march 2016 - nhs grampian · june 2016 performance against the 4 hour a&e standard: for the...
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Improvement Programme
March 2016
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Contents
Section 1: Overview
Section 2: HIS Short Life Working Group report – Actions Outstanding
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Section 1: Overview
Introduction
1.1 This report summarises the progress that has been made to address the findings from the invited review of Quality and Safety at Aberdeen Royal Infirmary, the Royal College of Surgeons (England) report and the findings and recommendations from the unannounced Older People in Acute Hospitals inspection.
1.2 The Improvement Programme which was formally approved by the Board in April 2015 gave a commitment to delivering against high quality patient care based on:
Executive and senior management leadership
Engagement between the Board, staff and our patients in terms of planning for future services and the delivery of performance and quality outcomes
Clarity around management structures and operational effectiveness
Commitment to continuous improvement and learning from staff and patients
Supporting staff and building capability, capacity and resilience across all services.
1.3 The aim is not only to make improvements that will have an effect in the short term but also to have a long term impact in relation to the role of NHS Grampian as a partner in the north east of Scotland and north of Scotland health and care community Key findings from the Health Improvement Scotland (HIS) review
1.4 NHS Grampian has the ambition to be a high performing organisation - safe, effective, caring, responsive and well led. Performance against this ambition will be measured by clinical outcomes, patient experience and staff experience.
1.5 This report summarises how the Board have been addressing the key recommendations within the three reports issued on 2 December. The Board and Executive team remain committed to the implementation of all the recommendations in full and providing the leadership needed to deliver the vision, provide support to staff, promote staff engagement and effective team working and ensure that we fulfill our vision of delivering consistently high quality, compassionate and safe patient care.
1.6 A summary of the key outcomes achieved to date is noted overleaf, together with an overview of the status of the implementation of the recommendations arising from the Health Improvement Scotland review. In preparing this report we would wish to recognise the hard work and dedication of all our staff.
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Outcomes and Actions – delivered
Strategic Goal
Improve the health of the population within available resources
Outcomes and Actions
Leadership
We will ensure that effective leadership is established within all areas with clarity around the structure, roles and responsibilities and a sharp focus on the scrutiny of performance and risk mitigation. Nursing and medical staff and management will have equal responsibility and accountability for performance, patient safety and staff governance.
Implemented revised performance management arrangements at Board and Sector level and in support of new Integration Joint Boards
Organisational development plans in place
Commitment to ensuring our values are consistently applied
Established new Acute Sector Leadership Team
Implemented joint management and clinical accountability (pan Grampian)
Patient Welfare & Experience
We will listen and respond to feedback from patients and ensure a culture of learning and continuous improvement is embedded across all services
Improved response to patient feedback
Agreed operational policy
Responding to feedback real-time
Face to face meetings with patients
Changes in clinical practice and team working within General Surgery
Progress in improving care for elderly patients in acute hospitals
Access to Care
We will develop and implement robust and sustainable plans to ensure that patients can receive timely access to care that is high quality and patient-centred.
A sustainable plan for the staffing of the Emergency Department
Consistent and improved performance against the 4 hour A&E waiting times standard
Implemented an Acute Sector Access Times action plan – progress regularly monitored and close working relationship with Scottish Government
Fewer patients waiting with a delayed discharge and further progress planned for 2016/17
Joint responsibility with local authorities for patient discharge
Agreement to a fully integrated unscheduled care system – daily safety huddles in place as a key element of the winter plan
Workforce
We will ensure that the workforce challenges around recruitment, retention and sustainability are addressed and that appropriate mitigating actions are implemented to ensure we can deliver sustainable and resilient services. We will also ensure that all staff, including professional trainees, develop their skills and experience in a positive and supportive environment.
Fewer medical and nursing vacancies
Improved graduate conversion rates
Improved governance for ensuring safe and appropriate staffing cover
Significant increase in the number of consultants engaging in job planning
Evidenced improvement in trainee experience
Staff Engagement
We will ensure that there is a closer connection with all staff to enhance trust and confidence in the Board’s leadership. We will also ensure that the advisory structure is representative of health professions and professional staff and is connected to the Board with a common purpose and agenda.
Empowerment of staff to take decisions to improve care and address concerns
Commitment to an ongoing and meaningful engagement with staff.
