integrated improvement programme - july update€¦ · engaged clinicians and staff achieve better...

TB2019.73 Integrated Improvement Programme of 3

Trust Board Meeting in Public: Wednesday 10 July 2019 TB2019.73

Title Integrated Improvement Programme – July update

Status For information and discussion

History Integrated Improvement Programme update has been taken to;

• Trust Operational Forum on 20 June

• Trust Management Executive on 27 June

Board Lead(s) Sara Randall, Chief Operating Officer

Sam Foster, Chief Nursing Officer

Meghana Pandit, Chief Medical Officer

Jason Dorsett, Chief Finance Officer

Eileen Walsh, Chief Assurance Officer

Key purpose Strategy Assurance Policy Performance

Oxford University Hospitals NHS Foundation Trust TB2019.73


Executive Summary

1. A refreshed 2019/20 Integrated Improvement Programme has been developed to empower a culture of continuous improvement to enable our staff to deliver high quality care. It is built on our previous improvement journey and has a bottom up change and improvement approach as front line staff are driving the change.

2. There are six critically related improvement programmes;

I. Urgent and Emergency Care (Executive Lead: Sam Foster, Chief Nursing Officer)

II. Elective Care (Executive Lead: Sara Randall, Chief Operating Officer)

III. Theatre Productivity (Executive Lead: Meghana Pandit, Chief Medical Officer)

IV. Quality and Safety (Executive Lead: Meghana Pandit, Chief Medical Officer)

V. Governance (Executive Lead: Eileen Walsh, Chief Assurance Officer)

VI. Improving Non Clinical Productivity (Executive Lead: Jason Dorsett, Chief Finance Officer)

These are supported by three enabler programmes; workforce, finance and digital.

3. Trust Management Executive is a key element of the Integrated Improvement Programme governance and reporting structure. Programme is reviewed at TME monthly for one hour prior to being reported to the Trust Board and sub-committees.

4. A central improvement team is providing improvement facilitation and project management input working with local clinical and managerial leaders to deliver change. We are actively recruiting into vacancies and the team is being coached in supporting change, working with resistance, effective project management to enable improvement, facilitating engagement and so forth.

The Executive team recognises that their commitment to continuous improvement is critical for success and Executive Leaders are aligned to each programme as well as Chief Operating Officer monitoring and reporting to the Trust Board.

5. A standardised approach has been taken to scope the six improvement programmes, progress against programme initiation and set up. Highlight reports are developed to provide updates on delivery progress, benefits for patients and potential risks to delivery. The attached PowerPoint gives an overview of the programme structure, governance, resource, engagement plan and Integrated Improvement Programme scope.

Success metrics are currently being developed and change will be monitored through SMART (Specific, Measurable, Achievable, Relevant, Time Specific) goals and metrics to ensure plans are translated into actions and results.

6. A standardised improvement methodology is utilised to ensure that the learning can be applied across other areas. For instance, Plan, Do, Study, Act (PDSA) cycles are applied to test the change with the local clinical leaders. This approach enables change to be piloted, tested and refined to ensure they are fit for purpose and embedded. The approach involves ‘planning it’, ‘trying it’, observe the results and acting on what is learned.

7. A high level communication plan has been developed to ensure there is appropriate engagement at OUH and system level. There will be key elements to ensure senior leaders within the Trust are engaged. The communication plan will be developed with the aim to reach all parts of the organisation, utilising pop up

Oxford University Hospitals NHS Foundation Trust TB2019.73


stands around the sites to demonstrate what is being achieved.

Recommendation

The Trust Board is requested to take a note the content of the report and progress made to date

OUH Integrated Improvement Programme Trust Board – 10 July 2019

1

• Executive Summary • Programme structure • Governance & reporting • Programme resource • Engagement & communication • Improvement approach • Appendices

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Executive Summary OUH – Integrated Improvement Programme2019_20

OUH – The Improvement Journey Our Integrated Improvement Programme brings together, under one roof, a set of critically related programmes which will ensure that more of our patients receive timely, safe, compassionate, quality care in the right setting for them, whilst living within our means. We build on our previous improvement journey with a clear steer that we need to be more proactive and create a culture of continuous improvement to enable our staff to deliver high quality care. Effective partnership across Oxfordshire health economy is vital for achieving our overall goals and we are committed to collaborative and partnership working with the local and wider system.

