TRANSFORMING CARE FOR THE FUTURE 2015-2016 Report Vanessa Gardener, Director of Transformation Discover Design Deliver
Contents Overview Review Review of of Quarter Quarter 1 2 Contents Overview 3 Review of Progress against Commitments 4 2015/16 at a Glance 5 Progress on Setting CMFT Outpatient Standards 6 Progress on Maximising Elective Activity 7 Progress on Optimising Non-Elective Activity 8 Engaging our Staff 9 Progress against our Key Metrics 11 for Q3 13 14 17 2
Overview The Transformation Strategy was approved by the Trust Board in September 2014 and a 3 year plan produced. The 2015/16 Plan and Commitments was approved in May 2015 setting out how we will organise and deliver our transformation programme and management capability, in the context of delivering Transforming Care for the Future. The aim of our transformation strategy is to ensure we: Reach the top decile for quality - clinical outcomes, safety, patient experience, staff engagement and operational efficiency measures. Build upon and strengthen what is already in place but also carry out work across divisions and hospitals Build the capability of clinical leaders and also develop a robust change leader programme whereby staff at all grades and professions can be skilled up in transformation essentials Make better use of existing resources and teams support improvement by building a virtual team we have a change and innovation team in informatics, the quality improvement team in nursing, the OD&T team within HR; we need to ensure we all work closely together to offer support to the clinical teams and divisions in a coherent way Co-ordinate projects to ensure lessons are shared - the organisation is large and therefore it becomes more important to share across the organisation and also sharing examples of good practice internationally and nationally. The Transforming Care for the Future Programme objectives for the next 2 years are: 1. To create the right culture to deliver change through embedding the values and behaviors through distributed leadership 2. Give staff clear improvement methodology and build skills 3. Implement a governance process / PMO to ensure some rigour to the work and expectations. A PMO governance process is the backbone to successful project and programme management and ensures change occurs and is managed in a logical and controlled way. 4. Contribute through transformation circa 11m efficiency savings 3
Review of Delivery against commitments Workstream Commitment Progress Outpatients Eye Hospital & Altrincham early adopter Understand themes and agree priorities Elective Gap analysis against elective/theatre standards Gynaecology early adopter of preassessment model Agree ideal LOS with HPB and Upper GI teams Non-Elective Medium term Ambulatory Care Strategy Developed Complete CDT 30,60,90 day action plan Agree 24/7 capacity management model 7 day Services Engagement Session Support Divisions in Developing Options Culture change Capability Building Transform together learning event Roll out of distributed leadership by working with the surgical division leadership team to develop team surgery Explore development of Shelford Transformation Network Approach agreed with the Eye Hospital on transforming a clinic pod. Themes from Trust baseline assessment collated and presented to the Strategic Transformation Board in August 2015. Shared learning event took place in September 2015 for Divisions to share good practice. Gap analysis against theatre standards developed with the MRI and RMCH theatre teams. This is being rolled out across the other theatre teams during October, with presentations of the results planned in December 2015. Gynaecology have piloted and then implemented the new pre-operative assessment model, risk stratifying patients into low, medium and high risk categories. This approach can now be rolled out and surgery is the next Division. Ideal LoS has been agreed across one key pathway in each surgery sub-specialty. Improvement plans are being finalised by the end of October 2015. The Trust has completed the 12 month ambulatory care network programme and was awarded a certificate for the team who carried out the Most Effective Stakeholder Engagement and Involvement. The renewed focus has been on implementing the Community Assessment Unit, combined the ambulatory care function with urgent care access for GPs. This commenced on 1 October 2015. The majority of the complex discharge service action plan has completed. A shared learning event took place on 1 October with colleagues from Salford and Pennine Trusts to agree actions for the final outstanding actions relating to workforce and further process efficiencies. A proposal for 24/7 capacity management across the MRI has been produced and agreed in principle. A proof of concept is planned during the Embedding the SAFER standards week 12 October 2015. The engagement session took place on 3 July 2015,opened by the Chairman with over 100 attendees. plans have now been produced for review by the 7 day working group during Q3. The second Transform Together event took place on 24 September 2015 50K has been secured from charitable funds to encourage staff to think innovatively and carry out small changes that have big impacts for patients. OD&T and transformation are working with the new Surgical leadership team to ensure that the culture is understood and they are supported to develop Team Surgery. The inaugural Director of Transformation Shelford Network took place on 18 September. As a result Guys and St Thomas are visiting in November and UCL, Sheffield, Oxford and ourselves are working together on successful approaches to theatre improvement 4
