REMEDIAL
ACTION PLAN
A&E PERFORMANCE
22 October 2014
A&E PERFORMANCE
REMEDIAL ACTION PLAN
22 October 2014
1.0
Background information
1.1
Project team
Project sponsor (SRO)
Clinical lead (CRO)
TINA BENSON, DIRECTOR OF OPERATIONS
CHARLES CAYLEY, MEDICAL DIRECTOR
Project lead (PM)
JAMES WALTERS, DIVISIONAL GENERAL
MANAGER
Finance lead
1.2
SIMON CRAWFORD, DIRECTOR OF FINANCE
Version control
Date
Author
Summary of changes
13/08/2014
PHILIP VINING
INITIAL DRAFT
29/08/14
SEAN MCCLOY
FINAL DRAFT
12/09/14
JAMES WALTERS
AMENDED FOLLOWING COMMENTS
27/09/14
JAMES WALTERS
AMENDED FOLLOWING RAP CCG REVIEW MEETING
22/10/14
JAMES WALTERS
AMENDED FOLLOWING MEET WITH ANN ELGETI
1.1
For OFFICE use
Approved by
Date of approval
Location of file
Finance lead
Budget allocated
Budget code
Budget holder
Delivery plan due
Page 2 of 34
A&E PERFORMANCE
REMEDIAL ACTION PLAN
2.0
22 October 2014
Table of contents
Page
1.0
Background information
2
2.0
Table of contents
3
3.0
Introduction
4
4.0
Purpose
4
5.0
Objectives
4
6.0
Schemes identified by Joint Investigation
5
7.0
Benefits
7
8.0
Trajectories
8
9.0
Timescales
11
10.0 Finance
12
11.0 Risks, issues and dependencies
12
12.0 Governance arrangements
12
Appendices
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
Carroll Ward – additional 20 acute beds
Modular Unit – additional 60 acute beds
Jenner Ward – additional 8 acute beds
Old A&E space – additional 4 acute beds
Fletcher Ward – additional 22 acute beds
‘Golden Hour’ ward round
Pit stop
Senior review of decisions to admit
Medical registrar in A&E
New A&E department
New A&E staff rota
Discharge transport
Escalation plans
ED diagnostics resilience plan
A&E recruitment, retention and development plan
Weekend discharges - whiteboards
Ambulatory care pathways
Page 3 of 34
13
14
15
16
18
19
20
22
23
24
25
27
28
29
30
32
33
A&E PERFORMANCE
REMEDIAL ACTION PLAN
3.0
22 October 2014
Introduction
Following the issuing of a contract query, the Trust and CCG agreed to hold a Joint Investigation
process to identify the appropriate remedial action plan. This document represents that
remedial action plan with the associated projects designed to improve the performance of NWLHT
A&E and to provide a trajectory against which improvements could be measured.
4.0
Purpose
The purpose of this Remedial Action Plan (RAP) is to improve the quality of patient care within the
A&E department and related acute services at Northwick Park Hospital, to the extent that the
Trust improves performance towards the achievement of London (average) type 1 and its
contractual responsibilities in respect of the 95% A&E national target, in accordance with the
contractual letter dated 13th August 2014, para Viii. This is expected to happen after the
completion of the modular bed capacity at NPH during 2015/16.
5.0
Objectives
To achieve its purpose, the Trust will need to achieve the following objectives:
1. All schemes to have a designated clinical lead.
2. Demonstrate clear improvements in the quality of acute services that are provided to
patients at NWLHT as agreed with Clinical Commissioning colleagues during the JI.
3. Meet the submitted trajectory for ED performance.
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A&E PERFORMANCE
REMEDIAL ACTION PLAN
6.0
22 October 2014
Schemes identified by Joint Investigation
The following schemes were identified by the JI for inclusion within the remedial action plan:
No
Scheme title
1
Carroll Ward – additional 20 acute beds
2
Modular Unit – additional 60 acute beds
3
Jenner Ward – additional 8 acute beds
4
Old A&E Space – additional 4 acute beds
5
Fletcher Ward – additional 22 acute beds
6
‘Golden Hour’ ward round
7
Pit stop medical capacity
8
Senior review of decisions to admit
8
Medical registrar in A&E
10
New A&E department
11
New A&E staff rota
12
Discharge transport
13
Escalation plans
14
ED diagnostics resilience plan
Purpose
To improve service quality and patient experience by reducing the time taken to admit
patients to an acute assessment bed leading to a reduction in A&E breaches
To improve service quality and patient experience by reducing the time taken to admit
patients to suitable acute beds leading to a reduction in A&E breaches
To improve service quality and patient experience by reducing the time taken to admit
patients to acute heart failure beds leading to a reduction in A&E breaches
To improve service quality and patient experience by reducing the time taken to admit
patients to acute haematology beds leading to a reduction in A&E breaches
To improve service quality and patient experience by reducing the time taken to admit
patients to care of the elderly assessment beds leading to a reduction in A&E breaches
To improve the quality of patient care through a reduction in length of stay
To improve the quality of patient care by reducing the length of time taken for a patient to be
assessed on arrival in the NWP A&E department
To improve the quality of clinical decision making by requiring a senior decision maker to
review any decision not to admit following a referral from A&E to the medical team
To improve the quality of patient care and clinical decision in A&E by reducing the time taken
to admit patients once a decision to admit has been made
To improve the quality of patient care by opening a new, purpose built A&E department
To improve the quality of patient care by improving the alignment between staff availability
and patient demand
To improve the quality of patient experience by ensuring sufficient transport is available to
support discharge from A&E department to patient’s home
To improve the quality of patient care and patient experience by ensuring effective mitigation
arrangements are in place to meet unexpected demand levels in the A&E department
To improve the quality of patient care and patient experience by improving patient access to
appropriate diagnostic tests
Page 5 of 34
Details
Appendix A
Appendix B
Appendix C
Appendix D
Appendix E
Appendix F
Appendix G
Appendix H
Appendix I
Appendix J
Appendix K
Appendix L
Appendix M
Appendix N
A&E PERFORMANCE
REMEDIAL ACTION PLAN
15
A&E recruitment, retention and
development plan
16
Weekend discharges - whiteboards
17
Ambulatory care pathways
22 October 2014
To improve the quality of patient care and experience by ensuring that there are sufficient,
appropriately trained and well-motivated A&E staff available to meet patient needs
To improve patient access to acute inpatient beds at NWP by increasing the number of
weekend discharges associated with the new whiteboard related processes
To improve the quality of patient care and patient experience by improving access to
ambulatory care services as an alternative to admission
Page 6 of 34
Appendix O
Appendix P
Appendix Q
A&E PERFORMANCE
REMEDIAL ACTION PLAN
7.0
22 October 2014
Benefits
The tangible and intended benefit of the RAP is to improve quality of patient care and patient experience
by addressing specific aspects of the patient pathway which will lead to a reduction in A&E breaches as
follows:
Project
Carroll Ward – additional 20 acute beds
Modular Unit – additional 60 acute beds
Jenner Ward – additional 8 acute beds
Old A&E Space – additional 4 acute beds
Fletcher Ward – additional 22 acute beds
‘Golden Hour’ ward round
Pit stop medical capacity
Senior review of decisions to admit
Medical registrar in A&E
New A&E department
New A&E staff rota
Discharge transport
Escalation plans
ED diagnostics resilience plan
A&E recruitment, retention and
development plan
Weekend discharges - whiteboards
Ambulatory care pathways
Benefits
Reduce time to admit
Reduce time to admit
Reduce time to admit
Reduce time to admit
Reduce time to admit
Increase rate of discharges
Reduce time to assess patient
Reduce time to admit
Reduce time to admit
Improve patient experience and enabler of new work
practices
Match patient demand to staff availability
Reduce admissions
Improve patient flows at peak
Reduce time to assess patient
Improve patient care and enabler of improved
performance
Increase rate of discharges
Reduce admissions
Impact on Performance
The projects above should have a direct effect on performance and quality of care within the ED. Some
projects have a tangible effect such as the additional beds which are predicted to have the most significant
reduction in breaches per day respectively. Other projects will improve quality of care for patients within
the ED and support the flow of the emergency pathway. These are taken into account within the
trajectory and a gateway summary has been provided.
