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Special Measures Action Plan Heatherwood and Wexham Park Hospitals NHS Foundation Trust September 2014 KEY Delivered On Track to deliver Some issues –

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Presentation on theme: "Special Measures Action Plan Heatherwood and Wexham Park Hospitals NHS Foundation Trust September 2014 KEY Delivered On Track to deliver Some issues –"— Presentation transcript:

1 Special Measures Action Plan Heatherwood and Wexham Park Hospitals NHS Foundation Trust September 2014 KEY Delivered On Track to deliver Some issues – narrative disclosure Not on track to deliver 1

2 Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan & our progress What are we doing? The Trust entered the Special Measures programme and was selected following a CQC inspection in February 2014 which rated the Trust as “inadequate.” The Trust has to implement a range of recommendations, some of which are achievable in the short term and others which require a longer period of implementation to drive sustainable change. The Trust is committed to making the changes as quickly as possible in the very best interests of our patients and has taken a realistic and prioritised approach to the Improvement Plan. The Trust has agreed a summary action plan to deal with these 18 recommendations. We envisage that improvements will be made on an ongoing basis throughout 2014 to ensure that the Trust is ready when the Chief Inspector of Hospitals, Professor Sir Mike Richards, reinspects. The key themes of these recommendations are summarised by the headings below: Patient Safety: the CQC found that there is a lack of ownership of problems with acceptance of sub-standard care and poor patient experience, poor cohesion of staff groups, the existence of a ‘them and us’ culture, a safety culture is not embedded and there is a culture of poor incident reporting Patient Experience: the CQC found that staff are desensitised to patient experience being a priority, whilst complaints handling had improved considerably, awareness of how to complain or raise a concern was still too slow and the estate is not universally fit for purpose nor maintained in a timely manner Workforce and Culture: the CQC found that there was a high turnover of middle and senior management, consultant engagement is an ongoing problem, reports of bullying and harassment were widespread, performance management of consultants was inadequate, a lack of cohesive working between staff groups, concerns over staffing levels, ongoing reliance upon agency staff due to struggles to recruit and retain staff and examples of non adherence with local induction policies Governance: the CQC found that governance structures were not standardised across the Trust including mortality and morbidity meetings and that fundamental standards of care were not being met Patient Flow: the CQC found that there were significant problems with the flow of patients through the hospital and that the Trust is not meeting the 4 hour emergency access standard. Elective Access: the CQC found that there was a high rate of cancelled operations and that the referral to treatment standards were not being met. This document shows our plan for making these improvements and demonstrates our progress against the plan. While we take forward our plans to address the recommendations, the Trust is in ‘special measures’. Oversight and improvement arrangements have been put in place to support changes required. The Trust has a Quality Programme Board which meets twice a month to consider progress and key actions. A formal Quality and Safety Executive Board meets monthly to review the Trust’s performance in key areas such as patient safety, incidents, staffing and patient experience. External scrutiny will take place at a monthly Oversight and Assurance meeting chaired by NHS England which is also attended by commissioners and the Trust’s regulator, Monitor. The Trust has already benefited from the partnering arrangements with Frimley Park Hospital NHS Foundation Trust. Members of the Executive Team at Frimley Park have had input to the Improvement Plan and have attended meetings with clinicians to support the engagement process. The Trust has recognised the need for a sustainable organisational form as the key to addressing some of the longer standing issues and ensuring that there is a complete approach to ensuring that the Trust can make the required improvements. The Board is supportive of and committed to the proposed acquisition by Frimley Park Hospital NHS Foundation Trust. This will enable a longer term plan to be implemented to ensure that changes are fully embedded and sustainable. 2

3 Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan & our progress Who is responsible? Our actions to address the CQC recommendations have been agreed by the Trust Board. Our Acting Chief Executive, Grant MacDonald is ultimately responsible for implementing actions in this document. Other key staff include the Executive Team, the clinical chairs and clinical leads in the organisation. The Improvement Director assigned to Heatherwood and Wexham Park Hospitals NHS Foundation Trust is Mark Davies, who will be acting on behalf of Monitor and in concert with the relevant Regional Team of Monitor to ensure delivery of the improvements and oversee the implementation of the action plan overleaf. Should you require any further information on this role please contact Ultimately, our success in implementing the recommendations of the Improvement Plan will be assessed by the Chief Inspector of Hospitals, who will re-inspect our Trust within 12 months after entering the Special Measures programme. If you have any questions about how we’re doing, contact us at How we will communicate our progress to you We will update this progress report every month while we are in special measures. There will be regular updates on NHS Choices and subsequent longer term actions may be included as part of a continuous process of improvement. We will present our progress to the monthly Oversight and Assurance Group, chaired by NHS England and attended by our commissioners and regulators. Chair / Chief Executive Approval (on behalf of the Board): Chair Name: Mike O’DonovanSignature:Date:11/9/14 Acting Chief Executive Name: Grant MacDonaldSignature:Date: 11/9/14 3