at a Glance July Director of Transformation accepted onto the Founding Cohort of the Q Initiative run by the Health Foundation through the Academic Health Sciences Network 7 day services event Ratification of the Elective Standards Workshop to develop a theatre dashboard Presentation at Change Leadership Summit hosted by the HSJ on 13 July 4 day Improvement Practitioner course attended by 20 staff including consultants August Planning for hosting the Network event Poster developed for Ambulatory care event Work commenced on elective standards data collection tool developed with MRI and RMCH teams September 2015/16 Hosted the 3 rd Hospital Transformation Network with over 70 participants across 30 organisations on 11 September 2015 Shelford Transformation Network first meeting took place on 18 September 2015 2 nd Transform Together event on 24 September 2015; winning project: integrated rotational programme between acute and community services for Band 5 nurses developed with Bolton University Transform Together charitable fund launched for small projects creating big improvements for patients 8 September saw CMFT Ambulatory Care team present at the final Ambulatory Care Network event Shared learning event on outpatient improvement plans for all Divisions Ratification of the MRI / Trafford Urgent Care Strategy at TMB on 28 September 5
Outpatients Elective Non-Elective 7 Day Services Creating Culture for Change Building Capability Progress on Setting the CMFT Outpatient Standards Following the baseline assessments in June 2015, there were some excellent examples of good practice shared across all Divisions through a shared learning event held on 2 September 2015: Bespoke customer service training for administration and phlebotomy staff described by a number of Divisions Roll out of the virtual clinic models at Trafford and within Specialised Medicine Display of information for patients by AHP service based on what patients wanted Offer of choice to patients in Surgery Clinic Greeting Guide in DMACs Quality Box in Nuclear Medicine 1 question and each patient has a token to slot in 1-5 how they felt. Robust cancellation / leave processes across Trafford and Eye/Dental Quality forum and patient listening events in the Eye hospital Hello my name is campaigns in Eye/Dental/Trafford Key take home message for patients in Eye / Dental Patient pagers in the Eye hospital Bookwise hotelling system for clinic rooms in RMCH The common themes for improvement across most Divisions resulting patient experience tracker feedback are:- Limited information is provided to patients about what to expect prior to clinic Staff are not routinely explaining why there is a delay in clinic and how long the wait will be Cleanliness of Outpatient Areas is an issue Explanation of medication and results is not clear Availability of health records is an issue Clinic typing and reporting turnaround around times is too long in some areas Patients do not feel staff are present to help guide patients through their clinic journey Patients do not know who to contact if worried The Trust wide transformation programme has been updated to reflect these findings. In addition working with HR and OD, 2 engagement sessions have been held with Outpatient administrative & clerical staff who volunteered to co-design the work streams. 6
Outpatients Progress on Maximising Elective Activity Elective Non-Elective 7 Day Services Creating Culture for Change Building Capability During the Elective standards were ratified by the Quality Committee. The Transformation Team worked during August 2015 with the MRI and RMCH theatre teams to develop a self assessment template. This has now been rolled out to all other Hospitals for completion by November 2015. Work has continued with Gynaecology in developing a new pre-operative assessment model whereby high risk patients are seen by a consultant anaesthetist, medium risk by a pre-operative assessment nurse and low risk patients complete a screening tool. Example of the Transformation KPI Dashboard A pilot has been undertaken to test the screening tool for identifying the low / medium risk patients and the new consultant anaesthetic clinic will be set up in November 2015 for high risk patients. We are now working with the surgical division to roll out this model. A workshop was held on 8 th July with the aim of creating a consistent Theatre Dashboard to be used across all Divisions. Divisions identified priority areas for measurement and agreed on definitions in order to ensure each area is collecting the same data. This has been signed off by the Medical Director and is being rolled out across the Trust from October 2015. 7
