Trust Board Meeting 3 September 20 Title of the paper: Operational Recovery Plan Progress Update Agenda Item: 09a/29 Lead Executive: Author: Trust objective: Purpose: Lynn Hill, Deputy Chief Executive Jane Shentall, Director of Operations for Elective Care Caroline Landon, Director of Operations for Unscheduled Care Tick as appropriate: Achieving continuous improvement in the quality of patient care that we provide and the delivery of service performance across all areas; Setting out our future clinical strategy through clinical leadership in partnership and with whole system working; Creating a clear and credible long term financial strategy. The aim of this paper is to provide the Board with an update on progress against the Operational Recovery Plan Please add which panel and/or group that the paper has been previously discussed at prior to TLEC Panel Group Name: N/A TLEC Date: N/A 18 June 20 Benefits to patients and patient safety implications Patients referred to the Trust for elective care should expect to receive their diagnostic investigation or elective care treatment within the relevant national standard. This is underpinned by the NHS Constitution which aims to ensure that patients are diagnosed and receive appropriate care as soon as possible. Patients accessing emergency care at WHHT should expect to be seen and treated or discharge as appropriate within the constitutional standards set. This will support safe and effective care and treatment with high quality outcomes Risk implications for the Trust Delivery of safe, timely care Mitigating actions (controls) Links to Board Assurance Framework, CQC outcomes, statutory requirements Legal implications (if applicable) N/A. Financial implications (if applicable) Recommendations For information and assurance
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Agenda Item: 09/29 Trust Board meeting 3 September 20 Operational Recovery Update RTT, Cancer & Diagnostics Presented by: Jane Shentall, Director of Operations for Elective Care 1. Purpose 1.1 This paper provides an update on the progress made in relation to operational recovery plans to achieve compliance against the relevant national waiting times standards. The main objectives are: to reduce the number of patients that have waited over 18 weeks for their planned care and achieve compliance with national waiting times standards to deliver a compliant performance against Cancer waiting times standards to improve performance against Diagnostic waiting times standards to a compliant position 2. Background 2.1 WHHT has undertaken to achieve organisational compliance in 3 key areas of performance by the end of Q1 20/16, ie a compliant submission in July 20, against the following national waiting times standards: Referral to Treatment Time (RTT) performance standards: 90% admitted 95% non-admitted 92% incomplete/open pathways should be under 18 weeks Diagnostic waiting times performance standard for key diagnostic tests: 99% of should wait no longer than 6 weeks (month end) Cancer waiting times standards: 96% 31 day decision to treat to first treatment 85% 62 day decision to treat to first treatment. 2.2 Performance in terms of the diagnostic and cancer standards described above has been variable, both at Trust level and within specific tests/procedures and in Cancer, at specific tumour sites. 2.3 Work with the services where there are the most significant challenges is underway, and is supported with recovery plans and regular discussion with the clinical teams to 2
maximise the potential to achieve compliance. It is recognised that these services will not be compliant at the end of Q1, but performance in other areas will mitigate for this. 3 Progress 3.1 The Trust has achieved a compliant performance position against the incomplete, open pathway standard of 92% 3.2 At the end of July there was only 1 patient waiting over 52 weeks. The number of patients waiting for 40 weeks or more has decreased substantially (17 at 9/8/) and the overall backlog has decreased by more than 60% to 1656. 3.3 The Trust has not achieved compliance against the 95% non-admitted or 90% admitted closed pathways standards, but it should be noted that these are no longer national requirements. The financial burden of the additional sessions required to support achievement of these targets is unsustainable and therefore a decision to curtail ad hoc sessions (particularly at weekends) has been made as part of the Trust s financial recovery plan. 3.4 The review of the Trust s Access policy has been completed. This document has been re-designed and realigned with national guidance on 18 week RTT rules. It will be shared more widely for comment before the end of August. Diagnostics 3.5 The improved diagnostic performance continues with a further compliant month for July. 3.6 Additional diagnostic equipment for Cardiology has arrived which will allow the service to reduce the additional weekend working that has been required to meet demand and to manage the backlog of requests. 