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=2ahUKEwiC5NjZxcLhAhURThoKHSGiBqwQjRx6BAgBEAU&url=/url?sa%3Di%26rct%3Dj%26q%3D%26esrc%3Ds%26source%3Dimages%26cd%3D%26ved%3D%26url%3Dhttps://ern-euro-nmd.eu/healthcare-provider/oxford-university-hospitals-nhs-foundation-trust/%26psig%3DAOvVaw2T_5xtme4V_kgQzoh_Ux_g%26ust%3D1554883260498526&psig=AOvVaw2T_5xtme4V_kgQzoh_Ux_g&ust=1554883260498526

3

Programme structure in practice – high level example

Empowering our front line staff to drive change, we have created a dedicated improvement team to support and facilitate change, ensuring an effective and consistent improvement methodology is applied. The programme is an all encompassing vehicle to build our improvement capabilities; moving care closer to home; providing high quality patient care, which also costs less – in line with the principles of getting it right first time and focusing on excellence

4

Governance & Accountability & Reporting


5

Governance & Accountability & Reporting

Programme governance

Align with OUH

vision; track progress; hold to account; remove roadblocks; build

sustainable improvement

6

• We are developing a revised integrated performance

management framework which works with the delivery of our agreed improvement programme

• We will develop both the reporting via the

Integrated Performance Report to demonstrate to the Board, staff and our patients where improvements have been achieved

• By working together in an integrated way we will be

able to capture and explain where are performance needs to improve and how our services work together to make things better

Alignment of OUHs Integrated performance management approach and integrated improvement programme

7

Governance & Reporting

Progress update meetings • The improvement KPIs will be supporting

the delivery of the Trust’s key performance objectives

• Chaired by Interim Director of Clinical Services

• Attended by Executive Sponsors, Accountable Officers, Project Leads, Improvement Facilitators

At the meeting • Exception reporting only – with a highlight report • Focused on KPIs & progress • Success stories shared, impact on patient

experience captured • Risks and issues escalated for intervention

Aim: Track and challenge progress, unblock barriers, empower improvement

Metrics and patient focused update


8

The Programme Improvement Team resource & skills

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The Improvement Team – resource & skills (Team transitions - June 2019)

A central improvement team, providing project management and improvement facilitation input, working with local clinical and managerial leaders to deliver change

• Executive Sponsor as Chief Operating Officer and led by Interim Director of Clinical Services • Oversight and coaching provided by a senior improvement specialist & team • Team of project managers with improvement skills including QSIR trainers • Subject matter experts i.e. procurement/ workforce, finance • Recruited three team members in June and actively recruiting into vacant positions

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Engagement & Communication - Priorities


Focus areas

Goal

Involvement of patients & families

Improved engagement with OUH clinicians and

staff

Start Out Define & Scope

Measure & Understand Design & Plan Implement Sustain

Focus areas

• Engage with patient representation groups

• Review patient

complaints aligned to specific improvement projects

Web Page • Explore programme page

update Staff emails • Regular updates (how

frequent?) Clinical Staff • Explore best ways to

reach clinical staff Improvement Champions • Identify

Involving patients and families with changes about their care

Engaged clinicians and staff achieve better outcomes

Trust – Quality Service Improvement Programme

Programme Engagement & Communication

Engaging across the system

Commitment to build shared vision

Improved senior leadership and

engagement

Collaborative working

Engagement and communication • Agree attendance at key

Boards i.e. A&E • Identify a responsible

officer for communication with all health and social care partners

Collaborate & partnership working

Executive Leadership – presence • Senior leaders to go

and see improvement work

Visual Management • Programme visuals

within relevant areas i.e. Ops Centre

• Monthly engagement sessions to share success – Last Thu of each month

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12

Improvement Approach


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Standardised approach

An approach

encompassing a number of

improvement methods such as

Lean improvement; NHSI Quality

service improvement and redesign (QSIR); Kotter’s change management

principles (1995)