Progressing towards stronger working relationships between management and clinical staff
Advisory structure, staff partnership and Board working to common purpose
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Status of progress against the recommendations within the Health and Improvement Scotland review
Recommendation Completed Ongoing
Action 1: NHS Grampian executive team with senior staff in emergency department and other key stakeholders should develop a plan for a sustainable emergency department service that provides patients with safe, effective and person-centred care
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Action 2: NHS Grampian executive team should work with senior clinical colleagues and local managers to review the management of unscheduled care across the hospital, with emphasis transfer of patients from ED to inpatient areas.
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Action 3: NHS Grampian should ensure that the escalation policy for patients whose Scottish Early Warning System score is high is implemented by clinical staff
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Action 4: NHS Grampian should continue to build on collecting real-time patient experience data ensuring this is done reliably and consistently across the services
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Action 5: NHS Grampian should improve the way it investigates, responds to and learns from complaints. 6 -
Action 6: NHS Grampian should carry out a fundamental review of the acute sector leadership with the emphasis on ensuring clear accountability of acute services
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Action 7: NHS Grampian should take urgent action to engage fully with all clinical and nonclinical staff 6 -
Action 8: NHS Grampian should introduce strong and effective governance mechanisms for the clinical, operational and managerial control of services at Aberdeen Royal Infirmary
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Action 9: NHS Grampian should develop and implement a robust nursing workforce plan using mandated national workforce tools.
15 1
Action 10: NHS Grampian should develop & implement a robust medical workforce plan 1 3
Action 11: NHS Grampian should ensure that the training of trainee medical staff is given a sufficiently high priority, ensuring that the General Medical Council and National Training Survey results are reviewed by the Board
2 1
Action 12 Recommendations made by the Royal College of Surgeons (England) All actions on track
Action 13: Recommendations in OPAH report All actions on track
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Section 2: HIS Short Life Working Group report – Actions outstanding at 31 March 2016
Recommendation Progress Responsible Officer Date
Action 1: NHS Grampian executive team with senior staff in emergency department and other key stakeholders should develop a plan for a
sustainable emergency department service that provides patients with safe, effective and person-centred care. The plan should be
Be sustainable in terms of ability to recruit and retain
medical staff and recognise
the reality that the emergency department requires
senior input from specialist emergency medicine
medical staff
that senior trainees will continue to be in short supply
that staff from other specialties whilst valuable in their
own roles cannot be used to substitute for the
expertise of senior emergency medicine medical staff
that senior trainees can make a valuable service
contribution, but are also entitled to expect support
and training that adheres to the appropriate GMC
mandatory regulatory standards2
Outcome – Recruitment to vacant posts
We continue to recruit to all approved posts and
monitor the workforce position on a regular basis,
reporting the position through the Acute Sector
management and performance arrangements.
Outcome – Long term sustainable plan
The ED rota has been reviewed and changes made
to ensure that there is a sustainable Emergency
Department. These arrangements will be further
strengthened by additional training grade staff in
August 2016 and by recruitment to the vacant
consultant posts.
Acute Sector General Manager
Acute Sector General Manager
August 2016
August 2016
Explore the potentially valuable contribution that can be
made by non-medical staff, such as advanced nurse
practitioners, while recognising that senior doctors
leading care will always be required.
Outcome – Further development of front door model
The new front door model implemented as part of the
Board’s winter plan is being monitored throughout the
winter period and will be formally evaluated as part of
the debrief to be undertaken during May
Acute Sector General Manager
June 2016
Performance against the 4 hour A&E standard: for the year ending January 2016:
The total number of attendances was 137,992. This is 2.7% lower than the previous year.
The percentage spending 4 hours or less in an A&E department was 96.0% up from 94.5% for the year ending January 2015. It was also well above the Scotland wide rate of 93.7%.
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Recommendation Progress Responsible Officer Date
Action 4: NHS Grampian should continue to build on collecting real-time patient experience data ensuring this is done reliably and consistently
across the services. This work should include the following
Continue to use patient feedback as a
resource for continuous improvement
Outcome – implementation of rolling programme of surveys
The aim is to have 90% of patients reporting a positive experience of
care. One full round of real-time patient feedback has been completed
across all inpatient areas and several outpatient departments across
NHS Grampian. The surveys have involved the collection of real-time patient and staff
experience information using a survey tool. The purpose of the tool is to
encourage a caring conversation between the interviewer and the
patient, carer or staff member.
