Emergency and Unscheduled Care Right patient, right place, first time Update to Trust Board 3 June 2013 1

BSUH invited the Emergency Care Intensive Support Team (ECIST) to review our services as performance against the 4 hour operating standard had dropped to 82% with significant numbers of breaches of the 12 hour standard. There were also serious concerns raised by our clinical teams about their ability to consistently deliver the safety and quality standards.

A full programme of work was put in place, each part led by a clinician who has a team working with them on delivery. Safety and quality metrics were also agreed and a governance framework that included our Chief of Safety providing an independent view of progress.

Work began at the end of March but this is week 11 of a 26 week journey. Early improvement with Zero 12 hour breaches for last 11 weeks Performance against four hour operating standard showing sustained improvement (see next slide) Attendances and admissions remained largely steady with a steady increase in pts with a 0-1 day LOS. We believe this is because AMU is starting to work as we would expect but are monitoring closely:

Sustained improvement against the 4 hour operating standard - 97 Sustained improvement against the 4 hour operating standard - 97.77% performance for last week , 97.54% for the month & 93.07% year to date.

A sharper focus on discharge planning and early discharge of patients during the day, supported by the roll out of electronic whiteboards so all key staff from ward to board can access the current status of each patient means we are better able to maintain patient flow. We are seeing a reduction in the number of patients admitted with over 14 days length of stay:

Minimising the numbers of patients awaiting package of care has also helped although we have seen a recent up turn and this has been escalated:

Occupancy levels are down to 92% - our target is 85%.

This has all helped to minimise the occasions when the number of patients in ED exceeds the space available. The team is taking a snapshot of patients in the department at 3pm and 10pm daily:

The remaining slides summarise our current work streams

WORKSTREAM ONE OUTCOME Frontload clinical decision making and handover in the Emergency Department Enable ED to function properly Deliver sustained improvement against for 4 hour operating standard Current A significant improvement in performance against the 4 hour operating standard for our patients who need admission. Initial benefits from work streams 4-5 have given us beds at the start of the day so we can maintain flow. Work underway to finalise plans for operationalising Urgent Care Centre as Minors and to introduce Patient Assessment and Treatment (PAT) in ED from July 2013. .

Work in hand but more to do to: - Introduce a new streaming system WORKSTREAMS TWO and THREE OUTCOME Streamline processes and pathways, including for frail elderly patients and re-organise medical cover to best support Deliver right patient, right place, first time so patients are discharged at the optimal time. Medical cover in place to deliver these pathways 7/7 Work in hand but more to do to: - Introduce a new streaming system Appoint three additional acute physicians Change the medical cover rotas to ensure early senior clinical review. Dr Vincent Connelly from ECIST presented at the Grand Round on 15 May and his colleague Dr Ian Sturgess to a specially convened meeting on the care of elderly patients in acute hospitals on 20 May. Both were very well received. Additional clinical lead appointed to support implementation.

Early daily inpatient review and decision making. WORKSTREAM FOUR OUTCOME Early daily inpatient review and decision making. Consistency in practice and escalation of delays. Dates for discharge set on admission, agreed with pts and their families, only adjusted following consultant review and delivered consistently. Improved patient flow day to day. This work is bringing an absolute focus on discharge planning, escalation, but there is a lot more to be done to ensure everything is ready for patients being discharged the following day AND all patients who have been in hospital for more than 14 days are reviewed, reducing to 10 and 7 day reviews thereafter. We are monitoring discharges by day of the week and time of day as we standardise our approach. New electronic whiteboard technology is proving hugely beneficial and has been very well received.

Work well underway with: WORKSTREAM FIVE OUTCOME Increased options for rehabilitation at home. Less reliance on rehab beds. Timely management of all patients who need support on discharge. Alternatives to admission available 7/7 that optimise patient outcome and minimise loss of function. Reduction in the time patients wait in acute beds for support on discharge. Work well underway with: The move of our Hospital Rapid Discharge Team to ED to intervene at the front door to increase the number of patients discharged home directly – a three fold increase to 60 patients a week. The Team arranges community support as an alternative to admission. The number of patients awaiting packages of care is being closely monitored and deterioration in performance escalated. This work is continuing at pace with progress monitored weekly. ECIST is engaging with CCG and partner organisations also.

In conclusion This is not a ‘quick fix’. We have committed to a complete redesign of our systems and processes. At week 11 we have stabilised a little which has allowed some headroom to focus on day to day delivery AND redesign of our current practices. Work is well underway at RSCH and to follow at PRH. Our work is integrating with: the wider system and these relationships are key. Without this integration and close working, BSUH will be unable to deliver and sustain the safety and quality of service required. The fortnightly and monthly system wide meetings are continuing. our other initiatives to improve quality, safety and dignity notably: COMFORT rounds, quality review visits on all wards, nursing metrics, friends and family test & patient voice.