Standardised approach – improvement steps

Example

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Programme GOAL Improve Patient

Experience

(Continuous Improvement)

Ad-hoc Member As required Executive Sponsor

Accountable Officer /

Programme Lead

4b- Improvement Facilitator /

Change Lead

4a -Project Managers

Project Lead

5- Ad-hoc Project Member – as needed A clinical local lead for the specific

improvement cycle A managerial lead A system partner An informatics member

4a- Project Manager- Corporate • Supports setting up project teams • Collects and analyses data • Attends and actively participates at project meetings • Supports project leads in relevant reporting i.e.

highlight reports • Maintains risk and issues register, escalates where

necessary • Supports in tracking and reporting KPIs • Ensures standardised methodology • Prepares leads for programme delivery group • Facilitates key events i.e. mapping sessions

4b - Improvement Facilitator – Corporate • Overall coordination of each

programme and underpinning projects including setting up project & PDSA groups

• A facilitator of improvement sessions i.e. mapping

• A facilitator of PDSA sessions • Provides regular status update to

Project Lead

1 - Executive Sponsor • Approves the programme structure and

goals • Approves project goal and plan • Ensures project alignment with

undertakings • Monitors risk & governance • Reports to the Board • Ensures external partner involvements

2 - Accountable Officer – Operational Leader • Accountable Officers at programme level such

as Urgent Care or Elective Care • Drives improvement at Programme level • Holds project leads to account • Reports to relevant Committees and Boards • Provides change and improvement leadership

3 - Project Lead – Local Subject Matter • Leads project delivery, dedicated time for project • Drives improvement cycles • Provides relevant subject matter expertise • Follows through actions • Monitors impact and success measures • Provides check & challenge • Drives the project • Holds actions owners to account • Ensures action focus activities • Leads the change, enabler of change • Responsible for the completion as planned • Is supported by the Trust Improvement Hub

Project Team – Roles and Responsibilities

Start Out Define & Understand

Measure & understood

Design & Plan Implement Sustain

Example improvement project team - ideal

14

(4a

& 4

b - u

sual

ly s

ame

pers

on)

x 15

Plan, Do, Study, Act cycles for improvement

Project teams drive the improvement; testing cycles of change

• Set up improvement project meetings: Set up regular review meetings to drive improvement

• Determine goal and scope: ‘a clear plan’ with actions, owners and timeline

• Define: Understand scope and the problem, define the improvement need and impact on patients

• Baseline: Determine baseline for improvement • Understand: Understand current state • Analyse: Review performance data, capture

manual data if required • Measure: Determine SMART metrics and monitor

impact of changes • Improve: Test the change through ‘PDSA’

improvement cycles – note that no baseline no PDSA

• Standardise & sustain & change: Change becomes way of working; consider and plan at the first meeting

(Templates will be provided & project support will be in place)


Measure & understood


(Institute for Healthcare Improvement, resources)

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S Specific Are the goals clear and precise?

M Measurable Can we measure the problem and the improvement?

A Achievable Is it realistic?

R Relevant Is the objective relevant to the project and wider need?

T Time specific Are there dates to complete?

