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

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

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

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

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

ICNARC data Jan-Mar 2014

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

Post-op Destination By Post op Risk Prediction - UHBristol

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.

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)

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

Standards & checklists

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

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

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

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

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

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