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DATE OF MEETING 25 September 2018

REPORT FOR Trust Board of Directors – Public

REPORT FROM Peter Reading, Chief Executive Kathryn Helley, Deputy Chief Operating Officer – Improvement and Productivity Claire Pacey, Improvement Director, NHSI

CONTACT OFFICER Kathryn Helley, Deputy Chief Operating Officer – Improvement and Productivity

SUBJECT Improving Together Stocktake

BACKGROUND DOCUMENT (IF ANY) CQC Report

PURPOSE OF THE REPORT: To provide an update on the outcome of the Improving Together Programme Stocktake

EXECUTIVE SUMMARY (PLEASE INCLUDE: A SUMMARY OF THE REPORT, KEY POINTS & / OR ANY RISKS WHICH NEED TO BE BROUGHT TO THE ATTENTION OF THE TRUST BOARD AND ANY MITIGATING ACTIONS, WHERE APPROPRIATE)

The Improving Together Programme was established in early 2017 in order to bring together disparate but inter-related pieces of improvement work across the trust. It incorporated, at that time, the Care Quality Commission (CQC) action plan (including waiting lists) and the existing sustainability programme which was finance focused. The programme was reviewed in August 2017 by Ernst and Young and some changes were made to the workstreams and reporting mechanisms. Several of the current executives were not in post when the programme was originally set up and the trust was placed into financial and quality special measures after the programme was established. It was therefore timely to undertake a stocktake of the programme and the attached paper outlines the outcome of this review.

TRUST BOARD ACTION REQUIRED The Trust Board is asked to note the content of the report.

Prepared by Claire Pacey and Kathryn Helley NLAG Improving Together Programme Stocktake September 2018

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Improving Together Programme Stocktake

Introduction and Purpose

The Improving Together Programme was established in early 2017 in order to bring together disparate but inter-related pieces of improvement work across the trust. It incorporated, at that time, the Care Quality Commission (CQC) action plan (including waiting lists) and the existing sustainability programme which was finance focused. The programme was reviewed in August 2017 by Ernst and Young and some changes were made to the workstreams and reporting mechanisms. Several of the current executives were not in post when the programme was originally set up and the trust was placed into financial and quality special measures after the programme was established. It was therefore timely to undertake a stocktake of the programme and the following outcomes were agreed:

1. Collective understanding and agreement about the purpose and function of the Improving Together Programme

2. Agreed and defined workstreams with owners 3. Agreed governance and reporting arrangements and clear understanding of the difference

between ‘business as usual’ (BAU) and programme work (see Appendix 1)

4. Joint understanding and agreement around support structures and enablers.

The following sections provide an overview of the discussions and agreements reached during the stocktake session.

1. Purpose and function of Improving Together • Extra support/focus/effort on agreed pieces of work • Programme approach • Transformation vehicle – rebuilding the organisation • Quality story/narrative – wider than CQC • Getting the basics right • Sustainability • Moving things to BAU – without this there is a capacity problem in the programme • Developing solutions bottom up • Improving Together Programme Board agrees priorities and provides a framework to

enable flexibility – the ability to turn things on and off (Appendix 2) • Human factors and impact on decision making • Collective agreement of closing projects – moving to BAU and agreeing where it is

monitored


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2. Workstreams and Senior Responsible Officers (SROs)

The following workstreams and SROs/deputies were agreed:

• Quality and Safety – Kate Wood SRO, Tara Filby Deputy • Leadership and culture – Jayne Adamson SRO, Peter Reading Deputy • Access and flow – Shaun Stacey SRO, Pam Clipson Deputy • Finance (CIP and income improvement programmes) – Marcus Hassall SRO, Shaun

Stacey Deputy • Strategy and capital – SRO Pam Clipson, Peter Reading Deputy • Workforce and staffing – Shaun Stacey SRO, Jayne Adamson Deputy

3. Governance and reporting

• Improving Together programme board will remain monthly with reduced membership a. The board will be known as the Improving Together Executive Board (ITEB).

