TRUST OARD IN PULIC REPORT TITLE: EXECUTIVE SPONSOR: REPORT AUTHOR (s): REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date) Action Required: Date: Agenda Item: CQC Improvement Action Plan Update Fiona Allsop Chief Nurse Sue Jenkins Director of Strategy Executive Committee Approval () Discussion () Assurance ( ) Purpose of Report: This report provides the oard with assurance that the recommendations made following the CQC visit in May 2014 are being addressed Summary of key issues The Chief Inspector of Hospitals visited the Trust in May 2014. The Trust was rated as good for all domains. In terms of the 8 core services that were reviewed the Trust received a good rating for all services apart from Outpatients services which were rated as requires improvement. This report includes a summary of the initial recommendations that were made in the report and how the Trust has responded to them. Progress against the detailed action plan that has previously been reported to the oard is also included. This report provides a summary of progress to date which confirm that all of the four main work streams are rated as green or blue. The CQC also made some should do recommendations which are also reported against in this report. The system wide updates following the quality summit are also included in this report for completeness Recommendation: The oard is asked to consider this report and ensure that it provides assurance around delivery of the CQC improvement plan. They are also asked to consider content and frequency of future reporting. Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health
economy SO3: Caring Ensure patients are cared for and feel cared about SO4: Responsive ecome the secondary care provider and employer of choice our catchment population SO5: Well led: ecome an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Corporate Impact Assessment: Legal and regulatory implications Financial implications Patient Experience/Engagement Risk & Performance Management NHS Constitution/Equality & Diversity/Communication Attachment: 4.1a - Mouth Care Matters riefing 4.1b CC Update Compliance with CQC recommendations and delivery of action plan to address areas highlighted is essential Capital and revenue implications will be addressed through separate business cases Feedback from patients regarding their experience in outpatients is a key part of this action plan A monthly steering group is in place to ensure delivery of the plan N/A 2
TRUST OARD REPORT 26 March 2015 CQC Improvement Plan Update - Outpatients 1. Introduction The Chief Inspector of Hospitals visited the Trust in May 2014. The Trust was rated as good for all domains. In terms of the 8 core services that were reviewed the Trust received a good rating for all services apart from Outpatients services which were rated as requires improvement. This report includes a summary of the initial recommendations that were made in the report and how the Trust has responded to them. Progress against the detailed action plan that has previously been reported to the oard is also included. This report provides a summary of progress to date which confirm that all of the four main work streams are rated as green. The CQC also made some should do recommendations which are also reported against in this report. 2. Progress against recommendations and concerns raised in original CQC report Ref Issue raised in CQC report Update Safe Medical records not available for all clinics which results in incompleteness of patient records Safe Medical records availability not reported on Datix Safe Datix could only be accessed by band 6 and above staff to report incidents Safe Datix feedback to staff was not consistent Safe Location of medical records in Southampton compromised access to notes on occasions Safe Safe Safe Number of last minute ad hoc clinics compromised access and availability of medical notes Quality of note tracking information was not consistent Medical records working environment is poor Medical records staff extended to cover 24/7 which supports improvement of note availability Trial in place during April 2015 to support reporting of all notes non availability or incompleteness on Datix Datix now available to all receptionists and band 5s Audit afternoon has been reviewed and is to be restructured to support formal and informal feedback of concerns raised by staff Off site notes storage facility has been reviewed and re-procured. New contract agreed with supplier a few minutes from ESH Linked to demand and capacity work underway 2 major upgrades of system completed. Improved communications with users Immediate steps taken to improve minor issues raised and 3
Safe Safe Caring MCA and DoLS awareness of some outpatient staff was limited Staffing skill mix required more qualified nurses Environment of main outpatients is poor and overcrowded Responsive Clinics cancelled at short notice Responsive Clinics overbooked and overrun Responsive Play areas not available in waiting area capital identified to support reprovision of new department Training provided to all relevant outpatient staff Review underway which is linked to demand and capacity review Capital identified to support rebuild or reprovision of outpatients accommodation in 16/17 Linked to demand and capacity review Linked to demand and capacity review Will be included in plans for reprovision of outpatient accommodation Additional car parking provided for patients Responsive Patients felt that there is not enough car parking Responsive Appointments arranged multiple times Report to be developed to confirm number of times appointments are rescheduled Responsive Clinics cancelled at short notice (< 6 weeks) Well led Well led Well led Well led Must do Must do Senior leadership problems identified in outpatients Medical secretary and medical records leadership Staff engagement for outpatient staff to make improvements No evidence of clear strategies to respond to future outpatient activity Carry out a review of the outpatient service to ensure there is adequate capacity to meet the demands of the service Implement a system to monitor quality of outpatient service that includes number of cancelled appointments, waiting times for appointments and number of patients with no medical records available for their appointment Reported to oard each month and process put in place to record all changes with less than 6 weeks notice New outpatient manager appointed January 2015 Meetings held for these staff groups with senior members of staff and exec team have undertaken back to the floor exercises to raise profile Staff focus groups for outpatient staff being established in the spring Demand and capacity review looks forward as well as prospectively Updated progress detailed in plan below Updated progress detailed in plan below 3. Outpatient review update There are four key work streams that the outpatient action plan covers. They are Environment 4
