Felicity CoxMatthew DrinkwaterElliot Howard-Jones

Congestive Hospital Failure - Avoiding the Heart Attack

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Kent and Medway Acute Hospital Sites

Overview• A&E performance deteriorated

significantly across England over December 2012 to April2013.

• Recovery plans to ensure that the operational standard for A&E set out in the NHS Constitution is met.

• East Kent Hospitals FT called an ‘Internal Major Incident’ due to pressure in A&E without following an agreed escalation process

• The Secretary of State got on the phone:-

Week Ending 14.4.13 Percentage in 4 hours or less (type 1)

Percentage in 4 hours or less (all)

Dartford And Gravesham NHS Trust 93.89% 93.89%East Kent Hospitals University NHS Foundation Trust 89.59% 90.75%

Maidstone And Tunbridge Wells NHS Trust 89.85% 89.85%Medway NHS Foundation Trust 86.57% 86.57%

<94% >95% >95%

Hospitals in the Kent and Medway System routinely go into business

Continuity

THE OBJECTIVE

Reduce the number days on black alert in Kent & Medway to a maximum of 12 days between June 2013 and April 2014.

Root Cause AnalysisPeople:

• Have changed and newer recruits in the system no longer have the relationships or experience

• Staffing levels and skill mix in all organisations has become less rich

Process/Policies

• New organisational policy no longer followed the pattern of system escalation policies

• System escalation polices have been over time and were no longer consistent

• Other policy targets & PbR militate against stepping down routine work to enable urgent care to work

• Ambulance internal policies were not synchronised with provider policies.

Equipment

• Equipment to safely take people home was not immediately available

Environment

• National data shows that A&E 10/11 or 11/12 didn't recover from winter as normal in February

• National data shows no correlation between attendances & 4 hour waits

• Increase in total numbers attending happened when we started counting walk in centres and urgent care centres, major setting type1 units show a flat to decreasing trend

• There has been a 1.2% increase in admissions in 4% reduction in beds although no change in acuity identified

• Significant reductions in social care funding

has responsibilityfor

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Individualresponsibility

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commonlanguage

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Benefits of Shrewd

3. A LOCAL AREA TEAMreal time view of hot & cold system

pressures

4. Access down to single hospital indicator level for granular detail

2. A REGIONAL real time view of hot & cold system pressures

.

5. A nationally benchmarked data set and EPRR system

1. A NATIONAL real time view of hot & cold system pressures

.

Access to the detail in box 4 is a maximum of 3 clicks away from the LOCAL AREA TEAM, REGIONAL & NATIONAL views

Strategy Selection• Facilitate CCGs to produce a system wide plan to improve A&E

performance. Challenge the CCGs to cover four areas:-– Appropriately understand and diagnose issues in urgent care

performance– Have appropriate escalation procedures in place following

Emergency Planning Response and Resilience (EPRR) principles– Ensure that our urgent care system is efficient – as per King’s Fund

report – Urgent care system redesign for long term sustainability

• NHS England has lead responsibility for EPRR and therefore would operationally lead this as part of contributing to the programme.

Implementation Who Date

For 3 II Debrief regarding & agreement of Major incident Local Health Resilience Partnership (LHRP) Meeting

 

K&M System leaders2nd May

 

Monitor Roundtable on Urgent Care K&M System leaders & Monitor 2nd May

Clearly describe the taskUrgent Care Prep meetingConference Call by system to set out task and identify specific issues system one system two system three

 

Nationally DefinedNHS England `K&M Exec

 NHS England Director, Ops &

Delivery & CCGs

9th May8th May

 13th May14th May14th May

 

Set Clear parameters (see section 3)NHS England Nationally & Area

Team15th May

Open space event to generate buy in and generate ideas and actions K&M System leaders 22nd May

•Work with EPRR leads on principles and underpinning of approach•Circulate draft escalation approach

 K&M EPRR leads

6th June7th June

Prioritise Plan NHS England K&M AT 1st JuneGreater senior support in urgent care boards (UCB) system one system two system three

 

NHS England K&M AT Directors2nd May 26th June9th May 21st June

15th May 25th June

Sign off overarching plan and system escalation process at UCB NHS England K&M AT and RT As above

NHS England collaborating with CCG to strengthen primary care commissioning

NHS England K&M Medical Director & DoC

As above

Clarification of role and performance of primary care commissioned services NHS England K&M Medical DoC 18th July

Commence Implementation of Plan 

Whole System 3rd June

Training Events re escalation process• system one• system two• system three

 

NHS England K&M EPRR lead JULY

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23For 3 II Debrief regarding & agreement of Major incident Local Health Resilience Partnership (LHRP) MeetingMonitor Roundtable on Urgent CareUrgent Care Prep meetingClearly describe the taskConference Call by system to set out task and identify specific issues·system one·system two·system threeSet Clear parameters (see section 3)Open space event to generate buy in and generate ideas and actionsPrioritise Plan•Work with EPRR leads on principles and underpinning of approach•Circulate draft escalation approach

Greater senior support in urgent care boards (UCB)·system one·system two·system threeSign off overarching plan and system escalation process at UCB

NHS England collaborating with CCG to strengthen primary care commissioningClarification of role and performance of primary care commissioned servicesCommence Implementation of PlanTraining Events re escalation process• system one• system two• system threeEvaluation