4 Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan Summary of main concerns Summary of urgent actions required Agreed timescale for implementation External support/ assurance Progress against original timescale Revised deadline (if required) Patient Safety1.1.1We will communicate that completion of the WHO checklist is mandatory and that repeated non-compliance will be addressed through performance management We will appoint an accountable clinical lead for the WHO checklist together with WHO champions in each theatre team We implement a mandatory field in the theatre management system (IQTopia) that will enable near real time monitoring and audit. In lieu of this development we will ensure that an incident must be logged when the checklist is not completed and will monitor compliance through weekly compliance checks and regular audits We will commission an expert external clinical advisor to undertake a workshop with consultants on human factors that support implementing the WHO checklist. End of May End of June End of August Dr P McArdle, Plymouth Hospitals NHS Trust Acting CEO and MD have outlined the requirement with the clinical leads. Clinical lead and champions for the WHO checklist identified. Work on software for theatre system has commenced but has been delayed due to limited IT access in the anaesthetics room. A compliance process is ongoing in lieu of this development. Expert external clinical advisor attended the Academic Half Day on 15 July. The debate led to significant discussion about the need to move the focus on the action plan onto addressing the human factors in non- compliance with the checklist. Firm engaged to run a workshop on human factors for key theatre staff. This is scheduled for December. Quantitative audit process in place. Qualitative audits developed and introduced. The nurse in charge of theatres observes the process three times a week. A survey on staff engagement with the WHO checklist is planned to take place. Theatre manager nominated to log incidents on Datix. End Sept 4

5 Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan Summary of main concerns Summary of urgent actions required Agreed timescale for implementation External support/ assurance Progress against original timescale Revised deadline (if required) Patient Safety1.2.1We will obtain external support from the Thames Valley Academic Health Science Network – Patient Safety Academy to develop and implement a programme to improve the patient safety culture in the trust We will undertake the Listening into Action (LiA) programme of engagement with staff. This is a simple programme with a clear aim to transform the way the Trust works, putting staff at the centre of change. It is based on evidence about the link between engagement and outcomes of care We will ensure that there are regular forums for clinical leads to review quality improvement activity with the MD and CEO We will maintain a rolling programme for nurse leaders to ensure a sound knowledge of care standards that can be cascaded to others We will obtain expert clinical advice and implementation support on our plans related to patient safety and clinical engagement from Frimley Park Hospitals NHS Foundation Trust. End of November End of December End of June Thames Valley Academic Health Science Network Listening into Action Seminar held with Patient Safety Academy and senior clinical leaders to explore how they can support the Trust with cultural change. Trust to nominate 4 individuals to attend workshop in Autumn. The Trust will join the Sign up to Safety campaign upon acquisition by Frimley Park. This will be led by the Medical Director. Phase 1 of LiA has been completed and > 200 staff have taken part. Project teams now working to implement changes following launch events. Quick wins identified, implemented and communicated. Clinical lead, MD, CEO forums are ongoing and have identified how specialities can work to inform and implement this plan and a broader improvement agenda. Clinical advice agreed with FPH and meetings between clinicians have taken place. Nurse development programme has been extended due to positive feedback. Nursing standards developed and launched on Nurses Day. 5

6 Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan Summary of main concerns Summary of urgent actions required Agreed timescale for implementation External support/ assurance Progress against original timescale Revised deadline (if required) Patient Safety1.3.1We will review the use of risk assessments in A&E and take improvement actions where required We will meet the specific nutritional needs of patients who are in the A&E department for prolonged periods. End of May The use of risk assessments in the ED and the associated standards have been reviewed and implemented. Nutrition, waterlow and falls assessments are to be completed for all patients >75 years and others at risk who will be admitted but are awaiting a bed at four hours. If the patient is still in the department after 6 hours, they will be transferred to a bed and remaining assessments will be completed. Three audits have taken place in A&E to review documentation of falls assessments and fluid balance charts. Compliance levels are improving. Regular sample checks are now taking place on assessments via clinical compliance rounds. The Associate Director of Nursing reviews the outcomes of the audits quarterly. Hostess rounds have been increased in A&E to ensure that appropriate nutrition is available to all patients, including those attending for prolonged periods. 6