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A&E PERFORMANCE
REMEDIAL ACTION PLAN
8.0
22 October 2014
Trajectories
NB. This is subject to TDA funding by November 2014 and will be re-worked once the timeframes for the
new modular beds are assured post contract award.
Page 8 of 34
A&E PERFORMANCE
REMEDIAL ACTION PLAN
22 October 2014
Impact on A&E 4 hour Performance
Four Gateway Monitoring Points are proposed to monitor delivery against the RAP and associated benefit
realisation on A&E performance.
A&E 4-hour performance trajectories for 2014/15 & 2015/16 by
week ending
Gateway 1
30.09.14
Gateway 2
30.12.14
Gateway 3
01.08.15
Gateway 4
01.12.15
100.00%
95.00%
90.00%
85.00%
80.00%
75.00%
70.00%
TYPE 1
Type1 & 3
Four Gateway Monitoring Points, around which schemes complete or commence:
GATEWAY 1
GATEWAY 2
•Closure CMH
•Carroll Ward opens 20
beds
•Progress use of CMH
CoE model
•Moved to new ED
•Close 10 beds (obs
ward)
•Backend
improvements
•ED improvements
•Increased Bed capacity
opens 12 beds
•Progress use of CMH
CoE model
GATEWAY 3
•Increased Bed
Capacity 22 beds
•Progress use of CMH
CoE model
Page 9 of 34
GATEWAY 4
•Increased Bed
Capacity 60 beds
A&E PERFORMANCE
REMEDIAL ACTION PLAN
22 October 2014
Schemes within TDA 4 hour performance trajectory and those identified by the RAP Process
A number of schemes have been introduced by the RAP process; these schemes replace schemes that were
originally identified in the TDA trajectory which would normally have been removed. The below table
shows those schemes that formed part of the TDA trajectory and those that were identified during the RAP
process:
Project
Identified within
Carroll Ward – additional 20 acute beds
Modular Unit – additional 60 acute beds
Jenner Ward – additional 8 acute beds
Old A&E Space – additional 4 acute beds
Fletcher Ward – additional 22 acute beds
‘Golden Hour’ ward round
Pit stop medical capacity
Senior review of decisions to admit
Medical registrar in A&E
New A&E department
New A&E staff rota
Discharge transport
Escalation plans
ED diagnostics resilience plan
A&E recruitment, retention and development plan
Weekend discharges - whiteboards
Ambulatory care pathways
Page 10 of 34
Original TDA trajectory
Original TDA trajectory
Original TDA trajectory
RAP Process
Original TDA trajectory
RAP Process
RAP Process
RAP Process
RAP Process
Original TDA trajectory
RAP Process
RAP Process
RAP Process
RAP Process
RAP Process
Original TDA trajectory
Original TDA trajectory
A&E PERFORMANCE
REMEDIAL ACTION PLAN
9.0
22 October 2014
Timescales
This remedial action plan comprises 17 separate and distinct pieces of project work; the last of these to be
completed, the Modular Unit – additional 60 acute beds, is not due for delivery until 1st December 2015
and is still dependent upon external funding.
The detail of the individual project delivery plans can be found in the respective Appendices; however a
summary of the completion dates are shown below:
No
1
Scheme title
Completion Date
th
Carroll Ward – additional 20 acute beds
10 September 2014
th
Status
In Progress (subject to TDA funding)
Subject to business case
2
Modular Unit – additional 60 acute beds
14 December 2015
3
4
Jenner Ward – additional 8 acute beds
Old A&E Space – additional 4 acute beds
19th December 2014
27th February 2015
5
Fletcher Ward – additional 22 acute beds
31st July 2015
In Progress (subject to TDA funding)
In Progress
Subject to business case
1 November 2015
In Progress
6
st
‘Golden Hour’ ward round / 6 day working
th
(subject to TDA funding)
(subject to TDA funding)
7
8
9
Pit stop medical capacity
Senior review of decisions to admit
Medical registrar in A&E
27 February 2015
22nd November 2014
22nd November 2014
In Progress
In Progress
In Progress
10
New A&E department
30th December 2014
In Progress
11
12
13
14
15
16
17
New A&E staff rota
Discharge transport
Escalation plans
ED diagnostics resilience plan
A&E recruitment, retention and development plan
Weekend discharges - whiteboards
Ambulatory care pathways
Page 11 of 34
th
30 December 2014
27th February 2015
30th December2014
30th January 2015
31st December 2015
1st February 2015
1st April 2015
In Progress
In Progress
In Progress
In Progress
In Progress
In Progress
In Progress
A&E PERFORMANCE
REMEDIAL ACTION PLAN
22 October 2014
10.0 Finance
In respect of NWLH, the position is as follows:
Last year the government announced a 2 year indicative funding for “winter pressures”.
The Trust working with Commissioners identified and put in place a range of schemes to address existing
and predicted future pressure on the emergency pathway. The schemes implemented last year had a full
year effect cost of £7.3m and the Trust received £4.2m winter funding to support these last financial year.