We aim to have 80% of staff report a positive experience of care
delivery or work. Where patient/carer experience is being collected we
aim to collect staff experience data also.
The use of improvement trees for the capture of real time feedback has
expanded rapidly across Grampian with sixty trees displayed in clinical
areas and a further twenty mobile trees being used by staff who move
around the region. A total of 1084 improvements have been recorded as
a result of feedback posted on trees.
Patient Opinion is a website where the public can report their
experience of care. We are currently moving to the second level of
registration with Patient Opinion which will allow more staff to have
responding rights, bringing the responsibility for responding closer to
those staff responsible for service delivery. A video of our real-time
patient and staff experience work is available as an example of good
practice on the NHS Scotland Staff Governance website
Director of Nursing
and Midwifery
Completed1
1 Date for completion – originally 30 June 2015
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Recommendation Progress Responsible Officer Date
Action 4: NHS Grampian should continue to build on collecting real-time patient experience data ensuring this is done reliably and consistently
across the services. This work should include the following
Continue to use patient feedback as a
resource for continuous improvement
Outcome – enhanced pool of trained survey workers
The Person-centred Team profile has changed and there are now
more staff trained and participating in the collection of real-time
feedback.
There is a part-time member of staff who has been seconded to carry
out five surveys per ward per week at Dr Gray's Hospital. This is being
achieved most weeks for most wards. Recently we have adapted and
are testing the survey tool to include questions relating to the five must
do with me components of person-centred care
Director of Nursing
and Midwifery
Completed2
2 Date for completion – originally 30 June 2015
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Recommendation Progress Responsible Officer Date
Action 9: NHS Grampian should develop and implement a robust nursing workforce plan using mandated national workforce tools. These plans
should include the following
Detail on how to ensure that there are sufficient
numbers of nurses with the appropriate skill mix
at all times in all wards
Detail on how to fill the gaps, with defined dates
and hierarchical ordering of wards be based on
assessed priority. Through this process, nursing
staff should be made aware of the most recent
results of the national nursing workforce and
workload tool
Consideration of the current bed model in the
context of a 20% gap between staff
establishment in-post and establishment-
assessed-as-being-required, especially in the
absence of a robust plan to successfully recruit
and retain nursing staff
Opportunities to create learning and
communication sessions with senior charge
nurses regarding workforce requirements. This
should include positive communication regarding
the funded skill mix and patients-per-registered
nurse per-shift ratio
Outcome – re-assessment of acute nursing workforce
We have reviewed the acute nursing workforce
encompassing Nursing and Midwifery Workload and
Workforce Planning (NMWWP) tools, professional
judgement, registered nurse:patient ratios, registered
nurse:non-registered nurse ratios, quality data,
supplementary staffing (for example ward house keepers
and bed busters), roster management, senior charge nurse
(SCN) supervisory time, senior professional judgement and
triangulation.
Workforce risks are articulated on the risk register to enable
an overarching view that will support the prioritisation of any
redesign requirements.
Significant work is being undertaken to improve recruitment
and retention.
Outcome – review and challenge of assessment of
workforce
We are embedding consistent governance and assurance
mechanisms across the Acute Sector that focus on safe
staffing models that enable high quality care delivery and
build nursing confidence and capability.
We are in the process of establishing an escalation process
that includes roles and responsibilities that promptly address
concerns raised by nurses about a risk of delays
or omissions of care
Developing and supporting the organisational and Nursing &
Midwifery workforce of the professional responsibility to
assure robust workforce planning.
ADN Modernisation
ADN Modernisation
Completed
30 June
2016
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Recommendation Progress Responsible Officer Date
Action 10: NHS Grampian should develop and implement a robust medical workforce plan. This plan should:
Have a significant focus on securing full
recruitment, including anticipating
retirals and proactively working to
prevent gaps
Outcome – focus on recruiting to vacant posts
Steps that have been taken towards development of a medical workforce
plan are as follows:
Work to develop a full Medical Workforce Plan is progressing,
concentrating on key risk specialities. The final Plan will identify the
risks and gaps for each clinical specialty reviewed, including locum
spend to identify the actions needed to ensure service resilience. This
initial plan will be available by April 2016, with a wider plan for all
specialities developed during 2016-17.