7 Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan Summary of main concerns Summary of urgent actions required Agreed timescale for implementation External support/ assurance Progress against original timescale Revised deadline (if required) Patient Safety1.4.1We will develop and communicate a programme of initiatives aimed at developing an incident reporting culture, so that it is seen as a mechanism to learn rather than attribute blame We will review the incident reporting process to identify how learning can be better shared with the individuals reporting the incident and throughout the wider organisation. End of August End of July Feedback mechanism reviewed and updated. All incidents classified as moderate and above must now be fedback to reporters. Guidance to this effect has been updated and released to all staff with clear instructions on the mechanics of using Datix. Cleanse of Datix system to remove duplicate incidents and users has been completed. System upgrade to facilitate feedback is on hold as an outsourced solution is being jointly progressed with Frimley To support the Duty of Candour, the Trust has amended Datix to capture when a patient or relative has been informed when something has gone wrong for all incidents graded moderate and above. Plans in place to share learning via monthly updates at all levels of the Trust (e.g. all staff , Team Brief, Bilaterals etc). Patient Safety and Quality newsletter issued monthly. Divisions are taking it in turns to present a report on key themes from complaints and incidents to the PSG. Matrons slidepack has a placeholder on key learning. A maternity newsletter has been developed and disseminated within the team to highlight key learning points. 7

8 Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan Summary of main concerns Summary of urgent actions required Agreed timescale for implementation External support/ assurance Progress against original timescale Revised deadline (if required) Patient Safety1.5.1 We will review the investigation of incident process and implement improvement actions. The scope will include consideration of who is appointed to the investigating team, how the investigation is conducted (including root cause analysis, data review and involvement of those who use the service together with staff) and how the outcome of the investigation is shared. End of JulyThe investigation process has been reviewed. Some clarification of roles and responsibilities was required and the Trust policy has been updated and has been signed off. 8

9 Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan Summary of main concerns Summary of urgent actions required Agreed timescale for implementation External support/ assurance Progress against original timescale Revised deadline (if required) Patient Safety1.6.1We will provide additional safeguarding training to staff to ensure that they are able to respond to patients appropriately We will provide all staff with information on how to respond to patients with a learning disability We will develop and embed initiatives to improve the care of people with dementia. End of August End of May End of October Capacity for training identified and being programmed. DOLS to be included in level 2 safeguarding training. Awareness increasing and more DOLs applications are being made. DOLs and safeguarding was included on the agenda for the matrons meeting inAug. Plans for level 3 childrens safeguarding training developed and sessions (training up to 66 individuals) are due to take place in November and December with further phasing over an 18 month period to ensure that relevant staff are trained. All staff provided with information on people with learning disability at the end of May via monthly payslip. Working version of LD protocol is in place and is to be discussed at NMAC. Plans in place to train a further 16 dementia champions in October individuals are already trained. A dedicated dementia bay with four beds on ward 5 has been established. Dementia garden has been opened, dementia awareness week has taken place together with a workshop by a dementia carer highlighting key challenges. Individuals made personal pledges around dementia care. 9

10 Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan Summary of main concerns Summary of urgent actions required Agreed timescale for implementation External support/ assurance Progress against original timescale Revised deadline (if required) Patient Experience 2.1.1We will implement and resource a co-ordinated programme of activities aimed at improving the experience of patients and their friends and family We will develop and implement a customer care programme which will be rolled out to all patient facing staff. This places the patient experience at the centre of the training. The curriculum includes a number of ‘always’ events that we expect from our staff (e.g. Introducing yourself to patients, following hand hygiene protocols etc). End of November Picker Institute Curricula and mobilisation programme developed for customer care programme. Roll out has commenced. Since February and at 10 Sept, 350 people had attended training and a further 250 scheduled to attend. The Trust has developed and is implementing a co-ordinated programme of activities including: A workshop facilitated by a patient with patient and clinical involvement to develop top 5 priorities for the next 12 months Patient stories at the Trust Board Mystery shopper telephone calls to wards and departments assessing customer service skills “Hello – my name is..” was successfully launched on 7 July. Bedside guide for patients developed. HWP patient and advocate for improved patient experience involved in induction training for new junior doctors in August. To be filmed to facilitate ongoing training. Work is ongoing to consider the organisational structure for complaints. A Complaints Newsletter has been developed and circulated to all staff with key learning points from each division. 10

