Action Plan Arising from RCPCH Evaluation Recommendation Obstetric, Maternity and Gynaecology Services Strategy and Patient safety 1 Expedite the Phase Two business case and commence development to provide a high quality environment for consultant-led maternity care and compliant facilities for neonates. 2 Develop a clear sustainable strategy for obstetric, midwifery Formally establish Phase 2 project and develop business case for Welsh Government consideration. Multi-disciplinary clinical group to Initial business case by Spring 2016 September 2016 Chief Executive (as SRO of Phase 2 Project Group) General Manager, W&C Directorate Phase 2 Project Group established November 2015. Clinical User Groups and Project Team currently developing design specification for individual elements of project. Multi-disciplinary clinical group 1
and gynaecology services, prioritising patient safety, patient access and quality of care, building on and completing the changes of services introduced in August 2014. New ideas, perhaps from a task and finish innovation group can refresh the team, harnessing external support to examine new ways of working with the support of the local clinicians and women be established involving consultant, midwifery and Gynaecology staff to develop strategy and prioritise innovation ideas and new practice. (Task & Finish groups to be agreed for specific projects). established 6 th January 2015. 3 Identify clinical line management for the Directorate to provide visible and robust professional support, mentoring and development to the clinical leads for obstetrics and paediatrics and the Head of Midwifery. An independent member at Board level should have a remit of responsibility for women's and children's issues Acute Service operational structure to be reviewed. Independent Board member with lead responsibility as Children s Champion to be confirmed In Place Director of Operations Mr Mike Ponton Acute Service operational structure under current review. Proposals currently being developed. Achieved (Independent Board member identified as Children s Champion) 4 Expand community based Plan for September 2016 General Manager, Multi-disciplinary 2
consultant and midwifery based services at Withybush, developing more comprehensive EPU, EGU, day theatre, and clinical community based services there in line with RCOG standards 1 5 Retain provision of dedicated transport facilities 6 Rationalise major in patient gynaecological surgery onto one site, if accommodation allows. expansion of community based consultant and midwifery services to be developed by multi-disciplinary clinical group (referred to above). Renew SLA for DAV for 2016/17 Clinical Task & Finish Group to be established (involving Directorate & GGH / WGH site representation) to undertake review of capacity and service implications Review of capacity and service implications by June 2016 W&C Directorate Executive Director of Commissioning Clinical Lead, O&G (via multi-disciplinary clinical group) clinical group established 6 th January 2015. Health Board agreement to retain DAV for 2016/17 Clinical T&F Group to be established February 2016 to assess clinical and service implications. 7 Phase out the obstetric and Clinical Task & Finish Group to Review of capacity and Clinical Lead, O&G (via multi-disciplinary Clinical T&F Group to be 1 2013 Good Practice 15 Reconfiguration of women s services n the UK RCOG 3
gynaecology out of hours consultant rota at Withybush with a target date of April 2016, integrating and strengthening the obstetric and gynaecological consultant team at Glangwili. be established (involving Directorate & GGH / WGH site representation) to undertake review of capacity and service implications service implications by June 2016 clinical group) established February 2016 to assess clinical and service implications. 8 Review of the uptake of midwife led care, and plan to expansion of use by women who have been appropriately risk assessed. Unified patient pathways, guidelines and clinical governance structures must be incorporated into all units within 6 months Promote awareness of All Wales MLU guidelines amongst all midwifery staff. Monthly monitoring of MLU usage via Directorate. February 2016 Senior Midwife MLU / Community Senior Midwife MLU / Community Current MLU Utilisation Jan Dec 2015 (22%) Establish database of all women who are suitable for MLU care and audit of outcome Senior Midwife MLU / Community Review all supporting pathways, June 2016 Senior Midwife MLU / Community 4