Programme focus

Start Out Define & Scope Measure & understood


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Improvement cycles with SMART metrics

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Appendices Integrated Improvement Programme Improvement Projects & Priorities

Urgent and Emergency Improvement Programme Executive Sponsor: Sam Foster Accountable Officer: Lily O’Connor Non-executive Director: Paula Hay-Plumb Improvement Projects

Goal

P1 - Implement discharge to assess

P2 - Improve in hospital acute pathways & same day emergency care processes



Workstreams (PDSA cycles are being determined)

Patients who require surgery that needs to be carried out in 24hrs • Daily clinical prioritising of patients who

require emergency surgery within 24hrs • Review patients who are waiting more

than 24 hours-NCPOD categorisation – consultant in charge

• Appropriate escalation Reconfigure JR to infrastructure to support emergency flow Reducing breaches • Increase ambulatory opportunities,

reducing LOS • Optimise children’s and adult footprint,

processes and pathway for urgent and emergency care

Transport • Reducing clinical harm from transport

failures • Increasing utilisation of the discharge

lounge • Prevent transfer failures, work with CCG

& Transport provider

Reduce length of stay for all bed based patients through implementing discharge to assess

Streaming • Define core function of urgent care

assessment units and ED to ensure that patients are rapidly triaged/ signposted

GP Streaming • Improve GP streaming to reduce waits

Tertiary referrals • Review tertiary referral process direct to

specialty Radiology & diagnostics • Service Level Agreement (SLA) and

commitment to radiology reporting • Improved process for CT&MRI out of

hours cover Manage Interdependencies • Work together with System Urgent Care

group to ensure interdependencies identified and managed

Improving patient pathways for children and adults Improve the allocation of patients to the most appropriate clinical areas of a hospital, and the most appropriate clinical pathways


HART Improvement Programme • Enabler for D2A project Discharge to Assess – D2A • Agree protocol for the

identification of people suitable for D2A

• Confirm early Memorandum of Understanding to cover risks, roles & responsibilities

• Escalation plan to manage in-day risks

• Criteria and protocols are developed to allow further ‘trusted /generic assessment’

SMART KPIs - examples

Pilot, set baseline, increase discharges by 8%

Increase number of ambulatory opportunities, reducing LOS

Reduce breaches between 17.00-9.00 from x to y

Increase GP streaming by 30 patients per day

P3 – Improve urgent care out of hours

Overnight • Reducing number of breaches

overnight • Focus on improvements and

staffing between 17:00 – 09:00 • Efficient overnight escalation

processes and develop support protocol

• Applying internal professional standards to support operational decision making process at all times

• Senior clinical decision maker demand and capacity to support patient management

Weekends • Review work plans for senior

cover 7 days a week

Improve patient flow, ensure patient care is quicker and they are seen at the right time

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Improvement Projects

Goal

P4 - Improve OPEL & escalation response

P5 Enabler - Daily reporting, data quality and external

reporting



Workstreams • Review and reflect

accurately OPEL stands • Develop SMART actions for

OPEL status • Consistent OPEL standards

applied (review, understand, root cause, address issues)

• Monitor for learning and to maintain safety for all patients

• Define duty manger roles and responsibilities

• Agree metrics to measure improvements, monitor medical bed occupancy (92)

Accuracy • Review accuracy of data (shared

internally and externally) • Clarify ownership and visibility of

data • For key reports define data

source, review process, validation process

Transparency • Development and the use of the

DCMT tool • Development and the operational

use of the Trust live bed board • Develop a suite of urgent care

reports and information is shared on system C

• Service designed and built reports

Action • Develop response to escalation

from daily reporting

Ensure patients get appropriate care in time by making system work more effectively when acute hospital is under pressure

Data accuracy and transparency to enable clinical and operational staff to make improved decisions to improve patient care


SMART KPIs - examples

Increase Opel 3 to Opel 2 conversion average (10 am to 4pm) from x to y

Reduce extended LOS for all patients under 21 days

Urgent and Emergency Improvement Programme Executive Sponsor: Sam Foster Accountable Officer: Lily O’Connor

P6 - Timely management of patients who present with

mental health issues Reducing the number of patients with an extended LOS

P7 - Reduction in the number of patients with an extended

LOS over 21 days

Patients who present with mental health • Patients who present to ED with

MH issues are seen within one hour of referral

• Length of stay for patients with mental health presentations kept to– under 12 hours

• All children with mental health presentation are risk assessed with a management plan before admission

• Agreed persons identified who are responsible decision makers for children admitted with mental health issues

• Develop Standard Operating Procedure with the system partners so there is clear response times and an approved mental health professional (AMPH)

Patients access timely and appropriate care

Access to bed availability data in real time within seconds of data entry

All patients are seen within one hour of referral

• All patients to have an EDD and criteria for discharge

• Agreed whole economy written system process for review of patients with an extended LOS

• Develop delay themes from Oxfordshire level 2 escalation meeting (includes MH) will monitor effectiveness.