A joint health board and university group has been established, and
continues to meet. Joint workforce opportunities continue to be
investigated, including joint posts.
We have empowered clinical leads to take action (with support) to take
forward any innovative solutions to address gaps in clinical capacity,
including proleptic appointments.
Development of new roles, including Clinical Development Fellows to
support service delivery and education, aimed at recruitment and
retention.
A revised framework for Medical leadership was approved by the
Remuneration Committee in November and will be rolled out in April.
This extends the number of clinical leader roles.
The action plan from the GP workforce summit is progressing well.
The GP lead to support workforce planning has established a live blog
and face book page for vacancies, which has been positively received.
A number of GPs have supported attendance at Career fairs.
Director of Workforce
and Medical Director
30 April
2016 for
first section
of Plan.
Full Plan
for all
Specialities
by
December
2016.
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Recommendation Progress Responsible Officer Date
Action 10: NHS Grampian should develop and implement a robust medical workforce plan. This plan should:
Ensure that the experience of trainees in
their training is consistently good so that
they will be attracted to work in NHS
Grampian after completing training
Outcome – positive experience for trainees
The Associate Medical Director – Education and Training within the
new medical directorate structure has been appointed.
The Director of Medical Education (DME) structure, with divisional
leads for Education and training in acute, has been established.
We have established Medical & Dental Education Governance Group
(MDEGG) to ensure appropriate governance around medical & dental
education. We hosted a successful Medical education Conference in
November 2015, with 100+ participants, including GMC.
Development of new roles, including Clinical Development Fellows to
support service delivery and education, aimed at recruitment and
retention.
e-rostering system for Doctors in Training (DiT) implemented in
Emergency Medicine, Acute Medical Initial Assessment (AMIA) and
rolled out in anaesthesia for DiT & consultants and for DiT in surgery.
Plan to begin roll-out during 2016-17, across acute.
Medical Director and
Director of Workforce
31
December
2016
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Recommendation Progress Responsible Officer Date
Action 10: NHS Grampian should develop and implement a robust medical workforce plan. This plan should:
Ensure all consultants and specialty doctors
complete a job plan review annually, and
have an up-to-date job plan that explicitly
and fairly outlines what is expected of them,
and
Outcome – confirmed and agreed job plans for all consultants
We have defined how engagement and non-engagement with
revalidation and job planning will be measured and support clinical
leads to ensure that there is mandatory application of the need for
all consultants to engage in an annual formal appraisal and job
planning process.
We are liaising with the GMC enquires in relation to the historic
processes for revalidation of posts, clarity regarding the current
position and how we intend to move forward with stronger links
between job planning and revalidation.
NHS Grampian achieved an 86% Job Plan return rate across all
specialties for the year 2014/15. There is a clear picture of the
status for each individual, including under negotiation, on
secondment/leave and non engagement for all individuals. Work
has commenced to improve the quality of job planning, linked to
service requirements and educational and research commitments
in each job plan.
For 2015/16, the number of Job Plans agreed at beginning of
March 2016 is 61%, although a much higher number (88%) are in
the process of being signed off by the Medical Lead – Acute.
Work continues on improving the Job planning process and
electronic templates are being used to simplify the process. This
will allow direct upload into personal files and reduce the
administrative tasks on medical and admin staff. NHS Grampian is
represented on the national work to review job planning.
In consultation with the Job Planning Steering Group, a
specification for the introduction of an electronic job planning
system has been developed. Work will continue this year to further
and improve the quality of the Job Plans and simplify the process.
NHS Grampian is also represented on the national Job Planning
group established in partnership with the BMA.
Medical Director 30 June
2016
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Recommendation Progress Responsible Officer Date
Action 11: NHS Grampian should ensure that the training of trainee medical staff is given a sufficiently high priority, ensuring that the
General Medical Council and National Training Survey results are reviewed by the Board. This arrangement should
Ensure that particular attention is paid to the
current training experience in general
surgery and emergency medicine
Outcome - specific improvement plan for ED and General
Surgery
We will seek to eliminate all red flags in both services by the
2016/17 General Medical Council National Training Survey. The
plan will be presented to the new Medical and Dental Education
Committee in June 2015.
Medical Director 31 March
2017