Urgent Care Improvement Board: 4 Hour Performance December ... · The graph to the right shows the...

Urgent Care Improvement Board: 4 Hour Performance December 2014

Executive Summary

Improvement Trajectory

■ The target trajectory is to achieve between 81.8% and 93.3% for 2014/15 Q4; 88.4%

most likely. The trajectory has been refreshed to reflect December 2014 actual

performance and all types from April 2014. The most likely performance trajectory

outcome is January 85.45% , February 90% and March 90.3%.

■ Clarification and confirmation of SRG plans in line with the expected trajectory

improvements is required.

Key performance measures for the Trust are improving since the introduction of the

Urgent Care Improvement Programme, specifically during the 4 hour step up

improvement period.

Key issues and root causes

■ ED admission rate increased in month 38.6% (target 37.5%), reflection of the increased

patient acuity. Estimated that the rate would have been lower if Medical Assessment Unit Area

C (MAC) had been functional for the whole month, due to escalation preventing admission

avoidance and utilising alternative pathways.

■ Ambulance conveyance (+7% in FY14/15); weekly peak increase of 16.9% highest recorded

level

■ ED is performing well regarding time to treatment performance and patient feedback

■ Majority of 4 hour breaches remain attributable to bed availability (70.5%)

■ Impact of the community ORCP schemes during December, to be quantified and the response

to demand and DTOC increases inadequate.

Planning

■ The Trust is continuing to run its Urgent Care Improvement Programme

■ Key project for the 2014/15 Programme the development of both Medical and Surgical GP

direct admissions to the Medical and Surgical Assessment Units – operational 12th November.

Requires review following period of prolonged escalation and the use of this capacity due to

bed capacity demand – trolleys replaced with beds.

■ Medium term improvement to support delivery from November 2014, including sustaining all

urgent care schemes, delivery of GP expected pathways as direct admissions to both

Medicine and Surgery and the delivery of CCG Operational Resilience and Capacity plans

(ORCP). ECIST visit completed 17th December 2014 to review progress.

■ Final stage involves the implementation of a community wide urgent care strategy across the

four CCGs – learning from prolonged escalation and RCA in November 2014 requires SRG

leadership to lead outcome and recommendations.

■ Performance based upon no greater than 15 DTOC’s in total across all CCG’s.

Current Performance

■ December 4 hour performance was not achieved; 84.2% (All Types includes Urgent Care

Centre Activity)

■ Weekly red performance throughout December; Trust in prolonged Red escalation and

Black escalation from the 27th December 2014

■ Q3 4 hour performance not achieved ; 90.6%

Governance and Assurance

■ The RUH Urgent Care Improvement Board is responsible for the programme and

reports monthly to both Management Board and Board of Directors.

■ ECIST planned follow up site visit completed 17th December 2014; report awaited.

■ RUH to receive feedback from the Wiltshire CCG 100 Day Challenge at the 15th

January 2015 System Resilience Group. Urgent SRG focus required for Q4.

■ November BaNES RCA; specific focus on community response to demand, late

presentation and all providers to review ORCP schemes to ensure recued non

elective admission and contribution to 4 hour performance.

The graph to the right shows

the current trajectory.

RUH 4 hour step up

improvement plan commenced

8th September 2014 and stage 1

completed 31st October 2014.

Key action to continue to

review 4hr performance daily in

Stage 2, linking performance to

ongoing delivery of the Step up

plan operational actions.

Daily monitoring of the

Medically Expected and

Medical and Surgical Direct GP

admission pathways in place.

Ongoing metric review will

confirm that the actions taken

are supporting 4 hour Step up.

Reportable through the Urgent

Care Improvement Board.

Clarification and confirmation

of SRG ORCP plans and

delivery in line with the

expected trajectory

improvements is required.