Workforce and leadership skills Communications Systems and processes The table below details the key actions that are being undertaken for each of the four areas and a RA status is included:- RA A R Definition Action complete Action being delivered to plan Action delayed or outside of budget but plans in place to bring back on track Action unlikely to be delivered to plan Ref Details RA status 1.0 Environment 1.1 Minor redecoration and refurbishment in the existing department have been completed 1.2 The Earlswood centre opened on 4 February for their first diabetes and endocrinology clinics. All clinics (except ante natal) have moved from East Surrey hospital to The Earlswood Centre. Initial feedback from staff and patients has been very favourable. Three Chipstead clinic rooms that were released by move to Earlswood are being refurbished and due to commence with new activity on 2 March 2015. 1.3 IT solution being explored to support room allocation and monitoring of clinic space. Onsite visit from potential supplier of software system to support room use and allocation has taken place and further meetings to progress a pilot have been planned. A business case has being developed and was considered and supported by CHI in February. The capability of the new Cerner release is being considered but timing of this could compromise a prompt solution. No capital has been allocated to this scheme at the moment and likely cost is estimated at 24k. A capital bid pro-forma is therefore being developed. 1.4 Accommodation for additional ophthalmology clinics was considered at Horsham but unlikely to progress. A meeting with a property developer has also taken place to discuss the opportunity of having additional outpatient capacity built on the Earlswood estate. A specification for the service is currently being developed by the clinical team and this will potentially release space on the ESH site for ophthalmology 1.5 Refurbishment of haematology clinic areas included in capital plan for 2015/16 but work planning to start in March 2015. Revised plans are A being reviewed with clinical staff. 1.6 Chemo outpatient clinics to be accommodated on ESH site following repatriation from Royal Surrey Hospital. Some of these clinics have commenced and the rest will be accommodated when rooms have been identified 1.7 Report requested from information team to review allocation of patients waiting for outpatient clinics to nearest location to home address and information now available and to be used to inform appointment bookings. 1.8 Outpatients refurbishment and works project group established and 5
meeting on a weekly basis 2.0 Systems and processes 2.1 Trust wide review of demand and capacity underway. Projections around anticipated growth and improvements in new to follow up ratios and DNAs have also been modelled. The top three specialties which equate to more than 20% of all outpatient activity are being focussed on to test forecast demand against clinic templates and job plans. This work will go beyond the 31.3.15 deadline that was originally proposed. 2.2 Service level review of demand and capacity underway and will be matched with trust wide review. 2.3 New templates implemented and in place for ad hoc clinics, cancellations and room requests 2.4 Separate partial booking project team established and plan to be A completed. Original aim was to implement January 2015 using Cardiology and Rheumatology as pilot areas but this has been postponed due to lock down of Cerner. Plans being revised to reflect availability of Cerner support staff who are essential to support go live 2.5 Electronic process for referrals being considered and developed with Ps. Trial being developed with two P practices. 2.6 KPIs and metrics agreed for monitoring outpatients by steering group 2.7 Consultant to consultant process reviewed and referrals reduced to minimise financial penalties 2.8 Monitoring of new to follow up ratios in place on a monthly basis to ensure financial penalties are minimised 2.9 Weekly monitoring of KPIs commenced and reporting in place at divisional level. Detailed reports for key breaches to be developed and reported at monthly outpatient steering group 2.10 Telephone clinics in place for some specialties and tariff being developed to support this more efficient and effective way of working. Rheumatology and gastroenterology are looking at this area in more detail and some software with a years free trial is being explored to support 2.11 leep system to enable patients to leave the department has been explored with other trusts who have system in place. Not considered viable as patients too concerned that they will lose their appointment slot. Self-check kiosk option being considered as an alternative and pilot being explored with potential supplier and a case to support the trial was considered and supported by CHI in January 2015. Proof of concept being developed for go live in August. Capital confirmed 2.12 Outpatient booking office call answering currently at 98%. Plan in place to improve to 99% 3.0 Workforce and leadership 3.1 Interviews for Outpatient Service Manager completed and offer made to strong candidate who commenced at beginning of January 2015. Interim management arrangements in place. 3.2 Skill mix review of outpatient services continually underway and reviewed each time vacancies arise. 3.3 Single line management of all outpatient staff considered and agreed not to progress at this point 3.4 Outpatient steering group and weekly operational groups all in place 3.5 ack to the floor session by Director of Strategy undertaken in outpatients department 3.6 Programme to extend skills of nurses being developed and to be 6
