated on within 36 surgery to completion of implementation hours surgery Increase in emergency surgery undertaken in line with NCEPOD recommendations Reduced Length of stay for emergency surgery and #NOF patients Improved outcomes for emergency surgery 6. Risks Reduction in surgery undertaken at night Average length of stay Increase in #NOF and trauma surgery undertaken in laminar flow theatres 2 months after implementation 6 months after implementation 3 months after implementation The project team manage and maintain a risk register associated with all ISTC changes and escalate these through the programme board and the Executive Committee. There are a number of key risks associated with this proposal which are outlined in the table below. Risk Rating Ward Areas Action Due Risk that the Trust is unable to adequately staff the new acute surgical care unit and other 12 Scale of shortage has been mapped and staff have been allocated to appropriate areas ward areas, postreconfiguration based on skill mix. Identifying other sources of staff e.g. re-deployment pool Constantly being monitored by senior management team. September 2011 General Surgery Potential deterioration in post admission care for emergencies when medical staff rotate back to working at QEII Orthopaedics Patients being transported to the incorrect hospital site by East of England ambulance service, causing delays to patient care 12 Surgical Directorate to implement robust system of handover to ensure safe transfer of care from one consultant to another. 8 Formally written and met with ambulance service to describe changes. Guidelines have been produced to inform decision making re: location. Will feedback any concerns to ambulance service on a regular basis. Page 9 of 10 October 2011 October 2011
Lack of Registrar support at QEII overnight for the management of patients 7. Conclusion 12 Clear pathways in place for escalation and support for QEII overnight cover. Registrar at Lister will be designated point of contact and will attend QEII if necessary. October 2011 The proposals agreed at the Board in October 2010 were ambitious and carried significant risk given the scale of change and timescales involved. This challenge has been further exacerbated by the delays in ISTC implementation and uncertainty over the final go live dates. The work undertaken to date represents a huge success for the teams involved and, when delivered, the proposals will ensure sustainable provision of surgical services in the interim between phase 1 and 4 of OCH whilst also improving the quality of care provided to patients, as well as delivery of the required financial savings. The implementation of these changes will continue to be monitored through the Operations Group and ISTC programme management structures. In addition, due the business critical nature of the Lister Surgicentre project, progress, key risks and issues are managed at the weekly Executive Committee. Benefits realisation will be a key feature of these management structures moving forward and progress will be reported back to the RAQC at an appropriate timescale. Page 10 of 10