The board will be chaired by the Chief Executive Officer (CEO) and membership is the executive SROs, the Deputy Chief Operating Officer – improvement and productivity, Turnaround Director. In attendance is the Improvement Director, NHSI.

b. Reporting will be by exception c. ITEB reports to go to Trust Management Board (TMB) for information and

discussion d. ITEB reports directly to Trust Board

• It was agreed that the existing workstream oversight meetings would continue where needed. They would be reviewed once the trust performance meetings were set up and running.

• It was agreed that future reports needed to be a combination of numbers/facts and narrative to provide process and outcome information to support driving improvement.

• A 4 quadrant report was suggested that would: a. Facilitate gaining support/help from other SROs b. Provide assurance for the CEO in order to report to the trust board c. Include Gantt/run charts to make tracking progress easier and more visual

• It was agreed that a single version of the truth was essential. This would be a single data set in digital format with the ability to filter/interrogate the information. There would also be an agreed subset/dashboard for each workstream.

• It was agreed that the level 1 and 2 KPIs would stop and be replaced by the workstream dashboards.


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4. Support structures and enablers • The Improvement Team was established in September 2017 and a programme of

recruitment took place during the early part of 2018 leading to a fully established team being in post from May 2018 and staff are aligned to the different workstreams within the programme (see Appendix 3). It was recognised that the team have supported the organisation over the last year to delivery some significant improvements, some of which are outlined in Appendix 4. The support to each workstream was reviewed and it was agreed that, with the exception of the staffing workstream, support was sufficient. It was agreed that the Deputy Chief Operating Officer – Improvement and Productivity, would review how additional project support could be provided which has led to a temporary movement of one member of the team from the Access and Flow workstream to Safe Staffing, with the approval of the SRO.

• Some workstreams may require some additional expertise/skills and the is outlined in Appendix 5. The exact nature of this support is currently being worked up with support from the NHSI Improvement Director.

• In addition to this, the Trust is receiving support from external bodies such as NHSI. It was agreed to review this support to ensure that it is targeted to the right areas. The Deputy Chief Operating Officer – Improvement and Productivity, is to meet with the Trust’s Improvement Director and Delivery Improvement Lead from NHSI and review current support.

5. Workstream Scopes • A review has taken place, with confirm and challenge from each of the SROs to identify

the key priorities which should be included in each of the workstreams, taking into account the issues identified within the CQC report. The output of this work is attached as Appendix 6.

6. Conclusions

The Improving Together programme has evolved over the past 12 months and continues to respond to the needs of the organisation. This will continue to be monitored to ensure that if Trust priorities change, this is reflected appropriately in the programme.


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Appendix 1


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Appendix 2


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Appendix 3

Improvement Achievements to Date

Appendix 4

Deteriorating Patient NEWS2, OEWS & PEWS implemented

Hand-held devices in use across the trust to record clinical observations

Deteriorating patient escalation policy implemented

Maternity Revised staffing model implemented at SGH

Embedded Maternity Safety Assessment Tool (escalation policy)

95% staff completed CTG mandatory training 100% compliance with WHO checklist

Competency framework in place for trainee doctors

A&E Care & comfort rounds in place

NEWS2, OEWS & PEWS embedded New trust-wide documentation in place

Environment is clean and fit to deliver care Children’s pathway flow-chart in place to guide

escalation and staff undertaken PILS Ambulance handover process reviewed & changes

implemented

Theatres WHO checklist implemented across the trust

(not just theatres) – 98.8% compliance in theatres, 99% in endoscopy & 94.9% in radiology

Systems in place to provide dedicated anaesthetic support to obstetrics 24/7

Second obstetric theatre policy & escalation in place with associated SOP and onsite sleeping

arrangements

Mental Capacity Mental Capacity Act lead nurse appointed

Process for recording patient’s mental capacity in place

Method for monitoring MCA/DOLS in place Delirium policy and pathway developed &

associated training provided

Mortality Clinical leads for each site appointed

Mortality analyst appointed New learning from deaths process in place

Quality and Safety

Pride and Respect Programme commenced with over 100 staff

volunteering to drive this forward

Listening Together Listening to staff through crowd-fixing

events has led to numerous initiatives to drive patient and staff experience

Communication Strategy Review of trust

communication/engagement mechanisms and establishment of the Leadership

Community Briefing from the CEO with cascade to all staff

Medical Engagement Divisional Clinical Directors leading on all

aspects of engagement within their division – including developing engagement drivers and identifying barriers to communication