The Trust took the decision to maintain these initiatives in place, so internally as part of its budget setting
approval process, agreed with the Board to establish these posts recurrently. As part of the contract
negotiation process for 14/15 the Trust clearly highlighted that these schemes had continued and expected
to receive £4.2m funding in-year from national funding. Commissioners were clear that this assumption
was at the Trusts risk and that they couldn't agree or underwrite it. This was also made clear in the merger
business case discussions.
The Trusts budget setting process, annual plan submission to TDA and LTFM for merger were all based on
£4.2m of non-recurrent funding being received from central funds in 2014/15. The Trust has stated that if
funding is not forthcoming the Trust will be unable to meet its current financial plan and/or would have to
consider dis-investing in some of these schemes which will have an adverse impact on A+E performance.
We wouldn't expect any unilateral actions to be taken by the Trust without discussion with Commissioners
and TDA.
11.0 Risks, issues and dependencies
See separate project plans in each of the appendices. The Trust would not expect to be unreasonably
peanalised where the delivery of milestones are contingent upon external factors out of its control.
12.0 Governance arrangements
It is proposed that the Governance arrangements should be based on:

It would be appropriate for the delivery of the A&E Remedial Action Plan to be monitored via the
CQG.

The scrutiny of contractual delivery - as in oversight as to whether the RAP is delivered to the
proposed timetable and if there are any contractual implications – these should be with the PCE.

In relation to the CQG, the CQG may be minded that it asks a clinical working group, say for urgent
care issues, to work through the detail of RAP delivery and report on progress to the CQG formally.
Page 12 of 34
A&E PERFORMANCE
REMEDIAL ACTION PLAN
22 October 2014
APPENDIX A
PROJECT TITLE
Carroll Ward – additional 20 acute assessment beds
CLINICAL
Dr Keith Steer
DIRECTOR
EMAIL
[email protected]
SPONSOR Tina Benson
EMAIL
[email protected]
EMAIL
[email protected]
PROJECT LEAD Maeve O’Callaghan-Harrington
PURPOSE
To improve service quality and patient experience by reducing the time taken to admit
patients to an acute bed leading to a reduction in A&E breaches
The shortage of acute beds on the NWP site is the major cause of A&E breaches as
REASON patients wait for an empty bed in order to be admitted – with a corresponding
reduction in the quality of care provided
The objectives of this project are:
OBJECTIVES
1. Improve service quality and patient experience by reducing the time taken to
admit patients to an acute bed following a decision to admit
2. Open an additional 20 acute assessment beds by 10th September 2014
3. Deliver additional beds at a cost of £2.5 million
4. Reduce number of A&E breaches
EXPECTED
IMPACT ON Additional 20 beds are expected to reduce A&E breaches by 6 per day
BREACHES
The closure of CMH A&E will result in an increase in patients attending NWP A&E and,
as a consequence, an increase in patient admissions at the NWP site. Without the
additional bed capacity on Carroll Ward the number of breaches would be expected to
rise. The project is to refurbish and staff Carroll Ward at Northwick Park to provide
BRIEF OUTLINE additional acute assessment bed capacity for short stay medical patients.
The resulting increase of 20 acute assessment beds and the clinical model will
contribute to a reduction in the number of A&E breaches that are estimated to be an
average of 6.7 per day less.
OUTCOME
DATE ACHIEVED
Heating, water pipes complete; furniture delivered
SUMMARY
Final decoration complete; start suspended ceiling tiles
TIMESCALES
Completion including inspection by building control
22.08.2014
A&E department closes at CMH and Carroll Ward opens
10.09.2014
RISK
TDA rejects business case for investment
RISK ANALYSIS
Carroll ward not complete when CMH A&E
closes on 10th September 2014
Page 13 of 34
29.08.2014
05.09.2014
MITIGATION
Shared understanding and regular reviews
with the TDA. Engage with CCG’s for
support
Close Private Ward and use for NHS
patients
A&E PERFORMANCE
REMEDIAL ACTION PLAN
22 October 2014
APPENDIX B
PROJECT TITLE
Modular unit – additional 60 acute beds
CLINICAL LEAD Dr Charles Cayley
EMAIL
[email protected]
SPONSOR Chris Pocklington
EMAIL
[email protected]
EMAIL
[email protected]
PROJECT LEAD Matthew Longmate
PURPOSE
To improve service quality and patient experience by reducing the time taken to admit
patients to an acute bed leading to a reduction in A&E breaches
The Trust faces significant operational challenges in both emergency and elective
surgical care, which additional bed capacity on the NPH site would help to alleviate. The
review of demand and capacity commissioned by the local CCGs with the Trust from
REASON Capita identified a deficit of circa 100 beds. Its conclusion was that if this deficit is not
addressed the Trust will continue to fail both the A&E waiting times and 18 week
referral to treatment target standards, as well as the quality of care suffering through
poor clinical adjacencies and high bed occupancy rates.
To provide a further 60 acute beds on the Northwick Park site comprising:
 2 x 24 bed wards – medical / ambulatory care
OBJECTIVES
 1 x 12 bed ward – infectious diseases
 Cost circa £10 million
EXPECTED
IMPACT ON Reduction of 17 A&E breaches per day
BREACHES
BRIEF OUTLINE Plan, tender and construct a 60 bed modular unit on the Northwick Park site
OUTCOME
DATE ACHIEVED
Approval of business case by TDA
31.12.2014
SUMMARY Appoint modular build contractor
TIMESCALES Construction starts
30.01.2015
Construction complete
25.11.2015
New wards handed over for use
14.12.2015
RISK
TDA rejects business case for investment
RISK ANALYSIS
09.02.2015
Revenue costs (staffing, etc.) prove
unaffordable
Activity flows are not as anticipated–
higher or lower (due to different
flows/changes in demography /
epidemiology etc.).
Page 14 of 34
MITIGATION
Shared understanding and regular reviews
with the TDA. Engage with CCG’s for
support
Review developing revenue model and
assumptions to monitor affordability.
Ensure full cost and efficiency analysis is
undertaken for service reconfigurations
and new operating models.
Monitor Trust performance and escalate
as necessary. Close monitoring of activity
levels. Engagement with CCGs to agree
changes from plan.