11 Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan Summary of main concerns Summary of urgent actions required Agreed timescale for implementation External support/ assurance Progress against original timescale Revised deadline (if required) Patient Experience 2.2.1We will develop the estates management system as a way of logging and responding to and monitoring planned and reactive maintenance We will implement year one of a 5 year prioritised plan to address circa £40m of estate issues identified in a 6 facet survey. End of August End of March Revised system and process aimed at improving the estate management system being finalised. First phase of training has been completed for management, engineers and team leaders. In total, 75% of staff have been trained. Scoping meeting held with Qube to develop management information and performance reports. This will support more effective management and decision making within estates. Business process mapping is complete and mobile devices have been deployed to trained staff. Comms to clinical staff on changes has commenced at matrons mtg and will be cascaded to all wards and depts. The backlog of outstanding jobs has reduced by a third since March. Capital plan and timeline has been agreed with DoH. High level capital plans for 14/15 agreed and work commenced. Regular meetings held with Frimley to prioritise plans. The Trust has invested in two new fully equipped and modern wards, one of which is now fully operational. Second ward will open in September. 11

12 Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan Summary of main concerns Summary of urgent actions required Agreed timescale for implementation External support/ assurance Progress against original timescale Revised deadline (if required) Workforce and Culture 3.1.1We will work with ACAS to undertake a comprehensive review of staff perspective on fairness in the workplace with a specific focus on bullying and harassment We will commission ACAS to undertake a programme of development following the initial phase of the diagnostic work described above We will commission ACAS to undertake training to prepare key managers and leaders for difficult or crucial conversations, how to manage and control the workplace discussion process and how to ensure they are talking to employees in as productive a way as possible We will complete an external assessment of the Trust’s approach to longer standing employee relations issues. End of August End of July End of May ACAS ACAS have been jointly commissioned between management and staff side to undertake diagnostic work on the culture of the organisation with a specific focus on bullying and harassment and training on how to have a difficult conversation. ACAS have largely completed their diagnostic work and anticipate that their draft report will be available in early October. At 3 September, 123 people had booked in for training, 53 people were scheduled to attend a focus group and 28 individuals had requested a one to one interview. A separate training session is being scheduled for booking centre staff to accommodate their workload and opening hours. Feedback on the training sessions to date has been positive and additional sessions have been arranged for September and October. A review of employee relations issues undertaken and revised approach agreed. 12

13 Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan Summary of main concerns Summary of urgent actions required Agreed timescale for implementation External support/ assurance Progress against original timescale Revised deadline (if required) Workforce and Culture 3.2.1We will review, develop and implement our recruitment and retention plans to drive an increase in substantive staff and reduce our reliance on temporary agency staff We will enhance our monitoring of progress and report on progress on a regular basis. End of July Revised R&R plans have been developed and are being implemented. The Trust has attended overseas recruitment events in Spain and Italy to focus on increasing the numbers of qualified nurses. Good progress has been made at recent overseas events and UK job fairs. Over 100 people were interviewed and the Trust expects staff to commence between September and November. The Trust has future plans to attend further job fairs and additional overseas recruitment. Offers have been made to a number of middle grade doctors, subject to work permits and GMC registrations. Revised reporting is being finalised for the monthly resourcing group meeting. Roles and responsibilities between HR and operations have been clarified. 13

14 Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan Summary of main concerns Summary of urgent actions required Agreed timescale for implementation External support/ assurance Progress against original timescale Revised deadline (if required) Workforce and Culture 3.3.1We will review our nursing establishments and adjust as required We will implement governance and reporting systems to monitor and report on safe nurse staffing levels We will publish their staffing fill rates (actual versus planned) on the NHS Choices website We will review medical staff capacity to ensure that we can meet the capacity required for planned and emergency care. End of May End of June End of July The Trust has reviewed nurse staffing levels to inform budget setting and increased nursing levels where required. The Trust has agreed a policy on nurse establishment and skill mix. The Trust has developed and implemented a governance and reporting system to monitor and report on planned nurse staffing levels. Further action is being taken to provide assurance that remedial actions for short staffed shifts are being undertaken. Data and accompanying narrative posted on NHS Choices to demonstrate key staffing metrics such as fill rates The Trust has reviewed the requirements for consultant medical staffing for unscheduled care and is recruiting against this. Demand and capacity work on scheduled care is progressing. This will provide clarity on the medical staff required to deliver this capacity. 14