3.7 All DEXA requests continue to be outsourced to Mount Vernon Hospital. A business case for a replacement machine is underway. 3.8 The monthly Diagnostic Performance group is now established. The month end forecast for each of the tests are reviewed and actions identified to ensure month end compliance. Cancer 3.9 The Trust is on track to deliver a compliant performance against the 62 day referral to first treatment standard in July. 3.10 Weekly scrutiny of the Cancer PTLs (at patient level) is now undertaken, with tracking from day 0. 3.11 Patient choice continues to be a significant challenge, particularly for 2ww and breast symptomatic. The national picture for breast symptomatic is similar. All breast symptomatic breaches in July were for patient choice. Progress has been made to bring the offer of a first appointment in to the 0-7 day period. While all offers were made within 0- days, previously there was often insufficient time to rebook within the target time. An offer in the first week allows the Trust an opportunity to make a second offer within the required timescale. It should be noted that there is currently a national breast cancer campaign running which has increased pressure on this particular area of cancer service. 3
3.12 The Cancer Improvement Group continues to meet weekly, to review the issues specific to each tumour site and address these challenges. 3.13 The new NICE guidance for suspected cancers has been shared with services with a view to identifying potential issues/increased demand, eg in Radiology where there may be an increased demand for direct access MRI. There are 8 key priorities (the Trust is already compliant against 3) which must be met and work is already underway to ensure we achieve these. 4 Monitoring Performance 4.1 Patient level waiting times are closely monitored at the following: weekly organisational level RTT and Cancer Performance meetings weekly divisional level Access meetings (RTT) Patient level detailed review of PTLs by Director of Operations for Elective Care. Monthly Diagnostic Performance meeting 4.2 Weekly updates of the RTT recovery plan trajectories ensure services are on track to deliver reduced waiting times, giving services opportunities to focus on areas which require additional input. These will continue to be used beyond the end of Q1 to support the scheduling of appointments and admission dates to sustain performance. 4.3 The following tables and charts demonstrate the improvements in performance. Waiting List Profile 19 August 20 Oct- Mar- Apr- May- June- July- Total pathways 26978 21817 23043 23576 238 21345 Total backlog 5019 2285 2340 21 2171 1656 Non-admitted pathways 22231 17459 18473 18780 19346 17265 Non-admitted backlog 4121 74 1633 32 1603 10 Admitted pathways 4747 4358 4570 4451 4469 4080 Admitted backlog 898 711 707 582 568 506 52 week waits 12 7 2 5 3 1 Long waits (40+ weeks) 6 90 84 54 32 4
WAITING LIST PROFILES 5
DIAGNOSTIC WAITING TIMES PERFORMANCE JUNE 20 (provisional) 1000 Total number of patients waiting over six weeks WHHT performance National standard Trend - WHHT performance 100 10 135 1 132 129 56 60 70 128 86 86 44 45 41 1 Diagnostic Performance July 20 Description 6 wks + % compliance W01: Imaging - Magnetic Resonance Imaging 0 100.00% W02: Imaging - Computed Tomography 0 100.00% W03: Imaging - Non-obstetric ultrasound 1 99.5% W04: Imaging - Barium Enema 0 100.00% W05: Imaging - DEXA Scan 33 83.7% W06: Physiological Measurement - Audiology - Audiology Assessments 1 99.74% W07: Physiological Measurement - Cardiology - echocardiography 8 96.43% W08: Physiological Measurement - Cardiology - electrophysiology 0 - W09: Physiological Measurement - Neurophysiology - peripheral neurophysiology 0 100.00% W10: Physiological Measurement - Respiratory physiology - sleep studies 0 - W11g: Physiological Measurement - Urodynamics - pressures & flows (Gyn & Surg) 1 98.36% W12: Endoscopy - Colonoscopy 0 100.00% W13: Endoscopy - Flexi sigmoidoscopy 0 100.00% W: Endoscopy - Cystoscopy 0 100.00% W: Endoscopy - Gastroscopy 0 100.00% Total 41 99.84% 6
Referrals Seen First Treatments CANCER WAITING TIMES PERFORMANCE Maximum 62 day - Urgent GP Referral to First Treatment 80 70 60 50 40 30 20 10 0 Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- WHHT Compliant 54.5 39.5 39.5 50 47.5 49.5 58 59 70 45.5 49.5 41 Breached 12 19.5 11 12.5 18 12 12 4 11 13.5 7 Total 69 51.5 59 61 60 67.5 70 71 74 56.5 63 48 WHHT Performance 79.0% 76.7% 66.9% 82.0% 79.2% 73.3% 82.9% 83.1% 94.6% 80.5% 78.6% 85.4% Standard 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% National Performance 84.0% 82.0% 82.2% 83.8% 84.7% 81.1% 80.8% 83.9% 83.0% 81.1% 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 250 200 0 100 50 0 Maximum 2 week wait - Breast Symptoms Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- WHHT Compliant 61 188 174 139 5 164 5 200 129 123 176 36 Breached 125 32 8 9 16 9 2 4 8 21 27 19 Total 186 220 182 8 171 173 7 204 137 4 203 55 Jul- WHHT Performance 32.8% 85.5% 95.6% 93.9% 90.6% 94.8% 98.7% 98.0% 94.2% 85.4% 76.7% 67.9% Standard 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% National Performance 93.3% 94.9% 95.8% 94.5% 94.4% 94.2% 95.3% 94.5% 92.7% 94.5% 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 7