A&E PERFORMANCE
REMEDIAL ACTION PLAN
22 October 2014
APPENDIX C
PROJECT TITLE
Jenner Ward – additional 8 acute heart failure beds
CLINICAL LEAD Dr Nigel Stephens
EMAIL
[email protected]
SPONSOR Tina Benson
EMAIL
[email protected]
EMAIL
[email protected]
PROJECT LEAD Maeve O’Callaghan-Harrington
PURPOSE
To improve service quality and patient experience by reducing the time taken to admit
patients to an acute bed leading to a reduction in A&E breaches
The shortage of acute beds on the NWP site is the major cause of A&E breaches as
REASON patients wait for an empty bed in order to be admitted – with a corresponding
reduction in the quality of care provided
The objectives of this project are:
OBJECTIVES
1. Improve service quality and patient experience by reducing the time taken to
admit patients to an acute bed following a decision to admit
2. Actively pull appropriate cases from the assessment areas
3. Complete 8 additional acute heart failure beds by 19th December 2014 by
relocation of the existing Jenner Day Care Service
4. Deliver additional beds at a cost of £300k
5. Reduce number of A&E breaches by 2 per day
EXPECTED
IMPACT ON Additional 8 beds are expected to reduce A&E breaches by 2 per day
BREACHES
BRIEF OUTLINE
The existing Jenner Ward day care service can be relocated to an alternative location on
the NPH site. This will facilitate space that can be converted into 8 acute heart failure
beds, which the cardiology team will oversee.
The resulting increase of 8 acute heart failure beds will contribute to a reduction in the
number of A&E breaches that are estimated to be an average of 2 per day less.
OUTCOME
DATE ACHIEVED
Commission main works and prepare new day care area
SUMMARY
Building works commence
TIMESCALES
Completion including inspection by building and infection control
New acute beds handed over for use
RISK
TDA rejects business case for investment
RISK ANALYSIS
Further requirement or building snags
prevent completion to timescale
Page 15 of 34
04.08.2014
01.09.2014
14.11.2014
19.12.2014
MITIGATION
Shared understanding and regular reviews
with the TDA. Engage with CCG’s for
support
Project Team managing and Clinical
Strategy Committee overseeing the
delivery plan
A&E PERFORMANCE
REMEDIAL ACTION PLAN
22 October 2014
APPENDIX D
PROJECT TITLE
Old A&E Space – additional 4 haematology beds
CLINICAL LEAD Dr Charles Cayley
EMAIL
[email protected]
SPONSOR Tina Benson
EMAIL
[email protected]
EMAIL
[email protected]
PROJECT LEAD Maeve O’Callaghan-Harrington
PURPOSE
To improve service quality and patient experience by reducing the time taken to admit
patients to an acute bed leading to a reduction in A&E breaches
The shortage of acute beds on the NWP site is the major cause of A&E breaches as
REASON patients wait for an empty bed in order to be admitted – with a corresponding
reduction in the quality of care provided
The objectives of this project are:
OBJECTIVES
1. Improve service quality and patient experience by reducing the time taken to
admit patients to an acute bed following a decision to admit
2. Temporary use of old A&E space will be prioritised for services that release bed
capacity or avoid bedded admission to the hospital
3. Ambulatory Care and the Surgical Assessment Unit (SAU) will be temporarily relocated to old A&E space to allow Fletcher Ward to be fully rebuilt and
refurbished
4. Re-open an additional 4 haematology beds on Kingsley Ward by end of January
2015 through relocation of the day care service to the old A&E space
5. Scheme must be delivered with minimal capital cost
6. Reduce number of A&E breaches by 1 per day
EXPECTED
IMPACT ON Additional 4 haematology beds are expected to reduce A&E breaches by 1 per day
BREACHES
The existing Kingsley Ward houses Haematology day care and the bedded ward facility.
The day care service can be relocated to the old A&E space when it is vacated (planned
for December 2014). This will release space that can be re-established into 4
haematology beds, which the haematology team will oversee. In addition the old A&E
BRIEF OUTLINE
space will provide a temporary home for Ambulatory Care and the SAU to allow
Fletcher Ward to be fully rebuilt and refurbished
The resulting increase of 4 haematology beds will contribute to a reduction in the
number of A&E breaches that are estimated to be an average of 1 per day less.
OUTCOME
DATE ACHIEVED
Planned use of old A&E space approved in principle by Clinical
Strategy Development Group
SUMMARY
TIMESCALES Space plan refined against clinical priority
16.09.2014
31.10.2014
Space plan agreed
30.12.2015
Move to new space completed and services operational
27.02.2015
RISK
RISK ANALYSIS New A&E department and/or relocation to
it are not completed on time
Page 16 of 34
MITIGATION
Close monitoring and planning around
committed handover date. Operational
A&E PERFORMANCE
REMEDIAL ACTION PLAN
22 October 2014
Steering group with external membership
set up to support the transition and actual
move to the new department
Page 17 of 34
A&E PERFORMANCE
REMEDIAL ACTION PLAN
22 October 2014
APPENDIX E
PROJECT TITLE
Fletcher Ward – additional 22 CoE assessment beds
CLINICAL LEAD Dr Charles Cayley
EMAIL
[email protected]
SPONSOR Tina Benson
EMAIL
[email protected]
EMAIL
[email protected]
PROJECT LEAD Maeve O’Callaghan-Harrington
PURPOSE
To improve service quality and patient experience by reducing the time taken to admit
patients to an acute bed leading to a reduction in A&E breaches
The shortage of acute beds on the NWP site is the major cause of A&E breaches as
REASON patients wait for an empty bed in order to be admitted – with a corresponding
reduction in the quality of care provided
The objectives of this project are:
OBJECTIVES
1. Improve service quality and patient experience by reducing the time taken to
admit patients to a Care of the Elderly (CoE) assessment bed following a
decision to admit
2. Complete additional 22 beds by 31st July 2015
3. Deliver additional beds at a capital cost of £4.4 million
4. Reduce number of A&E breaches by 6 per day
EXPECTED
IMPACT ON Additional 22 beds are expected to reduce A&E breaches by 6 per day
BREACHES
The existing Fletcher Ward houses Ambulatory Care and the SAU; both services can be
relocated to the old A&E temporarily, until such time as the modular unit (Appendix B)
is delivered. This will decant Fletcher Ward allowing it to be fully rebuilt and
BRIEF OUTLINE refurbished. Timescale is reliant upon TDA approval to fund in November 2014.
The resulting increase of 22 CoE assessment beds will contribute to a reduction in the
number of A&E breaches that are estimated to be an average of 6 per day less.
OUTCOME
DATE ACHIEVED
Approval of business case by TDA & Relocate Amb. Care & SAU
SUMMARY
Works start (6 month programme) on or around:
TIMESCALES
Completion including inspection by building and infection control
22 New beds completed on or around
RISK
RISK ANALYSIS
TDA rejects business case for investment
or delays funding
Delays with building works occur
Page 18 of 34
30.12.2014
05.01.2015
15.07.2015
31.07.2015
MITIGATION
Shared understanding and regular reviews
with the TDA. Engage with CCG’s for
support
Early procurement of a trusted provider,
with clear checkpoint management by a
dedicated project lead
A&E PERFORMANCE
REMEDIAL ACTION PLAN
22 October 2014
APPENDIX F
PROJECT TITLE
‘Golden Hour’ ward round
CLINICAL LEAD Dr Keith Steer
SPONSOR Tina Benson
PROJECT LEAD James Walters
PURPOSE
EMAIL
[email protected]
EMAIL
[email protected]
EMAIL
[email protected]
To improve the quality of patient care through more frequent consultant review,
improving clinical outcomes and reducing length of stay.