15 Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan Summary of main concerns Summary of urgent actions required Agreed timescale for implementation External support/ assurance Progress against original timescale Revised deadline (if required) Workforce and Culture 3.4.1We will review the boarding passes used to induct agency staff on the wards and reiterate the mandatory requirement of checking identities and competencies when the agency member of staff arrives at the ward We will monitor compliance with completion of the boarding passes. End of May End of June Boarding pass format finalised to ensure consistent application. Spot check audits have been undertaken to monitor compliance. Compliance with boarding passes is also included as a question within the clinical compliance rounds to ensure sustained compliance. Project team in place to agree templates for boarding passes for locum medics. Paper based process has been designed (and is already in use in A&E). Project plan is in place to roll out across inpatient wards. Frimley locum induction process and templates obtained to progress implementation at HWP. 15

16 Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan Summary of main concerns Summary of urgent actions required Agreed timescale for implementation External support/ assurance Progress against original timescale Revised deadline (if required) Governance4.1.1We will review and revise the existing governance structure and submit the revised framework for review by the Good Governance Institute (GGI) We will implement the revised arrangement and processes following initial feedback from the GGI We will ask the GGI to review the arrangements in practice when established and undertake any ongoing improvements recommended. End of May End of June End of August Good Governance Institute The GGI has examined the proposed arrangements and are satisfied that they will provide a framework for adequate clinical governance system. The Trust has rolled out the revised system and associated processes. An interim review has been completed to identify any emerging issues following a month of operation. No significant issues identified but some improvements to be introduced as a result of the findings. The GGI has been on site and performed a review of the compliance with and operating effectiveness of the new arrangements. The Trust has received positive verbal feedback and anticipates that a draft report will be received during September. 16

17 Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan Summary of main concerns Summary of urgent actions required Agreed timescale for implementation External support/ assurance Progress against original timescale Revised deadline (if required) Governance4.2.1We will design robust and transparent structures and processes to manage and improve individual and team clinical safety and quality. The project to do this is being carried out by KPMG in conjunction with the Faculty of Medical Leadership and Management who have brought in senior external medical expertise to work with the medical staff at the Trust to understand how clinical governance currently operates and help to design a robust new structure that can be rolled out across the Trust. The review is considering six areas incorporating a mix of medical, surgical and diagnostic specialties. It includes a desktop review of documentation (minutes, job descriptions, structure) followed by observation of existing mortality & morbidity and multidisciplinary meetings. The team will then work with divisional chairs to develop a consistent approach to these meetings across the organisation We will implement the recommendations from this review across the Trust. End of July End of September KPMGThe review is complete. A number of recommendations have been made to improve the medical governance arrangements at the Trust. The recommendations are at Trust-wide and specialty level and have been drafted with the acquisition in mind. 17

18 Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan Summary of main concerns Summary of urgent actions required Agreed timescale for implementation External support/ assurance Progress against original timescale Revised deadline (if required) Governance4.3.1We will implement and embed a system for direct monitoring of compliance with point of care standards We will fully embed ward dashboards and ensure that they are understood and owned from ward to board as a tool to monitor point of care standards by care area or by care issue We will embed a robust system to review the decision when a caesarean section is performed. End of May End of July End of June The Trust has developed and implemented a standard operating procedure for compliance checking in service areas. Escalation procedure developed to clarify to staff what action will be taken if compliance rounds are not undertaken or if scores are poor. This is monitored weekly and has resulted in significantly improved levels of compliance. The Trust has developed and is embedding ward dashboards as a key assurance product. The Trust has progressed to using the data from the reviews as a means of identifying further areas for improvement. C section meeting has taken place with lead consultant and midwife and CCG representatives. Agreed to do a thrice weekly (Monday, Thursday and Sunday) review of caesarean sections with a focus on category 1 and 2 cases. Case notes are reviewed in detail led by an alternating consultant of the week. Meetings are open to all. A monthly “Improving Normal Births” meeting is also held. 18

