1. Transforming surgical services UHBristol
Andrew Hollowood PhD FRCS
Clinical Chair Division Surgery Head and Neck
University Hospitals Bristol NHS Foundation Trust

2. Bristol Acute Services Review
UHB and NBT with significant clinical engagement
Assisted by PWC
Financial Challenge to Bristol of £230M next 5 years
Scale of change needs ambitious wide ranging solutions, integrated with health and social care
Service Review inc T&O and general surgery
Urgent Care Pathways in medicine, ED and stroke

3. Bristol Acute Services Review
Centralisation of Specialist Paediatrics
Head and Neck, Breast & Urology
Vascular reconfiguration
Cleft
Benefit for further rationalisation of services was not recommended through the review

4. Strategic challenges
Optimising productivity & operational efficiency
Transforming the ways in which we deliver care
Making strategic choices that directly address the challenge
Disinvest
Reconfigure

5. UHBristol Strategic intent
A range of local and regional services
Developing our specialist services
Promoting teaching & research - and recruiting the best
Working in partnership
Supporting community provision
Patients at the centre

6. ICNARC data Jan-Mar 2014

7. UHBristol Data
Inpatient mortality (locked data) was 4/41 (9.7%)
Predicted mortality 14.3%
NELA overall mortality 13.4%

8. Post-op Destination By Post op Risk Prediction - UHBristol

9. The Challenge Agreed protocols to assess and manage risk.
Timely input of senior decision makers according to the needs of the patient.
Appropriate facilities, laid out in such a way as to provide safe and expeditions patient care in a acute setting.
Careful planning and provision of adequate resources to enable sufficient and timely access to emergency theatres.
Appropriate pre-and post-operative arrangements, including the early involvement of anaesthetists and critical care specialists and resources where required.
A focus on patient centred care, which involves consultant-led communication with patients and supporters.

10. Separate pathway models
Emergency
Surgical and Trauma Admissions Unit
23 beds , 7 chairs, 4 assessment rooms
USS in assessment unit – radiographer 5 days a week
Short stay emergency ward
18 bed
Trauma and Orthopaedic ward
40 Beds, #NOF bay to rehab
Co-located on same floor with ICU and theatres
Dedicated NECOPD staffed separately
Local Networks - OG, HPB, Thoracics (on call rota)

11. Emergency Floor ITU Heygroves theatres STAU Short Stay ward
POD preop assessment
Trauma and Orthopaedic

12. Standards & checklists

13. Divisional Escalation
Implementation escalation rota
Clear internal divisional support on a daily basis

14. Wards 700 & 800 PULL patients up from Level 6
SCHEDULING
WLO allocates TCI date
Weekly scheduling meeting & list ‘sign off’
Elective surgical bed allocation. EDD based on procedure norms
Daily checkpoint meeting
Next day list ‘sign off’
ACTIVELY MANAGED BEDS
All teams working from same list
Critical care and ward beds pre-allocated so theatres can start on time
Critical care, Wards & CSMs are expecting patient
EDD – patient transferred to discharge lounge by 12pm
Home
ESCALATION
Wards 700 & 800 PULL patients up from Level 6
Ward 700
Ward 800
Level 6 – emergency floor
Divisional outliers
Emergency Department

15. Patient Access and Experience
Benefits realisation
Surgical Flow Dashboard
29/08/2014
ID No
Report Item
Train Track Category
Generated by
Frequency
Green
Red
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Patient Access and Experience 1
Number of patients on cancer pathway whose elective surgical procedure was cancelled on the same day (Non Clinical Reason).
Medway
Daily 7 12 8 4 10 17 2
Number of patients breaching a cancer standard as a result of theatre cancellation
Hannah Marder
Monthly 5 6 3
% of patient complaints related to elective surgical cancellations
Bev Fitzjohn 0% 3% 2% 6% 5% ED
Number of BRI Surgical Patients waiting over 4 hours in ED
37%
43%
42%
27%
26%
44%
38%
Number of Ambulance handovers taking more than 60 minutes
South West Ambulance Service 15
Theatre
Number of in-patient elective surgical procedures on BRI site 1%
192
175
227
195
185
178
147
% of same day cancellations for elective surgical procedures (non-clinical reason)
0.80%
1.50%
1.6%
1.8%
0.8%
1.7%
1.5%
2.1%
2.9%
% of same day cancellations for elective thoracic surgical procedures (non-clinical reason) 8%
10.7%
10.0%
8.8%
4.9%
16.7%
10.2%
18.8%
7.6% 9
Number of list changes <48 hours before procedure date
List start time (% lists starting ≤15 mins of start time)
≥95%
<95%
54%
47%
64%
65%
62%
66%
53.8% 11
List Utilisation
≥85%
<75%
79%
75%
81%
82%
69.9%
List Picked Up
≥96%
<94%
93%
87%
92%
90%
94%
91.7% 13
Theatres daily checklist completion
Theatres
98%
25%
Recovery 14
Number of patients overnight in recovery
Critical Care
ITU daily checklist completion 16
% of patients transferred from ITU to the ward within 4 hours (from fit for discharge decision)
Helen Dunderdale
Monthy
45%
40%
34%
41%
18%
35%
32%
Wards
Wards daily checklist completion 18
STAU daily checklist completion 19
Number of patients in surgery beds with a stay of over 14 days 30 36 38 42 35 41 20
Number of inter-specialty outliers on Ward 700 and 800 21
Number of non-surgical outlier patients placed into protected, elective surgical beds on Ward 700 and 800 22
Bed Occupancy rate on ward 700
 91% to 92.5%
 ≥95% and ≤85%
100.0% 23
Bed Occupancy rate on ward 800
103.1%
Discharge 24
Number of patients to the discharge lounge before 12am 90 70 69
102 93 91 83 53 25
Number of Patients on Green to go List
Site team
Dashboard to measure
Delivery of improvements to emergency and elective flow.
Reflects benefits to productivity, performance and patient experience
4hour flow
ITU discharge
Complaints due to cancellations
List utilisation list pick up
Start time
Completion of checklists.
Specific divisional targets to deliver operating plan

16. Measurement - Are we on time?
Surgical Flow Dashboard - Improvements in real time flow measures

17. Define the emergency service/patient pathway
Summary
Define the emergency service/patient pathway
Assess deliverability against standards
Review data against standards
Supporting Networks for local hospitals
Cross trust service reconfiguration where evidence
Develop local networks for speciality care
OG, HPB, Vascular, ITU

18. Strategic challenges Optimise emergency care pathways
Transform the ways in which we deliver emergency care
Make strategic choices that reconfigure emergency services