The shortage of acute beds on the NWP campus is the major cause of A&E breaches as
REASON patients wait for an empty bed in order to be admitted – with a corresponding
reduction in the quality of care provided
To identify a resource amongst consultant teams caring for in-patients which facilitates
two formal (all patient review) ward rounds per week, effectively increasing the bed
OBJECTIVES
base at both Northwick Park and Central Middlesex Hospitals. A pilot study will be
conducted to assess the impact
EXPECTED Based on a model of good practice identified by the RCP which improved patient
IMPACT ON outcomes and reduced length of stay. This scheme should improve discharges either
BREACHES side of the weekend, eventually incorporating weekend discharges
‘Golden Hour Ward Round’ concept: all newly admitted, seriously ill and potentially
dischargeable patients are reviewed daily by a consultant or senior clinical decision
maker. Initially a pilot will be run, this would be four times a week review (Monday and
BRIEF OUTLINE
Friday with formal rounds on two other days) and eventually, with increased consultant
input following reconfiguration of services across NPH and CMH, it may be possible to
include weekends for certain specialties.
OUTCOME
DATE ACHIEVED
Release of CMH inpatient Consultant PAs due to closure of CMH ED
30.01.2015
SUMMARY Implementation of Phase 1 pilot for a certain specialty (subject to
31.03.2015
TIMESCALES individual and departmental job planning): four times a week
(Monday and Friday with formal rounds on two other days)
Design of Phase 2 dependant on outcome of pilot and subject to
01.11.2015
individual and departmental job planning
RISK
MITIGATION
This scheme is subject to individual job
planning and capacity utilisation.
Consultant job plans not signed off would
limit progress
Escalation to Medical Director. Dedicated
Job Planning resource in place
RISK ANALYSIS
Insufficient PAs within specialty to provide
service as described
Failure to release CMH Consultant rota
PAs due to need to continue support to
ITU
Page 19 of 34
Submission of business case for Executive
decision
Devise new system before end of
December. Fortnightly engagement with
CMH acute physicians to agree solution
A&E PERFORMANCE
REMEDIAL ACTION PLAN
22 October 2014
APPENDIX G
PROJECT TITLE
Pit stop medical capacity
CLINICAL LEAD
Dr Julie Bak
Dr Miriam Harris
SPONSOR Tina Benson
PROJECT LEAD James Walters
PURPOSE
EMAIL
[email protected]
[email protected]
EMAIL
[email protected]
EMAIL
[email protected]
To improve the quality of patient care by reducing the length of time taken for a patient
to be assessed on arrival in the NWP A&E department
Currently initial assessment is undertaken by nursing staff as there are insufficient
senior medical staff to undertake this activity on a regular basis. Failure to be seen by a
REASON
senior clinician early can delay appropriate investigations and medical management and
contribute to increasing the likelihood of A&E breaches
A dedicated system to operate between 08:00-22:00 hours where all ‘majors’ patients
are assessed on arrival by a senior ED doctor to:
OBJECTIVES
EXPECTED
IMPACT ON
BREACHES
BRIEF OUTLINE
1. Improve efficiency
2. Improve patient outcomes by reducing delays in giving appropriate treatment
early
3. Reduce A&E breaches and
4. Reduce unnecessary investigations
Reduce breaches by:
1. Putting patient onto the existing ambulatory pathway when appropriate
2. Direct immediate referral to other specialities if the criteria are met
Between 08:00-22:00 hours all ambulance cases (excluding blue-light) and majors
patients to be seen on arrival by a senior doctor in EM and a pit-stop proforma sheet
will be completed on arrival. The consultant will take a very brief history and
examination and decide if the patient is to be seen in the ED or ‘streamed’ directly to
one of the following areas thus by-passing the main ED:
 UCC
 Ambulatory Care
 Surgical Assessment Unit (includes surgical sub-specialities e.g. ENT)
 Gynae Direct Referral Unit
Streaming to an area other than the ED will depend on the patient meeting the
appropriate set criteria. A short outline of the reason why the patient has been
streamed to an individual area should be stated on the proforma sheet.
All other patients will be seen in the ED. In these cases the ‘pit-stop’ doctor will advise
of what investigations are to be undertaken initially and to allocate the patient to be
taken to the appropriate zone for a full work up by the ED team.
In the event of insufficient staffing levels it may only be feasible initially to implement
during peak attendance times to maximize performance and reduce potential breaches.
OUTCOME
SUMMARY Begin process to reconfigure A&E medical rota
TIMESCALES Implemented for peak hours
Page 20 of 34
DATE ACHIEVED
22.11.2014
27.02.2014
A&E PERFORMANCE
REMEDIAL ACTION PLAN
22 October 2014
RISK
RISK ANALYSIS
Failure to recruit to required staffing level
and expertise
New system does not have an impact
Page 21 of 34
MITIGATION
Recruitment Plan. The pit-stop role should
only be undertaken by substantive or
regular locum staff who have a full
working knowledge of the alternative
pathways for streaming.
Review expertise and working practices in
other well performing A&E departments
A&E PERFORMANCE
REMEDIAL ACTION PLAN
22 October 2014
APPENDIX H
PROJECT TITLE
Senior review of decisions to admit
Dr Julie Bak
CLINICAL LEADS Dr Miriam Harris
Dr Keith Steer
SPONSOR Tina Benson
PROJECT LEAD James Walters
PURPOSE
REASON
OBJECTIVES
EXPECTED
IMPACT ON
BREACHES
BRIEF OUTLINE
EMAIL
[email protected]
[email protected]
[email protected]
EMAIL
[email protected]
EMAIL
[email protected]
To improve the quality of clinical decision making by requiring a senior decision maker
to review any decision not to admit following a referral from A&E
The number of patients’ returning to the A&E within 24 hours for the same clinical
reason is one of the CQUIN indicators. Currently there are a small but significant
number of patients discharged after referral from A&E who return within the 24 hour
period and are subsequently admitted.
