Belfast 9 th December 2014 Northumbria NHSFT Work in progress David Evans Medical Director Dave.evans@northumbria-healthcare.nhs.uk
In the beginning. 1998 3 Trusts to 1 Very low baseline difficulties Inefficient clinical model Unsustainable services Recruitment difficulties Staff unsettled Political pressures 12 years..
Northumbria 503,000 pop. 2,500 sq.m. 75% in 25% +/- 1,100 beds 9,300 staff 255 Consultants 280 Doctors 9 I/P sites Turnover > 440 million Largely Emergency driven 65 : 35 Largely secondary care Provincial Medical School Mature symbiotic relationship with Newcastle
We are a bit odd.. Mobile workforce with Trust wide contracts 30% off site Flat structures Stability with Flexibility Willingness to try Community Hospital decant Rural pressures = drive for innovation centralise when clinically better, devolve where clinically safe Lots of Hub & Spoke Ageing population 83, 84 Adult Social Services, Northumberland CC
Clinical Policy Group Keeper of clinical governance Every clinical manager = 82 + 6 GPs Monthly 3 cycles NSECH SUIs & governance Forward thinking
Clinical Policy Group Keeper of clinical governance Every clinical manager = 82 + 6 GPs Monthly 3 cycles NSECH SUIs & governance Forward thinking Soul & conscience = FRANCIS
1999: Clinical Leadership Development Programme 7 days over 9 months 2 + 1 + 1 + 2 + 1 multidisciplinary collaborative absolute requirement for management role a few said no thanks
Trust values Myers Briggs CEO / DoF /MD Change management NHS $ $ Business case Law / corporate manslaughter Scene setting PO Peer group support Work based project
2004 : O & G / ITU 7/7 Centralise maternity Extended working day 08:00 20:00 On-call = work Surgery / Ortho 7/7 Sole commitment is to emergency stream & emergency theatres Rolling Consultant rounds Rapid assessment clinics Every patient seen every day Medicine Foundation Programme Pilot Single door point of entry Consultant led Acute Care Stream = reborn ACPs ACP 08:00 22:00 Split FOH / BOH Develop H@N Teams NNP s All clinically driven on Safety & Quality
7 Day Working Re- badged Acute Care Physicians Started with 6 New ways of working Blurring the boundaries Business Units oversee everything No surprises please No deals No No extra staff. 42 week year Everything annualised & in your job plan
2004 Consultant recruitment Competencies of a Northumbria Consultant Developed by everyone 2 days Formal meeting BUD & GM Psychometrics - Horgan & Neo pi Clinical scenarios x 2 1hr 10 min structured interview x values Weighted scoring 70% bar
Tailored welcome Changed teams Changed sites Mentorship Y1 PDP in place Know & understand strengths & weaknesses New Consultants Programme 30%
2006 Foundation Trust Business Units & service line reporting BUDs x 4 50:50 Health as a business Financial consequences of clinicians actions Cost efficiency No deals, no surprises, no corridor conversations Control with responsibility & accountability = freedom Good things happened Captured the natural competitiveness
Visible clinical leadership & management Flat structures Open doors Easy access Exec / non exec walk around Board to Ward programme Board development ( HSJ ) Clinical lead presentations each month
Safety & quality LIPS x 4 Safety panels Quality council Safety & Quality committee Safety walk around Patient Safety Fridays Feedback
Real time improvements (n= 12,000)
Safety & quality Mortality reviews Ward based SPCs Trust harm rate IHI trigger tool Dr Foster etc. Unexpected / high & low risk codes Trust mortality review Horgan < 1% > 3, 4 x 4 VLADs
Grow a new workforce Advanced Neonatal Nurse Practitioners, Level II Night Nurse Practitioners Nurse Practitioners Advanced Critical Care Practitioners Surgeons assistants Specialist Nurses Clinical Pharmacists Phlebotomists Co-located OOH service GP Clinical Directors 2013
New ways of working Protocol driven = the Northumbria way Handover + SBAR Shared ownership eg post-op care Fast track hip & knee Day case > 95% POW = POD = PO ½ D Facilitated discharge & ticket home Ambulatory care Every change or development ECC proofed
Why not be radical?. A whole system change.. Create a Specialist Emergency Care Centre Split Elective / Emergency work 24/7 resident Consultant in Emergency Care Extended working day 7/7, 9 clinical teams Change DGH s for elective / community care KIDD. Develop Ambulatory Care & Frail Elderly Direct access to palliative care Builds on our existing decant model Puts a building around our new ways of working
ECC location map to do. *
Focussed around 1 major emergency site 3 major sites Outpatients Diagnostics Day cases Elective Surgery Sub acute in-patients Acute inpatients A&E Emergency Admissions Minor injuries hot diagnostics Specialist Emergency Hospital Acute inpatients A&E Emergency admissions Outpatients Diagnostics Day cases Elective Surgery Sub acute in-patients Acute inpatients A&E Emergency Admissions Minor injuries Outpatients Diagnostics Day cases Elective Surgery Sub acute in-patients Acute inpatients A&E Emergency Admissions Minor injuries
Front line. Emergency Care Consultants 24 / 7 Acute Care Physicians Surgery x 2 Orthopaedics x 2 Cardiology + Respiratory + Stroke + Elderly care Intensivists O & G Paediatrics ( 8 til late ) + Nurse practitioners / ACCPs + Clinical Pharmacists 210 beds + 6 theatres + 18 ITU + 2 x CT + MRI + 4 PF Ambulatory care + surgical assessment + mat + paeds Endoscopy + cath lab
NSECH UK s first dedicated emergency care centre Serve 530,000 Merges 3 acute streams into 1 Consultant led, 24/7, 365 9 specialist teams Linked with Primary Care and Social Services Hyper-acute stroke Patient centred = Keogh MAJOR A & E
? 200 million over 10 years 70 + FTFF 90 build Rest from CIPs & productivity Emergency Care Centre 2 new Community hospitals Bed neutrality by 6 to 4 bed bays ( A little bit about the politics)
114.2 mill
Co-located 5 GP practices 2 ambulance stations social services fire station
Community links are key..