Current Trajectory

Week

Ending

Actual

Performance

Standard

06/04/2014 86.0% 95%

13/04/2014 92.7% 95%

20/04/2014 97.7% 95%

27/04/2014 96.8% 95%

04/05/2014 95.4% 95%

11/05/2014 97.1% 95%

18/05/2014 97.0% 95%

25/05/2014 94.9% 95%

01/06/2014 94.6% 95%

08/06/2014 88.1% 95%

15/06/2014 90.2% 95%

22/06/2014 93.5% 95%

29/06/2014 96.1% 95%

06/07/2014 98.0% 95%

13/07/2014 96.7% 95%

Week Ending Actual

Performance

Standard

20/07/2014 94.7% 95%

27/07/2014 94.5% 95%

03/08/2014 96.3% 95%

10/08/2014 92.6% 95%

17/08/2014 89.0% 95%

24/08/2014 90.8% 95%

31/08/2014 87.5% 95%

07/09/2014 91.4% 95%

14/09/2014 94.9% 95%

21/09/2014 95.5% 95%

28/09/2014 96.9% 95%

05/10/2014 96.5% 95%

12/10/2014 90.9% 95%

19/10/2014 87.7% 95%

26/10/2014 95.8% 95%

Week Ending Actual

Performance

Standard

02/11/2014 95.7% 95%

09/11/2014 90.1% 95%

16/11/2014 93.0% 95%

23/11/2014 97.0% 95%

30/11/2014 96.1% 95%

07/12/2014 92.6% 95%

14/12/2014 82.0% 95%

21/12/2014 85.0% 95%

28/12/2014 84.1% 95%

04/01/2015 68.8% 95%

3

DRAFT FOR DISCUSSION PURPOSES ONLY Current Performance

84.2% of patients meeting the 4 hour

performance target in December 2014.

Stage 2 of the Step Up Improvement in

place. Focus on Medical Ambulatory

Care development (MAU Area C GP

expected admissions) and Surgical

Ambulatory Care extension of hours.

Services went live 12th November 2014,

and sustaining delivery up to and

including 15th December after which

due to escalation beds used the

functionality was lost.

NHS England Type 1 performance

benchmarking RUH ranked 70 of all

NHS Trusts. In December there were

no green weeks.

Diagnostic shows; reduced

performance due to the impact of

norovirus, increase in ambulance

activity, non-elective admission

increases, loss of direct admission

pathway changes due to the scale of

escalation required to manager

demand; and reduced community

response from the 16th December.

Performance could have been

improved by 5.3% if all ORCP schemes

delivered as per trajectory.

Key action to remain focused on de-

escalation, regaining direct admission

pathways, flow and back door. No

identified Emergency Department

Issues.

The Trust has not consistently met the 4 hour performance target

over the last 2 years, achieving 91.9% in FY12/13, 93.7% in

FY13/14 and is currently 93.0% FY 14/15 year to date.

4 hour performance has been achieved for 2 of the first 9 months of

the year (see table above). The Trust therefore identified the need

for a Step Up Improvement plan to further improve performance

which is overseen by the Urgent Care Improvement Board.

NHS England benchmarking for November 2014, the RUH ranked

70 of all NHS England Trusts, reduced by one place compared to

November 2014. Overall FY 14/15 year to date 1.3% above NHS

England FY 14/15 year to date compliance (improved compared to

last month).

Performance below expected national compliance and currently

below RUH trajectory. Performance could have been improved by

3.4% if all schemes delivered as per trajectory – RUH 3.1%,

BaNES 1.2%, Wiltshire 0.7% and Somerset 0.3%

Diagnostic: Compared to trajectory assumptions Green to Go and

DTOC patients increased from the 11th and 19th December

respectively contributing to a reduced back door flow and an

increase in patients with a LoS > 14 days. RUH bed capacity

reduced from the 2nd December to the 15th December due to wards

closed to new admissions, peaking at 25 empty beds on the 8th

December. For the whole of December there were 6 wards closed

for a total of 41 days; 13 confirmed cases, and 181 bed days lost.

In response twenty planned escalation beds opened from the 11th

December

2014/15 ED 4 Hour Performance (All Types)

in mitigation and the RUH lost the function of both medical and

surgical Area C’s from the 16th December due to the front door

demand for bed capacity (non elective admissions increased by

4.8%). Ambulance conveyance sustained daily increase from the 11th

December, peaking at 16.9% w/e 27th December and continuing to

rise into January, in line with South West reported activity levels and

unprecedented national demand for Emergency services preceding

and during the Christmas period. RUH reported overall admission to

discharge imbalance from the 15th and increasing towards and during

the Christmas period reducing the Trusts resilience to respond and

the opening of at its peak 93 escalation beds; early analysis

demonstrates that the community was under pressure with regard to

sufficient capacity and an inability to respond to reduce DTOC and

Green to Go. Medical and Surgical pathways changes for GP direct

admissions as per ORCP had a positive impact on performance and

GP direct admissions up to and including the 15th December., when it

ceased to provide additional bed capacity in escalation.