To reduce the number of patients returning within 24 hours who were initially referred
to a specialist in-patient team and subsequently discharged without admission. In
addition to improve the flow through the department for patients who await clinical
decision timescales
 Improves the flow through the department and supports ED clinical decision
making
 Reduces the level of re-admissions
All medical cases referred by A&E must be seen by the medical registrar. He/she may
decide not to admit under the medical team. In such instances the case must be
discussed by the medical registrar with the duty A&E consultant on the floor (between
consultant hours) or A&E middle grade (level ST4 or above) at all other times. In the
event of the A&E senior disagreeing with the decision not to admit he/she may:
 Refer the patient back to the in-patient specialist team to admit
 Admit the patient to the observation ward but only if the clinical criteria for this
area are met
 Agree to discharge the patient but ensure an adequate onward management
plan is in place with appropriate follow-up arranged
OUTCOME
Agree communication to all staff involved
SUMMARY
Implement new arrangements
TIMESCALES
RISK
Lack of 24/7 consultant opinion directly in
RISK ANALYSIS
the ED
Inappropriate referrals accepted
Page 22 of 34
DATE ACHIEVED
30.10.2014
22.11.2014
MITIGATION
All such cases to be discussed with the oncall A&E consultant where required
Audit cases if required
A&E PERFORMANCE
REMEDIAL ACTION PLAN
22 October 2014
APPENDIX I
PROJECT TITLE
Medical registrar in A&E
CLINICAL LEAD Keith Steer
SPONSOR Tina Benson
PROJECT LEAD Sarah Ingham
PURPOSE
EMAIL
[email protected]
EMAIL
[email protected]
EMAIL
[email protected]
To improve the quality of patient care and clinical decision in A&E by reducing the time
taken to admit patients once a decision to admit has been made
Approximately 60 % of admissions are medical. In-patient beds are not allocated until a
formal decision to admit (DTA) has been made by the duty medical registrar after
REASON
assessing the patient. Improving the time for the medical SPR to review referrals will
improve the quality of care and avoid delay.
To improve patient care by:
OBJECTIVES
1. Co-locating a medical registrar in A&E for core pressure points
2. reducing the time taken for a patient to be reviewed by the duty medical
registrar
3. reduce the time for DTA to be made
4. improve patient turnaround times in the A&E
EXPECTED
IMPACT ON Reduce breaches related to delay to be seen by the medical registrar
BREACHES
A medical registrar (in addition to the medical on-call SPR) is to be based in the A&E
department and available to take direct referrals from the A&E team. He/she will work
BRIEF OUTLINE closely with the A&E staff to help alleviate potential blocks in the patient pathway and
improve admission times (where bedded capacity is available) or redirect appropriately
to Ambulatory Care Services.
OUTCOME
SUMMARY
Implement at peak periods (17:00 – 22:00)
TIMESCALES
RISK
The medical registrar must have no other
clinical commitments when on duty.
Likely to be restricted to daytime only
RISK ANALYSIS unless staffing levels permit
The medical registrar is pulled into ED
staffing due to vacant shifts or sickness
Page 23 of 34
DATE ACHIEVED
22.11.2014
MITIGATION
Escalate to consultant where required
Ring-fence capacity and provide member
of staff with a unique visual identity within
the department
A&E PERFORMANCE
REMEDIAL ACTION PLAN
22 October 2014
APPENDIX J
PROJECT TITLE
New A&E department
CLINICAL LEAD
Julie Bak
Miriam Harris
SPONSOR Tina Benson
PROJECT LEAD James Walters
EMAIL
[email protected]
[email protected]
EMAIL
[email protected]
EMAIL
[email protected]
PURPOSE To improve the quality of patient care by opening a new, purpose built A&E department
The current A&E has restricted space and is logistically poorly positioned in relation to
REASON other acute service areas, which are integral to providing good clinical care e.g. CT scan
& ward block
To use the design of the new department to its maximum potential. This will be
OBJECTIVES supported by developing new ways of working focussed on team building and providing
good quality care
EXPECTED
Other departments will be able to respond more quickly, reducing breaches for
IMPACT ON
assessment and decision delays
BREACHES
The new department is comprised of clinical areas or ‘zones’ with a dedicated x-ray
BRIEF OUTLINE facility and CT scanner incorporated into the build. It is well positioned for quick
accessibility to ITU, CCU and theatres
OUTCOME
DATE ACHIEVED
Plan outline move arrangements
30.10.2014
SUMMARY
Develop transitional plan
TIMESCALES
New A&E department to open on or around (subject to planning & agreement)
RISK
Building work or commissioning does not
complete as planned
A&E does not open on planned date due
to operational pressures
TDA does not approve business case,
RISK ANALYSIS required beds not delivered, leading to
longer waits in a more dispersed
environment and thus increasing clinical
risk
Clinical risks and/or breaches increased
through transitional period
Page 24 of 34
30.11.2014
30.12.2014
MITIGATION
Clear checkpoint management by a
dedicated project lead. Regular interface
with building contractor
Implement Silver Control to monitor and
oversee. Remain in current location until
pressure point resolved
Clear bed capacity development plan and
support from within the health economy.
ED Consultant team involved in planning
and approving plans
Changes planned through clinical
involvement in project board, simulation
events, estates & ED group, new ED
service mobilisation group and emergency
pathway performance meeting
A&E PERFORMANCE
REMEDIAL ACTION PLAN
22 October 2014
APPENDIX K
PROJECT TITLE
New A&E staff rota
CLINICAL LEAD
Julie Bak
Miriam Harris
SPONSOR Tina Benson
PROJECT LEAD James Walters
PURPOSE
EMAIL
[email protected]
[email protected]
EMAIL
[email protected]
EMAIL
[email protected]
To improve the quality of patient care by improving the alignment between staff
availability and patient demand
1. The current working pattern is not suitable for ‘zonal’ working as required by the
layout of the new department.
REASON 2. At present medical staffing levels are poorly matched to peaks in patient
attendances which lead to increasing numbers of A&E breaches particularly between
18:00 -02:00 hours.
To implement a new medical rota that is more closely matched to anticipated patient
attendances:
OBJECTIVES
1. Consult medical and nursing workforce on proposed changes
2. Redesign rota’s and publish
3. Implement and develop a structured team approach integrating medical and
nurse staff to provide an improved efficient and effective working model
EXPECTED
IMPACT ON Improve quality of care. Reduction in ED breaches.
BREACHES
1. Staff will work in small teams and be allocated across the various zones.
2. Each team will comprise of nurses and doctors of varying skill-mix.
3. The medical rota is expected to be based on a ‘3 shift’ pattern over a 24 hour period.
4. The absolute numbers of doctors working has been increased at any given hour and
is more closely related to peak attendance times.
5. There is a marked increase in the number of middle grade doctors to support
BRIEF OUTLINE
improved clinical decision making and junior supervision.
6. Pit stop will attract medical support (as per appendix G)
7. A consultant will be designated as the ‘shift lead’ and will work closely with the senior
nurse in charge to oversee the department as a whole.