Outpatients Elective Non-Elective 7 Day Services Creating Culture for Change Building Capability Progress on Optimising the Non Elective Pathway Planning took place in Q2 for Embedding the SAFER Standards week in October 2015 following the success of the Perfect Week in February 2015. The week of 12 October was chosen two main reasons: we have failed the A&E four hour standard during Q3 for the past two years and know that there is an influx in activity during October following the start of term at Universities in September. Therefore by focusing on fully embedding the SAFER standards and across every ward and department during a week in October we could reenergize staff and be proactive in responding to a predicted increase in demand SAFER KEY SUCCESSES Senior Review 80% of patients received a board/ward round by 10am 6% improvement in average length of time patients spent in A&E Assessment More patients were seen in the Community Assessment Unit Increase in the number of beds available on AMU and ESTU in the morning to help admissions EDD set on admission improved by 38% within DMACs and 16% in Surgery Every Division saw an improvement number of patients who were compliant with antibiotics, VTE prophylaxis, falls, pressure ulcers and nutrition from a baseline of 82% compliant, improving to 91% compliant Improvement in response for specialty review Flow Inreach by Specialised Medicine in AMU reduced outliers from 15 to 0 by the end of the week 17% increase in number of portable x-rays being carried out within 20 mins from request 91% of ED patients seen within 20 mins of request for x-ray Reduction in clinical cancellations on the day of surgery Critical Care go ahead pilot improved start times of theatres Early Discharge Reduction in patients with a length of stay (LOS) over 14 Days 100% increase in use of the discharge lounge 41% of patients were discharged by 10am from Specialist Medicine wards Increase of 3% more discharges from previous week Regular Review Improved response times in Surgery to urgent bleeps, all under 1hr Daily review of patients with LOS >5days with support from Social Care and CDT undertaken through Bronze Rooms and enabled the discharge of 20 longer length of stay patients 8
Outpatients Elective Non-Elective 7 Day Services Creating Culture for Change Building Capability Supporting 7 Day Services In June we planned and supported an engagement session for 7 day services. The event was designed to engage with Clinical Teams and develop a shared understanding of the vision for 7 Day Services. Divisions shared their assessments against the 10 standards and established top priority areas. Each Division used a framework to develop and assess their plans. It provided the opportunity for Divisions to work collaboratively and support each other. All Divisions presented their priority areas at the engagement session and worked up one plan. Since the engagement session the following timeline is being followed:- End of August all plans developed on priority areas. Shared with Divisions in September at 7 Day Implementation Group Reviewed by Panel during November 2015 Divisions ensuring plans are aligned to the annual business plans during November 9
Outpatients Elective Non-Elective 7 Day Services Engaging our staff The Transformation/OD teams undertook 8 events in Q2 engaging with over 300 staff: 7 Day Services Creating a theatre dashboard Improvement Practitioner course Outpatient Shared Learning Event Ambulatory Care Network Meeting 3 rd Hospital Transformation Network Shelford Transformation Network Transform Together Shared A selection of feedback: In July 2015, the Charitable Funds Committee approved 50K from charitable funds to encourage staff to think innovatively and carry out small changes that have big impacts for patients. This has now been launched across the Trust. Creating Culture for Change Building Capability 10
Review of Q2 Key Metrics LoS The MRI capacity plan has been refreshed at the end of Q1 and plans are on track. A trajectory is in place linked to the capacity plan. LoS continues on a downward trajectory. Each MRI Divisions plans are being monitored through the Capacity and Efficiency fortnightly meeting. 11
Review of Q2 Key Metrics Theatre Utilisation Following the workshop to develop a consistent theatre data set the measurement for theatre utilisation has been updated. The Elective programme is gathering pace and an improvement in utilisation has been seen in Q2. 12
Outpatients Priorities for Quarter 3 OUR Q3 COMMITMENTS, WE WILL:- Elective Non-Elective 7 Day Services Creating Culture for Change Building Capability OUTPATIENTS Work with divisions to improve on baseline Work with the nursing team to develop an accreditation tool ELECTIVE Gen Surgery Action Plan fully implemented Agree ideal LOS for top HRG for each surgical specialty and agree enhanced recovery pathways Urology and Non-Endovascular teams Carry out a rapid improvement project in surgery to increase elective activity and improve theatre starts NON-ELECTIVE Implement 24/7 capacity management model for MRI Implementation plan for each of the 6 strategic priorities from the MRI /Trafford Urgent Care Strategy 7 DAY SERVICES Development of Options CREATING CULTURE FOR CHANGE Transform together learning event BUILDING CAPABILITY Develop a mentoring scheme for those involved in change management Co-produce and run courses with AQuA on quality improvement techniques 13
