UNIVERSITY HOSPITALS OF MORECAMBE BAY NHS FOUNDATION TRUST Date of meeting: 27 June Title / Subject: Status Purpose: Report of: Prepared by: BOARD OF DIRECTORS Public To update the Board of actions being taken to consistently achieve waiting time targets in both Emergency Departments. To detail a performance trajectory for 4 hour standard To document further planned actions in the Unscheduled Care plan across UHMB. Juliet Walters Interim Chief Operating Officer Suzanne Contact for queries: Suzanne Suzanne.tytler@mbht.nhs.uk Action required / recomendation: The Board of Directors are asked to note the contents of this paper 1. Comment on the contents of this paper 2. Note and ratify the action taken under delegated authority University Hospitals of Morecambe Bay Hospitals NHS Foundation Trust - Page 1 -
Supporting Information Not Applicable Background papers/ supporting agenda items (if applicabe): Previously considered by (if applicable): Not Applicable Link to UHMB s objectives (select those objectives this paper supports): Link to UHMB s business plan: Continuously improve the patient experience - becoming the provider of choice for excellence with safe and effective patient care Support and develop all staff to take responsibility for what they do and help them to do their best - getting staff truly engaged in how the trust works Encourage staff to be innovative when delivering and planning high quality and sustainable services - achieving long term financial sustainability Work with our partners to provide an integrated health service that meets the needs of the local population providing local access, including to specialist services wherever that is feasible Positively contribute to the well-being of the local community Yes Yes Yes Yes Yes Link to UHMB s Assurance Framework: Link to a Care Quality Commission standard(s): Risk 4 hour standard may not be achieved. Identification of any statutory / regulatory implications for UHMB: Public and patient enagement: Eqality Impact Assessed (if applicable): Not yet assessed University Hospitals of Morecambe Bay Hospitals NHS Foundation Trust - Page 2 -
UNIVERSITY HOSPITALS OF MORECAMBE BAY HOSPITALS Emergency Department Performance Improvement Report INTRODUCTION 1. Due to the challenges faced in both Emergency Departments in providing an excellent quality service and sustainably achieving the 95% national standard, a number of core work-streams were developed. One of these work-streams, Transforming Unscheduled Care, aims to deliver improvements in the patient experience and sustained achievement of the four hour standard in both Royal Lancaster Infirmary and Furness General Hospital Emergency Departments. 2. Work commenced initially at Royal Lancaster Infirmary in early March, however, work has now commenced at Furness General Hospital, with the first planning meeting with clinicians having taken place on 18 May. 3. A detailed action plan to support the implementation of the Royal Lancaster Infirmary work-stream can be viewed via the Programme Management Office link on the Trust intranet. A similar detailed action plan for Furness General Hospital is being developed to reflect the specific actions required for this site. 4. This paper provides the Board with an update on the work undertaken so far at Royal Lancaster Infirmary and Furness General Hospital in response to under-performance against the four hour Emergency Department standard for 2011/12. 5. The sections in this report are: a) Recent performance b) Root causes c) High level action plan d) Actions completed since March e) Delayed actions f) Future actions to be implemented g) Monitoring arrangements h) Trajectory for performance improvement (attached as appendices) RECENT PERFORMANCE 6. Recent performance is detailed at Trust level and at individual site level. The 95% four hour standard was not achieved for 2011/12. The final 2011/12 performance for the Trust was 93.95%, with performance of 92.20% for Lancaster Royal Infirmary, and 96.75% for Furness General Hospital. University Hospitals of Morecambe Bay Hospitals NHS Foundation Trust - Page 3 -
Table 1: Recent Performance Year To Date Performance Up to Week 10-04 June Attendances Breaches Performance Royal Lancaster Infirmary 10854 508 95.32% Furness General Hospital 7338 564 92.31% Trust Total 18192 1072 94.11% ROOT CAUSE Table 2: Root Cause University Hospitals of Morecambe Bay Hospitals NHS Foundation Trust - Page 4 -
7. Bed availability The Royal Lancaster Infirmary underperforms in comparison to peer hospitals. Length of stay At Royal Lancaster Infirmary average length of stay for non-elective admissions is 6.7 days compared to a national average of 5.4. 44.46% of breaches relate to waiting for specialist input and bed availability. Non-elective patients admitted into the Royal Lancaster Infirmary who stay for over 15 nights, have an average length of stay of 33.4 days. 8. Furness General Hospital average non-elective length of stay is 5.3 days, with patients who stay over 15 days averaging a 33.4 day length of stay. 43.41% breaches relate to waiting for specialist input and bed availability. By decreasing our length of stay, we will experience fewer breaches. 9. Delays to first assessment in the Emergency Department - 32.47% of breaches are attributed to this delay at Furness General Hospital, with 41.69% applying to the same delay at Royal Lancaster Infirmary. The lack of sufficient physical capacity within both Emergency Departments directly contributes to this breach reason. 10. Ambulatory Pathways Minimal use of recognised ambulatory pathways resulted in increased numbers of admission for conditions that could be seen in an ambulatory environment. Such clinical condition include, cellulitis, headaches, epileptic seizures, and low risk chest pain. University Hospitals of Morecambe Bay Hospitals NHS Foundation Trust - Page 5 -
