WINTER CAPACITY PLAN. seamless and integrated services for our patients. Active from 1 st Nov 2013 to 31 st Mar 2014 Version 1.0

WINTER CAPACITY PLAN seamless and integrated services for our patients Active from 1 st Nov 2013 to 31 st Mar 2014 Version 1.0 1

Policy Director Jayne Tunstall Chief Operating Officer Contact Officer Adriel Lowe MSc BA Head of Resilience & Business Continuity Walsall Healthcare NHS Trust Trust Headquarters Moat Road Walsall West Midlands WS2 9PS Tel: 01922 721 172 ext. 4589 Mb: 07920 451 029 Email: adriel.lowe@walsallhealthcare.nhs.uk Winter Capacity Planning (WCP) Emergency Planning Resilience and Response (EPRR) 2

Contents 1.0 Context 5 Page 2.0 Lessons from last winter 12/13 7 3.0 Arrangements for winter 8 4.0 Aim, objectives and key actions of the winter plan 12 5.0 Risk management 14 Risk Management Tables 16 6.0 Management of patient flow 21 Patient flow through the Emergency Department diagram 25 Patient flow through the Acute Medical and Short Stay Units 26 7.0 Clinical operating principals and standards 27 8.0 Governance arrangements 29 Quality and safety assurance forums 30 9.0 Winter SITREP reporting through UNIFY2 31 10.0 Winter Action Plans 33 10.1 Diagnostics management interventions to support patient flow 33 10.2 Rapid Response in-reach into AMU 33 10.3 FEP ICT and Community Matron support for in-reach into AMU 34 10.4 Senior staff measures to improve escalation and patient flow 34 10.5 Review of complex frequent patients by specialist nurse to avoid admissions 34 10.6 In-reach model supporting AMU from specialities with hot week 35 10.7 Six-day Hot Week increasing consultant rounds and discharge potential 35 10.8 Recruitment of 40 Apprentices to reduce falls 35 10.9 Advanced Nurse Practitioner as part of Badger to stream A&E patients 35 10.10 GP Support Line into AMU 36 3

10.11 Increased HALO Hours to assist with patient handovers 36 10.12 Seasonal Flu Campaign to reduce staff sickness during winter 36 10.13 Flexing of Surgical Capacity to create additional in-patient capacity 36 10.14 Implementation of infection control measures 37 10.15 Porters support 37 10.16 Catering arrangements 38 10.17 Housekeeping support 38 10.18 Linen Services 38 10.19 HSDU support 38 10.20 Creation of additional cubical capacity in ED 39 10.21 Opening of additional capacity 39 10.22 Loss of Ward 8 from mid-february 2014 40 10.23 Additional Bedframes 40 11.0 Additional capacity considerations - Pharmacy 41 10.0 Lorenzo Cutover Planning 43 Phase 1 Go Live Cutover Planning Chart (subject to approval) 45 4

1.0 Context 1.1 The national assessment of the coming winter anticipates a challenging period ahead. The current Health Secretary Jeremy Hunt stated that, this winter is going to be tough that s why the Government is acting now to make sure patients receive a great, safe service, even with the added pressures the cold weather brings. But this is a serious, long-term problem, which needs fundamental changes to equip our A&Es for the future 1 1.2 Information received this year from The Office of National Statistics most recent data set for Walsall revealed that the Borough saw a 23.1% increase in the number of excess winter deaths across the population - up from 130 to 160 deaths 2. 1.3 Walsall Healthcare NHS Trust has experienced on-going pressures since the last winter period technically ended in April 2013 in the delivery of national access targets. Whilst the volume of patients attending has not increased, there have been unprecedented increases in the levels of admissions i.e up to 20 % which have repeatedly led to sustained pressures over particular periods for the whole health economy. 1.4 All inpatient capacity available to the Trust has now been opened (1 st April 2013) on a substantive basis. This means the Trust no longer has additional inpatient capacity to open during the winter on a sustained basis, as done in previous winter periods. A number of measures have been enacted substantively to meet the on-going increased demands since the official winter period for 2012/13 ended. 1.5 Intense remodelling of services and improved pathways has taken place to ensure the current models for delivery of Urgent and Emergency Care and associated patient pathways provide improved robust resilience within overall acute and community services, to cope with the continued sustained pressure. The Urgent and Emergency Care Improvement Programme (UECIP) is midway through its two year programme and continues to focus on improving performance and optimising patient experience. Over the next 12 months this programme aims to deliver against new Clinical Quality Indicators (CQI s), organisational effectiveness and financial efficiency. 1.6 Improvements to the models of Urgent and Emergency Care continue to take shape to position the Trust to meet both winter and future surge/pressure challenges. Current projects as part of the Urgent and Emergency Care Improvement Programme will contribute to winter 13/14 resilience. These include: - The Integrated Models of Emergency Care & Assessment Project continues to enable patients to be seen, treated and discharged as soon as clinically possible the RATs model is in place in A& E (Rapid Assessment and Treatment). - The Ambulatory Care & Short Stay Project - a short stay Unit situated on AMU has appropriate clinical pathways and models of care to support admissions avoidance, reduce length of stay and create capacity for other appropriate groups of acutely ill patients. 1 https://www.gov.uk/government/news/hunt-nhs-must-fundamentally-change-to-solve-ae-problems 2 http://www.ons.gov.uk/ons/publications/re-reference-tables.html?edition=tcm%3a77-277047 5

- The Effective Discharge Project continues to develop a fit for purpose function that drives the discharge of all patients from an inpatient bed earlier in the day and includes board and ward rounds for the daily review of patients. - The Patient Pathways for Complex Medicine Project continues to focus on reducing the number of patients staying in hospital for over 14 days by 50% over a period of time and create sustainable patient management plans. - The Clinical Support Services & Diagnostics Project continues to embed key performance indicators for diagnostic tests aimed at minimising delays in the patient pathway and enabling rapid assessment and treatment. 1.7 Joint planning and cooperative working between our primary care partners, Social Care and Inclusion, Mental Health and West Midlands Ambulance Service Foundation NHS Trust remains critical to the Trust s internal improvement initiatives. 1.8 Findings from a recent bed modelling exercise indicate a further 60-90 bed/places are required within the Walsall health economy to address predicted demand. This is in addition to the 84 bed inpatient introduced substantively in the Trust from 1 st April 2013. 1.9 A major focus for this winter will be on the creation of improved capacity within the community. Effective community provision will be critical to our model of patient flow during the winter challenge period. As a result, additional community nursing resources will be put in place in order to maximise Care Closer to Home and thus reduce/avoid hospital admissions. 1.10 On average each day the Trust continues to care for 50 clinically stable patients who no longer require an acute inpatient bed. Urgent discussions continue to take place as part of the joint planning process between health and social care partners, to agree how processes can be streamlined to minimize the number of steps required to discharge these patients into more appropriate care settings. 6

2.0 Lessons from last winter -12/13 2.1 A significant amount of planning took place in preparation for Winter 2012/13 during which time the Trust experienced an exceptional increase in admissions for patients with a higher level of acuity and patients from Staffordshire. Emergency admissions for A&E during this time provided an indicative set of figures reflective of the actual increase in demand for acute beds. In two of the weeks during this period, the Trust saw an increase of over 100 patients each week which had a direct impact on patient flow and performance. Last year the West Midlands Strategic Health Authority reported Walsall Healthcare NHS Trust saw an increase of 22% for Quarter 3 compared to the previous year for emergency admissions. 2.2 The Winter Plan Review 3 report for Winter 2012/13 was presented to the Trust Management Board on 17th April 2013 and contained a list of key issues for future learning. The Table below provides an indication of how these issues have informed the planning process for winter 2013/14. Learning from Winter 2012/13 Progress to Date Impact on planning for 2013/14 1. The Urgent and Emergency Care Improvement Programme (UECIP) needs to continue with the on-going improvements to service redesign with a particular focus on the short stay/ambulatory care model and Estimated Date of Discharge (EDD) 2. Review of infection control arrangements in the context of additional activity 3. The need to build on the improvement made with regards to patient transport and co-ordinated booking 4. The need for additional beds in both Surgery and Medicine - defining the exact requirement and how additional provision for the winter period of 2013/14 will be provided, including support services. 5. Improvement of on-site support and Director On-Call development 6. The need to focus on community development and integration of services 7. Development of robust out of hours psychiatric assessment support 8. Explore/improve the current integrated discharge team arrangements to provide greater focus to patient pathways. Short stay model has been developed; Ambulatory care has been redesigned; Patients on AMU have EDD Rapid response cleaning teams are in place; High risk areas have been demisted; 7 day working infection control team proposal developed; Ongoing review of provision A new contract is in place with West Midlands Ambulance Service NHS Foundation Trust; transport booking is undertaken centrally from the Operations Centre/Bed Bureau Two additional medical wards (56 beds) have been established along with 28 additional surgical beds Arrangements are in place for on-site senior support for responding to capacity pressures Models of care for Frail and Elderly patients are in place and the nursing model for Wraparound and rapid response have been approved. A proposal has been developed to provide a crisis team link at weekend The Urgent and Emergency Care Improvement Programme (UECIP) continues to feature as part of this year s winter preparedness. Measures for infection control and 7-day service provision have been included in arrangements for winter 2013/14. West Midlands Ambulance Service NHS Foundation Trust has plans in place for service continuity during severe weather conditions and for responding to increase demand. Having made the previous winter capacity substantive throughout the year, the Trust no longer has any surge capacity available for further pressures. Arrangements will continue through winter with a view to further enhancing arrangements. These services will continue to develop through the winter, with the recruitment of community nursing teams to further enhance care closer to home Intended specifically for Walsall during winter-pending confirmation Recruitment of Care Group Manager to focus on Patient Flow management 3 Tunstall, J and Gibara P (2013) Trust Management Board Report, Winter Plan Review 12/13, 17 th April 2013 7