• OUH: peer review of those who are not medically fit with an extended LOS over 21 days

• 16% reduction in the number of patients with a LOS over 21 days

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IMPROVEMENT PROJECT HIGHLIGHT REPORT - Exception Reporting

Reporting period 01/06/2019 Project P4. Improving OPEL and escalation response Project Start Date 18-June-19

Improvement Workstreams (or PDSA cycles) Key Performance Indicators Target Baseline Data

source Last week This week Trend Target

Achievement Date

Lead/Owner

Development and implementation of OPEL escalation criteria

Percentage of days where OPEL is measured three times a day 100% 0% EPR 0% 0% Static 31-Jul-19 Lily

O'Connor

Development and implementation of OPEL escalation criteria

Percentage of days at OPEL 1 and 2 when assessed at 10am TBC TBC EPR - - Static 31-Jul-19 Lily

O'Connor

Development and implementation of escalation actions and responsibilities

Percentage of appropriate OPEL escalation actions completed by divisional bronze, clinical site manager and duty manager

100% 0% EPR 0% 0% Static 31-Jul-19 Lily O'Connor

Development and implementation of escalation actions and responsibilities

Percentage of bed meetings where attendance is captured 100% TBC% EPR 0% 0% Static 31-Jul-19 Lily

O'Connor

Exception Reporting Update 1- What works - share success from the previous reporting period

• Developed of OPEL escalation criteria and appropriate response. Based on best practice from Cornwall which was developed in conjunction with NHSI / E. Initial review and amendments undertaken by interim Deputy Director of Clinical Services and Deputy Director of Urgent and Emergency Care.

• Piloted new OPEL criteria to evaluate appropriateness of criteria and responses with senior clinical co-ordinators within Urgent and Emergency care. Weekly Plan, Do, Study, Act (PDSA) improvement cycles taking place to evaluate success.

• Completed a workshop on 11 June with all duty managers to review escalation criteria. Session took 3 hours and each induvial criteria and triggers was discussed and agreed. Two further workshops are required to evaluate OPEL 2 and 3 actions and responsibilities have been scheduled on 25 June 2019 and 9 July 2019

2- What improvement has been made for the patient, over the previous reporting period?

• Piloting new OPEL escalation criteria increases awareness of pressures on JR site to ensure appropriate escalation actions by responsible owners can be taken to ensure patients get appropriate care in time by making system work more effectively

3 - What are the blockers to achieving what you plan to achieve over the next reporting period?

• Input of Urgent and Emergency care key stakeholders. Requirement of large time commitment for a large number of senior key stakeholders. Mitigated by planning workshops in advance and ensuring invitations are sent by Interim Deputy Director of Clinical Support and articulates the importance of input

• Acceptance of new OPEL escalation criteria, triggers, actions and responsibilities. Addressed through early engagement of key stakeholders, continued input throughout including piloting to refine final process

Example of highlight report


Goal

Project 1 – Manage Outpatient Demand

Project 2– Improve Clinical Productivity



Workstreams

• Understand current non face to face outpatient appointments and explore opportunities within specialities

• Increase the use of technology from x

specialities to y

• Decrease of unnecessary/ inappropriate follow up appointments (define scope)

• Review and identify additional opportunities for advice and guidance and implement

• Reduce hospital & patient cancellations

including annual leave booking process • Pilot patient portal for improved patient

experience

Reduce demand for follow up outpatient appointments by x,000 patients per

Work with system partners to reduce outpatient demand within acute Gynae specialty by x,000 patients per year (align with business case)


