Operational Performance Trajectory for Q1 and Q2 …...1. This paper updates the Trust Board on the...

TB2015.55 Operational Performance Trajectory Q1 and Q2 FINAL of 41

Trust Board Meeting: Wednesday 13th May 2015 TB2015.55

Title Operational Performance Trajectory for Q1 and Q2 2015/16

Status For information and review

History The paper provides an update on actual performance in Q4 2014/15 to date and forecasts for Q1 and Q2 2015/16 with the detailed action plans to demonstrate sustainable delivery of the core standards.

Board Lead(s) Paul Brennan, Director of Clinical Services

Key purpose Strategy Assurance Policy Performance

Oxford University Hospitals TB2015.55


Executive Summary

1. This paper updates the Trust Board on the forecast trajectory for operational performance in Q1 and Q2 2015/16, as approved by the Finance and Performance Committee at its meeting on 15 April 2015, under delegated authority of the Board.

2. This paper outlines a briefing on Access and Outcomes measures used by Monitor as part of the regulator’s assessment of the governance of foundation trusts and of FT applicants.

3. The performance of OUH against these standards is shown for 2014/15 to date.

4. The proposed performance trajectory for Q1 and Q2 2015/16 was considered by the Finance and Performance Committee at its meeting on 15 April 2015, where it was approved under delegated authority of the Board, and reviewed by the Trust Management Executive [TME] at its meeting on 23 April 2015.

5. Recommendation The Trust Board is asked to:

• Note actual performance for 2014/15 to date • Note the Urgent Care, RTT and Cancer Action Plans (as updated), which

have driven the proposed trajectory for Q1 and Q2 2015/16 • Note and ratify the trajectory set out in paragraph 5.1, as approved by the

Finance and Performance Committee under delegated authority of the Board.



Operational Performance Trajectory for Q1 and Q2 2015/16

1. Monitor’s governance rating 1.1. Since October 2013, Monitor’s Risk Assessment Framework has set out the

regulator’s approach to overseeing NHS Foundation Trusts’ compliance with the governance and continuity of services requirements of their provider licence.

1.2. The governance rating is generated by Monitor considering:

• performance against selected national access and outcomes standards;

• CQC judgments on the quality of care provided;

• relevant information from third parties;

• a selection of information chosen to reflect quality governance at the organisation;

• the degree of risk to continuity of services and other aspects of risk relating to financial governance; and

• any other relevant information.

2. Use of the governance rating 2.1. For NHS Foundation Trusts, Monitor uses this rating to determine whether

support or intervention takes place. Prompts for governance concerns, which may in turn lead to intervention, are set out in the table below.



2.2 The assessment process for Foundation Trust applicants is aligned with the governance rating process and minimum standards are set in Monitor’s Guide for Applicants – for example, that Trusts must have at least a ‘Good’ rating from the CQC and be better than specified scores for quality governance and national access and outcomes standards.

2.3 This paper focuses on the access and outcomes element of the governance rating.

3. Access and outcomes 3.1. Thirteen national standards are included in Monitor’s framework, covering:

• 18 week Referral to Treatment Time (RTT) standards

• A&E four hour wait

• Cancer waiting time standards

• C. difficile cumulative cases

3.2. The cancer standards are organised into four groups, meaning that there are nine groups of targets. Against each group, failing a standard for a quarter generates a point. The points are totalled for each quarter and ‘over-riding rules’ applied, including that no more than two points can be accumulated in a quarter from the three RTT standards. However, it is important to realise that for the RTT standards, failure in any individual month causes failure for that quarter. For the 4 hour and cancer standards, the quarter’s position is an average for the quarter and for C Difficile performance is based on the cumulative position at the end of the quarter.

3.3 Applicant Trusts are required to score 3 or below to be authorised, and to be able to demonstrate realistic plans for improvement where performance is currently below the standard.

4. OUH historical position 4.1 The quarter by quarter ‘score’ in 2014/15 has been as follows:

Quarter ‘Score’ Areas of breach

Q1 7 RTT Admitted, RTT Non-admitted, RTT Incomplete (total score of 2 for RTT), A&E, 62-day cancer, 31-day radiotherapy, 31-day cancer first treatment, two week wait (suspected breast cancer)

Q2 5 RTT Admitted, RTT Non-admitted, RTT Incomplete (total score of 2 for RTT), A&E, 62-day cancer, 31-day radiotherapy

Q3 4 RTT Admitted, RTT Non-admitted, A&E, 62-day cancer



4.3 Performance in January – March 2015 is expected to generate a score of 3 in Q4. Performance to date is as follows (with final cancer wait figures for March due in the second week of May):

Standard Month Score January February March 4 hour 83.45% 88.27% 84.9% 1

RTT Admitted 84.17% 86.15% 86.7% 1

RTT Non-Admitted 95.03% 95.12% 95.13% Nil

RTT Incomplete 92.66% 93.19% 92.61% Nil

62 day Tumour 72.2% 76.5% 1

62 day Screening 91.3% 90% Nil

31 days 96.3% 98.4% Nil

31 days subsequent surgery 96% 98.9% Nil

31 days subsequent drug 100% 100% Nil

31 days subsequent radiotherapy 97.1% 99% Nil

2 week wait 97.2% 97.7% Nil

2 week wait breast symptoms 98.4% 98.6% Nil

C Difficile 4 3 Nil

5. Forward plan 5.1. The forward projection for 2015/16 is based on the following assumptions.

• The RTT Non-admitted and Incomplete standards continue to be delivered in each month during Q1 and Q2.

• The RTT Admitted standard will be delivered in June 2015 and continue to be achieved in each month in Q2. Based on the way Monitor’s Risk Assessment Framework calculates performance the Trust will receive a score of 1 in Q1 and nil in Q2.

• The the 62 day cancer standard will be delivered in June 2015 and continue to be achieved in each month in Q2. The Trust will therefore score 1 in Q1 and nil in Q2.

• The 4 hour standard is not predicted to be met in Q1 and is forecast to be achieved in Q2. The Trust will therefore score 1 in Q1 and nil in Q2.

5.2. Overall, this gives a forward trajectory of 3 for Q1 (RTT Admitted, 62 day, 4 hour), and Nil for Q2.

6. Action Plans 6.1 The Urgent Care Improvement – No Delays programme is in place to implement

recommendations made by the national Emergency Care Intensive Support Team (ECIST) and the Trust’s internal improvement programme. Details of the programme and a project update are set out in Appendix 1.



6.2 The Trust-wide Improvement Plan for RTT is attached at Appendix 2 and will be supplemented by individual plans for each division which will mirror the Trust-wide plan.

6.3 The Cancer Plan is attached at Appendix 3.

7. Governance 7.1. Detailed delivery plans, with milestones, are set out in the appendices to this

report and the table below sets out the reporting and accountability framework.

Governance RTT Admitted ED 4 hour 62 day cancer Plan in place Yes Yes Yes

Milestones agreed Yes Yes Yes

Progress reported to Bi weekly performance meeting chaired by DCS

Bi weekly performance meeting chaired by DCS

Bi weekly performance meeting chaired by DCS

Accountable lead Director of Clinical Services

Director of Clinical Services

Director of Clinical Services

How OUH Board receives information on progress

Specific report, including an update on individual action plans to F&P in April, June and August. Detailed progress report within the IPR to Trust Board in May, July and September



8. Recommendation 8.1. The Trust Board is asked to:

• Note actual performance for 2014/15 • Note the Urgent Care, RTT and Cancer Action Plans, which have driven the

proposed trajectory for Q1 and Q2 2015/16 • Note and ratify the trajectory set out in paragraph 5.1, as approved by the

Finance and Performance Committee under delegated authority of the Board..

Paul Brennan Director of Clinical Services May 2015

Oxford University Hospitals Appendix 1 Urgent Care


Urgent Care Improvement – No Delays Context The Trust has failed to achieve the four hour access target in all but two quarters since the start of 2013/14. Quarter 3 of 13/14 has been a particular challenge with the Trust rarely performing above 85%. Oxford University Hospitals received national winter monies in the second tranche and this has been used to provide additional community bed capacity to support winter pressures.