5 Next steps - Sustainability 5.1 Establishing the forward looking approach to RTT pathway management which includes use of a 71 day escalation report which identifies all patients who have tipped over 10 weeks without an appointment (ie waiting 71 days). In addition services have been supported with a daily tracker of clock stops, open pathways and performance which has increased ownership and awareness of performance at service level. 5.2 Embed the review of patients from week 35 onwards at Access meetings with a view to further reduce this incrementally down to patients at 18+ weeks over the course of the next few months. 5.3 Roll out of the revised Access policy (by 30.9.), to include clear guidance for diagnostic and cancer waiting times, with steps in place to ensure that the Trust s Access Policy is followed by all scheduling staff. 5.4 Development of the demand and capacity tool in partnership with NHSE & CCG. 5.5 Development of the GOO report on i-reporter (general other outcome patients who have had a first appointment but without any definitive pathway outcome). This will be achieved with the support of Information in the development of GOO PTLs for each service. 5.6 Ongoing 18 week RTT training for all staff involved in the administration of the patient pathway and inclusion in mandatory training requirements for relevant staff groups. 6 Risks 6.1 Delivery of a sustainable compliant position remains a major challenge for the organisation in all three areas (RTT, Diagnostics and Cancer). 6.2 The reduction in weekend working and ad hoc lists puts sustainability further at risk although the more forward looking approach to performance delivery will give an early indication of the month end position with opportunities to take remedial action. 7 Recommendation 7.1 The Committee is asked to note: The achievement of the 92% incomplete pathway standard. The sustained performance in Diagnostics. The provisional achievement of the 62 day referral to first treatment cancer waiting times standard. Jane Shentall Director of Operations for Elective Care 8
Operational Recovery Update Unscheduled Care Presented by: Caroline Landon, Director of Operations, Unscheduled Care 1. Overview 1.1 In the past month, key achievements have been made, including: Relocation of the discharge lounge to Castle ward to accept up to 5 stretcher patients Trial of a new patient flow manager role for the medicine division was started in July Implementation of the single point of access for GPs in AAU and reallocation of consultant sessions Development of a proposed model of care for Urgent Care in ED Simulation Modelling initial outputs tested with the clinical team - data calibration ongoing Information team training on the simulation model in preparation for handover from EY Further work up of A&E reconfiguration scenarios (patient flow and resource allocation) 1.2 A&E performance continues to improve, with a July position of 91.2% against the 4 hour standard. Whilst demand has dropped slightly over the past two months, in the first week of August activity levels were at the same height as the first week of May, which saw performance at 84%, whereas in August performance was 92.8%. 1.3 Length of stay and bed days used in month has also decreased which suggests efficiencies and improvements to flow both in and out of hospital are starting to be felt at ward level. 2. Progress Updates Front Door Flow Single Point of Access 2.1 Following a review by the new AAU working group, it was agreed to implement a single point of access, delivered by senior nurses, to GP admissions. This service will run 7 days a week, and started on 1 st August. This will incorporate the Ambulatory care phone and the GP admissions phone into one point of access. 2.2 Through the first month of the new service, the team will audit Care of the Elderly calls as well to establish how many of these come through and consider incorporating this as well. There are currently 4 nurses allocated to take part in this rota to ensure a 7 day service. 2.3 A new nursing pro-forma is being developed to ensure all calls are managed and directed in the same way, with a view to reducing admissions and ensuring patients are directed to the right clinical team. We are also seeking to better manage the 9