8. Requires redesign of rota and full staff consultation with union input.
9. Needs agreement with Executive Team and finance sign off.
OUTCOME
DATE ACHIEVED
Initial consultation
22.08.2014
Professional rota development to meet working time regulations,
SUMMARY
other limitations imposed on unsocial hours, training commitments
TIMESCALES
and work/life balance
30.10.2014
Reconfigure A&E medical rota
22.11.2014
Agree go-live date for new staff rota on or around
30.12.2014
RISK
RISK ANALYSIS Failure to agree new rota and turnover
increases as a result of implementation
Page 25 of 34
MITIGATION
Pre-consultation to engage staff in rota
development and capture opinion,
A&E PERFORMANCE
REMEDIAL ACTION PLAN
22 October 2014
followed by formal notice of new rota
Failure to recruit to required staffing level
and expertise
Page 26 of 34
Recruitment Plan. Possibly delay
implementation until safe to do so
A&E PERFORMANCE
REMEDIAL ACTION PLAN
22 October 2014
APPENDIX L
PROJECT TITLE
Discharge transport
CLINICAL LEAD Julie O'Donoghue
EMAIL
[email protected]
SPONSOR Tina Benson
EMAIL
[email protected]
EMAIL
[email protected]
PROJECT LEAD Yvonne Smith
PURPOSE
REASON
OBJECTIVES
To improve the quality of patient experience by ensuring sufficient transport is available
to support discharge from A&E department to patient’s home
To ensure patients are discharged home instead of being admitted where clinically safe
and appropriate to do so
Improving transport at core pressure points by:
1. Identify problem time zones
2. Audit and analyse findings and produce an action plan
3. Consider options to increase transport provisions at pressure points
EXPECTED
IMPACT ON Expected to reduce patients admitted, largely to the ED observation area
BREACHES
Increase in transport resources will assist in reducing the amount of patients admitted
due to late transport
BRIEF OUTLINE
ED Observation Ward data will be collected via a review of patients admitted and the
reasons for admission, to identify any transport related cases
OUTCOME
DATE ACHIEVED
Gather ED Observation Ward data for admitted patients
14.11.2014
SUMMARY Analysis of data
TIMESCALES
Commence Project Group
10.12.2014
19.12.2014
Implement Project Plan (subject to recruitment or procurement timescales)
RISK
27.02.2015
MITIGATION
Transport provider unable to staff/cope
with peak demand periods
Clarify time zones where peak ED demand
exists and focus capacity here
Unable to agree additional contractual
requirements with existing transport
provider
If audit presents a cost / benefit case; seek
in-house or alternative provider to
enhance capacity
RISK ANALYSIS
Page 27 of 34
A&E PERFORMANCE
REMEDIAL ACTION PLAN
22 October 2014
APPENDIX M
PROJECT TITLE
Escalation plans
CLINICAL LEAD Miriam Harris
SPONSOR Tina Benson
PROJECT LEAD James Walters
EMAIL
[email protected]
EMAIL
[email protected]
EMAIL
[email protected]
To improve the quality of patient care and patient experience by ensuring effective
PURPOSE mitigation arrangements are in place to meet unexpected demand levels in the A&E
department
REASON Escalation plans are essential for dealing with unforeseen demand
OBJECTIVES To have an established and agreed escalation plan with the rest of hospital support
EXPECTED
IMPACT ON Improve quality in ED and reduce number of system pressure related breaches
BREACHES
1. The plan will cover the procedures that will be undertaken when the ED is
under pressure.
2. This is to improve the efficiency and effectiveness of the systems throughout
BRIEF OUTLINE
the hospital to enable provision of high quality clinical care as to meet the 4
hour standard.
3. To draft and agree escalation plan with support from specialties
OUTCOME
Initial draft
SUMMARY
Consultation period started
TIMESCALES
Clinical Director sign off
DATE ACHIEVED
12.09.2014
30.10.2014
30.12.2014
Agree launch date
30.12.2014
RISK
RISK ANALYSIS Plan fails to deliver a true culture change
Page 28 of 34
MITIGATION
Senior support and backing of Royal
College of Emergency Medicine through
‘Exit Block’ campaign
A&E PERFORMANCE
REMEDIAL ACTION PLAN
22 October 2014
APPENDIX N
PROJECT TITLE
ED diagnostics resilience plan
CLINICAL LEAD
Michelle Marshall - Radiology
Gillian Williams - Pathology
EMAIL
[email protected]
SPONSOR Tina Benson
EMAIL
[email protected]
PROJECT LEAD Nitin Parmar
EMAIL
[email protected]
PURPOSE
REASON
OBJECTIVES
EXPECTED
IMPACT ON
BREACHES
BRIEF OUTLINE
To improve the quality of patient care and patient experience by improving patient
access to appropriate diagnostic tests
Radiology and pathology departments need to provide a robust and timely service to
patients and the A&E department to enable the delivery of the 95% A&E target
The objectives of the resilience plans are:
1. to deliver radiology test results received by A&E department in accordance with
the agreed service specifications
2. to deliver pathology test results received by A&E department in accordance
with the agreed service specifications
3. The agreed targets to be met 24 hours per day 7 days a week.
Delays in the A&E department receiving diagnostic test results currently cause an
estimated 1.1 breaches per day (July 14 data). However, a secondary breach reason
may still have occurred had the tests been resolved more quickly. The achievement of
the above objectives is expected to reduce the number of diagnostic breaches.
ED, Pathology and Radiology to meet to discuss and agree appropriate service
specifications or standards that ensure that referrals from the A&E department are
processed and test results returned to A&E within a timescale that improves the care
provided.
In addition, service downtime procedures to be assessed to ensure they are in place,
documented and robust enough so that diagnostic tests are performed in a timely
manner.
OUTCOME
DATE ACHIEVED
GMs for ED, Pathology and Radiology to meet and discuss processes
to support delivery where required
30.10.2014
SUMMARY
TIMESCALES Implement system changes where possible
Regular performance meetings
RISK
Skills shortages mitigate against
RISK ANALYSIS achievement of service specifications
Investment funding not available from
within Trust’s existing resources
Page 29 of 34
30.12.2014
30.01.2015
MITIGATION
Consultation with providers to identify
investment requirements
Priority on releasing bed capacity
A&E PERFORMANCE
REMEDIAL ACTION PLAN
22 October 2014
APPENDIX O
PROJECT TITLE
A&E recruitment, retention and development plan
Julie Bak
CLINICAL LEAD Miriam Harris
Julie O'Donoghue
EMAIL
[email protected]
[email protected]
[email protected]
SPONSOR Tina Benson
EMAIL
[email protected]
PROJECT LEAD Nitin Parmar
EMAIL
[email protected]
To improve the quality of patient care and experience by ensuring that there are
PURPOSE sufficient appropriately trained and well-motivated A&E staff available to meet patient
needs
1. The current A&E medical locum cost is approximately £2 million /year.
REASON 2. There is a recognised lack of experienced middle grade staff.