In October/November 2014 the Emergency Care Intensive Support Team (ECIST) undertook a whole system review of the emergency and urgent care system covering both health and social care. In response to this the Trust developed a Trust wide Urgent Care Improvement Programme to take forward the recommendations from that review. The milestones and associated actions are detailed in this action plan.

Reasons for Under Performance The majority of Breaches (over 50%) are due to lack of available in-patient bed capacity. Although ambulatory pathways are utilised as much as possible, there has been a significant increase in admission of very sick, elderly patients who require a greater level of care, longer stay in hospital and an increase in post-acute support. ECIST also undertook a length of stay review at John Radcliffe Hospital and identified that 43% of the “fit for discharge” cohort were waiting for post-acute community support. . The lack of sufficient post-acute support to meet demand has resulted in longer waits for access to services and put greater pressure on hospital capacity and a greater challenge in meeting the 4 hour standard.



9am and 9pm, but discharges do not tend to occur until after 12pm with the majority of discharges occurring after 4pm. This mis-match between admissions and discharges is further amplified late into the night as a back log of patients waiting builds up. The main contributors to lack of flow through inpatient beds are: 1. Numbers of medically fit patients awaiting discharge to a community or social care placement 2. Reduced numbers of discharges at week-ends and discharges occurring late in the day. There has also been an increase in the number of patients attending the A&E department in the 70 years of age and above age range. This represents an annual increase of 10% since January 2012

In January 2015 the number of patients waiting in hospital for post-acute support rose by 20% above the monthly average of patients medically fit for discharge. In February 2015 this rose to 25% above the monthly average for the year. The capacity gap in community support was further exacerbated leading to longer a 50% increase in the average number of days wait for discharge into post-acute community support.



Urgent Care Improvement Programme

Programme Workstreams

Emergency Department Work stream

Clinical Lead: Dr Larry Fitton Nursing Lead: Louise Rawlinson, Management lead: Siophan Hurley

Work Stream Objectives KPIs

No less than 95% of patients are assessed, treated amd admitted, transferred or discharged within 4 hours of arrival

• % pts discharged within 4 hour standard

All patients will be assessed within 15 mintues of arrival or ambulance handover whichever is the quickest.

• time to Initial assessment from arrival

Ambulance handovers will take place within 15 minutes of arrival • time to treatment

No patient will wait on a trolley for more than 12 hours from decision to admit •ambulance turnaround time

To provide safe high quality care for all patients attending ED/EAU •LOS in emergency dept

There will be a model of staffing in place that meets peaks and troughs in demand, with an appropriate skill mix that enables safe, high quality patient care and effective management of patient flow.

•Family and friends score •Number of reported untoward incidents and near misses

No patient will be delayed in the Emergency Department waiting for diagnostics or specialty assessment

To avoid overcrowding in Emergency Department

Emergency Assessment Unit and Ambulatory Care Work Stream

Clinical Lead: Dr Suhdir Singh Nursing Lead: Lily O'Connor Management Lead: Siobhan Hurley


To develop an appropriate multisidiplinary staffing model on EAU to ensure safe, high quality patient care and effectively manage patient flow.

•Average LOS by consultant/ day of the week

To embed locally agreed performance standards and minimise variation in practice.

To ensure LOS on EAU does not exceed 12 hours and aim for 20- 35% of patients refered to be managed on an ambulatory pathway

• % of patients discharged directly from EAU • % of patients discharged within 12 hours • % of patients treated in a chair instead of admitted to a trolley EAU • % of patients treated in EAU instead of admission to medical bed. • % of patients treated on an ambulatory pathway

To ensure ambulance handovers take place within 15 minutes of arrival • Ambulance turnaround times

To promote integration and closer working between health and social care.

Inpatient Flow and discharge planning Work Stream

Clinical Lead: Dr James Price Nursing Lead: Lily O'Connor Managerial Lead: Kathleen Simcock




All patients will have a consultant review each day seven days a week • number and time of wards rounds over a seven day period

All patients will have a clinical management plan within 24 hours of admission • Number of pts with EDD

All staff to be competent and confident in managing all aspects of a patient's discharge including complex discharges

• DTOC report • LOS by specialty/wards

40% of all patient discharge will take place by lunch time • % of discharges before lunch time • % discharges by day of the week

To promote integration and closer working between health and social care. • DTOC report

To improve access to community services that support patient discharge • DTOC • LOS from referral to discharge

To minimise the number of days a patient is delayed awaiting repatriation or transfer

• Number and LOS of pts waiting repatriation



Urgent Care Improvement – No Delays Project update as at 1/5/2015

Programme to implement ECIST recommendations

Milestones and associated actions Activity Type

Task owner

Original Due Date Comments Activity

Status

EMERGENCY DEPARTMENT WORK STREAM

1

To develop an appropriate medical and nursing staffing model that meets NICE and CEM guidance and is sufficient to meet clinical needs of patients and respond to varying levels of activity within the 4 hour access target

Milestone Dr Larry Fitton

19/01/2015 Complete

2

To increase the consultant presence in ED from 12.3 WTE to 16.3 WTE to provide 2 consultants at peak times in order to enhance the capacity for timely management of patients in ED.

Task Dr Larry Fitton

01/04/2015 interview and board on 26/27 April. One candidate.

In progress

3

To review medical and senior nursing support in ED out of hours to ensure effective management of patients within the four hour target

Task Paul Brennan

01/06/2015

perfect week identified that out of hours continues to be vulnerable and the time when most breaches occur

In progress

4 Increase level 1 medical support with senior clinical decision makers Task Dr James

Price 19/01/2015 Complete

5 Recruit to all middle grade vacancies Task Dr Larry Fitton

19/01/2015 Complete

6

Avoid variation in practice by minimising the use of locums and aim to only employ staff currently employed in department. Migrate pool of internal staff undertaking locums to NHSP


19/01/2015

usually only current staff or known locums are employed for clinical safety reasons

Complete

7 benchmark staffing against NICE and CEM guidance Task

Siobhan Hurley/

Larry Fitton

30/04/2015

awaiting final guidance. Horton likely to have biggest gap. Plan in place to develop band 4 posts as nursing assistants. This will give greater versatility in support staffing depending on where the greatest demand is.

In progress

8

Expand GP capability in ED with the introduction of the GPSI (General Practitioner with Specialist Interest) Job Description and bespoke training programme.


01/02/2016 to consider the role of GPSI in paediatrics ED

In progress




Task owner


Status

9

Provide senior nursing leadership 24 hrs a day with band 7 and 6 experienced nurses as shift coordinators

Task Louise Rawlinson

19/01/2015 To undertake and further review of out of hours support

Complete

10 Train internal staff to develop the ANP workforce to a total of 5.5 WTE to provide 1 per shift in ED


01/01/2017

longer term action- 2 post funded but a business case is being developed for a further three posts.

In progress

11

Review and further develop the role of flow navigator to monitor adherence to the 4 hour target and support patient flow.


01/04/2015

further work required to embed role and ensure maximum impact for improving 4 hr performance

In progress

12 To develop a medically led Rapid Assessment and Treatment process for all patients who attend ED

Milestone Dr Larry Fitton

01/04/2015

dependant on availability of a late shift consultants. Need to identify a process for early identification of patients who will be medically referred and move to EAU quickly

In progress

13 Introduce nurse led RAT process 24 hrs day as the default when insufficient consultant availability to support RAT.


19/01/2015 Complete

14

Establish a process whereby consultants will support RAT on a flexible basis depending on need and staffing. Following recruitment provide 2 consultants on a late shift to support RAT during peak periods.


19/01/2015 Complete

15 Develop a culture of zero tolerance for avoidable breaches of the 4 hour access target

Milestone S Shannon ongoing

launched during the perfect week and will be developed as a trust wide campaign.This will include a marketing and publications programme with all divisions included. initial meeting with comms and marketing set up to discuss approach

Complete

16

Implement service level agreements between clinical services to reduce variation in processes when patients are referred for specialty opinion.