Project 3 – Improve quality, efficiency and patient experience

Improve patient experience, improve administrative efficiency with an impact on clinical time

Elective Care - Outpatients Improvement Programme Executive Sponsor: Sara Randall Accountable Officer: Peter Fry Non-executive Director: David Mant

Increase the use of digital outcome forms from x to y Improvement in the quality of outpatient outcome

data completeness from x to y

% (TBC) decrease of referrals into acute gynae (Note: restriction in place Apr – Jun) )

% (TBC) monitor the conversion rate from community into acute

To be agreed with clinical lead

Increase usage of Advice & Guidance from x to y Reduce NEW/ FU ration from x to y

Reduce hospital cancellations from x to y Reduce patient cancelations from x to y

SMART KPIs- example

• Referral + triage audit with consultants + GPs - baseline of referrals and appropriate triage to clinics (i.e. community)

• Review of clinical pathways – update for community model + new NICE guidance

• Make any adjustments to community model > audit as agreed

• Agree educational support (to include developing FAQ + educational resources)

• Implementation plan to pilot tier 1

• Review current outcome forms in use

• Scope standardisation opportunities, improve outcome forms

• Develop an implementation plan • Explore patient involvement

opportunities • Revenue cycle project – for further

discussion

• Stop pulling records – discuss scope

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Elective Care - Diagnostics Improvement Programme Executive Sponsor: Sara Randall Accountable Officer: Peter Fry Non-executive Director: David Mant


Goal

P2 - Increase productivity and communication

Preparation – One plan, improvement scope

Workstreams

• Improve clinical patient pathways (administrative processes within the hub, referral to book and vetting)

• Improve patient

communication channels (text, letters etc.)

• Amalgamation, oversight and delivery of all diagnostic improvement plans

• Develop one improvement plan • Oversee delivery of single

integrated consolidated diagnostic improvement plan

Effective management of the existing improvement programmes into one coherent plan & delivery

Improve capacity though improving patients communications so they access diagnostics at the right time



Methodology - Quality Service Improvement Programme; Improvement Projects; Plan, Do, Study, Act

- Achieve call pick up rate of XX by XX - Reduction in patient level cancellations of xx by XX

Completed One plan

SMART

KPIs - examples

P1 – Diagnostics Improvement plan

• Deliver the Cancer plan • Reduce time between

diagnostic test request • Complete demand and

capacity analysis and develop improvement plan based on findings

Improve efficiency, reduce waiting times, improve patient experience

- Reduction in waiting times for XX to xx weeks by xx - Meet 7 day Request to Report for ALL cancer patients by January 2020 - Reduction in tertiary referrals of XX by XX

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Goal

P1 – Development of a Trust Cancer Strategy



Workstreams • Development of a Trust

Cancer Strategy

• Developed through the Joint Cancer Committee (OUH and Oxford University)

• Development of an electronic questionnaire for all key stakeholders

Published Trust Cancer Strategy aligned to overall Trust Strategy


Elective Care - Cancer Improvement Programme Executive Sponsor: Sara Randall Accountable Officer: Hazel Craig Non-executive Director: David Mant

Completed Trust Cancer Strategy by October 2019 Reduction in Waiting Times

SMART

KPIs - examples

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P4 - Cancer care pathway (tumour site improvements)

Prioritise and improve cancer patient diagnostic and diagnosis waiting times (Priority on 62Day Pathway)

• Improvement in the Urology Cancer Pathway

• Improvement in the Head

and Neck Cancer Pathway • Improvement in the

LGI/Colorectal Cancer Pathway

• Improvement in the Gynaecology Oncology Pathway

• Improvement in the Lung Cancer Pathway

P3 - MDT reform

Improve MDT processes to reduce their duration and number of patients reviewed

• Agreement of criteria and protocolisation for patients listed on MDT

• Implementation of

standard guidelines for MDT meetings and outcome reporting

• Develop pro-forma

templated to ensure all information regarding patients is uploaded directly to IT systems

x% reduction in time and number of patients on weekly

MDT meetings

P2 – Information Systems

Reduce dual entry of patient data between systems

• Maximising the potential of InfoFlex and improvements in data completeness

• Development of a Cancer Performance Dashboard

• Review of ONEVIEW and BARCO products through Cancer IT Subgroup

x% Reduction in 'Incomplete Records'