11. GP Expected Patients The Emergency Departments at both Royal Lancaster Infirmary and Furness General Hospital are routinely used as contingency areas due to lack of timely in patient capacity being available. This results in patients defaulting to the Emergency Department from outpatient clinics, GP surgeries and MDT meetings, whilst waiting for a bed to become available. 12. Discharge planning Routinely, patient discharges take place later in the working day. In 2011/12 elective and non-elective discharges taking place before 10am at Royal Lancaster Infirmary were 15.85%. At Furness General Hospital this figure was only 8.71%.There are significantly less discharges occurring at weekends and Bank Holidays. 13. Delays in wider health economy There are a number of delays which occur in the wider heath economy, which result in patients remaining in an acute medical bed for longer than is necessary. For example, there is a paucity of community services and intermediate care beds. The Trust is working with partner organisations to understand this issue better, as currently this is an area which is data rich, but information poor. It is accepted that in order to make improvements, these delays need to be visible and clearly understood by all parties. HIGH LEVEL ACTION PLAN 14. The six key elements of the action plan are: a) Emergency Department four hour standard becomes everybody s business b) Engage and work with the consultant body to model working practices responsive to demand c) Engage the wider health economy in responsibilities associated with length of stay d) Introduce an acute medical model of care e) Increase capacity in Emergency Department f) Decrease length of stay by increasing ambulatory care Actions completed since March 15. During March a number of improvements were identified and actions implemented to improve the way in which Unscheduled Care is delivered at Royal Lancaster Infirmary. A similar approach commenced in May at Furness General Hospital. Actions implemented include: Table 3: Royal Lancaster Infirmary Actions Month Completed Introduction of Unscheduled Care newsletter Feb Pathways agreed to facilitate Medical GP expected away from Emergency Department Mar University Hospitals of Morecambe Bay Hospitals NHS Foundation Trust - Page 6 -
One additional nurse on each shift to stream minor and major patients and ensure minor patients never breach. Daily consultant ward/board rounds undertaken on all medical wards at Royal Lancaster Infirmary Provision of 23 Short Stay beds (two single sex wards) Specialist consultant input into Short Stay Wards Mar April April April Negotiate extension of REACT service April Formal handover agreed at the start and end of each shift April between clinical teams at shift handovers GP expected patients directed straight to the Medical Assessment Unit (MAU), or Surgical Assessment Unit (SAU) Recruitment of a 4 th (locum) acute physician to strengthen the existing Acute Team Increase capacity in ambulatory care delivered in the Clinical Decisions Unit (CDU) Emergency Department Away Day planned to agree new ways of working and Rapid Assessment and Treatment (RATS), with the aim of eliminating breaches caused by delays to first assessment. Establishment of a Discharge Improvement Collaborative to improve complex discharge planning processes, tackle issues of delayed transfers for care and improve provision of nonacute medical beds in the community Stop specialities using Emergency Department as a contingency plan until a bed is available. April April April April April May Negotiate pharmacy discharge lead to expedite discharges May Reorganisation of bed meetings May Table 4: Furness General Hospital Actions Month Completed Additional support on site for Clinical Site Manager at peak April times Introduction of Unscheduled Care newsletter May Formation of project team for Unscheduled Care May Re organisation of Service Managers to allow site based June approach Agreement in principle to model of acute care using short stay June model Establishment of a Discharge Improvement Collaborative to improve complex discharge planning processes, tackle issues of delayed transfers for care and improve provision of nonacute medical beds in the community June University Hospitals of Morecambe Bay Hospitals NHS Foundation Trust - Page 7 -