Conclusion: Performance deteriorated at the start of the month due

to the impact of norovirus, mitigated by opening of escalation

capacity. Increasing ambulance conveyance and non-elective

admissions from the 16th necessitated the opening of additional

escalation; however the community's capacity to respond from the

11th greatly reduced RUH resilience, and subsequent level of

escalation. Review of escalation required due to the significant

contribution of Medical Assessment Area C to 4 hour performance.

No identified issues with ED performance.

Financial Year Quarter Month Attendances 4 Hour Breaches Performance

April 6516 436 93.3%

May 7189 248 96.6%

June 7106 491 93.1%

July 7197 255 96.5%

August 6732 570 91.5%

September 6865 361 94.7%

October 7006 448 93.6%

November 6747 406 94.0%

December 6837 1081 84.2%

2014/2015

1

2

3

4

DRAFT FOR DISCUSSION PURPOSES ONLY Factors Contributing to Adverse Performance

Four Hour performance

affected in month by;

• Norovirus

• All planned and unplanned

escalation open

• Increased days lost to

DTOC

• Increased Green patients

• Unprecedented levels of

Ambulance activity

• Increased medical outliers

• Increased non-elective

admissions

Four hour performance is not adversely affected by a single factor but

a combination of factors including principally although not limited to the

following ;

•Number of Medical outlier days

•Average Adult Acute Beds Occupied

•Average Adult Length of stay

•Average Green Inpatients

•Number of adult discharges

Statistical analysis has shown that some of these factors have a

stronger impact on 4 hour performance than others. Monthly

performance analysis over time indicates that poor flow out of the

hospital and the consequences of this (such as increased number of

medical outliers and an overall increase in occupancy markers of

reduced flow) has the most significant impact on performance.

ED attendances . On average this financial year the Trust has seen a

3.2% increase in ED attendances compared to the same period last

year. In December however, activity was broadly in line with last

December (+0.8% or +45 patients).

Non-Elective Admissions. There has been a 4.6% rise in NEL

admissions (1200 patients to month 9). In December this trend

continued with a 4.8% increase on last December (+150 patients).

NHS BaNES variance from last year peaked in December at 14.1%

(average until November was 3%).

Ambulance activity. Overall ambulance conveyance (+7% in

FY14/15). From the 11th December the Trust experienced 3 weeks of

sustained high activity. This was in line with the South West

Ambulance Service Trust reported activity across the whole area and

National demand.

Green to Go. The number of Green inpatients started to rise on the

11th Dec (79) and by the 18th were at 122. Although this figure then

stabilised it remained at an average of 101 over the period. The

proportion of Green patients that were official DTOCs took a stepped

increase on the 19th December and remained at that level until 6th

January.

Non-Elective Length of Stay. For December there was no material change,

average of 6.6 days in line with previous months. The impact of acuity,

increased DTOC and Green to Go may not be seen until January

performance reporting as many of the long length of stay patients are still

active inpatients.

Delayed Transfer of Care (DTOC). Analysis of the number of ‘days lost to

DTOC’ shows that NHS BaNES and NHS Somerset levels peaked on the w/e

21st Dec having grown steadily for the preceding 4 weeks. NHS Wiltshire

however started to rise w/e 14th Dec and was still rising w/e 4th Jan. All CCGs

have historically had higher levels of days lost but all three experienced an

upward trend in the run-up to the Christmas period.

Bed Capacity. In response to the loss capacity due to norovirus, additional

complexity of patients and reduced flow at the back door, the Trust increased

its acute bed base by 20 beds on the 11th December and increased further on

the 27th (averaging total beds open 615 , peaking 630 on the 4th Jan).

Patient Flow. At the start of December, despite periods of red escalation and

high breach numbers, recovery flow was regained. However despite

increasing unplanned escalation beds to manage both demand and mitigate

bed closures due to norovirus on the 11th December and again on the 27th

due to demand alone flow was not regained. Four consecutive days of low

discharges 25-28 Dec added a final factor to reduced performance.