guidelines and unit governance structures 9 Assurance to public of the safety of birthing in MLU s in line with the All Wales Pathway for Maternity Care; community midwives should take a stronger lead in this. A band 7 midwife should be appointed to champion a team to develop each of the MLUs in terms of increased usage, active birth supporters and midwives competence and confidence in supporting active, non pharmacological birth. Develop communication strategy to engage with women across Hywel Dda to promote MLU as a viable option for giving birth Responsibility of Band 7 Community midwives to be confirmed. April 2016 Senior Midwife MLU / Community Senior Midwife MLU / Community Communication strategy to be developed by April 2016. Role and responsibilities of Community midwives to be confirmed by. Staff Team and Leadership Development 10 Conduct medical staff job planning to provide a unified safe service which delivers professional satisfaction to staff Review and update all job plans General Manager W&C Directorate/Clinical Lead O&G All job plans to be reviewed by 5
across both sites. 11 Develop a programme of opportunities for midwifery development that reflects the aspirations of service developments these should be achieved within a 12 month period 12 In order to meet RCoA standards and secure future allocation of anaesthetic trainees further additional sessions are needed on the labour ward. 13 The multi-disciplinary training opportunities for doctors, nurses and midwives are considerable and need further development. A training lead should be identified to ensure training is carried out across all groups including simulation and skills/drills. To be progressed in parallel with multi-disciplinary clinical group and midwifery OD programme. Anaesthetic workforce development plan to be produced in parallel with HB IMTP. Multi-disciplinary clinical group to review current multi-disciplinary training plan to ensure availability of appropriate skills. December 2016 Head of Midwifery Multi-disciplinary clinical group established 6 th Workforce Development Plan by March 2016 (Implementation plan subject to IMTP) June 2016 Service Delivery Manager, Anaesthetics Clinical lead O&G / Head of Midwifery January 2015. Midwifery OD programme commenced December 2016. Priority identified via IMTP / Clinical Strategy development sessions held 14/15 th January 2016 Multi-disciplinary clinical group established 6 th January 2015. Identify a training lead to coordinate training April 2016 Head of Midwifery Training lead to be confirmed 6
programme across multidisciplinary team. 14 A programme of organisational development should be instigated to build team working and a sense of one service ; across all staff groups from all three sites including community. This could be informed by the Fundamentals of Care audit, and include encouragement and time to nurture potential future medical leaders Implement programme of Organisational development for clinical staff, commencing with midwifery teams before consideration of roll out to medical staff and neonatal / paediatric teams. Commenced December 2015 Head of Midwifery OD programme commenced. Governance and Accountability 15 The new Band 7 maternity risk manager should administer the clinical governance programme including three monthly reports with action plans to the Trust Board and clinical directorate meetings Confirm substantive appointment of interim Band 7 postholder within current resources General Manager Quarterly reports to be considered via HB Q&S structure from 7
16 The maternity dashboard, should be reviewed by the directorate Quality and Safety Committee quarterly for review and appropriate action. Review of compliance with the RCOG Maternity Standards should be under immediately and upon publication of the new standards expected during 2016 Ensure implementation of new All Wales Maternity Network Dashboard and include as standing agenda item at Directorate Q&S meeting. January 2016 Head of Midwifery All Wales Maternity Dashboard report to be considered at W&C Directorate Q&S Committee in January 2016. Review compliance of new standards once published Once published O&G Clinical Lead/General Manager W&C directorate Publication of new standards awaited. 17 Review of the midwifery workforce establishment using Birthrate Plus acuity tool should be completed immediately and at least every 2 years. Confirm HOMS recommended Birthrate Plus assessment tool Head of Midwifery Confirmation of recommended assessment tool awaited via HOMS. BR+ exercise to be conducted following confirmation of recommended tool. To commence upon confirmation of HOMS recommended assessment tool. Head of Midwifery To commence upon confirmation of HOMS recommended assessment tool. 8
18 Quality Improvement projects such as the Productive Ward, Releasing Time to Care should be used to involved all groups of staff in the quality improvement programme Quality improvement projects to be prioritised by multi-disciplinary clinical group. From February 2016. Head of Midwifery Multi-disciplinary clinical group established 6 th January 2015. Public Engagement 19 The Maternity Service Liaison Committee should be re instated with membership drawn from local recent service users. Additionally the service should seek out ways to engage with the local families living in the three counties. 20 A social media campaign should promote positive birth experiences / normal birth in various media and establish a user group to provide feedback and advice on improving take-up of the MLU Programme of MLSC meetings to be reestablished. Women & Children s Communication & Engagement Strategy to be developed. Women & Children s Communication & Engagement Strategy to be developed. April 2016 April 2016 May 2016 Head of Midwifery Head of Communications & Engagement Head of Communications & Engagement Programme of MLSC meetings to be confirmed. W&C Communications & Engagement Group established 14 th December 2015. W&C Communications & Engagement Group established 14 th December 2015. 9
