Transforming surgical services UHBristol
Andrew Hollowood PhD FRCSClinical Chair Division Surgery Head and Neck
University Hospitals Bristol NHS Foundation Trust
Bristol Acute Services Review
• UHB and NBT with significant clinical engagement• Assisted by PWC• Financial Challenge to Bristol of £230M next 5 years• Scale of change needs ambitious wide ranging solutions, integrated
with health and social care
• Service Review inc T&O and general surgery• Urgent Care Pathways in medicine, ED and stroke
Bristol Acute Services Review
• Centralisation of Specialist Paediatrics• Head and Neck, Breast & Urology• Vascular reconfiguration• Cleft
• Benefit for further rationalisation of services was not recommended through the review
Strategic challenges
Optimising productivity & operational efficiency
Transforming the ways in which we deliver care
Making strategic choices that directly address the challenge• Disinvest• Reconfigure
STRATEGIC INTENT
A range of local and regional services
Developing our specialist
services
Promoting teaching & research -
and recruiting the
bestWorking in partnership
Supporting community provision
Patients at the centre
UHBristol Strategic intent
ICNARC data Jan-Mar 2014
UHBristol Data
• Inpatient mortality (locked data) was 4/41 (9.7%)
• Predicted mortality 14.3%
• NELA overall mortality 13.4%
Post-op Destination By Post op Risk Prediction - UHBristol
Ward HDU/Level 2 ITU/Level 3
16
21
7
0 01
9
5
Post-op Mortality Risk Prediction< 5 % 5-10 % > 10 %
The Challenge
• Agreed protocols to assess and manage risk.• Timely input of senior decision makers according to the needs of the
patient.• Appropriate facilities, laid out in such a way as to provide safe and
expeditions patient care in a acute setting. • Careful planning and provision of adequate resources to enable sufficient
and timely access to emergency theatres. • Appropriate pre-and post-operative arrangements, including the early
involvement of anaesthetists and critical care specialists and resources where required.
• A focus on patient centred care, which involves consultant-led communication with patients and supporters.
– Emergency• Surgical and Trauma Admissions Unit
– 23 beds , 7 chairs, 4 assessment rooms– USS in assessment unit – radiographer 5 days a week
• Short stay emergency ward– 18 bed
• Trauma and Orthopaedic ward– 40 Beds, #NOF bay to rehab
• Co-located on same floor with ICU and theatres• Dedicated NECOPD staffed separately
– Local Networks - OG, HPB, Thoracics (on call rota)
Separate pathway models
Emergency Floor
STAU
Short Stay ward
Trauma and Orthopaedic
ITU Heygroves theatres
POD preop assessment
Standards & checklists
Divisional Escalation
• Implementation escalation rota
• Clear internal divisional support on a daily basis
WLO allocates TCI date
Weekly scheduling meeting & list ‘sign off’
Elective surgical bed allocation. EDD based on procedure norms
Daily checkpoint meeting
Next day list ‘sign off’
SCHEDULING
All teams working from
same list
ACTIVELY MANAGED BEDS
Critical care and ward beds pre-allocated so theatres
can start on time
Critical care, Wards & CSMs are expecting patient
EDD – patient transferred to discharge lounge by 12pm
Home
ESCALATION
Ward 700 Ward 800Wards 700 & 800 PULL patients up
from Level 6
Level 6 – emergency floor
Emergency Department Divisional outliers
Benefits realisationSurgical Flow Dashboard
29/08/2014
ID No Report Item Train Track Category Generated by Frequency Green Red Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14
Patient Access and Experience
1Number of patients on cancer pathway whose elective surgical procedure was cancelled on the same day (Non Clinical Reason).