3.0 Arrangements for Winter 3.1 The Trust has undertaken a significant amount of internal planning and partner engagement to ensure arrangements for responding to seasonal challenges are resilient. Occupancy of 92% has been modelled based on the Key Performance Indicators within the Integrated Business Plan. Assumptions have been made that our length of stay will not worsen during the winter period given the service improvements made and the fact that the level of acuity of patients has not improved since last winter. 3.2 The current number of beds has been base lined at 521. This figure represents: - 44 Acute Medical Unit beds (3 beds, 1 trolley assessment and 40 short stay beds) - 248 Medical Beds - 141 Surgical Beds - 56 Maternity Beds - 18 Paediatric Beds - 6 Intensive Therapy beds - 8 High Dependence Unit beds 3.3 (These detailed figures include 28 extra surgical beds and 56 additional medical beds, substantively established in 13/14 (previously used as winter capacity 12/13) in readiness for combined admission increase and winter planning.) 3.4 With regards to additional provision of ITU/HDU beds, there is potential to increase bed stock by an additional 2 bed by utilising capacity within Theatre Recovery for ITU/HDU as required. However, any additional requirement will be directed to the Critical Care Network. 3.5 Community beds also form part of the Trust s capacity. There are: - 36 Integrated Care Team (ICT) Supported beds (21 Hollybank House, 15 Richmond Hall) and - 34 Complex Discharge beds (Swift Discharge Suite) based at Walsall Manor Hospital site commissioned by CCG and Social Care. 3.6 The CCG through the use of potential non-recurrent Winter Pressures allocation are seeking to provide further resilience through the increased use of spot purchasing and additional intermediate care support by procuring an additional 20 (virtual) beds within Intermediate Care and 25 nursing home spot purchase beds. 3.7 As previously stated our high-level assessment of capacity for winter 2013/14 is that to accommodate activity at similar levels to 2012/13 and manage peaks in demand we will need a further mixed provision of 60 90 (beds, places, care packages or care closer to home). Further increases above 2012/13 levels would require further beds for planning purposes we are working on an extra 50. 8

3.8 Additional capacity available (for the entire winter period) within the Trust will equate to a total of 8 beds. In extreme circumstances the Cardiac Unit 6 beds would also be used for acute inpatients) but, limited to when procedures are not been carried out. 3.9 The Urgent Care Board is working collaboratively for the provision of additional resource and capacity (equivalent to between 10 and 20 beds) throughout the winter. A multi-agency surge plan for the Walsall Health economy has been submitted to NHS England. A number of initiatives included within the plan to address the shortfall in capacity require further clarification, development and finalisation in order for this plan to be robust and enacted. - GP direct admission to Swift Ward; - Diversionary pathways; - End of life pathways; - GP in a car - Mental health initiatives. - Risk Stratification - Sign posting patients to acute medical clinics - Strengthening the intermediate care team - Including additional therapy staff - Admission avoidance through the intervention of Integrated discharge team in A&E - Investment in community nursing to enable expansion of case management and Intermediate Care Team has been agreed part year funding to support care closer to home - Additional nursing home placements (>20) - Agreement with CCG to spot purchase an additional nursing home placements (>25) - Geriatrician review in A&E - Post discharge planning alongside Reablement services to ensure the patient is supported in the community to prevent readmission - The Trust is in discussion with external community care providers in order to explore the possibilities of supporting Rapid Response service provider - Additional social care investment in Reablement (circa. 10 beds) 3.10 The Trust is currently in the process of establishing substantive additional medical and surgical bed (84) staffing (including community services) is as follows: Surgical and medical beds - 40WTE qualified nurses - 42WTE Clinical Support Workers - 2WTE Occupational Therapists - 2WTE Physiotherapists - 4WTE Pharmacists 9

- 2WTE Discharge Coordinators - 3WTE Housekeepers - 3WTE Porters Community - 420k for 13/14 (part year investment) - 14WTE Community Case manager staff nurses - 4WTE Nurse Practitioners - 2WTE Clinical Sisters - 2WTE Physiotherapists - 2WTE Occupational Therapists - 2WTE Assistant Practitioners - 4 Therapy Support Workers 3.11 The Trust is making 213 nursing and Clinical Support Worker appointments which includes the investment plan and vacancies. Some 86 staff have commenced; 53 appointments are due to commence; and 74 appointments are outstanding (36 Registered Nurses and 38 clinical support workers) 3.12 In order to recognise the growing complexity of frail elderly patients the Trust is also recruiting an addition 40 apprentices to support the falls and dementia pathway. Other recruitment initiatives include: A&E - 17 WTE Nurses Band 5 - These additional staff represent a combination of substantive appointments and winter staff in readiness for the winter period 3.13 In the last 12 months the Trust has invested in the following number of consultants to ensure the development of short stay acute medicine / ambulatory care, 6 day consultant cover on speciality wards and sufficient numbers of A&E consultants for rapid assessment processes: 10 - A&E 2 additional Consultant posts (takes the establishment to 6 consultants) - AMU 4 additional Consultant posts (in post takes the establishment to 6 acute physicians) - Ward 12 & 14 - Medical Wards: 2 Consultants in post (locum) 2 Staff Grades (locum) 2 FY2s - Cardiology 1 additional Consultant post (appointed commences Nov 13) - Gastroenterology 1 additional Consultant post (in post) - Respiratory 1 additional Consultant post (appointed commences Nov 13) - Elderly Care 1 additional Consultant post (currently vacant)

Maternity - 3 Middle Grades paediatrics 3.14 As ever, the invaluable role played by volunteers, stakeholders, corporate partners and our staff remains key to ensuring our services and pathways remain aligned to maximise the delivery of seamless integrated services for our patients at all times. 3.15 Section 10 provides a further outline of the action and contingency arrangements for Trust-wide services. Included, are arrangements that have been put in place on a substantive basis due to the significant on-going pressure experienced. The plan also includes temporary initiatives designed to address the expected increase in capacity over the winter period. 11

4.0 Aim, objectives and key actions of the winter plan 4.1 The focus on continuous improvement of patient pathways and services (within the community and acute setting) and integration of acute and community services for adults and children has continued to act as a key driver over the last 12 months and will continue to do so. 4.2 In April 2013 the Trust launched Our Year of Integration as part of the continued process of meeting strategic priorities and to sharpen focus on design and delivery of services, through a pathway approach and to ensure all other services are as seamless and integrated for our patients as possible with care closer to homes wherever possible. 4.3 The Trust s main strategic priorities are: - Improving the patient experience - Delivering high quality care - Making the best use of our resources. 4.4 This winter plan sets out how the Trust will: - maintain resilience over the winter period in detail - manage and improve patient flow including discharge - focus on maximising independence models of care for our patients - ensure alignment with arrangements with health economy and social care partners 4.5 The Plan reflects work undertaken across hospital and community based services and by partners to implement robust, effective and timely preparation for additional pressures brought on by winter. 4.6 The outcome sought throughout this period, is the uninterrupted provision of high quality, timely care an effective contribution to how the health and social care system as a whole manages winter, seasonal flu, and other pressures that present real resilience challenges. 4.7 The aim of the plan is: To underpin the continuity of safe, resilient, good quality integrated services and provide response flexibly for managing seasonal pressures. 4.8 The above aim will be achieved by the following objectives: a. Ensuring divisional and service level action plans and arrangements for managing increased pressure are in place across the Trust and documented as part of the detailed Trust Winter Plan - Action plans and arrangements for responding to capacity pressures on hospital and community services are detailed in Section 10.0 12