Medical Outliers. Throughout the month medical outliers have been

relatively constant at 25. The week following Christmas saw a stepped

increase in medical outliers (into the increased acute bed base) peaking to

100 from the 29th onwards.

5

DRAFT FOR DISCUSSION PURPOSES ONLY Ambulance Conveyance Review

Ambulance activity

increased by 7% compared

to FY 13/14

3 Weeks of sustained

activity in December;

peaking at a weekly

average increase of 16.9%

Weekend ambulance

activity continues to

demonstrate a marked

increase. Highest levels

compared to the last 5

years

Ambulance activity is a

marker of acuity, linked to

non-elective admission

increase

Analysis by South West

Ambulance Foundation

Trust required to

understand the source of

demand i.e. 999, 111 or

HCP

Ambulance conveyance rates in 2014/15 financial year have been

consistently above 2013/14 activity.

Overall ambulance conveyance (+7% in FY14/15).

From the 11th December the Trust experienced 3 weeks of

sustained high activity. This was in line with the South West

Ambulance Service Trust reported activity across the whole area

and National demand.

No data has been made available with regard to the proportion of

999, 111 or HCP arrivals and this is expected through the system

resilience groups as part of the review of this exceptional period.

When compared to the same period last year there have been

significant increases during this period; peaking at 16.9% ,the

highest recorded level.

Daily ambulance activity data is collected as part of the 4 hour

improvement step up scorecard and has been shown statistically to

link to 4 hour performance outcome. Whilst daily activity

increased specifically during three weeks of December it is also

important to note that activity continues to increase on Saturday

and Sunday; at its peak 100 ambulance arrivals on Sunday 7th

December. Ambulance conveyance is used as a marker of patient

acuity and this links to the increase in non-elective demand; 4.8%

increased compared to FY13/14. Without the step up of community

response the RUH resilience to manage the demand during these

peak periods is reduced.

The following chart shows the daily activity ED conveyance activity

throughout December, peaking over the Christmas period comparing

RUH (red ), GWH (blue) and Salisbury (green).

Period Last Year This year Variance % Variance

w/e 21st Dec 527 602 75 14.2%

w/e 28th Dec 499 582 83 16.6%

w/e 4th Jan 537 628 91 16.9%

The following chart shows the weekly activity profile of ambulance

conveyance comparing the last financial year and also the 5 year

profile. Activity in December is significantly higher than the last 5

financial years.

Overview:

The Trust has created a low and high range target reduction per

week based on their calculation of how many breaches each

scheme will save.

The majority of the reduction in Q3 relates to the Trust’s step up

plan which was planned to take partial effect in October and full

effect from 1st November 2014. The impact of this is a forecast

trajectory of between 97.3% and 99.7% in December 2014 which

was not delivered in month. December has not seen the impact of

the community schemes as anticipated in line with the ORCP to

reduce breaches as per the forecast trajectory.

Improvement Trajectory – 4 Hour Step Up Improvement Plan

The step up plan had three work

streams, front door, flow and

backdoor and twenty immediate

recovery actions were

identified.

Individual plans tracked using

the 4 Hour Step up Daily

Scorecard.

The trust anticipates that the

combined key actions will

reduce the number of breaches

in the Trust through a

combination of front door and

back door improvements.

The low range target is for a

reduction of 49 breaches a week

whilst the stretch target is for a

reduction of 105 breaches per

week.

The analysis shows that the

Trust will need internal and

external plans to deliver the

stretch target in order to

achieve the 4 hour standard in

both February and March 2015.

January performance has been

affected by the prolonged

period of Black escalation at the

end of December into January;

at the time of reporting it is not

possible to achieve the standard

for January.

RUH GP direct admissions to the Medical Assessment Unit only has

directly contributed the avoidance of 174 breaches in month (part

month effect due to prolonged escalation) which would have

improved 4 hour performance by 2.5%.

Further system wide plans are anticipated to take effect in time for

winter. The Trajectory shows that all schemes (excluding the UCC

counting) will need to achieve 60-70% of the stretch target to

maintain performance during February and March.

The target trajectory is to achieve between 95.0% and 95.4% for

Q4. The trajectory has been refreshed to reflect December 2014

actual performance and all types from April 2014.