19/01/2015

All SLAs currently under review, to be put into a standard format for ease of use - will be signed off at the next ED

Complete




Task owner


Status

steering group.

17

Develop a standard escalation process which includes ED consultants admitting directly to specialty beds if there is no response within 30 minutes to request for specialty opinion.


01/04/2015

In place and the breach analysis will identify where there is any variation in compliance.

Complete

18

Implement a standard escalation process with defined action at key time points whenever there is a risk of breach of the 4 hour access target

Task S Shannon 01/04/2015 In place and tested during the perfect week

Complete

19 Introduce daily/ weekly breach analysis and agree actions for improvement Task Siobhan

Hurley 01/03/2015

breach meetings to be reviewed with memberships and TOR revised.

Complete

20

map availability of senior decision makers at times of peak activity and analyse impact on 4 hour access performance

Task Siobhan Hurley

01/03/2015

identified the need for more out of hours and weekend management support for early escalation

Complete

21

Implement a rapid referral pathways for patients with fracture neck of femur pathway on the JR site to ensure patients are assessed and admitted within 2 hours

Task

Claire Pulford /

Larry Fitton

01/04/2015

New rapid pathway for suspected fractured neck of femur patients has been agreed and is being trialled

Complete

22

Neuroradiology to accept direct referrals from ED consultants for Cauda Equina Out of Hours and NOC Radiologists in hours.


19/01/2015 Complete

23

Develop a protocol whereby transfers from the Horton ED for specialty opinion to be direct to SEU and medical inpatients accepted without a second opinion


19/01/2015 Complete

24 Enhance diagnostics availability in SEU to the level of ED and EAU Task Paul

Brennan 19/01/2015 Complete

25

Reinforce MaxFax, Plastic and ENT pathway for direct GP referrals (to SSIP). Ensure patients who present in ED and are RNA as requiring surgical opinion are transferred to SSIP

Task Neil Cowan

31/01/2015

ED Consultants now have direct access to book to HAPI clinic in Plastics which has also helped with flow as they can book appts in ED and patients go home and come back to Plastics next day. In January 2015 the SSIP GP referral unit treated and admit or discharge 181 patients, up from 32

In progress




Task owner


Status

in January 2014 equating to an entire days JR ED activity and helping relieve operational pressure in the system. The MOPS room at NOC also became fully operational for Plastics Trauma patients in 2015, and in February 2015 it saw 120 patients treated on the NOC site, nearly all Trauma patients were treated the same day where clinically appropriate, all of whom would have been treated the JR in February 2014.

26 Introduce additional rapid access clinics in the Rowan day Unit to avoid admission.

Task Dr James Price

19/01/2015 Complete

27 Implement First Net in EAU to support effective and efficient management of the patient journey.

Task Pete Male 01/05/2015 need update on progress from Pete Male

In progress

28 Develop a robust system whereby information is used for planning and decision making

Milestone Dr James Price

29/02/2015

Ed dashboard in development. First draft likely to be available in the next week or so. A new bed management report has been developed and will launch on 23rd march which will aid planning and decision making.

Complete

29

Establish performance standards for steps within the 4 hour timeframe – to initial assessment, to be seen and treatment - discharge


19/01/2015 Complete

30 Include all performance standards on the ED/ EAU dashboard and review at weekly performance meetings

Task Lily O'Connor

29/02/2015

awaiting development of the new dashboard.- almost complete

In progress

31 Develop a system that uses historic and current data to predict future activity including likely peaks in

Task Sandra Shannon

30/03/2015 awaiting development of the new dashboard.

In progress




Task owner


Status

demand.

32

Develop a system that uses the predicted activity data to plan increased staffing levels to mitigate risk to patients.

Task

Siobhan Hurley/

Larry Fitton

30/03/2015 awaiting development of the new dashboard.

In progress

33 benchmark staffing against NICE and CEM guidance Task

Siobhan Hurley/

Larry Fitton

30/03/2015 In progress

34

Develop a set of ED capacity triggers and trust wide escalation responses to avoid overcrowding in ED and reduce the time patients are delayed.


19/01/2015

New tighter escalation agreed with earlier response times

Complete

35

To develop a system where breach analysis and review of the previous weeks activity and escalation can be used to learn lessons and make process improvements.

Task Siobhan Hurley

30/03/2015

the breach analysis process will be reviewed and replaced with a daily debrief to ensure more rapid identification of issues/ required action

In progress

36 Develop a whole system escalation process with clear and rapid response actions from all health partner.

Milestone Paul Brennan

29/02/2015 Complete

37 Improve access to PCDU for children in ED Milestone

Nettie Dearmun/

Tony McDonald

29/02/2015 New locum SPR in

post Savarithi Ratnaparlin.

Complete

38 Agree an escalation process to avoid children being kept overnight in ED Task

Nettie Dearmun/

Tony McDonald

30/03/2015

Transfer to CDU/Escalation to

Children's Manager on Call. Paeds SLA in

place.

In progress

39

Update the Trust risk register with risk and impact of ED overcrowding including controls in place and mitigation

Task Lily O' Connor


EMERGENCY ASSESSMENT AND AMBULATORY CARE WORK STREAM

1

Develop an EAU operational model that is appropriately staffed to effectively and efficiently manage the EAU and ambulatory pathway

Milestone Louise Rawlinson

26/01/2015 Complete

2 Expand EAU and reconfigure unit to provide additional assessment rooms Task Louise

Rawlinson 26/01/2015 Complete

3 Undertake a capacity review of level 1 ED/EAU/Diagnostics. Task Dr James

Price 01/04/2015 In progress

4 Develop a system to more accurately and effectively manage patient flow Milestone Siobhan

Hurley

The perfect week demonstrated that

Complete




Task owner


Status

through EAU. keeping assessment spaces available and focusing on no patients over 12hrs in EAU significantly improved flow.

5 Agree escalation triggers for decision making and LOS in EAU Task

Louise Rawlinson

/ Sudhir Singh


6 IT: Alden access for all SpRs + SHOs (read only) + EAU co-ordinators Task

Alex Mona-ghan


7 Develop standard processes for the medical take, managing the patient journey on EAU and optimising LOS.

Task

C Mills/ L Rawlinson / J Light-howler

01/04/2015

2 weeks value stream mapping to be undertaken on Eau which will inform a rapid process improvement workshop to implement standard working

In progress

8 To develop a range of condition specific pathways;- to include PE. DVT, renal colic and low risk chest pain.

Task Sudhir Singh

30/03/2015

awaiting clinical consensus and national guidance from RCRP.

In progress

9 Implement the dementia pathway in ED and EAU and monitor patient outcomes

Task Lily O' Connor


10

Develop an optimum staffing model on EAU that makes best use of available medical and nursing resources and enables early assessment and treatment and optimises LOS.

Task

James Price / Sudhir Singh

01/04/2015

Meeting set up on 24/3 to review medical staffing model and agree workforce plan

In progress

11

Write up proposal for medical model of "on take" whereby consultant on take will review and discharge from EAU and follow patients through SSW. Map out resources required and develop workforce plan to track progress toward optimum model

Task

James Price / Sudhir Singh

01/04/2015

Meeting set up on 24/3 to review medical staffing model and agree workforce plan

In progress

12 To further develop a RAT approach in EAU involving medical, nursing, SHDs and therapy clinicians 8am - 7pm


30/03/2015 works well at present Complete

13

To utilise near patient testing to support early assessment and diagnosis and to support early direct discharge from EAU.

Task Sudhir Singh


14 Implement a clinically led system of telephone triage of all GP referrals and provide advice on alternatives to


01/04/2015 in place but can be further developed

Complete




Task owner


Status

emergency referrals. - explore option of using networked phone

15

Develop communication package/literature for GPs, patients and relatives op include information on zero length of stay and based on assessment rather than admission


30/03/2015

To be included in the zero tolerance of non-clinical 4 hour breaches campaign

In progress

16 Further develop a directory of services for admission avoidance Task Caroline

Mills 19/01/2015

complete but can be expanded

Complete

17 Introduce MDT board rounds twice daily Task Louise

Rawlinson 19/01/2015

clinical huddle approach to focus on quick review and agree actions for patient flow.