MAY June

Evaluation• Three of four have stayed out of business continuity so far• No further major incidents called• One Trust remains on black - bigger issue related to Keogh

Review, Culture & Medical Leadership

Week Ending 14.4.13 Percentage in 4 hours or less (type 1)

Percentage in 4 hours or less (all)

Dartford And Gravesham NHS Trust 93.89% 93.89%

East Kent Hospitals University NHS Foundation Trust 89.59% 90.75%

Maidstone And Tunbridge Wells NHS Trust 89.85% 89.85%

Medway NHS Foundation Trust 86.57% 86.57%

Week Ending 16.6.13

Dartford And Gravesham NHS Trust 95.86% 95.86%

East Kent Hospitals University NHS Foundation Trust 96.40% 97.36%

Maidstone And Tunbridge Wells NHS Trust 98.20% 98.20%

Medway NHS Foundation Trust 89.14% 89.14%

<94% >95% >95%

SUM SUM CCG Federati

NK1 CCGs NK2 CCG

Section A57 1. Strengthening primary and community care for frail and elderly people 17 15 17 860 2. Use of community diversion schemes 17 14 16 1349 3. Strengthening GP out-of-hours services 15 14 14 648 4. Use of virtual wards in the community 14 13 16 553 5. Support to care homes to avoid emergency referrals 14 13 15 1155 6. Peer Review of GP emergency referrals 13 12 18 1255 7. Reducing ambulance conveyance rates 12 13 17 1343 8. Patient education on appropriate use of emergency services 12 12 13 660 9. Roll out arrangements for NHS 111 14 15 16 15

Section B50 1. Prompt booking of patients to reduce ambulance turnaround delays 14 11 13 1250 2. Full see-and-treat in place for minors 15 18 11 635 3. Prompt initial senior clinical assessment within A&E and rapid referral if admission is needed 10 12 7 638 4. Prompt initiation of blood and radiological tests with rapid delivery of test result 12 10 8 840 5. Prompt Access to specialist medical opinion 13 12 7 856 6. Full use of computer-aided patient tracking and system for progress-chasing 14 13 13 1648 7. Regular seven-day analysis should be in place for rapid identification and release of bottlenecks 11 13 9 1561 8. Bed base management 16 16 13 1651 9. Daily consultant ward rounds 11 18 4 1857 10. Provision of specific services for patients groups such as those with mental health problems 15 15 10 17

Section C58 1. Designation of expected date of discharge (EDD) on admission 16 15 12 1555 2. Maximisation of morning and weekend discharges 14 14 12 1560 3. Full use of discharge lounges 15 15 14 1652 4. Minimisation of outliers 11 14 12 1547 5. Delayed transfers of care reduced 10 11 11 1545 6. Flexing of community service capacity to accept discharges 9 11 11 1454 7. Review of continuing care processes 13 12 15 14

Learning through the process

• It is hard to reduce the problem to a simple statement• Naming and defining the problem collectively developed

shared understanding• In addressing the simple problem other things improved

– what is measured changes?• Analysing the root cause identified it wasn’t the reason

being described• Many alternatives identified are still being pursued so

process useful• It is all about relationships

Commissioning togetherNHS England commissioning Related commissioning

Essential and additional primary medical services through GP contract and nationally commissioned enhanced services

Out-of-hours primary medical services (where practices have retained the responsibility for providing OOH services)

Out-of-hours primary medical services (where practices have opted out of providing OOH services under the GP contract)

Community-based services that go beyond scope of GP contract (akin to current Local Enhanced Services) - CCG

Pharmaceutical services provided by community pharmacy services, dispensing doctors and appliance contractors

Meeting the costs of prescriptions written by member practices (but not the associated dispensing costs) - CCG

Primary ophthalmic services, NHS sight tests and optical vouchers Any other community-based eye care services and secondary ophthalmic services - CCG

All dental services, including primary, community and hospital services and including urgent and emergency dental care

Dental Public Health – Local Authority

Health services (excluding emergency care) and public health services for people in prisons and other custodial settings (adult

prisons, young offender institutions, juvenile prisons, secure children’s homes, secure training centres, immigration removal

centres, police custody suites)

Emergency care, including 111, A&E and ambulance services, for prisoners and detainees present in geographic area

Health services for adults and young offenders serving community sentences and those on probation

Health services for initial accommodation for asylum seekers - CCG

Health services for member of the armed forces and their families (those registered with DMS)

Prosthetics services for veterans(Primary care for member of the armed forces will be commissioned

by the Ministry of Defence)

Health services for veterans or reservists (when not mobilised) for whom normal commissioning responsibilities apply

Emergency care including A&E and ambulance services, for serving armed forces & families registered with DMS practice present in

geographical area - CCG

Public health services for children from pregnancy to age 5 (Healthy Child Programme 0-5), including health visiting, family nurse

partnership, responsibility for Child Health Information Systems

Healthy Child Programme for school-age children (5-19), including school nursing – Local Authority

National Screening & Immunisation programmes Sexual Health programmes – Local Authority

Public health care for people in prison and other places of detention

Sexual Assault Referral Services Sexual Health programmes – Local Authority