Forecast Trajectory

Month Low Range Stretch Target

Apr-14 92.7% 92.7%

May-14 96.3% 96.3%

Jun-14 92.4% 92.4%

Jul-14 96.1% 96.1%

Aug-14 90.5% 90.5%

Sep-14 94.3% 94.3%

Oct-14 95.2% 96.3%

Nov-14 96.8% 98.7%

Dec-14 97.3% 99.7%

Jan-15 94.1% 97.5%

Feb-15 93.7% 96.8%

Mar-15 96.0% 99.5%

Impact on 4 hour wait performance

Month

RUH Sirona Wiltshire Somerset SWAST Dorothy House Primary Care UCC Total

Low High Low High Low High Low High Low High Low High Low High Low High Low High

Oct-14 1.1% 2.2% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 1.1% 2.2%

Nov-14 2.3% 4.4% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.5% 0.2% 2.8% 4.6%

Dec-14 2.2% 4.3% 0.5% 0.9% 0.0% 0.0% 0.0% 0.2% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.4% 0.0% 3.1% 5.5%

Jan-15 2.2% 4.3% 0.5% 0.9% 0.6% 1.5% 0.0% 0.2% 0.1% 0.2% 0.0% 0.1% 0.0% 0.1% 0.9% 0.4% 4.3% 7.6%

Feb-15 2.0% 3.9% 0.4% 0.8% 0.6% 1.4% 0.0% 0.2% 0.1% 0.2% 0.0% 0.1% 0.0% 0.1% 0.8% 0.4% 3.9% 7.0%

Mar-15 2.3% 4.4% 0.5% 0.9% 0.6% 1.6% 0.0% 0.2% 0.1% 0.2% 0.0% 0.1% 0.0% 0.1% 0.6% 0.1% 4.1% 7.6%

Appendix 1 December 2014 System Resilience Group Bath and North East Somerset CCG

4 Hour Improvement Trajectory

■ The RUH target trajectory is to achieve between 95.0% and 95.4% % for Q3. The

trajectory has been refreshed to reflect December 2014 actual performance and all

types from April 2014.


improvement of between 7 and 14 breaches avoided per week for BaNES CCG

SRG.

■ Total BaNES contribution to adverse 4 hour performance in December = 1.2%

Key issues and Root Causes

■ ED attendance has increased by 0.7% compared to 13/14

■ Non-elective ED admissions has increased by 14.2% compared to 13/14

■ Trust wide average numbers of Green to Go total 107 (BaNES daily average 36) and 165 >

14 days length of stay

■ Trust wide average number of complex discharge daily average 7

■ High level of delayed transfers of care (DTOC) – monthly snapshot 4.9%

Planning


■ The Board initiated an improvement plan to regain performance through September

and October 2014, stage 1 evaluated

■ Medium term approach to support delivery from November 2014 in place, including

care system planning and the delivery of CCG Operational Resilience and Capacity

plans (ORCP)

■ Based upon no greater than 5 DTOC’s

■ Final stage involves the implementation of a community wide urgent care strategy

across the four CCGs supporting 4 hour position

Current Performance

■ December 4 hour performance was not achieved; 84.2% (All Types)

■ Year to date 4 hour performance has been achieved for 2 of the first 9 months

■ CCG contribution to adverse performance (all DTOC and complex patients) equivalent to

20 x 4 hour breaches = 0.3%


■ BaNES CCG System Resilience Group (SRG) KPI monitoring

■ RUH Urgent Care Improvement Board and Management Board

■ Urgent Care Provider Forum Key Projects and overview of progress

Diagnostic Exception Reporting

■ Early analysis indicates increasing green and DTOC pressures building from the 16 th

December 2014.