- A table-top exercise has been planned to test Trust and partner plans triggers, actions, interoperability and specific measures taken when patient demand across the Walsall Healthcare system experiences severe pressure and patient flow is disrupted. b. Ensuring risks are appropriately managed which includes identifying areas of risk and ensuring specific, suitable and measurable mitigations are put in place and monitored - A matrix detailing risks is set out below in section 5.0. c. Ensuring measures for the management of patient flow in and out of care settings across the health economy are in place, document and monitored - A detailed description of key factors that are critical to ensuring effective patient flow are set out below in section 6.0 d. Ensuring clinical operating principals and standards are monitored throughout the period of pressure to ensure the patient safety and experience is of the highest standard - Clinical operating principals and standards are set out at section 7.0 e. Ensuring governance arrangements established for the sole purpose of providing strategic, tactical and operational level oversight and timely direction throughout the winter period are in place and include partner participation - A timetable setting out forums, frequency terms of reference and membership (from internal divisions and external partners) is set out at section 8.0 f. In addition to the governances arrangements requirements for SITREP reporting to NHS England through the UNIFY2 system are set out in section 9.0 g. Ensuring appropriate preparedness planning is in place for severe weather and the Christmas and New Year holiday periods - The severe weather plan is at Appendix I - Planning has begun to develop the Trust s Christmas and the New Year plan to be released on 1 st December 2013 13

5.0 Risk Management 5.1 The Department of Health highlighted eight key areas deemed vital to ensuring all services and winter planning arrangements across local health and social care systems are well coordinated, responsive and resilient. Measures have been actively taken to manage risks associated with each of these key areas and to ensure mitigation strategies are included in plans across the Trust. The eight key areas are: - Handover of patient care from West Midlands Ambulance Service - Operational readiness (bed management, capacity, staffing and New Year elective restart etc.) - Out of hours arrangements - NHS/Social Care joint arrangements and work with Walsall Council to prevent/avoid admissions and speed discharge - Links between West Midlands Ambulance Service NHS Foundation Trust, Walsall CCG and the Trust - Critical care services - Preventative measures, including flu campaigns, infection control and pneumococcal immunisation programmes for patients and staff - Communications 5.2 In addition to these key areas, care has been taken to ensure objectives orientated towards achieving the Trust's organisational vision, to, 'provide first class integrated care for the people we serve in the right place at the right time', remain resilient. These objectives centre on: - First-class patient experience consistently providing all of our patients with a first class experience - Safe, high quality services continued focus on high standards of care in both hospital and community (including good management of infection control, pressures sores, falls and nutrition and dignity) and reducing hospital mortality rates; and improving care for older people and end of life care - Integrated care working with hospital and community teams, social care and GP colleagues to ensure services are able to be wrapped around the patient - Engaged and empowered workforce ensuring staff are engaged and supported in successful delivery of services - Good use of resources continued delivery of the Cost Transformation Programme 5.3 An additional significant risk faced by the Trust is the implementation of a new IT system programme during this period. Lorenzo is the Trust s new Patient Administration System (PAS) which is replacing the community ipm System and the acute PAS system. Replacement requires downtime of current and downstream systems that interface with the PAS in order to be successfully implemented. 5.4 In excess of 2000 end user will need to be trained in a two month period spanning January 2014 to February 2014. Downtime disruption of critical systems and the demand placed on staffing 14

resources due to training requirements will occur during the height of demands placed on the Trust from winter pressures. 5.5 Transfer to a new IT systems during the period where the Trust experiences significant sustained pressure (which may be intensified by the onset of severe weather episodes) will serve to further complicate operational difficulties across the winter period. 5.6 Further details regarding mitigation strategies adopted and actions put in place to manage the risk of disruption to the areas above are outlined in the 'Table for the Management of Identified Pressures and Other Risks Associated with Winter' below. 15

Risk Management Tables 5.7 Poor operational readiness and inefficient bed management; failure to identify/create additional bed capacity; failure to recruit required staffing levels which reduce ability to staff clinical areas; and New Year elective re-start. Impact Mitigation Actions Risk Owner(s) Lapse in standards of care offered patients resulting in poor patient experience, harm and/or loss of staff confidence in management; breach of acceptable patient waiting and ambulance turnaround times leading to financial penalties. (Patients arriving via ambulance must be handed into clinician care within 15 minutes. This is a maximum handover time placed on Ambulance and Acute Trusts to ensure patient safety and quality of care, and is expected to be achieved at all times. After 30 minutes with no recorded handover time 200 penalty will be applied After 60 minutes with no recorded handover time 1000 penalty will be applied) Substantive establishment of 84 additional beds; 56 in medicine across wards 12 and 14; and 28 additional beds across surgical wards. Recruitment of up to 40 additional nursing staff to support winter pressures to provide cover for the winter and reduce reliance/use of agency staff and maximise efficient use of resources Implementation of step change plans for reconfiguration of elective activity throughout winter period in order to increase day case activity Identification of shortfall in capacity and schemes worked up with partner organisations to bridge the gap of 60-90 beds. Paul Gibara Angie Wallace Sue Wakeman Sue Hartley Angie Wallace Jane Tunstall 5.8 Unserviceable levels of demand for critical care services Impact Mitigation Actions Risk Owner(s) - Increased risk to patients in need of ITU and HDU services - Implementation of West Midlands protocol/contingency arrangements for responding to/managing excessive pressure within ITU HDU (captured within the Birmingham and Black Country Critical Care Network) by requesting assistance from Network - On-going participation in the Birmingham and Black Country Critical Care Network which require twice daily reporting this involves levels of patients (1-3) and beds Paul Gibara Paul Gibara 16

Risk Management Tables cont 5.9 Severe cold weather Impact Mitigation Actions Risk Owner(s) - Increase in risk posed to vulnerable members of the community from severe cold temperatures - Disruption to road networks and transportation services with adverse impact on staffing arrangements - Disruption to delivery of community services due to inaccessible side roads - Work with partner agencies (including those beyond the boundary of Walsall) to develop specific severe winter plan and ensure arrangements for cold weather are communicated and implemented effectively across Trust - Development of business continuity measures to facilitated continuation of critical services to vulnerable clients during periods of severe weather including arrangements for managing the risk posed to vulnerable people by cold weather by maintain appropriate temperatures - Implementation of arrangements for gritting the manor site to ensure ambulance access to A&E and all roads and footpaths are maintained free from snow and ice formations and are gritted. Adriel Lowe Deputy Divisional Directors Colin Plant/ Alan Walsh 5.10 Failure to maintain safe, high quality services and continue focus on high standards of care in both hospital and community Impact Mitigation Actions Risk Owner(s) - Monitoring of Key Performance Indicators - Lapse in standards of care offered patients resulting in poor patient experience, harm and/or loss of staff confidence in management - Reporting and monitoring through the winter dashboard - Review of key issues as part of the agenda across Winter Resilience Assurance Framework meetings - Ensure appropriate staffing is in place to meet demand and capacity requirement Jayne Tunstall Sue Hartley Amir Khan 17

Risk Management Tables cont 5.11 Short term, widespread sickness including poor roll out and take up of preventative measures, including flu campaigns and pneumococcal immunisation programmes for patients and staff Impact Mitigation Actions Risk Owner(s) - Disruption to services which may include an inability to staff wards and support services - Raise profile of flu campaign across the Trust and promotion of flu and infection control campaigns to staff via communications media such as Chief Executives Update - Revise and refresh business continuity arrangements for loss of staff Val Woodruff David Shakespeare Deputy Divisional Directors: Paul Gibara JO Newens Angie Wallace Colin Plant 5.12 Failure to provide sufficient capacity to meet winter requirements for patients who need on-going winter care and wraparound services [Integrated care working with hospital and community teams, social care and GP colleagues to ensure services are able to be wrapped around the patient] Impact Mitigation Actions Risk Owner(s) - Lapse in standards of care offered patients resulting in poor patient experience, harm and/or loss of staff confidence in management; breach of acceptable patient waiting and ambulance turnaround times leading to financial penalties - Development of new model of care with additional investment into intermediate care team and wrap around service for the frail elderly - Partner organisations investment in scheme aimed at creating additional capacity to the number of 60-90 beds to be approved through the Urgent Care Board Paul Gibara Jayne Tunstall 18