21 Ensure all staff in contact with expectant parents are fluent in the service arrangements, choices available for women, thresholds for transfer and outcomes. 22 Facilities for birth partners, whose partner may not be in established labour, to rest and obtain a hot drink should be available 24 /7 at Glangwili. Neonatal Service Refresher training /update on services to be provided to all midwives and Health Visitors Establish an interim facility pending Phase 2 redevelopment. Head of Midwifery W&C Communications & Engagement Group established 14 th December 2015. Revised communications pack to be prepared. Senior Midwife Acute Interim facility identified (pending Phase 2 redevelopment). Minor refurbishment works being under. Strategic Planning and patient safety 23 Implement the Phase 2 developments to provide adequate accommodation for neonates and families. Formally establish Phase 2 project and develop business case for Welsh Government Initial business case by Spring 2016 Chief Executive (as SRO of Phase 2 Project Group) Phase 2 Project Group established November 2015. Clinical User 10
consideration. Groups and Project Team currently developing design specification for individual elements of project. 24 Gain commitment and support from the Health Board and The Wales Neonatal Network for a strategic plan for neonatal care towards designation of the unit as an LNU. Agree a joint development plan with the Wales Neonatal Network Agreement of plan by May 2016 Clinical Lead, Children s Services All Wales Neonatal Standards Compliance Report (as at Sept 2015) published Dec 2015. Wales Neonatal Network Annual Compliance Visit 8 th January 2016 report awaited. Further All Wales Neonatal Standards Compliance Report (as at Dec 2015) expected will inform joint 11
development plan. 25 Conduct a training needs analysis amongst medical staff for competencies pertinent to operation as an LNU and a plan to meet those needs Training needs analysis to be under as per Wales Neonatal Standards. Outcome to inform joint development plan with Neonatal Network as above April 2016 May 2016 Neonatal Clinical Lead To commence February 2016. 26 With facilitated OD, continue to develop team cohesion and a sense of one service 27 Include EMRTS procedures into MLU protocols at WGH Extend Organisational Development programme to Neonatal Service clinical staff, following initial phase with midwifery teams. MLU protocol to be revised to reflect EMERTS availability. September 2016 Directorate Nurse Neonatal Organisational Development programme to commence September 2016. February 2016 Head of Midwifery Policy currently being reviewed for operational approval via 12
Directorate Q&S Committee February 2016. 28 Strengthen and formalise clinical meetings with Singleton, reviewing all cases weekly and documenting discussions and actions Programme of review meetings with Singleton NICU to be arranged. February 2016 Neonatal Clinical Lead Joint HDd / ABM Neonatal review meeting scheduled 12 th February 2016. 29 Ensure the Wales Neonatal network guidelines are available to all staff working on the unit Ensure availability of Wales Neonatal Network Guidelines via shared drive on the Neonatal Unit. January 2016 Senior Nurse (Quality Assurance), Neonates Achieved (guidelines available via shared drive). 30 Review protocols and skills for emergency out of hours stabilisation given that CHANTS is not a 24-hour service. Review protocol(s) for emergency out of hours stabilisation to support management of babies pending arrival of CHANTS retrieval service. January 2016 Neonatal Clinical Lead / Senior Nurse (Quality Assurance), Neonates Achieved (Neonatal Network protocols for premature babies available on Unit. All supporting resuscitation guidelines are current). 13
31 Initiate and support opportunities for the neonatal leads to join sessions at the Singleton to help sustain and further develop their neonatal expertise. 32 Ensure that all consultants providing out of hours cover have some daytime involvement on the neonatal unit which could be attendance at the weekly grand round as a minimum 33 Revisit the BLISS audit with service users and develop an action plan you said-we did Agree programme of joint rotations / visiting sessions with Singleton NICU team. Remove all Community Paediatricians from acute on-call rota. Parent Support Group to be established to review audit and develop supporting action plan. April 2016 December 2015 April 2016 Neonatal Clinical Lead Clinical Lead Children s Services Senior Nurse (Quality Assurance), Neonates Initial discussions commenced between Medical Directors. Further discussion scheduled between joint Neonatal teams 12 th February 2016 (Joint HDd / ABM Neonatal review meeting). Achieved (all consultants providing out of hours cover of Neonatal Unit have planned daytime sessions on Unit as part of Consultant of the Week rota) Parent Support Group to be established by April 2016. 14