Low Stretch

Step down beds x20↑ Discharge 3 3 Investment ORCP/Recruitment/Staffing

Night sitting service

Admission avoidance

↑Discharge

0 1 Recruitment

DN clinics at the weekend

↑ Discharge 0 1 Transport

Discharge at the weekend↑ Discharge 3 4 Investment ORCP/Recruitment/Staffing

IV Therapy↑ Discharge 1 2 Investment ORCP/Recruitment/Staffing

SWASFT Mobile rapid response/fallers Admission avoidance 0 1Investment ORCP/Recruitment/Staffing

Dorothy House Hospice at Home↑ Discharge

0 1Investment ORCP

Primary Care Extra GP Sessions

ED Attendance Avoidance

Admission avoidance 0 1

Investment ORCP/Recruitment/Staffing

Sirona

Scheme Potential Benefit Per Week Breach

Avoidance

Risks to Delivery

Appendix 2A December 2014 System Resilience Group Wiltshire CCG






improvement of between 9 and 22 breaches avoided per week for Wiltshire CCG

SRG.

■ Total Wiltshire contribution to adverse 4 hour performance in December

0.7%


■ ED attendance has decreased by 6.6% compared to 13/14

■ Non-elective ED admission decreased by -1.2% compared to 13/14

■ Trust wide average numbers of Green to Go total 107 (Wiltshire daily average 45)and

165 > 14 days length of stay

■ Trust wide average number of complex discharge daily average 7

■ High level of delayed transfers of care (DTOC) – monthly snapshot 6.7%

Planning




■ Medium term approach to support delivery from November 2014, including care system

planning and the delivery of CCG Operational Resilience and Capacity plans (ORCP)




Current Performance



■ CCG contribution to adverse performance (all DTOC and complex patients) equivalent

to 46 x 4 hour breaches = 0.7%


■ Wiltshire CCG System Resilience Group (SRG) KPI monitoring



■ RUH seeking feedback from 100 Day Challenge as drawing to a close

■ Early analysis of RCA indicates DTOC pressures at the beginning of the month,

continued from October

Low Stretch

Community Escalation CapaictyAdmission avoidance

?Discharge

1 3 Staff capacity

Overnight community support Admission avoidance 0 0 Recruitment

GWH community cluster teams Admission avoidance 1 3 Recruitment

Healthcare professional l ine Admission avoidance 0 0 None

Help to live at home brokerageAdmission avoidance

?Discharge

1 2 Care Home Capaicty

Step up and step down capacity ?Discharge 5 7 New model not tested

Simple point of access and rapid

response

Admission avoidance

?Discharge

1 3 None

Additional POC ? Discharge 0 1 Care Home Capaicty

Domicill iary Care Support ? Discharge 0 1 Staff capacity

Additional Hospital Social Care

Capacity

? Discharge 0 1 Staff capacity

Primary Care Nursing Home

Initiative Admission avoidance0 1 Primary Care Capacity

Wiltshire


Avoidance

Risks to Delivery

9

DRAFT FOR DISCUSSION PURPOSES ONLY Appendix 2B Wiltshire CCG Factors Contributing to Adverse 4 Hour Performance

Social Care: Funded

packages of care have

reduced since Christmas

The number of intermediate

care clients has been

steadily increasing overall.

Long stays noted in the

period after Christmas

causing a reduction in

capacity and flow.

Social Care Packages have decreased since December 2014;

both help to live at home and care home packages. The chart

below show the activity throughout

The number of intermediate care clients has increased

throughout December 2014, however in the period after

Christmas long stays are noted; limiting capacity and flow.

Appendix 3 December 2014 System Resilience Group Somerset CCG






improvement of between 1 and 5 breaches avoided per week.

■ Total Somerset contribution to adverse 4 hour performance in December =

0.3%


■ ED attendance has decreased by 6.8% compared to 13/14

■ Non-elective ED admission decreased by 9.3% compared to 13/14

■ Trust wide average numbers of Green to Go total 107 (Somerset daily average 18)

and 165 > 14 days length of stay

■ High level of delayed transfers of care (DTOC) 5.2% monthly snapshot

Planning




■ Medium term approach to support delivery from November 2014, including care system

planning and the delivery of CCG Operational Resilience and Capacity plans (ORCP)




Current Performance



■ CCG contribution to adverse performance (all DTOC and complex patients) equivalent

to 10 x 4 hour breaches = 0.1%


■ Somerset CCG System Resilience Group (SRG) KPI monitoring



■ Early analysis indicates DTOC pressures increasing towards the end of the month

Low Stretch

Enchanced out of Hospital Care Admission avoidance 0 1 None

Home Care Packages ?Discharge 0 1 None

Crisis Support Night Sitting Admission avoidance 0 1 Recruitment

GP Weekend Response Admission avoidance 1 2 GP Capacity

Mental Health Admission avoidance 0 0 Recruitment

Somerset

SWASFT


Avoidance

Risks to Delivery

Appendix 4 RUH Operational Resilience and Capacity Summary of Assurance December 2014

RUH Key Performance Indicators


■ Non-emergency patient transport

Planning

■ The Trust is continuing to run its Urgent Care Improvement

Programme

■ The Board initiated an improvement plan to regain 4 hour

performance through September and October 2014. Stage 1

completed and reported.