Risk Management Tables cont 5.13 Failure to deliver estates and information management & technology strategies i.e Failure to mitigate disruption created by Lorenzo forced system downtime period (Go live date is 2nd March; Wednesday 26th February data snapshot and manual recording of records commences) Impact Mitigation Actions Risk Owner(s) Downtime of current and downstream critical information systems Significant training demand in excess of 2000 staff to be trained between Jan and Feb 2014 (The project has a large data migration element and includes temporary disruption to community and Acute PAS systems. Arrangements will be required for dual recording of data and there will need to be a significant catch-up process to enter uncaptured data. This will have an impact on staffing resources and dedicated strong leadership will be required at all levels to ensure data quality is upheld.) (The level of complexity is increased due to: potentially poor data quality in the McKesson Star system, the requirement for merging different and distinct data, service re-designs within the Trust whilst a new system is being implemented.) Continued processes for data backup to ensure fast recovery or roll back and Reduced downtime period in order to significantly reduce any roll back that may be invoked Phased shut down of services (ipm at midnight on 28 th Feb 2014; Out Patients PMS 00:00 hrs. on 28 th Feb 2014 and In-patients and A&E PMS at 06:00 hrs. on 2 nd March 2014) to lessen disruption Detailed Cutover planning to include hour by hour and minute by minute actions and reporting over the Cutover period Establishment of command and control arrangements with regular Battle Rhythm (contact calls and reporting times) established from 26 th Feb to end of March 2014; also to include automation of information reports/systems Appointment of dedicated cut over manager to coordinate the planning and response activities over the period Full system dress rehearsal to take place on 8 th and 9 th February 2014 in order to rehearse cutover activities Development and resources of a detailed floor waling plan aimed at providing trouble shooters in Acute and Community settings (depending on need) Ensuring continued staff cover through implementation of staff annual leave management and continued work with divisional directors to ensure awareness of risks and mitigations and alignment to plans to meet operational needs Detailed planning for Lorenzo implementation monitored through Lorenzo Board chaired by Chief Executive. A separate detailed operational implementation plan is currently in development for the Go live period by the Chief Operating Officer and the Operational teams Lorenzo Programme Board Lorenzo Programme Board Lorenzo Programme Board Lorenzo Programme Board Lorenzo Programme Board Lorenzo Programme Board Lorenzo Programme Board Lorenzo Programme Board Lorenzo Programme Board 19

5.14 Loss of ward 8 from mid-february due to ICC Unit being developed in the area above: West Wing Reception Impact Mitigation Actions Risk Owner(s) - Loss of 9 beds bed spaces inclusive of 2 side rooms - To delay the loss of ward (in creating the Integrated Critical Care Unit) by reallocating a possible start date that may result in no impact during the current financial year. Colin Plant 20

6.0 Management of patient flow 6.1 The Urgent and Emergency Care Programme, now fully established, provides an effective focus on rapid assessment and management of patient flow and the maintenance of safe, high quality care at all-time including period of peak activity (see diagrams below). The Emergency Department Operational Policy, ratified in June 2013, sets out patient flow processes and associated interventions from healthcare professionals, clinical and non-clinical support services and Emergency Department Staff. A key outcome is the improvement of the patient experience, by: early assessment and signposting to appropriate pathways reduction in waiting times for diagnostic tests, and admission avoidance 6.2 The Intensive Support Team has worked with the Trust and have endorsed the changes made to redesign patient flow and support additional activity and efficiency Hot week working 6.3 Each specialty is working towards establishing a 6 day Hot week where the Consultant on Call focuses solely on emergencies and undertaking ward rounds to expedite discharge. This is currently in place for half of all medical wards; arrangements for the remaining wards will be brought on line by Dec 2013. Hot weeks have been planned for: - AMU; Wards 12, 14 and 16 (currently in place) - Ward 17 (will commence hot weeks during Nov/Dec 2013) - Wards 1, 3 and 4 (will implement hot weeks once the full complement of elderly care physicians have been recruited). Use of Estimated Discharge Dates (EDD) 6.4 The use of EDD across all medical wards is being established ahead of the commencement of winter pressures and form part of daily Board Round linked to Ward Round professional standard. We will continue to focus on the effective use of these dates to enhance patient flow. Admission avoidance pathways 6.5 As part of ambulatory care development a number of admissions avoidance pathways will continue to support patient flow during peak and non-peak periods. These include: - Frail Elderly Pathway (FEP): - Deep vein thrombosis (DVT): - Cellulitis: 21

- PE (Pulmonary Embolism): - UTI (Urinary Tract Infection): - Non-cardiac chest pain: - Hypoglycaemia: Diagnostics turnaround 6.6 Turnaround response times for imaging and pathology tests have been agreed to support the emergency 4 hour clinical standard to ensure timely diagnostics are undertaken and results are available to aid discharge and patient flow. In addition a short turnaround time (72 hrs.), aimed at maximising flow in short stay, has been agreed with AMU. Performance monitoring 6.7 A performance framework tool has been developed to measure the Key Performance Indicators against the trajectories formulated for each of the project areas within Urgent and Emergency Care Programme. Discharge lounge 6.8 The discharge lounge will continue to operate from its current location and provide a flexible service responsive to demand pressures placed on the Trust and ensure the timely and appropriate vacating of in-patient beds. Managing elective activity 6.9 An impact assessment has been undertaken in relation to reconfiguring elective activity to create a 19 week winter plan. The initiative seeks to provide 8 additional capacity inpatient beds between 20 th January and 29 th March 2013. This provides an additional month of capacity when compared to the 2011/12 winter measures, whilst taking referral to treatment time (RTT) into consideration. 6.10 The plan involves: - Increasing In-Patients and decrease Day Patients between 18th Nov to 13 Dec 2013 - Not running routine elective cases at all with the exception of backs and clinical priority cases between 16th Dec 2013 to 17th Jan 2014 - Increasing day cases and decrease in-patients with the exception of clinical priority patients between 20th Jan to 29th Mar 2014 in order to maintain 18 week performance 6.11 Implementation of these arrangements will also require the Trust to increase trauma lists, emergency theatre lists and out-patients clinics for the period 16 th Dec 2013 to 17 th Jan 2014 due to reduced theatre activity. (Trauma lists will be increased by 3 sessions per week and emergency lists by 3 sessions per week during this period.) This will allow bed capacity to be released in the 22

Day Case unit (up to 8 beds in total). This measure is mindful of cooperation required from support services and the impact on paediatrics as winter sees an increase in activity for paediatrics. Surgery will be required to ensure input is not increased through ward 21 and will seek, where possible, to reduce paediatric surgery. Managing patients with high risk of admission in the community 6.12 Work has been undertaken to produce data sets identifying patients of highest risk of admission during winter in order to inform discussions with CCG and GP partners and appropriately targeted actions. The data enables the Trust to look forward to predictions and shows 57 patients with 90% chance of becoming high impact users in the next 3 months. These are notably all from the most deprived postcodes and only 50% from >60 yrs. of age. 4 This data is being shared with community nursing to enhance patient profiling and manage patients in the community to avoid hospital admissions. 6.13 Community caseloads currently use Canar alert and all patients deemed at high risk of admission are included on vulnerable patient registers linked to Fusion. District Nursing and Community Matrons aim to reduce the risk of admission via appropriate care plans. However, where patients are admitted to hospital the responsible team are alerted and the community matron within each team liaises with the relevant ward with a view to reducing, where possible, length of stay without compromising safety and quality of care. Meetings are also held with GP and Community Matrons as part of the risk stratification DES process to identify these types of patients for on-going care. 6.14 A named nurse initiative has recently been introduced where nurses are allocated patients as a sub-set of the overall caseload. The named nurses are now responsible for the on-going coordination care for specific patients. This forms part of the Wraparound model and the progression of locality based model. 6.15 In order to provide support during periods of high demand, arrangements are in place for in-reach from community matrons; weekend in-reach from the community matrons on duty to AMU; and close partnership working with the FEP team in order to try and minimise patient stay and ensure more appropriate care settings. Management of Community Patient Flow 6.16 Community Services Patient Flow is managed in two ways:- 6.17 Planned Care will take direct referrals from Primary Care and Acute, providing a focus on triage, appropriate assessment and treatment maintaining safe, high quality care at all times. 6.18 The District Nurses will plan their workload prioritising the caseload and at regular intervals review and discharge patients facilitating capacity for new referrals. 6.19 District Nursing also take step-down IV Therapies as part of patient flow from Intermediate Care Services. Unplanned Care (Intermediate Care Services) 4 Information supplied by James Avery, General Manager to Medical Directorate, Trust HQ, Walsall Healthcare NHS Trust 23