Complete

18

To utilise near patient testing to support early assessment and diagnosis and to support early direct discharge from EAU.

Task Sudhir Sing

19/01/2015 Complete

19

To negotiate with Carillion to have a minimum of 2 dedicated porters available on ED /EAU 24 hrs day without the need to use the telephone referral system.

Task Alex

Mona-ghan

29/02/2015

an audit of porter request performance is being undertaken. a significant cause of blockage in patient flow. An RPIW to be undertaken to identify opportunities for improvement.

In progress

20

Implement a system whereby early social care or community support can facilitate early discharge direct from EAU

Milestone Siobhan Hurley

01/04/2015

SHDs and social workers regularly attend EAU to facilitate discharge. The biggest barrier to early discharge is that community beds are cancelled after 8 hours if a patient is sent in for assessment. This does not support discharge within 12 hours where patients may need slightly longer assessment.

Complete

21

To obtain access to social services patient information to easily identify those patients currently receiving care support. (swift)

Task Kathleen Simcock

01/04/2015 Barrier

22 Improve administrator access to Buff notes Task

Alex Monagha

n 30/04/2015

process mapping in progress

In progress

23 Include social worker and OH Task Kathleen 29/02/2015 In progress




Task owner


Status

community therapist as part of the ambulatory care team to undertake directed home visits and support discharges home direct from EAU.

Simcock

24

Develop a process whereby care packages remain in place for patients admitted and likely to be discharged within 24 hours or after 24 hrs, restarted within 12 hours of being fit for discharge.


29/02/2015 Complete

25

To ensure there are an optimum number of ANPs in SEU which will support a reduction in dependency on locum cover.

Task Alison Cornall

19/01/2015 Complete

26

To develop a process whereby performance against locally agreed standards can be monitored, reported and escalated as necessary on a real time basis. Use this information to minimise variation in practice.

Milestone Siobhan Hurley

30/03/2015 to be included in the EAU dashboard

In progress

27

Regularly record direct discharge rates and LOS by consultant and day of the week and use the information to support standard practice and minimise variation in practice.

Task Dr James Price

30/03/2015 to be included in the EAU dashboard

In progress

28 Join the ECIST/NHS Innovations Ambulatory Network Task Paul

Brennan 30/03/2015 Complete

29 Join the next Society of Acute Medicine Benchmarking Audit Task Dr James

Price 30/03/2015 not due Not started

30

Develop an SEU operational model that is appropriately staffed to effectively and efficiently manage the SEU pathway

Milestone Becky Easton

01/04/2015 Complete

31 To assess the potential and benefits of deploying RAT approach in SEU Task Becky

Easton 29/02/2015 Complete

32 Increase JR dedicated surgical consultants to 4. Task Alison

Cornall 30/03/2015 Complete

33 Increase from 5 to 7 day consultant physician presence on the surgical wards

Task Reiner Buhler

30/08/2015 Complete

34 Implement twice daily consultant led board rounds on SEU Task Mr Greg

Sadler 19/01/2015 Complete

PATIENT FLOW AND DISCHARGE WORK STREAM

1 All patients will have a consultant review each day seven days a week or twice


30/03/2015 To be included in best practice audit. See 35.

In progress

2 Ensure discharge planning starts on admission for all patients Task Lily

O'Connor 30/03/2015 Complete




Task owner


Status

3 For patients who may require social care support, ensure S2 is submitted as soon as possible after admission.

Task Sandra Shannon

30/03/2015

new S2 and 5 guidance has been developed for staff. Staff to submit S2 within 24 hrs of admission.

Complete

4

Develop a robust system of daily board rounds to support effective discharge planning and avoid delays in the patient journey

Task Louise Goddard

19/01/2015 To be included in best practice audit. See 35.

Complete

5

Develop a standard operating procedure (SOP) for board rounds so all staff are aware of the expected agreed process and prioritise their tasks to deliver this.

Milestone Louise Goddard

19/01/2015

SOP in place but being reviewed to provide greater clarity on roles and responsibilities at Board round.

Complete

6

EDDs for all to be set and visible on white boards at the first consultant review and updated daily at the board round

Task Sudhir Singh

29/02/2015

to be audited as part of the ward standards best practice audit.

In progress

7 Allocated Social Worker to attend board rounds Task Kathleen

Simcock 19/01/2015 Complete

8 Pharmacists to attend L7/L4 morning board rounds Task Boo

Vadher 19/01/2015 Complete

9 Review model of physician allocation at HGH including designation of short stay beds (MAU, SS)


01/06/2015 SES to work with Dr Price to develop a plan for HGH

In progress

10

complete options appraisal for medical model and resources required. Develop workforce plan to track progress towards optimum model

Task Dr James Price

01/06/2015 as number 8 In progress

11

Establish a system whereby no patients are delayed in their pathway of discharge as a result of waiting for diagnostics

Milestone Lily O' Connor

30/03/2015 as number 8 In progress

12 Agree and implement a set of internal response standards for all inpatient diagnostics



13 Implement a system of 7 day analysis to identify and release bottlenecks in the patient journey

Task Lily O' Connor

30/03/2015

daily review of R4 list. Recent one day review identified very few internal delays. An escalation process has been agreed for diagnostics if patients are waiting.

Complete

14 Agree an escalation process when patients discharge is delayed waiting for diagnostics


30/03/2015

to be included as part of the new operational planning meeting

In progress




Task owner


Status

15 Explore option of increasing availability of PEG lists for in patients Task Lily O'

Connor 30/03/2015

recent trust wide review identified there were currently no delays for PEG.

Complete

16 To implement a system whereby discharge TTOs are ordered the day before discharge

Task Sudhir Singh


17

Implement "one stop" ward rounds whereby TTHs and ordering of test are undertaken by junior doctors at the time of review rather than after the ward round

Milestone Sudhir Sing

30/03/2015 Not started

18 include TTO notification check in daily board round Task Luisa

Goddard 30/03/2015 In progress

19

Establish a system whereby no patients are delayed in their pathway of discharge as a result of waiting for diagnostics

Task Lily O’Connor

30/03/2015

perfect day undertaken on Tuesday 30 March. This will inform the planning for the perfect week.

Complete

20

Develop a system whereby no patients are delayed whilst waiting to be repatriated back to their original ward/ DGH

Milestone Sandra Shannon

30/03/2015 escalation process in place.

Complete

21 Develop daily patient tracking system for all internal trust and external repatriations

Task Sandra Shannon

30/03/2015 escalation process in place.

Complete

22

Develop a system whereby there is greater visibility across the health economy of community capacity and demand.


30/03/2015

whole health economy R$ list circulated twice weekly

Complete

23 Agree a local data set to inform discharge planning and community bed allocation at the 9.30 bed meeting

Milestone Lily O’Connor

30/03/2015

to be included as part of the informatics work stream

Complete

24

Develop a simple patient tracking system to monitor referral, assessment and time to discharge for patients requiring social care support.

Task Sandra Shannon

30/03/2015 whole system R4 list in place

Complete

25

Implement a model of integrated domiciliary and reablement support services that minimises delay in transfer of care between providers.

Task

Kathleen Simcock/

Lily O' Connor


26 Undertake a capacity and demand review of post-acute domiciliary and reablement requirements


30/03/2015 awaiting feedback from ECIST

Complete

27

Identify the staffing establishment and skill mix required to accommodate all patients referred to dom care or reablement within an agreed timescale

Task Lily O' Connor

30/03/2015 plan for additional recruitment agreed

In progress




Task owner


Status

28 Develop a data set to use for inpatient capacity and demand management and discharge planning.

Task Sandra Shannon

30/07/2015 informatics group set up to make faster progress on this.