Progress against the Commitments are as follows: SURGERY In the Wards Group, the ERAS+ project is well underway. The project has been planned at a high level and engagement started across the specialties. Each specialty now has an outline plan to introduce ERAS+ within its area working on one main pathway initially for early introduction (to prove the principle and get building blocks in place). After this first pathway, the specialties will work through the remaining procedures starting with the level three complex patients. This is a significant project for the division and is expected to provide important improvements in patient safety, experience and efficiency (length of stay). The Outpatient Group workstream is working through its current projects and a pilot in community based TWoCs (trial without catheter) is expected to start in Oct/Nov. The Theatre Group are planning for a rapid improvement event / perfect theatre week in late November. This event will concentrate on pushing forward improvements and implementation of the recently ratified elective standards. The Non-elective Group continues to work on the combined ACU with Medicine and review improved pathways for non-specific acute abdominal pain. SPECIALIST MEDICINE Continuing to track the detailed specialty plans for additional productivity in daycase and elective inpatient throughput in the latter half of the year Working with DMACS to develop and implement plans for In-reach to AMU/Outliers (to be established to run the Embedding Safer Standards Week in October). AKI nurses continuing with the roll out of AKI education and information sharing across the trust Roll out of Text Reminders for appointments across the Division Reviewing ambulatory care models Bed flow team now covering weekends. Work commenced on planning for Catheter Lab perfect week (will be held in December) utilising feedback from Boston Scientific review Assessment and mapping of Out-patient areas against CMFT standards. Working group developed. and Directorate meetings set-up DMAC Care of the Elderly Community Assessment Unit opened (in part) to receive patients on 1 October Discharge lounge relocated to ward 30 area as part of the CAU Geriatricians job planning in line with new model of service In reach speciality flag on AMU - 6 week audit undertaken - outcomes will inform the progression of flag to follow patient through hospital Ward 2 Trafford now operating as an Intermediate care/transitional Care Unit 14
ST MARYS Maternity Transformation Programme Perfect week took place as planned. The numbers of additional shifts covered did not reached the levels required to test the running of improved processes in all areas, so the extra staff available were focused on the post-natal wards to facilitate more timely discharge of patients and on extending the opening hours of the antenatal assessment unit to try and ease the pressure on the main triage unit. All the findings from the week are now being gathering into a report due to be completed by the end of October. Gynaecology Quality Improvement Programme The trial of having a designated Theatre Leader supported by a consistent theatre team commenced in Theatre 41. The purpose of the trial is to see whether the efficiency of the theatre improves if there is consistency with the staff operating within it. The trial of a pre-operative questionnaire to identify low risk patient also continued, with a second revision being developed following the feedback received from the first version. Newborn Services Quality Improvement Programme All work streams now have identified Consultant leads. Some of the work streams are now up and running and have started to list all the issues which they intend to tackle. The programme team have been going through a prioritisation with these lists to identify which issues will be focused on first. TRAFFORD Non Elective & Ambulatory Care: Participation in Perfect Week to continue to embed SAFER standards. Site assessment completed in preparation for transfer to electronic PSAG boards. Agreement that issue of discharge letters to family members needs to be managed through Length of Stay meetings. Discharge Team restructure- unsuccessful recruitment to Band 7 Discharge Team post. Re-advertised, closing date next week. Current non-elective workstreams to combine with Change Board led by Jon Simpson. Looking at AMU, Ambulatory Care, workforce, teams, integration and wards. Laura Foster supporting the Divisions in this work. Outpatients: Progress made with plans to address gaps in Outpatient Quality standards. Robust OPD performance monitoring established. Outpatient staff allocated responsibility each shift for offering patients the opportunity to complete the Patient Experience Tracker to improve feedback. Successful recruitment to Band 7 for Altrincham. Band 7 now permanently in place for main OPD. Trial of partial booking in diabetes clinic continues. To be evaluated after 3 months. SHINE assessments of the OPD environment undertaken with Estates and Facilities from 9/10/2015. Review of domestic provision in progress. Monthly QCR processes fully implemented and results fed back to staff. Theatre Transformation: Orthopaedic Team continue to work with Four Eyes Consulting who are working with the ward, theatres and scheduling team to review processes and suggest improvements to theatre and ward productivity. Over the last few weeks they have been meeting staff, attending meetings, doing ward and theatre 15 observations to get a better understanding of current systems and processes.