6.20 Unplanned Care (Intermediate Care Services) work in collaboration with both Community and Urgent and Emergency Care Services. The team will respond to Community i.e. GP, Social Care, West Midlands Ambulance Service NHS Foundation Trust within a 2 hour timeframe taking stepup patients who are clinically compromised. They will see assess, treat and access diagnostics. Once stable will discharge from caseload wither fully discharge or sign posting onto another site. 6.21 ICT also manage crisis interventions for other services such as COPD, End of Life, out of hours avert the crisis stabilise then hand back to the specialist teams at the earliest point. Use of Estimated Discharge Dates (EDD) 6.22 As part of the step down ICT utilise estimated dates of discharge providing information to Bed Capacity and Integrated Discharge Service to support Acute Patient Flow. Admission avoidance Pathways 6.23 Within the Community setting ICT / Rapid Response take direct referrals from West Midlands Ambulance Service (WMAS). They will respond in 2 hours but as little as 30 minutes following direct clinician- to clinician discussion, the aim being to avert an avoidable Hospital admission. 6.24 In addition ICT support a number of avoidance pathways which in turn support Patient Flow during peak and non-peak periods. These include:- - Frail Elderly Pathway (FEP) - Deep Vein Thrombosis (DVT) - Cellulitis - Pulmonary Embolism (PE) - Heart Failure - Minor Head Injury - Multiple Sclerosis Relapses (MS) - Urinary Tract Infection (URTI) - Hypoglycaemia - All of the above are either as completely Community Nurse Led programmes as part of Hospital Avoidance or - as step down from A & E, AMU, Acute beds. 24

Patient flow through the Emergency Department 25

Patient flow through the Acute Medical Unit and Short Stay Unit 26

7.0 Clinical operating principals and standards 7.1 This section sets out a series of key principles and standards, applicable to all areas, to assist patient flow whilst maintaining service quality and patient experience. These are in line with recommendations made by the DOH Intensive Support Team. 7.2 The Accident and Emergency Dept should primarily be accessed for serious and life threatening conditions and therefore all patients will spend as little time as possible within the A&E Department and in any event will not spend more than 4-hours waiting wherever possible 7.3 All patients will undergo triage within 15 minutes of attending A&E 7.4 All patients in A&E requiring assessment or admission will be pulled into the appropriate department or speciality bed within the 4-hour waiting time, and will be assessed where required by an appropriate decision maker working to a service agreed care pathway 7.5 As part of the Urgent and Emergency Care Improvement Programme (UECIP) the rapid assessment and treatment model continues to operate in A&E between 10:00 hrs and 19:00 hrs. The model provides a dedicated nurse and consultant in A&E for receiving patients allowing more clinical decisions to be made earlier 7.6 All specialties will adopt a case management approach 7.7 Reablement will be offered where appropriate to allow considered decisions about long-term care 7.8 All specialities will work towards agreeing the criteria for criteria led discharge, in the first instance, for the top 10 clinical conditions 7.9 All areas will adopt Estimated Date of Discharge (EDD) principles and work towards embedding Estimated Time of Discharge an maximise its effectiveness in aiding patient flow. 7.10 Any proposed change to the EDD will only be agreed by the consultant in charge of the patients care (regardless of reason for change) 7.11 All specialities will review all emergency patients daily six days a week and adopt a multi professional board/ward round approach to be completed each morning before 09:00 hours wherever possible based on clinical need 7.12 All specialities will agree Professional Standards relating to urgent and emergency care and these will be reported to Divisional and care group meetings 7.13 Appropriate elective beds will be ring fenced where possible 7.14 All patients will be assessed and wherever possible will be discharged via the Discharge Lounge if clinically appropriate 7.15 Patients agreed for discharge at the Board / Ward Round will be discharged before 13:00 hrs. as appropriate. 7.16 Specialities will provide appropriate in reach to admission areas to: 27

a. Provide specialist support in inpatient management b. Ensure appropriate patients are identified and rapidly moved to speciality wards c. Discharge/early supported discharge is expedited by specialist opinion/community management 7.17 Further to the principles detailed above, a process of escalation and professional standards will be agreed and implemented by the professional clinical leads. 28

8.0 Governance arrangements 8.1 There are three governance mechanisms in place that will ensure clinical operating principles and standards set out above are maintained and quality and patient safety standards are not compromised throughout the winter period. With the exception of the Winter Resilience Assurance Framework, each of the governance mechanisms is well embedded within the operational arrangements of the Trust. The three governance mechanisms for winter preparedness and response are: i. Ward Audits ii. iii. Quality and safety structures Winter Resilience Assurance Framework 8.2 Internal governance of the implementation of arrangements for winter is through the Trust Management Board. The Board will receive reports on: a. proposed plans for winter b. monitoring the monthly feedback on progress against the plan c. risk mitigations put in place d. overall performance against professional standards. 8.3 In terms of the partnership governance arrangements for the wider economy, formal reporting will be via the Local and The Black Country Emergency Care Network around winter resilience plans. 8.4 Detailed operational monitoring of the plan will be undertaken at monthly divisional reviews and weekly Operations Committee meetings. Progress reports will be brought to monthly meeting with detailed exception reports and actions to recover the expected trajectory. The Trust Management Board will be provided with a summary report. 8.5 A winter dashboard will be produced weekly by the Performance Information Team to provide aggregated data incorporating appropriate measures relating to performance, quality, risks and patient safety. This will also be constantly monitored by the Operations Committee to ensure real time impacts can be clearly identified and acted upon. 8.6 A full table of forums with responsibility for monitoring performance and compliance throughout winter are set out below. 8.7 Clarification is still being sought from the Department of Health regarding how winter reporting will be managed. Daily winter situation reports (SITREPs) will be submitted through the UNIFY2 system (and further details regarding UNIFY2 reporting are set out in section 9.0). 29

Quality and safety assurance forums MEETINGS FREQUENCY TERMS OF REFERENCE MEMBERSHIP & CHAIR Trust Management Board Monthly Review overall performance review update reports issues relating to winter and quality and safety Executive Directors Divisional Directors Clinical Directors Quality and Safety Committee Monthly (second Thursday of each month) Review of dashboard and reports on quality and safety performance (Chair: Non-Executive Director) Chief Executive Chief Operating Officer Medical Director Nursing Director Non- Executive Director Directors of Nursing Heads of Nursing Associate Medical Director Divisional Quality Team Monthly Reviews quality and safety issues escalated from Care Group Quality Teams and escalates to Quality and Safety Committee as appropriate (Chair: Associate Medical Director) Associate Medical Director Heads of Nursing Matrons Clinical Directors Care Group Quality Team Fortnightly Clinical Director Reviews Monthly Fortnightly Reviews quality and safety issues and escalates to Divisional Quality Team Safety Committee as appropriate (Chair: Clinical Directors) Clinical Directors Matrons Doctors Nurses Allied Health Professionals Care Group Manager Clinical Directors Matrons Doctors Nurses Allied Health Professionals Thursday Peer Reviews Weekly Weekly Peer review communicating with patients, friends and family and examine falls; pressure ulcers; comfort rounds Senior Sisters Matrons Heads of Nursing MEETINGS FREQUENCY TERMS OF REFERENCE MEMBERSHIP CAPACITY MEETINGS CLINICAL WINTER RESILIENCE FORUM PATIENT TRACKER MEETINGS (Acute) PATIENT TRACKER MEETINGS (Intermediate Care Beds) WINTER RESILIENCE COMMITTEE 3 times a day Fortnightly from Mid Nov Med Dec Weekly from Mid Dec Mid Feb 2013 Fortnightly from Med Feb - 28/02/13 Daily Weekly Fortnightly from Mid Nov Med Dec Weekly from Mid Dec Mid Feb 2013 Fortnightly from Med Feb 28/02/13 Ascertain bed capacity Manage breaches Consider clinical solutions to capacity issues Lessons learnt Dashboard Analysis each individual patient who is clinically stable Agree next action Support for escalation Agree EDD Agree next action Support for escalation Agree EDD/exception report against EDDs not met Consider current situation across health and social care economy Lessons learnt Heads of Nursing Care Group Manager for Patient Flow Deputy Divisional Director for Medicine and Long-Term Conditions Medical Director (Chair) and representation from: AMDs Clinical Directors All Consultants Director/Deputy Dir. of Nursing Heads of Nursing Divisional Directors Chief Pharmacist; Infection Control Social Care Chief Operating Officer Divisional Directors Heads of Nursing Discharge Coordinators Social Care Independent Discharge Team Rep Ward Managers GP Lead therapist Lead nurse Chief Operating Officer (Chair Communications Divisional Directors Senior Nurse A&E Operations Centre Infection Control Community Services Mental Health Pharmacy Badger Hospital Ambulance Liaison Officer CCG Independent Discharge Team Social Care The Winter Resilience Committee will meet for 1 hour on the following dates: Wednesday 6 th November 2013 (14:30 hrs.); Wednesday 20 th November 2013 (09:00 hrs.); Wednesday 4 th December 2013 (14:30 hrs.); Wednesday 17 th December 2013 (13:00 hrs.); Tuesday 23 rd December 2013 (11:00 hrs.); Monday 30 th December 2013 (11:00 hrs.); Monday 6 th January 2014 (14:00 hrs.); Tuesday 14 th January 2014 (14:00 hrs.); Monday 20 th January 2014 (14:00 hrs.); Monday 27 th January 2014 (14:00 hrs.); Monday 3 rd February 2014 (12:00 hrs.); Tuesday 11 February 2014 (16:00 hrs.); Tuesday 25 th February 2014 (14:00 hrs.); Tuesday 11 March 2014 (16:00 hrs.) and Tuesday 25 th March 2014 (14:00 hrs.) WEEKEND PLANNING & REVIEW GROUP 30 Weekly (Thursdays @ 13:00 hrs) To be convened in periods of severe or extreme capacity pressure CAPACITY COMMITTEE Escalation Mode - TBA As above but will includes PCT, Local Authority and Ambulance representation Patient flow focus Health and social care Agree operational plans On Call Director Divisional Directors Deputy Divisional Directors (Chair) Heads of Nursing A&E Operations Centre Rep IDT Team Rep Pharmacy Rep Chief Operating Officer Medical Director Director of Nursing Clinical Directors Heads of Nursing Associate Medical Directors, and representatives from: IDT; Divisions; A&E; Paeds; Community Nursing Leads; Capacity Team; Estates (SFS Rep); Theatre Matron; Intermediate Care; Divisional Director Infection Control