presentation of ambulant GP patients, to reduce numbers who arrive at the Trust post 5pm. 2.4 This change in process will release around 188 PA sessions which are currently providing this service by the Physician of the Day rota. During the month of August, the Consultants who previously took part in this rota have been instructed to participate in a coding audit and validation process. 2.5 To complete the coding audit, there will be a standardised approach for the consultants to follow, and data capture process in place which will allow the division to assess, at the end of the month, the financial impact of having a consultant work alongside the coder validating the coding. Additional income gains from this process will be reported through the CIP programme. 2.6 Alongside this review, a mini audit will also take place, to assess the quality of the discharge summary sent to the GP. This will be a simple exercise which the coding department will capture, following the assessment of the consultant of each discharge summary. This will be fed into ongoing work to reduce readmission rates. 2.7 As well as the coding validation, each Consultant will be meeting with their Service Manager and a member of the EY team to map out their rota for the remainder of the year, and agree what clinical sessions can be re-instated instead of the POD session. The agreed sessions must be direct patient care, and the number of clinical sessions re-instated will be documented and reported back at the end of the month. Emergency Department Visit & Support from NHS England 2.8 Dr Mitten Ruperalia visited the Emergency Department and the wards and has provided the team with feedback and recommendations for further improvements. A number of key recommendations have been taken forward as part of an AAU group action plan, with key themes around streamlining process, developing clear protocols and revaluating existing criteria for a number of pathways. 2.9 Further days of support from Dr Ruperalia are planned over the coming weeks to explore other areas and options for change, including external support to an audit of walk-ins to help inform the model and resource profile for Urgent Care going forwards. Hospital Patient Flow 2.10 The discharge lounge moved to Castle ward on 20 th July as part of a trial to see how well a bedded area would be used, to support longer term plans to renovate the existing discharge lounge area. 2.11 Initial data was encouraging, with 12 stretcher patients using the lounge in the first week of the trial. Work is ongoing to evaluate the best use of the lounge and how we can further increase throughput to support earlier hospital discharge. 2.12 As part of the trial, a role has been created temporarily to test the idea of a patient flow manager working in the medicine division. This role will be evaluated at the end of the trial, which is scheduled to last until mid-august. 2.13 The plan to improve the discharge co-ordinator function has progressed and the training programme for the co-ordinators has been initiated. This includes ensure all co-ordinators are able to deliver basic tasks to a consistent standard. 10
Apr- May- Jun- Jul- TREND 2. A ward discharge guide is being produced which will serve as a handbook for all wards in how to get help for complex discharges 2. Board round standards and consistency between wards continues to be a challenge, and the programme has now begun a process to create a training DVD, recording the optimal board round standard and highlighting areas for improvements which can be shown to all MDT board round members. 2.16 The Sarratt ward team are continuing to work on establishing their board round as an electronic board. A proposal is in development with the IT team to modify existing systems to allow for electronic whiteboards to be a core part of the daily board round. The ward team are trialling a standardised approach which could be implemented should the Trust wish to proceed with electronic whiteboards. 2.17 The perfect ward project continues to be rolled out to wards, which now includes Heronsgate, Gade and Aldenham. A&E Reconfiguration 2.18 The scenarios for the simulation modelling are still in progress, with some delays due to data quality which have taken some time to resolve. The testing should be completed during August, with the scenario outputs due to be presented in the first week of September. 2.19 The outline business case is expected to be completed by the end of September, based on the outcome of the scenario modelling. 3. Performance Monitoring There has been a continued upward trend in 4 hour A&E performance, with a July monthly position of 91.2%. Ambulance handover >60 minutes and 30-60 minutes both improved again in July. Length of stay has started to drop which is encouraging, as well as discharges in the morning reaching 20%. AAU length of stay over 72 hours has dropped as well suggesting an improvement in flow to the medical wards. Weekend discharges have appeared to stagnate which may need further review next month. KPI / standard Q1 /16 Target A&E 4hr waits (Type 1, 2 & 3) 78.4% 86.0% 87.2% 91.1% 84.0% 95.0% A&E 12hr trolley waits 0 0 0 0 0 0 Ambulance turnaround time between 30 and 60 mins 22.1% 12.7% 13.6% 11.6% 22.1% % Ambulance turnaround time > 60 mins 12.2% 4.9% 2.3% 2.0% 8.7% 0% 50% of NEL discharges occur between 8am and 12pm (main adult wards excl AAU) Achieve Peer group Average LOS Non Elective Medicine (Spell, case mix adjusted) Achieve Peer group Average LOS Non Elective Surgery (spell, case mix adjusted) 19.4% 16.6%.5% 20.6% 16.8% 50% 8.4 7.6 7.4 7.0 7.8 3.9 7.4 5.8 6.3 5.7 6.5 2.7 11