Goal

P5 – Living with and beyond Cancer P6 – 28 Day Standard



Workstreams • Define and agree for

each tumour site what constitutes diagnosis

• Reconfiguration of

InfoFlex to capture diagnosis

• Training of Cancer

Pathways Team to show improvements in recording, tracking and reporting

95% data completenesss of people with suspected cancer within 28 days of GP referral


Elective Care - Cancer Improvement Programme Executive Sponsor: Sara Randall Accountable Officer: Hazel Craig

SMART

KPIs - examples

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Improvements in eHolistic Needs Assessments, community care review and Health and Wellbeing offered to patients

• All Tumour sites being offered eHolistic Needs Assessment (eHNA) and improvement in the completion rate

• End of Treatment Summaries implementation

• Training for Staff in regards to Health Promotion and Health and Wellbeing

95% data completeness of people with suspected cancer within 28 days of GP referral by Oct 2019

Improvement in eHNA Completion of x% by x


Goal

P1 – Improve pre op assessment (POA)

P2 – Improve preparation for day of surgery

P3 – On the day improvements



Workstreams • Reduce admin burden by -

Standardisation of patient care across POA Trust-wide and implement accreditation process

• - Evaluation of current POA

structure, process and governance and identify options for improvement

• - Evaluate digital solutions to deliver

a streamlined, efficient and effective service for patients

• Improve patient scheduling (6-4-2)

• Effective session

scheduling • Reduce on the day

cancellations • Reduce Did Not Attends

• Commence theatres within 30 minutes of booked session start time

• Minimise theatre turnarounds • Reduce theatre over runs • Structural Improvements within

theatres • Implement all day theatre lists • Introduce three session days • Reduce back ups in recovery

Patients are treated as planned without a delay

Improve pre-op assessment (POA) Trust wide through following best practice, standardisation and ensuring healthcare equality for all patients

Improve patient experience, staff satisfaction – after Surginet implementation

Trust – Quality Service Improvement Redesign Programme

Elective Care – Theatre Productivity Programme Executive Sponsor: Meghana Pandit Accountable Officer: Mark Scarfe/ David Hallsworth

Scheduled utilisation (%) Actual utilisation (%) Closed sessions (%) Minutes over run Cancelled cases

Efficiency % Late starts (>30)

SMART

KPIs - examples

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Measure & Understand


Improving Non Clinical Productivity Programme Executive Sponsor: Jason Dorsett Accountable Officer: Jon Evans, Andrew Carter, Sara Randall, Gary Welch


Goal

P1 - Premium capacity P2 - Non clinical space P3 – Travel and transport

Workstreams • Optimise the use of space at

OUH@Cowley • Optimise the use of non

clinical space @ John Radcliffe

• Improve housing support to

key hospital workers

Deliver the Agency Ceiling savings and reduce premium

capacity costs through sustainable recruitment

• Implement one way system at the John Radcliffe

• Implement improved off site

parking options for staff at the JR, NOC and CH

• Implement automatic number

place recognition (ANPR) • Develop planning application for

multi story car parks

Better utilisation of space at OUH @Cowley to improve

working conditions

Deliver improved car parking, parking options and travel around

JR site

• Introduce grip and control (Additional sessions, Premium staff)

• Reduce premium staff

volume and costs (AFC, medical and nursing)

• Review clinical outsourcing

& insourcing and optimise premium capacity (radiology, gynae lists)