9.0 Winter SITREP Reporting through UNIFY2 9.1 On 4 th October 2013 Monitor, the TDA and NHS England issued a joint letter to Trusts regarding preparations for winter 2013/14. The correspondence set out arrangements for the reporting of local winter-focussed delivery information and reflects the changes to the system this year timely and accurate reporting of this delivery intelligence is a key element of effective winter management and crucial to providing early indications of any emerging problems which can then be responded to. 9.2 UNIFY2 will again be used for reporting local winter pressures and the daily SITREP and supporting guidance has recently been updated. Further clarity regarding SITREPs contents is expected from the TDA shortly, but current expectations are that they will record/report on: temporary A&E closures; A&E diverts; ambulance handover delays over 30 minutes; trolley-waits of over 12 hours; cancelled elective operations; urgent operations cancelled in the previous 24 hours; and those operations cancelled for the second or subsequent time in the previous 24 hours; availability of critical care, paediatric intensive care and neonatal intensive care beds; non clinical critical care transfers out of an approved group and within approved critical care transfer group (including paediatric and neonatal); bed stock numbers (including escalation, numbers closed, those unavailable due to delayed transfers of care etc.); and details of actions being taken if trust has considers that it has experienced serious operational problems. 9.3 The quality of daily SITREPs remains extremely important, along with their timely completion. Daily reports are required from acute hospitals only and it is the Trust s responsibility to ensure their return is accurate, complete, and fit for purpose. 9.4 In order to ensure that the NHS England Operations team can complete collation of daily figures and publish the data on the UNIFY2 system, returns must be provided by no later than 11am. This will allow for publication on UNIFY2 where reports can be accessed by local and regional stakeholders to monitor and address any operation problems resulting from these pressures. 9.5 Daily SITREP reporting will commence from Monday 4 th November 2013 and reporting requirements will be reviewed at the end of February 2014. This means that the first collection will be on Tuesday 5 th November 2013 in respect of the previous 24 hours up to 8am on that day. Monday s SITREP covers the period from 8am Friday morning to 8am Monday morning. As above, the Trust is required to submit our return by 11am daily. 9.6 For the Christmas period, it is intended that information covering 8am 24 th December 2013 until 8am 27 th December 2013 will be submitted in a single SITREP on 27 th December 2013. There will 31

be no SITREP on 1 st January 2014. The SITREP on 2 nd January 2014 will cover the period from 8am 31 st December 2013 to 8am on 2 nd January 2014. 9.7 Please note that although daily SITREPs via UNIFY2 are only required on working days, serious operational problems, which occur on non-working days, must be reported by Trusts by 11am the following day in order for information to be fed into daily reporting arrangements. 32

10.0 Winter Action Plans 10.1 Diagnostics management interventions to support patient flow Outline of Initiative Lead Officer Divisional Director Contact (via visit or phone call) will be made by a diagnostics manager at 09:00 hrs. and 14:00 hrs. Monday to Friday specifically aimed at minimising or avoiding delays caused by diagnostic tests and enable rapid assessment and treatment. In addition measures that will facilitate flow across winter weekends now in place include: Formation of routine inpatient CT sessions on Sundays Radiologist in-patient ultrasound sessions on Sundays Additional report typing capacity and additional evening support to A&E Jo Lydon/Trefor Watts Paul Gibara, Divisional Director of Medicine and Long-term Conditions Jo Newens, Divisional Director of Women s, Children s and Clinical Support Services. 10.2 Rapid Response in-reach into AMU Outline of Initiative Lead Officer Divisional Director Further development of Rapid Response as part of the community nursing remodelling will enable the team to inreach into AMU as part of the 7-day service provision to support reduction in length of stay. This includes: - 1 Nurse daily (Mon-Fri) - 1 Community matron (Sat & Sun) - From 1 st November a medical lead will join rapid response service enabling support of clinical compromised patients in the community avoiding hospital admissions - Commissioners have agreed an additional 25 spot purchase beds for intermediate care patients across the borough - Recruitment of 2 short term locum OT and 2 physio to expedite patient flow within bed based facilities and support the additional beds. Maggie Williams, Deputy Divisional Director of Medicine and Long-term Conditions Donna Roberts, Clinical Team Leader Intermediate Care and Rapid Response Wendy Lear, Head of Nursing - Medicine and Long-term Conditions Donna Chaloner Care Group Manager/Professional Lead - Long Term Conditions Care Group Paul Gibara, Divisional Director of Medicine and Long-term Conditions 33

10.3 FEP ICT and Community Matron support for in-reach into AMU Outline of Initiative Lead Officer Divisional Director Joint working across FEP, ICT and Community Matrons will be increased to facilitate greater in-reach into AMU to support expediting of discharges. FEP/MDT Team will visit AMU Monday to Friday at 11:00 hrs. Maggie Williams, Deputy Divisional Director of Medicine and Long-term Conditions Wendy Lear, Head of Nursing - Medicine and Long-term Conditions Paul Gibara, Divisional Director of Medicine and Longterm Conditions 10.4 Senior staff measures to improve escalation and patient flow Outline of Initiative Lead Officer Divisional Director A range of measure have been implemented aimed at improving escalation and patient flow: These include: Development and use of 1 st On-Call rota Staffing rota for additional staff to support management of patient flow discussion with HR Discharge Coordinators and IDT support staff 7days per week Jo Adams Jo Adams, Deputy Divisional Director of Medicine and Long-term Conditions Paul Gibara, Divisional Director of Medicine and Longterm Conditions 10.5 Review of complex frequent patients by specialist nurse to avoid admissions Outline of Initiative Lead Officer Divisional Director Diabetes, COPD and heart failure will review their top 10 patients who are considered at risk of admission into hospital over the winter period. They will review and action plan the patient for admission avoidance Maggie Williams, Deputy Divisional Director Speciality Medicine, Long Term Conditions and Elderly Care Paul Gibara, Divisional Director Medicine and Long- Term Conditions The processes will use data extraction to identify patients who have been readmitted within 7 days, cohort patients into specialities and then information will be forwarded to clinical discharging team which will include specialist nurses to review cases and make recommendations around community based clinical management. Donna Chaloner Care Group Manager/Professional Lead - Long Term Conditions Care Group Paul Gibara, Divisional Director Medicine and Long- Term Conditions 34