19 Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan Summary of main concerns Summary of urgent actions required Agreed timescale for implementation External support/ assurance Progress against original timescale Revised deadline (if required) Governance4.4.1We will reinforce and communicate the standards required in respect of documentation We will regularly review patient notes to ensure documentation is of agreed standard. End of July End of August Required standard of nursing documentation has been communicated. Nursing documentation is reviewed regularly, including as part of the clinical compliance rounds. Documentation standards workshop held and an improvement campaign took place in July. A reminder of good clinical record keeping was posted on the intranet for all staff. Key tips on good care and recording were also sent to all matrons. This included tasks for all matrons to complete with a focus on how improvements could be made. Proposal developed to introduce personalised doctor’s stamps with names and GMC numbers to provide greater clarity in patient records. Awaiting details of Frimley’s supplier to place an order. 19

20 Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan Summary of main concerns Summary of urgent actions required Agreed timescale for implementation External support/ assurance Progress against original timescale Revised deadline (if required) Governance4.5.1We will maintain a system which enables us to monitor when policies and guidelines are due for renewal and proactively review them in advance of the due date. End of JulyThe Trust has identified and is working through a prioritised schedule of polices requiring review. 20

21 Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan Summary of main concerns Summary of urgent actions required Agreed timescale for implementation External support/ assurance Progress against original timescale Revised deadline (if required) Patient Flow5.1.1We will review existing plans to improve the emergency care pathway and develop a focused recovery plan. This will include enhancing the role of ambulatory care, developing further seven day working plans and earlier initiation of patient treatment in the most clinically appropriate location We will obtain expert clinical advice and implementation support on our plans as part of the partnering arrangements from Frimley Park Hospitals NHS Foundation Trust We will engage the expert external support of the NHS Emergency Care Intensive Support Team in relation to the delivery of our recovery plans. End of June Frimley Park Hospital NHS FT Emergency Care Intensive Support Team Final draft of recovery plan being agreed following extensive clinical engagement. ECIST have conducted an initial review and have developed a series of recommendations which are being incorporated into the recovery plan. Ambulatory care has progressed well and has been embraced by the surgical teams. This was enhanced by an open day held in the area at the end of June. Clinical advice agreed with FPH. Initial meetings have taken place between clinicians. Individuals have been tasked with working in small teams to develop a plan to achieve an outstanding rating in each of the CQC domains at the next inspection. This will be developed with input from FPH. Additional resource secured for x-ray to operate a third machine. This commenced 7 days a week from 4 July to reduce A&E diagnostic waits. Meeting between key clinicians and managers from A&E and radiology is being set up to facilitate improved communication and team working. 21

22 Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan Summary of main concerns Summary of urgent actions required Agreed timescale for implementation External support/ assurance Progress against original timescale Revised deadline (if required) Patient Flow5.2.1We will minimise the number of patient moves by improving the emergency care pathway and specifically by undertaking the ‘Spring to Green’ initiative aimed at generating energy for change by doing things differently for a defined week to support patient flow; Right Patient – Right Bed and consequently improve patient care. End of JulySpring to Green event took place w/c 30 June. Significant levels of clinical engagement throughout the Trust at all levels. Escalation status improved throughout the week (from red to green). Sustainable changes identified including additional radiology and OT/Pt resource. There were a number of quick wins identified in Spring to Green which have been implemented by Executives immediately. This includes the provision of additional staff within radiology and rehabilitation. 22

23 Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan Summary of main concerns Summary of urgent actions required Agreed timescale for implementation External support/ assurance Progress against original timescale Revised deadline (if required) Patient Flow5.3.1The Trust will monitor escalation areas on a daily basis. This will include consideration of the mix of substantive/bank & agency staff. Clinical compliance rounds will incorporate a review of the documentation to ensure that patients meet the admission criteria. End of MaySnowdrop escalation area has been closed and is only being used when the escalation policy is implemented. Admission criteria has been agreed and communicated to staff. Compliance is monitored and discussed at daily bed meetings when escalation beds are open. Escalation beds were opened w/c 25 August and an audit of adherence to admission criteria has been performed. Further action to ensure adherence to the Escalation Policy all of the time has been implemented. The Trust has nominated substantive members of staff to cover escalation areas. An escalation methodology has been agreed. This includes agreement of key actions to be completed within 6 hours when escalation areas are open by 9am in the morning. Action cards are also being developed for escalation areas when they are opened. This includes actions for nursing staff, pharmacy, catering etc. 23