3. More consultants required to increase floor cover beyond 22:00 hours.
Recruit, retain and develop a committed workforce to:
1. Improve the image of Emergency medicine in the trust
2. Actively recruit middle grade doctors of ST4 level and above, and provide tailored
OBJECTIVES
development plans
3. Reduce the locum budget
4. Provide consultant cover beyond 22:00 hours when possible and accepted
EXPECTED
Improving decision making, leadership qualities, accountability, quality and
IMPACT ON
performance. Reducing breaches as capacity and quality builds
BREACHES
1. The new A&E department will act as a main driver to provide a ‘face lift’ for
emergency medicine in the Trust.
2. There is an active recruitment process in place to encourage experienced middle
grade doctors.
3. A middle grade teaching programme has been implemented which focuses on
success in the MCEM/ FCEM exams
BRIEF OUTLINE
4. All middle grade doctors have an allocated consultant educational supervisor and a
development plan specific to their individual needs.
5. Improvements to the medical rota which are palatable and provide a good work-life
balance, which provides an incentive to join the Trust
6. Developing a closer working relationship at senior level to dispel previous
perceptions of a poor working environment.
OUTCOME
DATE ACHIEVED
Continue to Improve substantive staffing levels
SUMMARY
Improve number of nurses to have PDPs
TIMESCALES
Improve number of PDPs at Middle grade doctors (MGD) level
RISK
Historic perception of the ED remains
RISK ANALYSIS challenged
Without the right level of bed capacity the
ED will remain a frustrating, difficult and
Page 30 of 34
31.03.2015
31.03.2015
31.12.2015
MITIGATION
New ED, new clinical leadership, improved
senior recruitment to support
development
Business case to increase bed base, with a
clear plan agreed with clinicians
A&E PERFORMANCE
REMEDIAL ACTION PLAN
22 October 2014
unpleasant place to work
Market risk – Lack of supply of suitable
Middle Grade Doctors.
Page 31 of 34
Liaising with head-hunters, overseas
recruitment drive and recruitment and
retention bonuses.
A&E PERFORMANCE
REMEDIAL ACTION PLAN
22 October 2014
APPENDIX P
PROJECT TITLE
Weekend discharges enabler – whiteboards
CLINICAL LEAD Keith Steer
SPONSOR Tina Benson
PROJECT LEAD Trish Winn
PURPOSE
REASON
OBJECTIVES
EMAIL
[email protected]
EMAIL
[email protected]
EMAIL
[email protected]
To improve patient access to acute inpatient beds at NWP by increasing the number of
weekend discharges associated with the new whiteboard related processes
Maintaining patient flow over the weekend improves the quality of patient care by
reducing LoS, leading to improved bed availability and a reduction in A&E breaches.
Improving weekend discharges where possible and clinically appropriate:
1. to achieve a further 5 discharges / transfers per weekend
2. The new A&E department will automate the Paediatric whiteboard
EXPECTED
Weekend discharges improved, releasing capacity and reducing the burden of patients
IMPACT ON
waiting on a Monday
BREACHES
Review and re-launch Criteria Led discharge using electronic whiteboard. Criteria will
include:
 Patients needing review following an intervention;
BRIEF OUTLINE
 needing review following treatment;
 needing review following stabilisation of their condition;
 need will be identified by the consultant on a ward round close to the weekend
OUTCOME
DATE ACHIEVED
Key wards to be using Expected date of discharge on electronic
boards
SUMMARY
TIMESCALES Complete review of Criteria led discharge bundle
Real time weekend discharges in place
RISK
RISK ANALYSIS Failure to adopt new system
Page 32 of 34
28.11.2014
28.11.2014
01.02.2015
MITIGATION
Senior support combined with local
champions and positive feedback from
early implementers
A&E PERFORMANCE
REMEDIAL ACTION PLAN
22 October 2014
APPENDIX Q
PROJECT TITLE
Ambulatory care pathways
CLINICAL LEAD
Shahir Hamdulay
EMAIL [email protected]
Tina Benson
EMAIL [email protected]
Sarah Ingham
EMAIL [email protected]
SPONSOR
PROJECT LEAD
PURPOSE
To improve the quality of patient care and patient experience by improving access to
ambulatory care services as an alternative to A&E and/or admission
The shortage of acute beds on the NWP campus is the major cause of A&E breaches as
patients wait for an empty bed in order to be admitted – patients will be removed from
REASON
the A&E setting or bypass A&E completely with GP direct referral to Ambulatory Care,
also preventing unnecessary admissions
Improve service quality and patient experience by:
OBJECTIVES



Improving access to prevent unnecessary A&E attendances and/or admissions
Extending the range of condition specific pathways
Promotion of the service with local GPs
EXPECTED
Decrease in A&E attendances as direct referral to Ambulatory Care. Increase in bed
IMPACT ON
capacity due to non-admissions.
BREACHES
Improve service access by:
BRIEF OUTLINE
SUMMARY
TIMESCALES
RISK ANALYSIS
1. Extending opening hours to incorporate weekday evenings to prevent
unnecessary A&E attendances and/or admissions
2. Implementation of additional Ambulatory Care pathways
3. Service re-launch with GP’s and other stakeholders, following recent service
award
OUTCOME
DATE ACHIEVED
Medical evening capacity starts (will be realigned until nursing capacity starts)
01.10.2014
Surgical pathways to be discussed at AECU Project Group and in
liaison with Surgical Division
01.02.2015
New cardiology pathways implemented
27.02.2015
Staff consultation for Nursing evening cover (90 days)
01.04.2015
RISK
Extended hours not possible from
current medical and nursing
establishment
Extending hours not viable in the longterm
Failure to move to new A&E
Availability of xray room to house ECHO
machine in old A&E department
Nursing staff have requested a formal
Page 33 of 34
MITIGATION
If appropriate business case; use bank and
agency to fill vacant shifts
Consider allocation of system resilience or
new tariff funding with CCG
Ambulatory Care to remain on Fletcher ward
and clinical room lost to accommodate ECHO
machine
Loss of clinical room to accommodate ECHO
not possible, no space for ECHO machine
Formal consultation, liaison with JNCC and
A&E PERFORMANCE
REMEDIAL ACTION PLAN
22 October 2014
consultation to change working pattern
to include unsocial hours
Page 34 of 34
union representatives – agree on case for
change at AECU Project Group