In progress

29

Use historic and current admission and discharge data and LOS to build in a prediction model and use to set targets for discharge and time of discharge


30/07/2015

included as part of the ED/ bed management dashboard

In progress

30

Implement a bed management dashboard to include time of discharge, day of the week, use of discharge lounge

Task Sandra Shannon

30/07/2015

weekly informatics workstream set up. Due to meet Monday 20th april

In progress

31 Ensure that all wards comply with best practice standards in discharge planning.

Milestone Lily O' Connor

30/05/2015

standards agreed and audit tool developed. To be trialed

In progress

32 Review discharge guidance for ward staff to ensure standard processes and practice in discharge planning.

Task Lily O' Connor

01/03/2015 New choice policy in place. S2 and S5 flow chart in place.

Complete

33

Develop a corporate trust wide integrated discharge team and develop a consistent approach to managing discharge for patients requiring post discharge support

Task Sandra Shannon


34 Ensure S2 are submitted within 48 hours of admission Task Lily O'

Connor 01/03/2015

new guidance in place. Daily monitoring taking place to ensure compliance across all areas. Likely to lead to higher numbers of S2 in place.

Complete

35

Undertake a series of ward audits against best practice standards for the management of inpatient flow to provide assurance to the board

Task Sandra Shannon

30/07/2015

audit tool developed and schedule of audits in place. First audit to commence wc 6.4.15

In progress

36 Undertake the ECIST Initiative " A Perfect Week" Task

Sandra Shannon/

Sara Randall

29/04/2015

Now completed. Evaluation in progress and plan to be revised to take account of lessons learned. Performance during the perfect week 96.4%.

In progress

Oxford University Hospitals Appendix 2 Elective Care


Elective Care Improvement

Context The Trust has failed to achieve the RTT Admitted performance of RTT since September 2013, with the most recent submitted performance being at 86.15% for February 2015. The Non-Admitted target has been achieved since the end of Q2 December 2014, with the most recent submitted performance being at 95.12% for February 2015. The Incompletes target of 92% has been achieved by at Trust level now since the end of Q1, September 2014. With the most recent submitted performance for February at 93.19%.

The Trust has reduced inpatients waiting > 52 weeks for their Referral to Treatment, with 5 patients > 52 weeks for February reported for the Trust.



The Trust has continued to maintain less than 1% of patients waiting > 6 weeks since July 2014 for the 15 reportable diagnostic tests and investigations.



Elective Care Improvement – No Delays

Milestones and associated actions

Task own

er

Original Due Date Comments

Related task number from the elective improvement

plan

Activity Status

Trust wide Plan

Elective Access

Key milestone numbers (from tab

2 from column C)

Each division needs to use this template to deliver and sustain a service by service model that meets all Elective care standards and milestones and is sufficient to meet clinical needs of patients and respond to varying levels of activity. This is to be used in conjunction with the Elective improvement plan that details explicitly the requirements that need to be delivered by each specialty.

1 zero 52 week waiting patients 30/04/2015 4,5,6,7,8,11,12,16 In

progress

2

zero active RTT patients waiting > 35 weeks dated and undated (unless patient choice)

31/05/2015 4,5,6,7,8,9,12,13,16 In

progress

3 90% of admitted patients being treated within 18 weeks

31/05/2015 1,4,7,8,9 In

progress

4 95% of non admitted patients to be treated within 18 weeks 30/04/20

15

maintain by Trust 30/04/2015 - by service 31/05/2015

2,5,7,8,9,21,26,29,33,38,39,40

Complete

5 92% of all incomplete pathways to be within 18 weeks

30/04/2015

maintain by Trust 30/04/2015 - by service 31/05/2015

3,4,6,7,8,9,11,12,13,38,39,40

Complete

6

Review the volume of patients on the inp/DC waiting list @ 0-6 weeks action when the numbers of this cohort of patients increase by over 7% each month

21/04/2015 3,4,6,17,18,22,26,29,33,36 Not

started

7


21/04/2015 3,4,6,14,15,16,17,18,22,36 Not

started




Task own

er



plan

Activity Status

8


21/04/2015 1,3,4,6,14,15,16,17,18,22,

36 Not started

9

Review the volume of patients on the outpatients PTL waiting list @ 6 and over weeks action when the numbers of this cohort of patients increase by over 7%

21/04/2015 2,3,5,6,17,18,22,36 Not

started

10

Review the volume of patients on the Diagnostics PTL waiting list @ 4-5 weeks action when the numbers of this cohort of patients increase by over 4%

21/04/2015 2,3,5,6,17,18,22,36,37,38,

39,40 Not started

11 no more than 1 % of patients waiting > 6weeks for a diagnostic investigation

30/04/2015

maintain by Trust 30/04/2015 - by service31/05/2015

2,3,5,6,17,37,38,39,40 Complete

12 zero planned waiting list patients with an active RTT code

30/04/2015 19,20,22 In

progress

13 zero planned patients waiting 6 weeks past their treatment by date

30/04/2015 19,20 In

progress

14 100% of patients added to the planned waiting list with a TBD date (treatment by date)

30/04/2015 19,20 In

progress

15

Review the volume of planned patients on the waiting list and monitor and action and changes

21/04/2015 19,20 Not

started

16 Zero past TCI's for admission on day cases and inpatients 21/04/20

15 1,3,4,6,9,10,11,12,13,16 Not started

17 Real time check in & check out by clinician for all appointments

01/09/2015

programme of work to start 01/09/2015 service by service basis?

5,34 Not started

18 zero past appointment dates within outpatients 30/04/20

15 2,3,5 In progress

19

All patients readmitted within 28 days of an on the day cancelation & avoidance of all on the day cancellations

30/04/2015 4,6,9,23,24,25 In

progress




Task own

er



plan

Activity Status

where alt all possibly.

20

multiple open pathways outpatient/Inpatients/incompletes i.e. Duplicate IP waiting list entries or duplicate referrals on the outpatient PTL

30/04/2015 1,2,3,4,5,6,7,8,21 In

progress

21

zero patients on an active waiting list with an inactive RTT status code (i.e. waiting/booked - RTT code of 90's)

30/04/2015 4,5,6,7,8,11,12,13,14,15,2

2 In progress

22 100% of Tertiary referrals with correct MDS data 30/04/20

15 1,2,3,4,5,6,14,15,16,36 In progress

23

Establish audit programme to assure the directorate that locally data quality is improving to a sustainable position, develop a method that enables service leads to retrain staff where necessary.

01/06/2015 N/A Not started

24

written process for managing and reporting of medical staff leave in line with the Elective access policy

01/05/2015 N/A In progress

25

Establish and stick to weekly PTL meeting and develop a standard escalation process which includes validation deadlines for all elective care targets and highlights and problems achieving the data sets, are Trajectories agreed at local level, has everyone within the service understanding of the key milestones they are working towards for Elective care?

01/05/2015 All In progress

26

Key service redesign issues identified with delivering 18 Week Compliance across whole specialty, this should include pathway mapping exercise that was recommended by the IST to reduce long waiting times

on-going N/A In progress

27

Level of ownership and responsibility across the directorate for the entire patient pathway from referral to treatment, including

01/05/2015 All In progress




Task own

er



plan

Activity Status

planned patients & direct diagnostic waits.

28

Avoid variation in practice by making sure all service standard operating process are in order and up to date especially if staff turnover is high and new starters are expected to follow them from the start.

01/05/2015 All Not started

29

Establish a learning programme, whereby issues from audits, previous breaches and complaints are reviewed and shared across the teams to embed best practice.

01/06/2015 All Not started



Elective Care Improvement Plan

Milestones and associated actions Task owner

Task number this relates to the

Elective access key milestones

comments Activity Status

Trust wide

Elective Improvement plan numbers

(from tab 1 column C)

The below is to be used in conjunction with the Elective access key milestones that details explicitly the requirements that need to be delivered by each specialty.