■ Medium term approach to support delivery from November 2014,

including care system planning and the delivery of CCG Operational

Resilience and Capacity plans (ORCP)

■ Final stage involves the implementation of a community wide urgent

care strategy across the four CCGs

Current Performance

■ All RUH schemes on plan



■ BaNES and Wiltshire CCG formal contract review of NPTS (Arriva)

completed 1st December 2014

■ KPI’s for all community ORCP schemes required to determine

impact upon 4 hour trajectory – key action for all SRG’s

Core ORCP Funding - Summary of plan to achieve requirement

Provider

Estimated

Costs in

2014/15

BaNES

Agreed

ORCP

Funding

(41.3%)

Wiltshire

Agreed

ORCP

Funding

(44.3%)

Somerset

Agreed

ORCP

Funding

(14.4%)

KPI Oct-14 Nov-14 Dec-14 Comments

95% 4 Hour Performance

(all types) 93.6% 94.0% 84.2%

Step up improvement plan in place as per the RUH Urgent Care Programme

which has been extended to moniotr the Surgical and Medical Assessment

Areas and the management of GP expected patients.

Total Trust Wide Beds Open

(monthly daily average).

Plan to open 22

9 6 24 Monthly average escalation beds open

Increased radiology capacity CT/MRI/US to support ED, MAU,

SAU, ESAC and Medical Ambulatory Care.

£389,870 £161,016 £173,000 £0

% CT/MRI inpatient

requests completed in 24

hours (target 80%)

85.6% 87.9% 89.4%CT/MRI scans completed within 24 hours of request (inpatient); continuous

improvement demonstrated.

Scheme A: Weekend discharge registrar (10am to 6pm

Saturday and Sunday).

Scheme B: Acute Oncology. Increase the service to 7 days per

week -

Scheme A: Evening ward rounds Medical Assessment Unit.

Scheme B: Increasing Medical Ambulatory Care Capacity until

8pm Monday to Friday (Medical Assessment Unit Area C -

MAC)

Weekend and Evening

Consultant MAU Ward

Rounds average number of

patient reviews (target

average 6 patient reviews

per round)

N/A 14 6 November 2014 service implemented. Proceeding as planned.

% of Medical direct

admissions to MAU Area C

discharged on the same

day. Target 20% snapshot

N/A 32.10% 18.8%

November 2014 service implemented. Performance from the 16th December

2014 reduced due to the escalation status of the hopsital and the requirement

to use the assessment areas. Performance from 01/12/14 to 15/12/14 26.9%.

4 Hour Performance (all

types) Target 95%93.6% 94.0% 84.2% Step up improvement plan in place as part of Urgent Care programme

Total Trust Wide Beds Open

(month average). Plan to

open 10

N/A N/A 4Capital works commenced on plan. Beds open 15th December 2014 as

planned. Additional 6 beds to open as per plan 19th January 2015

Additional non-emergency patient transport to support

patient flow during periods of high discharges and if discharge

needs to be less than the 4 hour NSL and Arriva contracted

response times. Piloted in 2013/14 programme and very

successful with x2 crews. Plan to use x1 crew 11:00-20:00 day

seven days per week which will be managed by the RUH

transport lead who will maximise activity.

£49,500 £20,444 £0 £0 4 per day 32 40 49

Additional capacity to support discharge. Subject to ongoing audit (led by

RUH transport lead with BaNES CCG). Capacity limited by level of funding

received against original plan. Block booking of additional capacity in place at

the end of December continuing into January 2015.