34 Improve accommodation arrangements for parents and communicate them clearly, perhaps utilising the CHC to audit awareness Promote availability of current facilities / services for all parents pending improvement of facilities as part of Phase 2 redevelopment. Immediate Senior Nurse (Quality Assurance), Neonates Achieved (profile of parents accommodation / transport needs included in Unit and handover meetings and awareness raised re supported transport arrangements). Paediatrics and Emergency care Emergency Pathway 35 Clarify the governance, decision making and pathway arrangements for paediatric attenders out of hours, particularly the relationships between paediatrics, ED and the Out of Hours GP service so patients, public and referrers are clear about whom to refer to at different times of day. and what telephone support is available Review current policies and protocols December 2015 Clinical Lead, Children s Services. Policy review meeting held 18 th December 2015. Policy amendment to be considered via W&C Directorate Q&S Committee. 15
from the Glangwili paediatricians to diagnose, treat and discharge locally where safe and appropriate. 36 Continue with the relocation of the Withybush PACU nearer to the ED 37 Audit WAST out of hour paediatric decisions around 999 destination, with a group including anaesthetists, WAST, paediatric and ED staff and revisit criteria/refresh training as necessary 38 Provide a further 12 month extension to the DAV to March 2017 reviewing again once other changes have been made Progress PACU relocation in parallel with redevelopment of WGH. Undertake audit in conjunction with WAST and relevant clinical teams Renew SLA for DAV for 2016/17 Spring / Summer 2016 July 2016 General Manager / WGH Clinical Lead Clinical Lead, Children s Services Executive Director of Commissioning PACU Relocation plans being progressed via WGH CDU / Ward 10 Project (relocation expected late Spring / early Summer 2016) Audit specification to be agreed by. Board agreement to retain DAV for 2016/17 39 Ensure there are adequately qualified staff with paediatric resuscitation skills available at all Training / Skills development programme to be From April 2016 Clinical Lead WGH (with support from HB Resuscitation Programme to be agreed from April 2016. 16
times at WGH, perhaps through a programme of training and skills development for the anaesthetic team with rotation to other units to maintain skills. The paediatric team should play a leading role in overseeing arrangements 40 Strengthen nurse staffing in ED through urgent appointment of Registered Children s Nurses (one per shift) to provide general paediatric expertise. Longer term consider development of Emergency Nurse Practitioner (ENP) roles, including nurse prescribers, and a 5-year plan for training and retention. arranged ED workforce development plan to be produced in parallel with HB IMTP. Workforce Development Plan by March 2016 (Implementation Plan subject to IMTP) Training Team & Paediatric Team) Joint planning required between: Lead Nurse, WGH site Directorate Nurse, Children s Services Lead Nurse, Unscheduled Care Priority identified via IMTP / Clinical Strategy development sessions held 14/15 th January 2016 41 Ensure that all staff who advise members of the public are aware of the correct clinical pathway to access early treatment and safe transfer. Review current policies and protocols and communicate to relevant staff. December 2015 Clinical Lead, Children s Services. Policy review meeting held 18 th December 2015. Policy amendment to be considered via W&C Directorate Q&S Committee and updated policies to be re- 17
issued with supporting communications / information. Paediatric Care 42 Formally merge the paediatric consultant team and remove the out of hours cover for Withybush with a target date of April 2016 once the paediatric, nursing and management team are sure that appropriate emergency arrangements (training access transfer) are in place. This assurance should be supported by monitoring of all attendances out of PACU operating hours to ensure appropriate case management occurred, and identify any incidents resulting from the changes. Clinical Task & Finish Group to be established (involving Directorate & GGH / WGH site representation) to undertake review of capacity and service implications Review of capacity and service implications by June 2016 Clinical Lead, Children s Services (via multi-disciplinary clinical group) Clinical T&F Group to be established February 2016 to assess clinical and service implications. 43 Redesign job plans for consultants and speciality Review and update all job plans General Manager W&C Directorate/Clinical All job plans to be reviewed by 18