1 to review Last months RTT Performance -Admitted (approx. number of clocks that are expected each month to stop)

3,8,16,20,22

2 to review Last months RTT Performance Non-Admitted (approx. number of clocks that are expected each month to stop)

4,9,10,11,18,20,22

3

to review Last months RTT Performance Incompletes (approx. number of clocks that are expected each month to be waiting for first definitive treatment)

5-11, 16,18,20,22

4 Predicted RTT Performance for the next month-Admitted % of compliant pathways (using the IP/DC PTL data produced & PTL's)

1-3,5-11,16, 19-22

5

Predicted RTT Performance for the next month -Non-Admitted % of compliant (using OP PTL & knowledge of diagnostic pathways & patients in a follow up status - incompletes Pathways Data will help)

1,2,4,9-11,17,18,20-22

6

Predicted RTT Performance for the next month-Incompletes % of compliant pathways, data will need to be validated,( if PTL's are validated this list should be in good shape)

1,2,5-11,16,19-22

7 trend analysis of breaches - previous weeks breaches, reasons actions taken to prevent the same thing happening

1-5, 20,21

8

Establish a process to review ,validate and resolve all RTT invalid date reasons actions taken to prevent the same thing happening (this could lead to retraining/technical changes) AP/NP & IP

1-5, 20,21

9

Establish a process to review ,validate and resolve discharges without clock stops (this information is sent to services on a daily basis via RTT Email)

3-5,16,19

10

Establish a process to resolve the volume of past TCIs on the EAL. (this data can be found on the IP/DC PTL and DQ dashboard ORBIT report) - what actions are required?

16,

11

Establish a admitted PTL validation status using the IP/DC PTL- Process Agreed prospective management by breach date without TCI dates - patients already breaching > 52 weeks - what actions are required?

1,5,21,16,

12 Establish a admitted PTL validation status using the IP/DC PTL- Process Agreed 1,5,21,16,







prospective management by breach date without TCI dates - patients already breaching > 35-52 weeks - what actions are required?

13

Establish a admitted PTL validation status using the IP/DC PTL- Process Agreed prospective management by breach date without TCI dates - patients already breaching > 18-35 weeks - what actions are required?

2,5,21,16,

14

Establish a process to manage & escalate the patients who are new to the admitted PTL (IP/DC) who have dropped in from the non admitted PTL/or completely new to the PTL (waiting list officers should know this number as they should know and understand the breach date of the patient when adding them to the waiting lists for treatment) - what actions are required?

7,8,21,22

15

Establish a process to manage & escalate the patients who have moved from 17 to 18 weeks dated and undated - what actions are required?

7,8,21,22

16

Establish a admitted PTL validation status using the IP/DC PTL- Process Agreed prospective management by breach date with TCI dates - patients already breaching > 18 weeks - what actions are required?

1,2,7,8,16,22

17 approve a process to review % of patients with a decision to admit date (DTA) at X weeks (an internal milestone set by specialty)

6,-11

22

Develop a method of managing additions to List-lag time and when issues should be escalated and how. (patients should be added to the WL within 24/48 hrs. of DTT date

6,10

23

Develop a method of managing patients on the planned with all planned patients having a valid clinical ready by date (TBD) date attached to their EPR/CRIS record. Review these dates in the weekly PTL meetings

12,-15

24

Review, manage and potentially Escalate patients on the planned waiting list that have past their TBD date (this could be either Inpatient/DC/diagnostic or at the outpatient stage of treatment)

12,-15

25

Develop and establish a process to action patients with multiple open pathways outpatient/Inpatients/incompletes i.e. Duplicate IP waiting list entries ( this information can be found on the DQ dashboard within ORBIT reports and also from the IP/DC & Outpatient PTL's

4,20

26 Develop a process to review and manage RTT Status' inconsistent with waiting list status on the IP/DC & outpatient PTL this should be

6-10,12,21,







discussed weekly in the performance meetings held within service

27 Review any on the day cancellations from the previous week and action with TCI dates if not done so by this stage

19,

28 Discuss any trends that are beginning to appear with cancellations and escalate from the weekly PTL meeting

19,

29

Review any patients that have breached the 28 day standard for on the day cancellations to avoid and change process or action accordingly.

19,

30

Review Total size of OP PTL on a regular basis (weekly look at trends and increase/decease in numbers) develop an escalation process where appropriate any big difference and investigate reasons -In line with the IMAS modelling

6,4

31 Review the Number of DNA's last month - both outpatients (work in line with transformation team project)

32

Understand the Percentage of Hospital Outpatient Cancelled appointments what impact is this having on capacity and start of patient pathway

33

Review Number of patients on C&B Breach list & ASI list in excess of 2 days take action immediately to book patients for outpatient apt

6,4

34

regular review of the Outpatient Triage Process -Turnaround by consultants? -Automated? -Pooled COD?

35 Outcome Forms Relevant to Specialty are they usable - can we check in & out electronically within this service?

36

Outcome and Attended Status Completeness /are they filled out (develop a regular audit process that everyone including clinicians are involved in)

37

Regular review of utilisation Rates - Capacity vs. booked look at all patients > 6 weeks on the outpatient PTL dated and undated- validate/date/remove/bring forward are the patients booked within the specialty agreed milestone?

6,4

38 Review the volume of outpatients - not checked in and not checked out (this data can be found on the DQ dashboard ORBIT report)

17,

39

Establish a process for review and amending appointments missing a follow-up (this data can be found on the DQ dashboard ORBIT report)







40

Establish a clear process/SOP for all Tertiary referrals and make sure we have all relevant minimum data set information, understand the approximate numbers of Tertiary referrals that come into the service each month.

6-10, 22

41 Review any potential 6 week diagnostic breaches and actions that need to be taken to resolve them

10,11

42

Review and develop Service Level Agreements in with all diagnostic services that are not delivered within the same specialty - how are the results reviewed and updated etc.

4,5,10,11

43

Monitor/review/validate/resolve all patients that are dated over 6 weeks, if not a patient choice issue then can they be bought forward?

4,5,10,11

44

Introduce within weekly PTL meetings DM01 validation accuracy, completion any discuss any problems in achieving the deadline review all data and breaches for sign off on a monthly basis.

4,5,10,11

45

Establish a process in the weekly PTL meetings that all paused patients on the INP/DC waiting list are reviewed. Making sure that the patients are in line with the 40 day pause policy. Make sure all patients approaching the 40 days are clinically reviewed.

1,2,3,5,7,8

Oxford University Hospitals Appendix 3 Cancer Plan


Cancer Improvement Programme

Programme Workstreams Work stream

Consultant Lead:Professor Mark Middleton Cancer Manager: Helen Baker

Standard Target 2 week wait

Maximum two-week wait for first outpatient appointment for patients referred urgently with suspected cancer by a GP 93%

Maximum two-week wait for first outpatient appointment for patients referred urgently with breast symptoms (where cancer was not initially suspected)

93%

31 days

Maximum one month (31-day) wait from diagnosis to first definitive treatment for all cancers 96%

Maximum 31-day wait for subsequent treatment where that treatment is surgery 94%

Maximum 31-day wait for subsequent treatment where that treatment is an anti-cancer drug regimen 98%

Maximum 31-day wait for subsequent treatment where the treatment is a course of radiotherapy 94%

62 days

Maximum two month (62-day) wait from urgent GP referral to first definitive treatment for cancer 85%

Maximum 62-day wait from referral from an NHS screening service to first definitive treatment for all cancers 90%

Maximum 62-day wait for first definitive treatment following a consultant’s decision to upgrade the priority of the patient (all cancers)

no operational standard set

Current performance

Target Standard OUHT-March 2015

2WW 93% 97.6%

31 day 1st 96% 97.7%

31 day subsequent-Surgery 94% 100% 31 day subsequent-drugs 98% 100% 31 day subsequent-RT 94% 99.5% Breast symptomatic 93% 95.8% 62 day screening 90% 92.3%

62 day GP referral to 1st treatment 85% 82.6%



Cancer Care Improvement – No Delays Updated 1 May 2015

Standards Activity Type

Task owner

Original Due Date

Comments Activity Status

Specialty Standard : 14 day GP to first seen : (2ww) target 93%

1 All

Reduce the number of breaches of the 2ww standard through patient choice to DNA, cancelling or change appointments

Milestone LC/SH Jun-15 To be discussed at the CCG meeting on 7th May

In progress

2 All

to work with the CCG to develop a public health campaign that will raise patient awareness of the need to take up 1st appointment within two weeks of GP referral and be available for diagnostics and treatment over the period of the pathway.