10.6 In-reach model supporting AMU from specialities with hot week Outline of Initiative Lead Officer Divisional Director For specialities that have developed a Hot Week there will be an in-reach model to support AMU and pick up relevant referrals Monday to Friday. These specialities will include: Cardiology; gastroenterology; Respiratory (from Nov 2013) and elder care unlikely to occur until full complement of consultants is in place. Telephone calls for advice will be available to AMU for those specialities as part of Speciality Consultants remit for the said speciality at 09:00 and 14:00 hrs. Jo Adams, Deputy Divisional Director of Medicine and Long-term Conditions Paul Gibara, Divisional Director Medicine and Long- Term Conditions 10.7 Six-day Hot Week increasing consultant rounds and discharge potential Outline of Initiative Lead Officer Divisional Director Six-day hot week will be implemented across medical wards to increase consultant ward rounds and potential for discharging patients. 6 day Hot week will be established for each speciality where the Consultant on Call focuses solely on emergencies and undertaking ward rounds to expedite discharge. Hot week is currently in place for AMU; Wards 12, 14 and 16; Hot week for Ward 17 is scheduled to commence during Nov/Dec 2013; and Wards 1 & 3 Hot weeks will be implemented once the full complement of elderly care physicians have been recruited. 10.8 Recruitment of 40 Apprentices to reduce falls NaJ Rashid, Paul Gibara, Divisional Director Medicine and Long- Term Conditions Outline of Initiative Lead Officer Divisional Director Appointment of 40 apprentices for 1 year to support wards in reducing falls. (However, as part of the total recruitment drive 69 apprentices have been appointed overall: 42 commenced work on 9 th September and 27 will commence work on 4 th November 2013) Mark Ingram (7138) Widening Participation Team Manager Sue Wakeman and Sue Hartley Executive Director Leads 10.9 Advanced Nurse Practitioner as part of Badger to stream A&E patients Outline of Initiative Lead Officer Divisional Director CCG have funded an Advanced Nurse Practitioner as part of Badger nurse streaming in A&E from 08:00 hrs. to 22:00 hrs. Outside of these hours GP and Clinical support worker is in place. Donna Chaloner Care Group Manager/Professional Lead - Long Term Conditions Care Group Paul Gibara, Divisional Director Medicine and Long- Term Conditions 35

10.10 GP Support Line into AMU Outline of Initiative Lead Officer Divisional Director Arrangements are being made to provide GP with a single phone line into AMU in order for GPs to leave their name and numbers with receptionist and request call back from a clinician between 09:00 hrs. and 17:00 hrs. This initiative is expected to start in mid-november 2013. Jo Adams, Deputy Divisional Director Paul Gibara, Divisional Director Medicine and Long- Term Conditions 10.11 Increased HALO Hours to assist with patient handovers Outline of Initiative Lead Officer Divisional Director West Midlands Ambulance Service, Hospital Ambulance Liaison Officer to increase number of hours at the Trust in order to assist in the management of patient flow and handovers. Tom Jackson, Hospital Ambulance Liaison Officer Paul Gibara, Divisional Director Medicine and Long- Term Conditions 10.12 Seasonal Flu Campaign to reduce staff sickness during winter Outline of Initiative Lead Officer Divisional Director Roll out of the occupation health service annual flu program for 2013/14, ensuring a robust plan is in place so that all front line staff are offered the seasonal flu vaccine. Valerie Woodruff Occupational Health Manager Jo Newens, Divisional Director of Women s, Children s and Clinical Support Services. 10.13 Flexing of Surgical Capacity to create additional in-patient capacity Outline of Initiative Lead Officer Divisional Director To release up to 8 day case trollies to be used as additional capacity (up to 8 in-patient beds for surgery) form 20 th January to 29 th March 2014 The plan includes: Increase In-Patients and decrease Day Patients between 18th November to 13 December 2013 No routine elective cases to run at all with the exception of backs and clinical priority cases between 16 December 2013 to 17 January 2014 Increase day cases and decrease in-patients with the exception of clinical priority patients between 20 th January to 29 th March 2014 Kim Skelding Deputy Divisional Director of Surgery Jo Lydon, Imaging Services Manager Sharon Dicken, Pathology Services Manager Angie Wallace, Divisional Director of Surgery 36

10.14 Implementation of infection control measures Outline of Initiative Lead Officer Divisional Director Implementation of the Norovirus outbreak arrangements including issuing pack for wards and departments to include: - Identification of designated ward to receive suspected Norovirus patients and commencement of ring-fenced sideroom - Assess need to ring fence and manage areas for direct admissions of potential Norovirus cases - Admission criteria to Norovirus side rooms / ward - Symptom checklist for medical staff - Patient and staff information during outbreak - Outbreak monitoring chart - Ward closure signs Provision of algorithm for Ward closure and ward reopening based on national guidance for management of Norovirus outbreaks including escalation Provision of mobile sinks for up to 4 weeks; (maintenance costs and associated additional cleaning). Purchase of additional vomit bags for ward areas and Infection Control Team to distribute when required. David Shakespeare, Head of Infection control Arrangements are for sinks to be hired in response to each outbreak episode from Teale, rather than institute them across the entire winter period. Jo Newens, Divisional Director of Women s, Children s and Clinical Support Services. Points of Note: - Issues of outbreak boxes (many stock items are readily available on wards) - Placement of direct admissions will be made on a case by case Consultant Microbiologist; consideration of allocating designated areas will be made at outbreak meetings or following discussion with the Director of Infection Control; ensure capacity management are involved in decision making and OOH ensure DOC is informed and ensure Senior Infection Control Officer is informed 10.15 Porters support Outline of Initiative Lead Officer Divisional Director Increased porters by 6 members to staff to allow amendments to porter s services to allow for greater flexibility during periods of significant pressure and rapid response to areas requesting porter assistance. John Dony, Facilities Manager Colin Plant, Divisional Director of Estates and Facilities 37

10.16 Catering arrangements Outline of Initiative Lead Officer Executive Lead Catering services will ensure sufficient supplies for increased capacity are available to maintain a catering service for patients by: - To hold stock to maintain a service for a period of 2 days. - To ensure additional food is available for any additional inpatient activity Paul Chadwick, Facilities Manager Colin Plant, Divisional Director of Estates and Facilities 10.17 Housekeeping support Outline of Initiative Lead Officer Executive Lead Housekeeping services will ensure housekeeping availability for increased capacity, extra cleaning due to infection control measures and to maintain Hospital entrances & Corridors during adverse weather conditions, core hours 07:00 hrs to 20:00 hrs and out of hours 20:00 hrs to 07:00 hrs. Paul Chadwick, Facilities Manager Colin Plant, Divisional Director of Estates and Facilities 10.18 Linen Services Outline of Initiative Lead Officer Executive Lead Linen Services have arrangements in place ensure that sufficient linen is available to maintain the required levels of service. From 1 st November 2013 to review daily, the linen levels with the Trust linen provider and to maintain levels of emergency linen in Maternity & West Wing reserve laundry cupboards Paul Chadwick, Facilities Manager Colin Plant, Divisional Director of Estates and Facilities 10.19 HSDU support Outline of Initiative Lead Officer Executive Lead Prioritise all orthopaedic equipment in preparation of any additional trauma patients throughout winter. (Label all trauma kit through tracking system to be prioritised.) Sara Cutter, HSDU Manager Colin Plant, Divisional Director of Estates and Facilities 38

10.20 Creation of additional cubical capacity in ED Outline of Initiative Lead Officer Divisional Director Intention to provide two additional cubical within the Emergency Department improving Emergency Department space by the end of December 2013 Colin Plant, Divisional Director of Estates and Facilities 10.21 Opening of additional capacity Opening of additional capacity will only be undertaken with prior approval of the Director On-Call in the following order. Care will be taken to ensure all patient meet appropriate criteria for admittance to additional capacity areas and consideration given to risk of falls. Order Ward No. of Beds Rationale for order of usage 1st Ward 8 9 beds 2nd Ward 20c 8 3rd Starling 6 Ward 8 will be used to address additional capacity demands first as this is an established clinical area able to take patients at short notice. Ward 20c will be considered for usage next as it is also an established clinical area, however patients must be MRSA clear before being admitted. Starling ward will be considered for use next. The Ward is co-located to a clinical area Ward 7. 4th Gynae Day Case (Ward 26) 6 Gynae Day Case is not pre-established for facilitating inpatients and has limited washing and toilet facilities this impacts negatively on patient privacy and dignity. 5th Endoscopy 4-6 Endoscopy would be utilised as a last resort as it too is not preestablished for facilitating inpatients and has limited washing and toilet facilities with associated negative impacts on patient privacy and dignity. In addition patients are required to be MRSA clear. The above must be kept under constant review in terms of capacity demand. Opening of additional beds will not be taken as a last minute decision, but reviewed formally by capacity team and site manager throughout the day and night. Opportunities to close these additional beds will be considered on a regular basis. 39

10.22 Loss of Ward 8 from mid-february 2014 Outline of Initiative Lead Officer Divisional Director Loss of Ward 8 from mid-february due to ICC Unit being developed in the area above: West Wing Reception Check with Paul regarding staffing Colin Plant, Divisional Director of Estates and Facilities 10.23 Additional Bedframes Outline of Initiative Lead Officer Executive Lead Provision of an additional 10 bedframes and mattresses to support contingency arrangements for responding to capacity and unit failure Adriel Lowe, Head of Resilience and Business Continuity Jayne Tunstall Chief Operating Officer 40