30% of total NEL (medical & surgical) discharges occur at the weekend Cancelled Operations within 24hrs due to lack of beds (per month) 17.7% 20.5%.7%.9% 17.6% 30% 21 13 22 33 56 0 Delayed Transfers of Care (DToC) 3.7% 8.8% 8.3% 3.5% Medical Ambulatory Care Admissions % of all NEL Medical admissions Surgical Ambulatory Care Admissions % of all NEL Surgical admissions 33.2% 33.0% 34.2% 26.2% 30.2% 31.1% NEL Admissions to ED attendance ratio 34.3% 33.7% 30.8% % of patients with a LOS on AAU1 >72 hours 11.2% 12.2% 7.3% Number patients (per month) with >3 ward transfers within one week's stay 62 52 38 23.2% 55.0% 33.8% 7.1% 47 33.5% 30% 29.3% 30% 32.9% 30% 10.4% 0% 2 0 4. Next Steps Front Door Flow 4.1 Complete reallocation of consultant sessions for the POD timetable and present activity & financial benefits. 4.2 Further work with Dr Ruperalia from NHS England to adopt recommendations, including audit of minors activity to determine relative split of primary/secondary care activity 4.3 Review of single point of access in AAU Hospital Patient Flow 4.4 Completion of the move of discharge co-ordinators to the wards and implementation of revised KPIs and management handbooks 4.5 Aldenham, Heronsgate and Gade perfect ward continuation 4.6 Feedback trial of standardised electronic board rounds on Sarratt ward A&E reconfiguration 4.7 Initial outputs from the simulation modelling outputs will be presented, with first round testing with key stakeholders 4.8 Strategic outline case to be refreshed and decision to be made regarding the timetable for resubmission. 4.9 The CCG is working to confirmation of a Watford GP lead to join the A&E working group and help shape the urgent care pathway going forwards 4.10 CCG review of the proposed model for Urgent Care to assess the strategic fit with the Health and Social care hub model as outlined in the strategic review 12
5. Risks 5.1 The 4 highest risks on the programme risk register are included below: Risk Ref Risk Description L C Total Mitigation Action Length of Stay Hospital Patient Flow Front Door Flow Emergency Department Risk that LoS initiatives will not enable the Trust to make efficiencies due to: (1) Increased number of DTOC bed days (2) Reduced income resulting from below plan NEL medicine activity (3) Insufficient number of beds closed in concentrated area for sufficient period of time to reduce staffing and make savings There is significant risk to ward improvement delivery and sustainability due to the limited ability to embed changes at ward level. There are capability gaps in ward manager staff group, minimal Matron support to bridge this gap and currently limited service manager-level involvement in ward improvements. There is a risk that ED workforce gaps and lack of agreed funding for key posts will prevent sustainable achievement of 4 hour target. CCG funding for additional posts has not been provided via winter funding. There is a risk that the environment, layout and structure of Emergency Department is not fit for purpose and is not conducive to safe and effective care 6. Recommendations 5 4 20 4 5 20 4 5 20 4 4 16 Actions currently in progress: (1) Review feasibility of levying penalty to social care for DTOCs (2) Ensure that all NEL activity is being captured and coded prior to freeze date. (3) Review the strategy for prioritisation of bed closures Revised Perfect Ward Steering Group and membership in place, Medicine Divisional Director leading. Request for additional nursing / matron capacity sent to DON to ensure basic ward management skills are being improved. Executive to support Division to ensure adequate attention given to ward improvement programme Risk assessment of unfunded posts underway in department nonessential posts to be removed. Workforce plan to be finalised and presented to Execs decision making required relative to finance/performance trade-off. The ED reconfiguration business case will assess all options for redesigning the department with national environmental standards applied Risk Owner Caroline Landon Elaine Odlum Debbie Foster David Gaunt Exec Owner Caroline Landon Caroline Landon Caroline Landon Caroline Landon 6.1 The Board is asked to note the performance improvement and progress against plan. Caroline Landon Director of Operations, Unscheduled Care 13