£19,000 £0

£0

Flexible non-elective medical bed capacity. 12 beds have

been identified to be used during periods of escalation and 10

beds overnight

£1,191,051 £491,904 £264,000 £100,000

29

Number of Discharge

reviews reported via the

Discharge Registrar (target

24)

28

(revised figure from

November report

due to improved KPI

reporting)

47November 2014 start as per ORCP; October start in line with identified

operational requirement. Proceeding as planned.

£97,000 £0£219,623 £90,704

Additional capacity on core specialty wards to support flexible

capacity modeling. Detailed bed modeling has been

completed by the RUH BIU team, in addition to demand

predictions (based upon 5 year averages) supporting flexible

capacity during periods of highest demand. 4 beds to open

mid December 2014 and a further 6 by the end of December.

£102,124 £42,177 £45,000

£43,913 £18,136

12

DRAFT FOR DISCUSSION PURPOSES ONLY Appendix 5 December 2014 RUH Urgent Care Improvement Programme

Overall assessment of the Urgent Care

Programme in December is AMBER.

Front Door. Medical ambulatory care activity

increased in month, direct impact of MAC

from 12th November 2014; this would have

been higher if not in escalation.

Median wait to treatment target sustained.

Continued focus on Medical Ambulatory Care

development (MAU Area C GP expected

admissions) and Surgical Ambulatory Care

extension of hours. Specific reference to use

in escalation and the services role in

supporting front door activity

Introduction of MAC has lowered the post

post take ward round number to below target

(i.e. reduced MAU length of stay), increased

in escalation.

Flow. Sustained adult bed occupancy,

increased medical outliers. All markers of the

trust in escalation, increased ED admission

rate and increased acuity. All seen from the

11th December.

Backdoor. Adult non-elective LoS in line with

target. Non-elective geriatric LoS average

sustained.

Overall decrease in bed days lost due to

DTOC and complex discharges.

Remain focused on Flow and Back Door as no

identified Emergency Department Issues.

ECIST planned site visit completed on the 17th

December 2014 – MAC/SAU and Trauma

Pathway review. Excellent feedback received.

Overview: The Trust has not consistently met the 4 hour performance

target in 2014/15. The diagnostic of 4 hour performance focused on

the impact of norovirus, days lost to DTOC, increasing green patients,

unprecedented ambulance activity and the use of all planned and

unplanned escalation to manage the demand and mitigate against the

community's reduced response. Review of the Trust escalation is

required due to the significant contribution of Medical Assessment

Area C to 4 hour performance.

Front Door. Urgent Care Improvement Board to review the impact of

the Medical and Surgical Assessment Areas and GP direct admission

pathways on 4 hour performance. Conservative estimate that 174

breaches could have been avoided and patient flow supported if MAU

Area C was fully operational from the 16th December and not used in

escalation, would have contributed 2.5% to the 4 hour performance

position . No identified issues with ED performance.

Flow: Four additional POU beds on line mid December 2014 in line

with ORCP, 6 further beds to be opened 19th January 2015 on

schedule.

Backdoor Metrics: 2 of the 5 metrics are green. The impact of acuity,

increased DTOC and Green to Go on non-elective LoS may not be

seen until January data as many of the long length of stay patients are

still active inpatients. Expect most metrics to be red in January 2015.

.

2014/15 Urgent Care Programme Trust Metrics

Conclusion: Continued focus on Flow and Backdoor actions and

improvement as per the step up improvement evaluation

recommendations to the Board of directors in November. ECIST report

due mid January 2015 – actions will be reviewed at the January 2015

Urgent Care Improvement Board and will be reported to management

board in February. Excellent feedback given on the day, specifically

with regard to the success of the MAC implementation since the 7th

October 2014 ECIST visit.

Key Actions;

1) Ongoing review of the GP direct admission pathway to the Medical

Assessment Unit (MAU) Area C. KPI monitoring through UCIB in

place daily. Contribution to 4 hour performance significant and

therefore its role in trust escalation needs to be considered by the

Chief Operating Officer and Divisions (including SAU Area C).

2) 4 hour step up improvement scorecard integrating MAC and ESAC

performance measures in place.

3) RUH ORCP scheme implementation and KPI monitoring in place

4) Wiltshire CCG ED attendance audit and anticipatory care planning

to support ED attendance avoidance.

5) ECIST recommendations awaited and appropriate action plan

development.

6) Focus on “sustain” work streams.

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