Task LC/SH Jun-15 CCG to provide update In progress

3 All Invite GPs to an education event and include feedback on performance

Task LC/SH Jun-15 CCG to provide update Not started

4 All

Reintroduce TWEEK Leaflet(two week wait) to GP practices , promote via clinical lead and via locality news letter.

Task HB Jun-15 CCG to provide update In progress

5 All

CCG leads (LC/SH) to identify source of funding for leaflet and arrange printing and distribution to GP practices

Task LC/SH Jun-15 CCG to provide update

6 All

Develop a process for monitoring each month the GP practices with highest numbers of patient choice breaches and feedback to GPs and CCG.

Task LC/SS Jun-15 In progress

7 All

Provide training to patient booking clerks and provide a standard script for them to use to emphasis the importance of attending an appointment within two weeks of referral but without causing anxiety to the patient.

Task LP Jun-15 to be discussed with Lesley Pinfold at next workstream meeting

In progress

8 All

Avoid breaches of the 2ww target through incorrect referral process by GP resulting in patients not being booked into clinc within two weeks.

Milestone LC/SS/PC ongoing

28.1.15. action plan in place. Approach to form part of the CCG 2 WW action plan

Complete

9 All

Send out communications to all GP practices that all suspected cancer referrals must be sent on the

Task LC/SH/HB May-15

To be sent out as a Trust/CCG communication. The be discussed at CCG

Not started




Task owner

Original Due Date


appropriate 2ww proforma meeting on 7th May

10 All

Develop rapid feedback system to GPs when suspected cancer referrals are not sent on the correct proforma or do not provide the required clinical information

Task PC May-15 in place for one tumour group but not the others

In progress

11 All To avoid breaches of the 2ww standard due to insufficient outpatient capacity

Milestone all ongoing Complete

12 Colorectal

develop a process to ensure all colorectal referrals from the 2WW bureau are received by Triage within 24 hours.

Task LP/BW May-15

All referrals are being triaged within 24 hours, the only exceptions are late Friday afternoon referrals which are triaged first thing Monday Morning

Complete

13 All

Develop an escalation process whereby booking clerks will alert managers if there is no OPA capacity to accommodate a 2ww referral

Task LP May-15 Complete

14 All

To develop a monthly process to monitor performance by specialty as an early indicator of capacity or management problems

Task HB May-15 To discuss with Lesley at workstream meeting.

In progress

15 All

For any speciality that fails the 2ww standard undertake a demand and capacity analysis to ensure sufficient 1st appointments within 2 weeks to meet demand.

Task HB/ OSM

for the specialty

42005 In progress

16 Urology Agree the patient pathway across the Trust for the five main urology cancers

Task AC May-15

currently use the agreed network pathways (prostate, renal, urethelial, bladder, testicular

Complete

17 urology To review the bladder pathway against latest nice guidance

Task AC Jul-15

Mapped out pathway and limited actions required to achieve nice guidance. Meeting next week to finalise

In progress

18 Urology Provide Gps with PSA guidance following testing

Task HB May-15 Helen to confirm this is in place

In progress

19 Urology

Provide patients with supported thinking time (7 days) to support patients to make decision about treatment option and enable treatment within target time scale.

Task FH ongoing

Current emphasis is for the pt to contact when ready, however, the specialist nurses will support and contact pts as appropriate.

Complete

20 All Avoid breaches of the 2ww target due to insufficient

Milestone




Task owner

Original Due Date


clinician capacity

21 Urology

create additional 2ww capacity by converting urgent access slots to 2WW 'one stop shop' clinics to run daily Mon - Thurs with additional capacity in general clinics

Task Anne-Marie

Williams Apr-15

The 2ww clinic runs Mon – Thurs with 8 slots per day, so total of 32 per week. In addition there are a total of 30 x 2ww flexible cystoscopy slots per week so this should provide sufficient capacity.

Complete

22 all

create additional 2ww capacity by providing 'one stop shops' for high volume specialties including breast, which enables conversion of FU appointments to new

Task HB/ KM Apr-15 urology (but not all) breast skin often treat on the day

Complete

23 all

Create additional 2ww capacity by developing nurse led follow up clinics which release consultant capacity for 1st appointments

Task HB/KM Apr-15 breast. Check colorectal

Complete

24 Breast

Implement early discharge pathway for women who have had 2 years follow up symptom free with rapid access back though GP or self referral

Task HB/SO Apr-15 1500 follow up slots per year to create approx 500 new slots

Complete

25 Lung

Undertake a pathway review following a significant increase in 2 wait referrals to identify options for managing 2ww demand within available capacity

Task KH/AS Apr-15

There has been a 58% increase in Lung pathway 2ww referrals from 2009- 2013. 2ww performance 100% in Nov & Dec 14.

Complete

26 urology Release consultant time by providing a nurse surveillance cystoscopy service

Task SO/HB Helen to confirm if this is in place

27 All Reduce the time to diagnosis by introducing straight to test processes

Milestone Apr-15 Complete

28 Lung

provide GP direct access for chest X ray with rapid reporting of abnormal films.

Task HB/AS Apr-15 Complete

29 Lung

Provide CT scan in appropriate patients within 7 days prior to first appointment

Task HB/AS Apr-15 Complete

30 Lower GI

Develop a system whereby patients referred with suspected Lower GI cancer go to triage within 24 hrs and straight to test. - GP have to compelte bowel prep. Those not fit will be triaged to specialist clinic

Task Apr-15

Gps provide bowl prep, referrals for patients not suitable will be sent straight to triage

Complete




Task owner

Original Due Date


Trust Wide/

Specialty Standard : 31 days from diagnosis to first definitive treatment

31 All

Ensure Trust systems support patients being treated at the

right time, by the right person in the right place.

Milestone Complete

32 Urologist Provide joint urologist and oncologist clinic

Task SO/HB Apr-15

currently able to provide same session clinics due to capacity. In place but under further development

Complete

33 Lung Provide joint clinics with respiratory physician, thoracic surgeon and oncologist

Task AS/EB/HB Apr-15 currently same session appointments

Complete

34 Lung

Develop nurse led clinics for patients with haemoptysis and normal chext xray, plus follow up for agreed patient groups

Task Helen to confirm if this is in place

35 Lung Ensure no delay in diagnosis occur due to lack of diagnostics capacity

Milestone KH/AS Apr-15 Complete

36 Lung

Undertake a capacity and demand review and identify the number of EBUS Bronchoscopy slots required

Task KH/AS Apr-15 Complete

37 Lung

Relocate bronchoscopy service to radiology JR to increase capacity, improving clinical support and improved histology turnaround times.

Task KH/AS Apr-15

Move complete and additional capacity in place. Patients able to have bronchoscopy/ EBUS within 2 weeks.

Complete

38 Lung

Purchase a 3rd CT PET scanner to increase capacity and reduce wait from 3-4 weeks to 7 days

Task KH Apr-15 wait for CT PET now 7 days

Complete

39 Lung Reduce waiting time to OPA, DTT through provision of additional OPA appointments

Task RT/EB Apr-15 Complete

40 Lung provide clinics at the Churchill and increase template to provide additional slots

Task RT/EB Apr-15 Pts. now seen <7 days MDT discussion.

Complete

41 Colorectal

To ensure there is sufficient radiology capacity to meet demand for treatment within 31 days from diagnosis.

Milestone SA/TM Jul-15

to set up a meeting with management team and cancer management team in next fortnight.

In progress

42 All Undertake a capacity and demand review of radiological capacity for all tumour groups

Task SA/TM Jul-15 In progress

43 Colorectal Meet with radiology manager to review options of increasing radiology capacity at HGH

Task SA/TM May-15 In progress

44 Colorectal Meet with radiology manager to review options of increasing radiology capacity at JR

Task SA/TM May-15

is there weekend working in place? Is there a Sunday colon list?

In progress




Task owner

Original Due Date


Trust Wide/

Specialty Standard : 62 days GP referral to first treatment

45 All

To reduce the number of patient pathway delays due to patients choosing to take holidays within the planned pathway.