24 Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan Summary of main concerns Summary of urgent actions required Agreed timescale for implementation External support/ assurance Progress against original timescale Revised deadline (if required) Elective Access6.1.1We will undertake detailed capacity and demand work for prioritised surgical specialties and implement a robust recovery plan We will obtain expert clinical advice and implementation support on our plans as part of the partnering arrangements from Frimley Park Hospitals NHS Foundation Trust We will get external assurance from the NHS Elective Care Intensive Support Team on the sustainability of our plans. End of July End of August Frimley Park Hospital NHS FT Elective Care Intensive Support Team The Trust has undertaken detailed capacity and demand work and agreed a recovery plan with specialities, which is being implemented. The Trust has increased capacity (through additional sessions and outsourcing) to undertake activity to reduce the number of patients with long waits. This has had a significant impact and the RTT >18 weeks has reduced by 53% since February No patients have breached the 52 week guidelines. The Trust has agreed an external review with the NHS Elective Care Intensive Support Team. The review took place during August A wide range of staff were interviewed and verbal feedback has been provided to senior operational staff. Clinical advice agreed with FPH. Initial meetings have taken place between clinicians. 24

25 Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan Summary of main concerns Summary of urgent actions required Agreed timescale for implementation External support/ assurance Progress against original timescale Revised deadline (if required) Elective Access6.2.1We will implement a radiology improvement plan which will factor in the forecast demand and capacity and enhanced performance standards to reduce waiting and turnaround times We will review and implement an improved radiology reporting tool. End of September End of August Newton Europe Ltd A radiology improvement plan developed, signed off and being implemented. A visioning event held to develop the plan. The department is working towards achieving a 2 day turnaround, including reporting, for inpatients for all modalities. For outpatients the national standard for diagnostics is 6 weeks from referral to exam. The Trust is working towards a 14 day turnaround, including reporting. Performance has improved significantly. The additional staffing provided as a result of Spring to Green is having a positive impact on performance. The radiology team is recruiting additional consultants to deliver 7 day working and there is progress and momentum to the plan. 25

26 Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan Summary of main concerns Summary of urgent actions required Agreed timescale for implementation External support/ assurance Progress against original timescale Revised deadline (if required) Elective Access6.3.1We will review options to improve the booking centre and related functions and implement the preferred option The booking centre will work to agreed key performance indicators and ten operational service standards. End of November Executive received an option appraisal and agreed that a clustered model of outpatient scheduling should be adopted. Operational changes identified and two phase project developed:- 1 - devolvement of the booking centre functions to specialities 2 - work around improvement themes and supporting projects to improve each service area. Management structure set up and staff in post using the cluster model. 26

27 Heatherwood and Wexham Park Hospitals NHS FT- How our progress is being monitored and supported Oversight and improvement action Agreed timescale for implementation Action ownerProgress Monthly Oversight and Assurance Group chaired by NHS England and attended by commissioners and Monitor to track delivery of the improvement plan. ImplementedNHS EnglandRegular meetings held Appointment of an Improvement Director (Mark Davies) by Monitor who will provide expertise to the Trust Board on how to improve our services and check that we’re meeting our promises to deliver our improvement plan. Commenced May 2014MonitorMark Davies appointed and has provided input and support Partnership working with Frimley Park Hospitals NHS Foundation Trust as a high performing provider organisation. This will provide best practice guidance, peer support and challenge. Commenced June 2014Acting Chief ExecutiveBuddying plan agreed and being implemented Agreement and regular monitoring of quality measures at the Quality Programme Board to demonstrate that the actions are leading to improved quality of care for patients. Monthly from end June 2014Acting Chief ExecutiveReports prepared in accordance with the agreed timescales Review and refresh of the Trust’s governance structure to facilitate improved visibility and reporting from the ward to Board. End May 2014Director of Corporate AffairsReview complete. GGI report on operating effectiveness has taken place. Report awaited External specialised communication support engaged. Communication with the public via NHS choices and development of a communication plan as actions are implemented. MonthlyActing Chief ExecutiveComms on progress issued to all staff by CEO. Posters printed and displayed on wards. To be issued bi-monthly. Re-inspection. 2015CQCTo be scheduled 27


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