Patient Access and Experience Medway Daily 0 1 7 12 8 4 10 7 17 8
2 Number of patients breaching a cancer standard as a result of theatre cancellation
Patient Access and Experience
Hannah Marder Monthly 0 1 5 6 3 3 2 4
3 % of patient complaints related to elective surgical cancellations
Patient Access and Experience
Bev Fitzjohn Monthly 0% 3% 0% 2% 3% 6% 2% 5% 0%
ED
4 Number of BRI Surgical Patients waiting over 4 hours in ED
ED Medway Daily 5% 5% 37% 43% 42% 27% 27% 26% 44% 38%
5 Number of Ambulance handovers taking more than 60 minutes
ED South West Ambulance Service
Monthly 0 15 4 4 5 3 5 1
Theatre
6 Number of in-patient elective surgical procedures on BRI site
Theatre Medway Daily 1% 5% 192 175 227 192 195 185 178 147
7 % of same day cancellations for elective surgical procedures (non-clinical reason)
Theatre Medway Daily 0.80% 1.50% 1.6% 1.8% 1.6% 0.8% 1.7% 1.5% 2.1% 2.9%
8% of same day cancellations for elective thoracic surgical procedures (non-clinical reason) Theatre Medway Daily 5% 8% 10.7% 10.0% 8.8% 4.9% 16.7% 10.2% 18.8% 7.6%
9 Number of list changes <48 hours before procedure date
Theatre Medway Daily 0 1 0
10 List start time (% lists starting ≤15 mins of start time) Theatre Medway Daily ≥95% <95% 54% 47% 64% 65% 62% 66% 66% 53.8%
11 List Utilisation Theatre Medway Daily ≥85% <75% 79% 75% 81% 81% 82% 81% 82% 69.9%
12 List Picked Up Theatre Medway Daily ≥96% <94% 93% 87% 92% 90% 94% 92% 92% 91.7%
13 Theatres daily checklist completion Theatres Daily 98% 94% 25%
Recovery
14 Number of patients overnight in recovery Recovery 0 3
Critical Care
15 ITU daily checklist completion Critical Care Daily 98% 94% 25%
16 % of patients transferred from ITU to the ward within 4 hours (from fit for discharge decision)
Critical Care Helen Dunderdale Monthy 45% 40% 34% 41% 18% 25% 35% 32% 6%
Wards
17 Wards daily checklist completion Wards Daily 98% 94% 25%
18 STAU daily checklist completion Wards Daily 98% 94% 25%
19 Number of patients in surgery beds with a stay of over 14 days
Wards Medway 30 36 38 42 42 36 35 41 35 42
20 Number of inter-specialty outliers on Ward 700 and 800
Wards Medway Daily 1 2 14
21Number of non-surgical outlier patients placed into protected, elective surgical beds on Ward 700 and 800 Wards Medway Daily 1 2 5
22 Bed Occupancy rate on ward 700 Wards Medway Daily 91% to 92.5%
≥95% and
≤85% 100.0%
23 Bed Occupancy rate on ward 800 Wards Medway Daily 91% to 92.5%
≥95% and
≤85% 103.1%
Discharge
24 Number of patients to the discharge lounge before 12am
Discharge Medway Daily 90 70 69 102 102 93 70 91 83 53
25 Number of Patients on Green to go List Discharge Site team Daily 4 8 10 8 17 17 6 11 11 13
Dashboard to measureDelivery of improvements to emergency and elective flow.
Reflects benefits to productivity, performance and patient experience
• 4hour flow• ITU discharge• Complaints due to cancellations• List utilisation list pick up • Start time• Completion of checklists.• Specific divisional targets to deliver
operating plan
Measurement - Are we on time?
Surgical Flow Dashboard - Improvements in real time flow measures
Critical Care Wards DischargeDivisional
Flow
Patient Access and Experience
ED Theatre Recovery
• Define the emergency service/patient pathway• Assess deliverability against standards• Review data against standards
• Supporting Networks for local hospitals• Cross trust service reconfiguration where evidence
• Develop local networks for speciality care– OG, HPB, Vascular, ITU
Summary
Strategic challenges
Optimise emergency care pathways
Transform the ways in which we deliver emergency care
Make strategic choices that reconfigure emergency services