doctors to deliver Facing the Future standards including consultant cover at peak times Lead, Children s Services 44 Ensure there is sufficient outpatient capacity for all local children to be seen in clinics at Withybush. This would be for general paediatric problems and also subspecialty clinics. Review paediatric outpatient demand / capacity plans (to account for acute / community paediatric and subspecialty / visiting clinics) Service Delivery Manager, Paediatrics Replacement Paediatric Service Delivery Manager to take up post 25 th January 2016. 45 Ensure that most investigations uncomplicated radiology and ultrasonography, venupuncture and ECG can be under at Withybush Review & Audit current availability of diagnostics and uptake at WGH for paediatric patients June 2016 Clinical Lead, Children s Services Audit of access to investigations to commence March 2016. 46 Develop a vision for PACUs as a single service for the Health Board Strategy for future development of PACUs to be developed (including review of operational policies for consistency) September 2016 Clinical Lead, Children s Services / Directorate Nurse Children s Services PACU Review T&F Group to be established February 2016 to progress development of strategy. 19
47 Review, with primary care colleagues, compliance with the Facing the Future Together for Child Health standards and establish a plan for implementation and audit. Establish task and finish group with primary care to review standards and plan for implementation. October 2016 Clinical Leads Children s Services / Primary Care Task & Finish Group to be established. 48 Continue development of the High Dependency service as part of the network with Cardiff as the local PICU, conforming to national standards 2 Review current PHDU service against national standards and identify areas for improvement. July 2016 Paediatric HDU Clinical Lead Paediatric HDU lead appointed to lead review work 49 Support investment in the Community Children s Health service towards compliance with the RCN 3 and RCPCH 4 guidance for community child nursing. There is an urgent need for recruitment of Consultant Community Paediatricians Develop a clear plan for community children s services Continue recruitment efforts to fill current July 2016 From January 2016 Directorate Nurse Children s Services Clinical Lead, Children s Services Priority identified via IMTP / Clinical Strategy development sessions held 14/15 th January 2016 Recruitment efforts continuing. Locum appointment 2 RCPCH/PICS Time to Move On 2015 3 NHS At Home developing Community Children s Nursing DH England 2011 4 Facing the Future Together for Child health RCOCH 2015 20
vacancies. scheduled to commence January 2016. 50 Develop the roles of specialist nurses, for example in epilepsy, asthma/ respiratory. Review current profile of specialist nurses and identify priority areas for development Directorate Nurse Children s Services Priority identified via IMTP / Clinical Strategy development sessions held 14/15 th January 2016 51 Review scope of on-call activity and maximise the role of nurses to help reduce pressure on doctors, including development of a criteria led nurse discharge programme. Review on call activity and demand Identify opportunities for extended roles for nursing staff in support of medical teams and discharge pathways. May 2016 June 2016 Clinical Lead, Children s Services Directorate Nurse, Children s Services Audit of on-call activity to under March/April 2016. Task & Finish Group to be established February 2016 Strengthen user involvement and public engagement 21
52 Develop ongoing communications and engagement plan through the new committee to include Pushing positive birth stories to the media and staff Proactive analysis of the did we deliver materials Engagement of GPs with clear information about referral criteria Women & Children s Communication & Engagement Strategy to be developed. May 2016 Head of Communications & Engagement W&C Communications & Engagement Group established 14 th December 2015. 53 Suggest CHC or user group be invited to audit/survey fathers about current arrangements and their experience of care. Women & Children s Communication & Engagement Strategy to be developed. May 2016 Head of Communications & Engagement W&C Communications & Engagement Group established 14 th December 2015. 54 Re-establishment of the user group and MSLC Programme of MLSC meetings to be reestablished. April 2016 Head of Midwifery Programme of MLSC meetings to be confirmed. Women & Children s Communication & Engagement Strategy to be developed. April 2016 Head of Communications & Engagement W&C Communications & Engagement Group established 14 th December 2015. 22
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