Milestone CC/SS Jun-15 CCG to provide update In progress

46 Colorectal

Work with the CCG to raise patient awareness through a public health campaign of the need for patients to be available for treatment throughout the pathway

Task CC/SS Jun-15 CCG to provide update In progress

47 Colorectal

To reduce the number of breaches of the 62 day standard due to longer and complex pathways in patients with metastatic disease/ more than one tumour site/ patient fitness.

Milestone CC/SS Jun-15 Complete

48 Colorectal

restructure patient tracking lists to enable earlier identification of patients with complex pathways

Task HB May-15

there are still patient with complex pathways but these are being identified earlier and tracked closely to minimise the overall pathway timescale.

Complete

49 Colorectal

To reduce the number of pathway delays due to "tight" deadline for MDT referrals by extending the time to MDT list closing by 24 hours to Thursdays to provide more flexibility in adding cases for discussion.

Task CC May-15

Dead line has been extended but impact will be monitored over the next few months to before signing off. Pathology and Radiology are also present at the MDT

In progress

50 All

To undertake breach root cause analysis of all 62 day breaches with complex pathways to identify opportunities for reducing the pathway.

Task HB Jun-15 In progress

51 Colorectal

lung urology

Focus improvement actions on high volume tumour groups of colorectal, urology and lung so that improvement has the biggest impact on overall trust performance

Milestone

52 All

To avoid breaches of the 62 day target occurring due MDT functioning and pathway coordination

Milestone CC May-15

weekly meeting to be set up with all trackers to review every patient on PTL

Complete

53 Urology Develop a new urology proforma for referral to MDT within the NICE guidance

Task AMW May-15 Complete




Task owner

Original Due Date


54 Colorectal Introduce weekly cancer PTL review with clinicians

Task HB May-15 Complete

55 Colorectal

provide further training and develop SOPs for all cancer coordinators/ trackers to improve cancer PTL management.

Task HB May-15 training / update ongoing

Complete

56 Colorectal

Review MDT role/ banding/career progression in order to improve retention of MDT co-ordinators and reduce high staff turnover.

Task HB May-15

MDT coordinators have a key role in facilitating MDTs and pathways monitoring. Additional 1.3 WTE tracker resource in place from 1/4/15

Complete

57 Urology Appoint a full time cancer pathway coordinator

Task HB May-15 in post Complete

58 Urology

Appoint additional cancer pathway trackers to ensure high volume PTLs can be kept up to date in 'real time'

Task HB May-15 Increased support to 2 WTE trackers

Complete

59 Urology

Review functioning and timings within the MDT meeting to enable all patients to be discussed and to avoid delays in progress of pathway

Task PC 20.10.14 Complete

60 Urology

Reduce the need for long discussion at MDT through the use of protocols and MDT ratification

Task PC May-15 Complete

61 Urology Reduce the number of patient pathway delays due to more than one discussion at MDT.

Task HB/KM/PC May-15 In progress

62 All To avoid breaches of the 62 day standard due diagnostic , OPA or surgical capacity

Milestone AS/KH/HB May-15 In progress

63 Lung

Relocate the bronchosopy service to Radiology dept at JR to increase capacity with improved clinical support and improved histology turnaround times.

Task AS/KH Apr-15

25/3/15 EBUS/ cancer bronchoscopies are performed within 2 weeks.

Complete

64 Lung Provide 3rd PET CT scanner to provide additional capacity

Task KH Apr-15 Waits now reduced to < 7 days

Complete

65 Lung

appoint an additional cardiothoracic surgeon to provide additional OPA and cross cover for leave.

Task RT/EB Apr-15

3rd surgeon now in post with operating lists 5 days a week and cross cover for leave.

Complete

66 Lung

increase the number of OPA slots by relocating all clinics to the Churchill site and increasing the number of clinic slots

Task RT/EB Apr-15 patients are now seen < 7 days of MDT discussion

Complete

67 Urology

Ensure close monitoring of all stages of the patient and escalate any delays to ensure earlier diagnosis by day 21 and

Task HB May-15

daily review of cancer PTL and compliance with escalation. Access to direct access

In progress




Task owner

Original Due Date


decision to treat by day 31 clinic is improving. To review day in pathway average. Ongoing issue is the clinical pathway.

68 Urology

Review current clinical pathway and introduce MRI pre biopsy as per NICE guidelines

Task RB May-15

01/05/15 meeting with Urology MDT to review progress on revised pathway and discuss pre Bx MRI

In progress

69 All

Meet with diagnostics OSM to establish a plan to ensure diagnostic capacity will meet required demand


70 Urology Create additional clinic capacity to meet demand

Task AMW/HH May-15

additional urology capacity in place from 5th May. To review impact on performance and identify whether any other pathway changes are required.

Complete

71 Urology

To develop joint/parallel clinic sessions within 7 days of MDT/ results clinic to ensure patient given diagnosis by a consultant and referred for early MRI as appropriate

Task AMW/HH Jun-15

Restructure of consultant clinics is underway. The existing Nurse clinics will continue with them providing the patient with the diagnosis and an overview of possible treatment options, with consultant clinics to follow 3-4 days later or once the MRI result is known if the patient requires one

In progress

72 Urology

Create an additional clinic and review appointment lengths to create sufficient new and FU appointments.

Task AMW May-15

Future consultant clinics will run on Tuesdays, Wednesdays and Fridays. Clinics will be sent for building w/c 30.3.15

In progress

73 Urology

Avoid breaches occurring through lack of capacity by reviewing arrangements for cross cover/ annual leave

Task AMW/MS May-15

clinics will not be cross covered as job plans do not allow for this but sufficient capacity will be included in clinics to provide a buffer.

In progress

74 Urology

Increase surgical capacity by an additional 3 lists per week. Currently sat lists. Business case in place. Send non cancer work to private sector.

Task MS/AM/RB May-15

Interim contract with Manor to cover May-July being proposed. RB to meet with Simon James w/e 01/05/15

In progress

75 Urology Submit business case to Task MS/AM/RB May-15 PID in development. In progress




Task owner

Original Due Date


increase capacity across the urology service including theatre, clinic and inpatient beds. Additional throughput would be 40 - 50 per month. 18 week.

Awaiting financial input to complete for submission to BPG

76 Urology Provide training session on cancer pathway/ targets for admin staff

Task HM/AM Apr-15 training provided and engagement improved

Complete

77 All Monitor impact of training by spot checks of cancer PTL and breach analysis

Task HB May-15 In progress

78 Urology Implement system to ensure 100% completed forms

Task MS/JR May-15 ask Ann-Marie what this is about

In progress

79 Urology

Issue of incomplete forms to be discussed at consultant meeting and information re process to be disseminated

Task MS/JR May-15 For review 30.1.15 In progress

80 Urology Provide training to relevant staff on completion of forms.

Task MS/JR May-15 In progress

82 all

Review cancer performance management processes to provide greater assurance on performance

Milestone RB/KM May-15

formal cancer performance meetings now set up and standard management assurance reports to be completed by OSMs

Complete

81 All

To develop a clear escalation system from trackers to departmental managers to clinical leads and divisional managers which describes what response is required to avoid a potential breach of the 62 day target

Task MS/JR May-15 Complete

83 all

Undertake a weekly review of all cancer ptls with cancer trackers and identify any pathway delays


84 all

undertake a weekly review of all patients on the 62 day backlog and agree plan to complete pathway

Task HB May-15

patient by patient review undertaken and list sent out to OSMs. To be monitored weekly

Complete

85 All

cancer management team to attend bi weekly performance meetings and provide management report

Task HB May-15 performance meetings now commenced.

Complete

86 Al Develop a weekly cancer target forward look report to identify early any risks to target

Task SES May-15 In progress

87 All

To ensure appropriate informatics support to enable effective monitoring and management of cancer targets

Milestone HB Jun-16 In progress




Task owner

Original Due Date


88 All Set up regular meeting with Health informatics team leader


89 All Set up wide informatics development meeting to identify gaps in support


90 All Review the cancer support team structure and informatics support required


Operational Performance Trajectory for Q1 and Q2 …...1. This paper updates the Trust Board on the...

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