11.0 Additional capacity requirements- Pharmacy 11.1 The following issues must be taken into consideration when redesigning areas or opening additional capacity during winter in order to ensure safety and quality are not compromised. These measures include arrangements for operational pharmacy provision. 11.2 Ward must hold a range of stock medicines to ensure patients receive routine and regular medicine doses on time. A Pharmacy Assistant will check the wards stock cupboards and supplies stock medicines against an agreed list of medicines that must be on the ward. The Pharmacy Assistant will then prepare the order for the ward in the pharmacy stores; produce a delivery note and pack the items to be delivered back to the ward. The picking and packing of stocks will depend on the complexity of the ward type (an independent assistant will check the order before it is dispatched). 11.3 The goods will be delivered by a porter and subsequent deliveries will be made thereafter depending on how many requests for patients individual medicines are needed. 11.4 The generation of drug charts for patients requiring medicines enables pharmacists to clinically check the chart for appropriateness of all medicines prescribed and advise patients accordingly about their medicines. For every 1 in 3 prescriptions, our Pharmacist intervenes on inaccuracies on drug charts written/transcribed by doctors. Therefore a Pharmacist must be assigned to wards to ensure there are no errors and the correct drugs; dose; route strength; frequency; and duration is prescribed. Pharmacists will also advise nursing staff on medicine enquiries. 11.5 Whether the ward is being run by agency staff (risks are higher when they are unfamiliar with Trust practices) or run by employed nurses, the necessity of a Pharmacist and Pharmacy Technician (demonstrated by when wards 12 and 14 were run last winter by agency staffs) is needed to ensure safe use of medicines for prescribing, and administration, is adhered to. 11.6 Depending on what medicines the patients is already taking a pharmacy technician will assess the patient s own medicines and order/requisition those medicines that the patient/ward does not have as stock. The nurse would pharmacy support here as nursing staffs very often send inaccurate information to Pharmacy on medicine requests when they are unfamiliar with the item. 11.7 Medicines are dispensed and labelled in pharmacy or by using a Medi 365. They are checked by pharmacy technicians and then sent to the ward via the porter or given to nurses to place into the locker if dispensed at ward level. 11.8 The Ward based Pharmacy teams ensure as much as possible medicines for discharges are dispensed in advance for anticipated discharges to facilitate discharges and the bed bureau for daily capacity plans. 11.9 Pharmacy Procurement Teams need advance notice to order in any special or non-stock medicines which are communicated via the ward based teams as nursing staff do not necessarily have this information to hand. 11.10 Again Pharmacy s specialist ward based teams support patient discharges for patients on dosette aids by liaising with the patient s local pharmacist and GP. 41

11.11 In order to meet governance standards for quality and patient safety the following audits are mandatory for the Trust a. Ward audits Storage of Medicines b. Ward audits Controlled Drugs c. Internal audits are also carried out by Pharmacy on prescribing of antibiotics and these are reported to the Trust 11.12 A daily inspection of storage of medicines and temperature monitoring is part of the ward medicines management pharmacy service. This is vital when beds are opened in areas that are not necessarily catered to accommodate ward patients and risk assessments have to be carried out. 11.13 The above is not exhaustive, it gives a brief summary of pharmacy s essential role on the ward when wards are being either opened or re-designed to admit patients. 42

12.0 Lorenzo Cut-Over Planning 12.1 Walsall Healthcare NHS Trust currently utilises two Patient Administration System (PAS) products to manage the patient administration functions across the Trust. These are: (1) McKesson STAR PMS in the Acute setting; and (2) ipm in the Community. 12.2 Following the successful submission of a business case the Trust has taken the decision to replace current Patient Administration Systems, with the requirement that the new system extend across the local health economy. The three underlining main reasons for replacement are: a. the Trust uses two patient administration systems across acute and community settings b. the current PAS system is not fit for purpose given the demands of NHS reforms and the Trust s role as an integrated provider c. critically current contract for Acute based PAS expires March 2014 12.3 The current PAS system used by the Acute services (previously Walsall Hospitals NHS Trust) has been in operation since 1993 and although it has had many upgrades, developments and enhancements, it is reaching its end of life. This is seriously affecting the Trusts ability to manage its day to day operations in the modern NHS. 12.4 The Trust has been on a trajectory to replace its PAS by moving to a national solution under the National Programme for IT (NPfIT) since 2006. This has not materialised until now due to the continued delays in the release of the Lorenzo product set. This is available for general release to the NHS. The early adopters of the systems in Birmingham Women s NHS Trust, Bury PCT and Morecombe Bay NHS Foundation Trust have formally sign-off the product as fit for purpose for the NHS. 12.5 McKesson STAR PAS within the Walsall Healthcare NHS Trust acute settings is currently used by 2000 hospital staff. 12.6 The contract with our existing supplier (McKesson) is due to expire at the end of March 2014 and it is highly unlikely that this will be extended. The Trust would be the only organisation remaining on this old legacy system and therefore running costs would be significantly higher. This is further compounded by the fact that McKesson s intent is to remove this product from its portfolio in March 2014. Current State Community Services (previously Walsall Community Health) 12.7 Community Services currently use an interim solution i.pm as the PAS system. This is remotely hosted by CfH Local Service Provider CSCA. The system is used by over 800 predominantly clinician users, across 40 sites and over 30 different services. This is a national contract and current expiry date is March 2015. This solution is annual, service charges associated with IPM are currently funded via the NPfIT that it would move to the longer term product Lorenzo in the near future. Go Live Cut-Over Planning 43

12.8 Phase 1 is planned to go-live in 2nd March 2014 and includes replacing the core Patient Administration functionality and will lay the foundations where clinical functionality will be introduced for the second phase. 12.9 A project team has been constituted and formed from staffing levels of approximately 10 during the planning stage with additional staff from within service areas throughout the lifecycle of the project rising to nearly 100 by go-live. The project will be split into work streams. Managing the Transition 12.10 During the transition, throughput and data quality dashboards and reporting will be managed is part of the overall project. This is where, from organisational, departmental and even user level hotspots, problems areas can be identified to ensure the transition and business as usual can be restored as soon as possible. Service areas can then be identified and targeted to ensure management and data quality standards, throughput, service levels and KPIs service levels are achieved.. This is an identified deliverable which will minimise risk and where in other implementations of this nature has failed or the ability to control the problems has intensified. i.e. Morecambe Bay. 12.11 This will be the responsibility of the control centre during the cut-over and go live period until the system usage has been stabilised. These dashboards will be then delivered to the areas for day to day management. 12.12 Work continues to progress in relation to planning the detailed management of the impact of the transition on the Trust and the risks associated with the cut-over period. A list of key risks has been included on the winter risk register and the diagram below provides a draft indication of key activities on a time line. 44

ATP ATP SDRC 5 ATP ATP Phase 1 Go Live Cutover Planning - Draft Key Activities & Timings (all subject to confirmation) Pre 26 th Feb Wed. 26-Feb Thur. 27-Feb Fri. 28-Feb Sat. 1-Mar Sun. 2-Mar Mon. 3-Mar Tue. 4-Mar Post 4 th Mar Initial Approvals Period Cut-Over Period Communications GO LIVE Communications Progress & approval telephone calls ipm Live Running (Community PAS) PMS Living Running (Acute PAS) Data extract ipm will continue until 23:59 on Friday 28th February 2014 Out patients PMS ends 23:59 on Friday 28 February 2014; In-Patients and A&E PMS will continues until 06:00 hrs. on 2nd March 2014 ipm System off-line PMS System off-line Data Merging into Lorenzo system Data from ipm & PMS merged into the Lorenzo System Data validation (by Project and End Users) 10:00 hrs. Data Validation Manual data entry and configuration System Validation Switch Tie Authority to Proceed (ATP) and GO LIVE Lorenzo Go Live Data Data Catch-up Business continuity arrangements Command, Control and Support Centre Business continuity processes for operating systems and capturing data to facilitate recovery Command Room is anticipated to run for approx. 1 week Support Floor Walkers and dedicated helpdesk is anticipated to run for approx. 4 weeks Standard Deployment Readiness Criteria 5 (SDRC5) Stage Gateway 25 th Feb 2014 (point where all activities must be completed for GO LIVE and signed off by HSCIS, Trust Chief Executive, Trust IT Clinical Lead and CSC (Supplier); Authority To Proceed (ATP); Cut-Over Progress Calls to track the merge of IPM and PMS; Post GO LIVE calls to monitor the Go Live Period identifying issues and troubleshooting; Switch Tie: when all the interfaces from ipm and PMS are switched off and pointed at Lorenzo) 45

Winter Capacity Planning (WCP) Emergency Planning Resilience and Response (EPRR) 46