REH & DENTAL Perfect Week Programme Theatre Launch of the improvement programme, commitment from new clinical champions secured Macular Kanban system has been tested and electronic version development completed Macular baseline metrics/kpis agreed and measurements complete and being compiled for analysis Macular week commenced and in progress Outpatients - Agreement to scope possibility of Outpatient Perfect Week (meeting re-scheduled) as well as experience based design Theatre Scheduling (Theo) Identified potential to leap forward with Dental s uptake of Theo, requiring more developments to allow in-clinic listing Showcase of Theo to clinical team rescheduled Commitment from eye hospital scheduling project lead secured to trial Theo Outpatients Process mapping of electronic clinic outcome form in oculoplastics completed Use of Choose and Book discussed and pilot agreed and admin processes process mapped #Hello my name is campaign launched Pathways Various discussions in sub-specialties to generate vision statements which consolidate the clinical pathways with a view to scaling up Organisational Development REH Away Day held on 7th October extremely positive feedback and been asked to repeat RMCH V2A continues throughout RMCH with Wave 6 entering week 7 of 12. Theatre Transformation programme continues with new reporting tool instigated and piloting of new reporting suite to commence which hopefully will help with scheduling. Out Patient project has been placed on hold until CSU has gained understanding of OP. To recommence the project November which should have allowed those concerned to have a more in-depth understanding of the service. 16
Outpatients Elective Non-Elective 7 Day Services Culture Change & Capability Building Q1 Virtual clinic blueprint Baseline Assessment against standards Develop & ratify elective/theatre standards Perfect elective week in Eye & Dental theatres Implementation of CMFT SAFER Standards Perfect Egress week Baseline for outlier management agreed approach going forward Workshop for developing urgent care strategy for MRI/TGH Perfect Week Cardiology Agree and finalise capacity plan Engagement Session Development of Transformation leaders programme Development with others a framework for change for CMFT for staff Q2 Eye Hospital & Altrincham early adopter Understand themes and agree priorities Gap analysis against elective/theatre standards Gynaecology early adopter of pre-assessment model Agree ideal LOS with HPB and Upper GI teams Medium term Ambulatory Care Strategy Developed Complete CDT 30,60,90 day action plan Agree 24/7 capacity management model Engagement Session Support Divisions in Developing Options Transform together learning event Roll out of distributed leadership by working with the surgical division leadership team to develop team surgery Explore development of Shelford Transformation Network Q3 Work with divisions to improve on baseline Develop Accreditation tool Gen Surgery Plan Fully Implemented (30,60,90 Day) Development of Pathways with Clinical Agree ideal LOS with Urology and Non-Endovascular teams Implement 24/7 capacity management model for MRI Implementation plan for outputs from Urgent Care Strategy workshop Development of Options Transform together learning event We will develop a mentoring scheme for those involved in change management Q4 Increase in virtual models Hold Theatre Think Tank workshop Implementation plan for Ambulatory Care Transform together learning event repeat the cultural survey in relation to change during 2015/16 to see how things have changed Through out 2015/16 we will have Baseline assessment for each division against the CMFT standards Eye hospital & Altrincham will be exemplar sites Improved Patient experience Efficient care and effective processes for pre-operative assessment, theatre listing and enhanced recovery. Agreed and implemented CMFT theatre standards Improve theatre utilisation from 72.5% to 79.4% (Theatre Benchmarking Network mean) Embed achievements seen in perfect week Reduce LOS across the MRI from 6 days to 5.5 days (Shelford mean) Run a Perfect Egress Week and Perfect Week in the Heart Centre Implemented 24/7 capacity /site management for the MRI Have hosted a number of engagement sessions with staff and stakeholders to develop options for scaling up services Developed with others a framework for change for CMFT for staff Introduced quarterly transform together 17