ommunity dmission avoidance COPD Program LTC Management Nursing & Care Home Initiatives- matrons DAART & ENP-NT Integrated End of Life incl Community & CS Health and social care integration Primary Care Incentive Scheme Front of House Ambulatory Care NGH, WGH Surgical assessment units Elderly Assessment Unit Phone Help lines IBD, TIA, Rheum Admission avoidance program A&E Consultant Telephone call Reducing Length of Hospital stay EDD AND Ticket Home Supported Discharge Nurse led early discharge Lung Improvement Program Discharge Lounge WGH+,NGH Specialist FDT in Orthogeriatric,Stroke Community Re-admission avoidance Alcohol Project Single Point of Access Pharmacy Incentive Community Hospital Utilisation Pulm Rehab-Nth Tyne Pulm Rehab N land CGA in hospital, Follow up in Community, 1 wk Short Term Support Team N land LINS Matron supporting nursing homes LTC Annual Rv OOH D/Nurse ^ Clinic Capacity Telehealth Hospital to Home Team Facilitated Discharge Team FDT Community Investment Hospital Frail Elderly Care Frail Elderly Care Pathway LINS JELS Early Discharge Pharmacy (Safeguarding) (Podiatric waiting list) (Sexual Health)
Community based pre-assessment Safe & timely assessment Investigations or interventions prior to surgery Identify complex patients early to the H2H team Collaborative working between GP s, Surgeons & Preassessment Early pre-assessment = pool of patients who can fill gaps on operating lists
Speeding up pathways At admission - identification of complex discharge (Mayo risk stratification tool) Estimated Day of Discharge & Ticket Home Hospital to home team = Community based MDT Pit stop approach to discharge Medicines reconciliation / over label / own meds / lockers Nurse led Discharge CGA in hospital = seen by D / Nurse < 7 days Single Point of access to Community Services Community based Short Term Support Service
Implant the idea Ticket Home postcard
Nurse led discharge Aim to smooth out variation in discharges over 7 days 60 50 40 30 20 WG D/C NT D/C 10 0 Weekend nurse led discharges = 2 extra discharges / ward
Ambulatory Care & Elderly Assessment Ambulatory Care 31,000 cases 13 / 14 Currently >3,000 per month 85% medical (implant the idea) Elderly Assessment Frail elderly pathway 50% home, 20% direct to rehab facility 30% admitted
Non Elective Admissions
NORTHUMBRIA HEALTHCARE NHS FOUNDATION TRUST Midnight bed occupancy 2012/13 and 2013/14 NTGH, Wansbeck, Hexham N.B. Excludes paediatrics beds, well babies, SCBU, obstetrics, critical care, Monthly occupied bed days Monthly total OBD OBD reduction trajectory (seasonal) 23000 22500 22000 21500 21000 20500 20000 19500 19000 18500 18000 NORTHUMBRIA HEALTHCARE NHS FOUNDATION TRUST Mean length of spell 2012/13 and 2013/14 NTGH, Wansbeck, Hexham N.B. Excludes paediatrics beds, well babies, SCBU, obstetrics, critical care, Mean length of spell* (days) 7.0 6.8 6.6 6.4 6.2 6.0 5.8 5.6 5.4 5.2 5.0 mean length of stay 11/12 mean length of stay 12/13 mean length of stay 13/14 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar *Mean length of spell (proxy) - occupied bed days in the month divided by total admissions in the month