worked up in more detail following appointment of new service manager 4.0 Communications 4.1 Lead clinician and members of outpatient team have met with a number of P practices and CC governance committee to consider views on referrals from P perspective. This is key to improve working relationships between the Trust and primary care. 4.2 Lead clinician meeting with clinicians on a 121 basis to gain views and feedback on outpatient services 4.3 Outpatient services to be included on agenda item for all consultants meeting Mid September 4.4 Outpatient nurse lead to meet with patient experience forum 4.5 Outpatient focus group for patients planned for 2 December and 157 members interested in outpatients have been invited. Focus groups completed with 14 participants and feedback has informed an action plan which is monitored by monthly outpatient steering group. 4. Progress against should do recommendations Requirements Lead Update on progress Outcome Review the training provided to clinical staff on the Mental Capacity Act to ensure all staff understand the relevance of this in relation to their work. Fiona Allsop Nursing: Currently rolling out ward based training for Nurses and now included within MDT MAST training. Reviewing general training compliance and monitored by safeguarding functions. Ensure that a review of mouth care is undertaken so that staff are clear where this should be recorded in the patients care record. arbara ray Fiona Allsop ELearning main tool for delivery of medical training. Mouth Care Matters is being rolled out and includes a revised documentation process. Medical compliance reviewed separately Improved oral health for hospitalised patients at SASH. See embedded document Mouth Care Matters brief Feb 2015 V2.doc Continue to focus on improving the trusts performance on complaints handling. Review the action taken to engage with Fiona Allsop The Trusts continues to implement the actions recommended by both the CQC inspection and internal audit review of systems (Feb 2014) a. Medical administration review in place to The Complaints team are updating the Trust s policy including updates to systems and monitoring. Complaints review group commenced March 2015. Front line non clinical customer care training rolled out to approximately 300 staff. a. Weekly progress report monitoring delivery of action plan reported at the 7
a. medical secretaries, b. ward clerks and c. medical records staff to ensure these groups feel more included in decisions relating to their role. Review the working environment for the medical records staff. Jim Davey Fiona Allsop Ian Mackenzie Ian Mackenzie support improved engagement of medical secretaries and implementation of Dictate IT. Fortnightly project board includes 2 medical secretaries as members b. Review of ward clerk establishment and role underway and regular meetings in place to review concerns raised c. ack to the floor and trust wide article on the role of medical records has helped improve engagement with this key staff group. Regular meetings in place for staff to raise concerns. Capital plan for 2015/16 includes reprovision of Maple House Annexe Executive team and at oard in November 2014 b. Update received at Exec 10.12.14 c. Weekly progress report monitoring delivery of action plan reported at the Executive team and at oard in November 2014 Weekly progress report monitoring delivery of action plan reported at the Executive team and oard in November 2014 Update against system wide quality summit actions Clinical Commissioning roups: Occupancy rates Reducing emergency demand establishing a clear and collaborative programme of action that delivers reduced occupancy in the short and medium term as a key output Discharge to assess Full commitment to support the programme going forward Stop undertaking Continuing Health Care assessments and DSTs in hospital These should be carried out in the community so that patients get the greatest possible benefits. On all three of these actions an initial response has been provided by the CCs but additional detail and clarity has been sought Move relationships from a transactional basis to a transformational one particularly regarding clinical pathway development through clinically led work Information sharing Improve access to and sharing of patient information Ortho rehabilitation (Including fractured neck of femur) and access to stroke rehabilitation Developing improved pathways and access to rehabilitation in community settings 8
Local Transformation oard developing Hospital Without Walls -Using existing expertise in the system including winter resilience preparation Collaboration on financial challenges Evidence of how actions are being achieved and success is being measured has been sought from the CCs and the attached plan has been provided in response to letters from the Trust. KD update trust board 130315 v2.doc Healthwatch Continue to be a critical friend Encourage Surrey & Sussex to share templates and paperwork (e.g. Continuing Health Care Assessments) Our Chief Nurse and Deputy Chief Nurse have met with Healthwatch members from both West Sussex and Surrey and have agreed to meet them together on a quarterly basis to discuss soft intelligence they have received about the Trust. They have also agreed to consider how representatives from Healthwatch can contribute to relevant work stream within the organisation to increase the patient voice. In addition the Trust has agreed to promote the face of Healthwatch within the organisation to facilitate better knowledge and understanding by patients. Healthwatch were also updated on the recent PLACE visits. eneral Medical Council Share lessons from the Surrey & Sussex Healthcare NHS Trust locally and nationally The MC public relevant reports on their website sharing findings and best practice on a national basis Health Overview & Scrutiny Committee Continue to bring organisations together and provide challenge Encourage proactive work with CCs, Ps & healthcare providers to find solutions for appropriate use of healthcare services Provide a means of promoting the users and the public to use health services appropriately Provide an opportunity for planning and dialogue with health and social care on demographic changes and access to health services for children and young people The Trust has had recent experience of the West Sussex HASC calling all providers to account for how services had been delivered across the winter months. They have been instrumental in facilitating the agreement of plans which have included a commitment to increasing the social service support being provided on the hospital site. 9
Recommendation The oard is asked to consider this report and ensure that it provides assurance around delivery of the CQC improvement plan. Sue Jenkins Director of Strategy March 2015 10