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

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Presentation on theme: "Transforming surgical services UHBristol Andrew Hollowood PhD FRCS Clinical Chair Division Surgery Head and Neck University Hospitals Bristol NHS Foundation."— Presentation transcript:

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

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 –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) Separate pathway models

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

12 Standards & checklists

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

14 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’ SCHEDULING All teams working from same list ACTIVELY MANAGED BEDS 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 Ward 700 Ward 800 Wards 700 & 800 PULL patients up from Level 6 Level 6 – emergency floor Emergency Department Divisional outliers

15 Benefits realisation Surgical Flow Dashboard 29/08/201 4 ID NoReport ItemTrain Track CategoryGenerated byFrequencyGreenRedJan-14Feb-14Mar-14Apr-14May-14Jun-14Jul-14Aug-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). Patient Access and Experience MedwayDaily Number of patients breaching a cancer standard as a result of theatre cancellation Patient Access and Experience Hannah MarderMonthly % of patient complaints related to elective surgical cancellations Patient Access and Experience Bev FitzjohnMonthly 0%3%0%2%3%6%2%5%0% ED 4 Number of BRI Surgical Patients waiting over 4 hours in ED EDMedwayDaily 5% 37%43%42%27% 26% 44% 38% 5 Number of Ambulance handovers taking more than 60 minutes ED South West Ambulance Service Monthly Theatre 6 Number of in-patient elective surgical procedures on BRI site TheatreMedwayDaily1%5% % of same day cancellations for elective surgical procedures (non-clinical reason) TheatreMedwayDaily0.80%1.50% 1.6%1.8%1.6%0.8%1.7%1.5%2.1%2.9% 8 % of same day cancellations for elective thoracic surgical procedures (non-clinical reason) TheatreMedwayDaily5%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 TheatreMedwayDaily List start time (% lists starting ≤15 mins of start time)TheatreMedwayDaily ≥95%<95%54%47%64%65%62%66% 53.8% 11List UtilisationTheatreMedwayDaily ≥85%<75%79%75%81% 82%81%82%69.9% 12List Picked UpTheatreMedwayDaily ≥96%<94%93%87%92%90%94%92% 91.7% 13Theatres daily checklist completionTheatres Daily98%94% 25% Recovery 14Number of patients overnight in recoveryRecovery 03 Critical Care 15ITU daily checklist completionCritical Care Daily98%94% 25% 16 % of patients transferred from ITU to the ward within 4 hours (from fit for discharge decision) Critical CareHelen DunderdaleMonthy45%40% 34%41%18%25%35%32%6% Wards 17Wards daily checklist completionWards Daily98%94% 25% 18STAU daily checklist completionWards Daily98%94% 25% 19 Number of patients in surgery beds with a stay of over 14 days WardsMedway Number of inter-specialty outliers on Ward 700 and 800 WardsMedwayDaily Number of non-surgical outlier patients placed into protected, elective surgical beds on Ward 700 and 800 WardsMedwayDaily Bed Occupancy rate on ward 700WardsMedwayDaily 91% to 92.5% ≥95% and ≤85% 100.0% 23Bed Occupancy rate on ward 800WardsMedwayDaily 91% to 92.5% ≥95% and ≤85% 103.1% Discharge 24 Number of patients to the discharge lounge before 12am DischargeMedwayDaily Number of Patients on Green to go ListDischargeSite teamDaily 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 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 Summary

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

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