• Review non-clinical

outsourcing & insourcing and optimise premium capacity

P4 – In year savings

• Deliver procurement savings and admin efficiencies

Deliver £8.6 M nonclinical recurrent in year savings in

2019/20eted

To be completed • To be completed To be completed

Deliver £2m savings – in year Improve utilisation of space at OUH@Cowley

Successful implementation of ANPR project

Deliver £8.6M in year savings against the agreed work plan

SMART

KPIs - examples

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Quality and Safety Programme Executive Sponsor: Meghana Pandit Accountable Officers: Dr Anny Sykes and Dr Peyton Davis Non-executive Director: Improvement Projects

P1 – Safe patient care P2 – Effective outcomes

Goal

Workstreams Improve mortality indicators • Improve HSMR and SHMI

compared to 2018/29 Improve sepsis care • Improve sepsis screening • Increase from 74% to more

than 90% the proportion of sepsis patients receiving antibiotics within an hour

Improve flu vaccination rates • Improve flu vaccination rate

Trustwide compared to 2018/19

Improve patient safety through reducing never events, serious incidents and improve compliance with WHO surgical checklist

Improve clinical outcomes Trustwide

Reduce Never Events • Reduce Never Events by 50%

compared to 2018/29

Serious Incidents Requiring Investigation • Reduce SIRI compared to

2018/19 Improve incident reporting • To achieve top decile Fully implement Quality Impact Assessment process WHO Safe Surgical Checklist • Embed the WHO Surgical Safety

Checklist Policy • Achieve 100% compliance

P3 – Supporting our staff

Roll out Patient safety response team Trustwide PSR pilot rolled out to Horton, NOC and Churchill Embed weekly safety messages • Circulate 52 safety messages

in 2019/20 Develop and embed LOCSSIPS • A minimum of 10 LocSSIPs

developed Clinical leadership • Strengthen and improve

clinical leadership in safe practice

Improve learning of clinical staff across OUH

Reduce never events by 50% compared to 2018/29

Achieve 100% compliance of the WHO

Safe Surgical Checklist

Increase from 74% to more than 90% the proportion of sepsis patients

receiving antibiotics within an hour 10 LocSSIPs developed

SMART

KPIs - examples

27




Governance Programme Executive Sponsor: Eileen Walsh Accountable Officer: Clare Winch Non-executive Director: tbc Improvement Projects

P1 – Corporate Governance P2 – Risk Management

Goal

Workstreams Trust Risk Management Strategy and Processes • Training needs analysis • Training programme in place Development of Corporate Risk Register • 19/20 refresh with Executive • Board workshop on risk

management Development of Divisional, Directorate and CSU Risk Registers • Tailored training for

accountable and responsible leads

Implement improvements to overarching Corporate Governance arrangements

Review and strengthen risk management arrangements linked with enforcement undertakings

Effective escalation to Board • Develop corporate governance

handbook and train Trustwide Well Led Review • Implementation of Well Led

Review recommendations CQC Inspection Response • Response to to be developed • Provider information request

review

To be completed

P3 – Performance & accountability framework

Performance Management Framework • Implement the updated and

revised PMF arrangements Accountability Framework • Develop and implement

Accountability Framework

Review and strengthen performance and accountability framework

P4 – Board Development

Board Development Plan • Review and update the

Board Development Plan

Develop and implement Board development plan

All recommendations implemented by x

SMART

KPIs - examples

Completion of Corporate Risk Register

X% of responsible leads are trained

Completion of Integrated Quality Improvement Performance

Management Framework by x

Completion of the Board Development Programme

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References Kotter, J. P. (1995): Leading Change: Why Transformation Efforts Fail. Harvard Business Review 73 ( 2 ): 59 – 67 .Harvard Business Review, January 2007

Online Resources: http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx https://improvement.nhs.uk/resources/quality-service-improvement-and-redesign-qsir-tools-stage-project/

http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx

https://improvement.nhs.uk/resources/quality-service-improvement-and-redesign-qsir-tools-stage-project/

















integrated improvement programme - july update€¦ · engaged clinicians and staff achieve better...

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