Table 5: Delayed Actions Due Corrective Response Gynaecology assessment area 04 June Estates work underway to prepare area to be open to direct admission from 18 June Surgical and Orthopaedic assessment area Discharge lounge area within medicine April April Examining options including combination ambulatory area for clothed patients whilst new ways of working agreed with surgical team. Norovirus limited use of allocated area. Post created to work in one of 2 areas identified. FUTURE ACTIONS TO BE UNDERTAKEN 16. There are a series of further actions which will be implemented over the coming months in order to further improve and sustain performance by 22 July. Some of these actions, for example, implementation of Interim Plan 2, and capital development works within the Emergency Department, will not be delivered until later this calendar year, nonetheless, sustained delivery of the 4 hour standard is expected by 24 June (see attached paper Trajectories). Table 6 Action Owner Target Division Lead Extending further the range of ambulatory care pathways delivered through the Clinical Decisions Unit Establishment of a discharge lounge area to facilitate efficient patient flow from Short Stay Wards GP expected patients directed straight to Gynaecology Assessment Unit Developing the ethos of Bed Before 10 on all inpatient wards Review of consultant job plans to progress Dr Y Seth Cullen Wells Mr Burch P. Grout August June June June August Wells Operational Monitoring Information Service manager Service Manager Information Service Manager Executive Monitoring Chief Operating Officer Director of Nursing Director of Nursing Chief Operating Officer Medical Director University Hospitals of Morecambe Bay Hospitals NHS Foundation Trust - Page 8 -
consultant weekend working Opening of new Minor Injuries Unit and refurbishment of existing Emergency Department facilities, to address clinical capacity within the Department, and allow effective streaming of major/minor patients Development of Interim Plan 2 in relation to Royal Lancaster Infirmary bed and site reconfiguration J. Pease August October Service Manager Service Manager Chief Operating Officer Chief Operating Officer MONITORING ARRANGEMENTS 17. Performance is monitored via the weekly Transforming Unscheduled Care groups. Performance against agreed key milestones is monitored, by exception, by the PMO team and weekly updates are made available to the Weekly Programme Board. 18. Key Performance Indicators have been developed which will ensure there is transparency of progress with the overall improvement plan, and also correlation between the introduction of changes and subsequent improvements in performance. 19. As previously noted, work commenced initially at Royal Lancaster Infirmary, although it was recognised that similar improvement work needed to take place at Furness General Hospital. Therefore a Transforming Unscheduled Care group has been introduced at Furness General Hospital, The governance and monitoring arrangements for this site will mirror those which exist for the Royal Lancaster Infirmary. 20. Trajectories are attached which show the progress made so far at individual site and Trust level. These trajectories are now updated on a weekly basis, and will be shared, discussed and noted in a variety of forums, including: Weekly Divisional performance meetings Weekly Unscheduled Care group meetings Weekly Divisional Management Team meetings Updates posted weekly on ED performance noticeboards Monthly Consultant forums Monthly Divisional Management Team meetings Monthly Emergency Department Performance meetings Monthly Divisional Quality Assurance meetings Monthly Divisional Performance meetings University Hospitals of Morecambe Bay Hospitals NHS Foundation Trust - Page 9 -
CONCLUSIONS 21. It has been recognised for some time that a more effective integration of the elements of the unscheduled care services is required across both acute sites. 22. Despite encouragement and support, clinical teams have struggled to find a way forward. External reviews have proved a stimulus, but whilst ideas for change are helpful, the implementation of required changes is always a struggle that requires strong leadership and real commitment. 23. The implementation steps will continue to be discussed and planned, and since they influence the working lives of nearly two thirds of the consultant body, and cover the care pathways for an even greater proportion of our admitted patients, this is a substantial undertaking and one which requires real culture change which will not be achieved overnight 24. This is a challenging time and we are asking a great deal of all our staff but it is heartening to see that the desire for change is widespread and recognition of the scale of the task broadly understood and accepted. 25. It is planned that a sustainable position will be achieved following the implementation of Interim 2. 26. Board members should note that the changes detailed in this paper are focussed on the improvement of patient care across all unscheduled care pathways. This is transformational change and the challenges involved in successful implementation must not be underestimated. A sustainable position will be achieved by 24 June. 27. The Board are asked to note those actions which have been implemented, as well as those actions which are planned for implementation, in order to sustain improved performance against the four hour standard across the Trust, and within each Emergency Department. University Hospitals of Morecambe Bay Hospitals NHS Foundation Trust - Page 10 -