with front-line staff

Leadership Development Divisional Clinical Directors undertaking a

development & leadership programme Apprenticeship programmes in place for

level 3,5 & 6 with 7 starting in September Nursing leadership programme commencing

in July 2018

Supporting Doctors in Training Gathered views from Junior Doctors to enable issues to be fixed and overall experience to be

improved

OD and Culture

On the day cancellations due to DNA in theatre

reduced by 10%

Text reminding for planned operations and

call reminding for out patients introduced

Out-patients utilisation increased month on month for 6 months (currently at 87%)

Hospital cancellations for outpatients below

Trust target for 8 months (6% against

target of 7.5%)

RTT/PTL training conducted to

refresh/upskill leaders and managers

Patient cancellations in out patients currently at

4.7% against target of 7.5%

DNA levels in endoscopy at 5% in May, down

from 6% in December 2017

JAG accreditation achieved at DPOW

Hospital cancellation within 2 days of TCI for

endoscopy at 4.3% against a target of 7%

Planned Care

ED Streaming implemented on both

sites with GP service at the front end of ED

62 additional patients per month admitted

through surgical ambulatory care

255 additional patients per month admitted to

medical ambulatory care compared to last

year

SAFER Red2Green rolled out to all wards

Length of stay reduced from 7.8 days to 6.8

days

Development of a single integrated discharge

team model for North Lincolnshire

3 month frailty pilot agreed with

commencement towards the end of June

Stranded patients with a length of stay over 7

days reduced from 409 to 378

Dedicated purpose built Medical Ambulatory

Care Unit with establishment of general

medical pathways

Unplanned Care

Delivery of £11,530k CIP savings in

2017/2018

YTD (M1 & M2) delivery of £1,453k CIP savings against plan of

£1,292k

Programme of work ongoing with NHSI

Operational Productivity Team

Team now fully established and in post

(See next slide)

Co-ordination and management of the

GIRFT programme now moved to the team

Monitoring of the CQUIN programme

now within the portfolio of the team

Finance and PMO

Workstream Support Workstream Current Support Required Support Quality and Safety Improvement Delivery

Manager Improvement Project Manager

Improvement Delivery Manager Improvement Project Manager

Leadership and Culture Improvement Project Manager Improvement Project Manager External specialist support with specific OD skills

Workforce and Staffing Improvement Delivery Manager

Improvement Delivery Manager 5 posts identified in W/S brief

Access and Flow Improvement Delivery Manager x 2 Improvement Project Manager x2

Improvement Delivery Manager x 2 Improvement Project Manager x1

Finance Finance Manager Improvement Project Manager

Finance Manager Improvement Project Manager

Strategy and Capital No current support from Improvement Team

May require specialist external support

Appendix 5

Patient Safety Clinical Effectiveness Patient Experience

Maternity including CNST Evidence based practice End of life

Emergency Department Mental Capacity & Vulnerability including dementia and LD

Always events

Children’s Services Nutrition & Hydration Way finding

Medical record keeping SI process/Clinical governance Links to Pride and Respect – experience of staff behaviours

Safe use and storage of medicines (Medicines Management)

Mortality strategy & learning from deaths

Deteriorating Patient, Sepsis & Critical care outreach

Ward Assurance Tool

Safety of patients on waiting lists Ward Excellence Programme

AKI ? Anti-microbial prescribing (CQUIN)

Pressure ulcers ? Alcohol and Tobacco use (CQUIN)

Positive identification of patients ? Assessment of wounds (CQUIN)

Equipment including training ? Personalised care & support planning (CQUIN)

Clinical coding

Quality and Safety Appendix 6

Leadership and Culture

In scope

Pride and Respect (including Listening to Improve)

Supporting junior doctors

Developing the Safety Culture – including medical engagement and human factors

Leadership development

Quality Improvement - methodology and mechanism

Retention

Career pathways

Organisational re-design (Operating Model) – staged single plan including interim arrangements

Workforce & Staffing Medical Nursing AHP

Job planning Establishment review AHP workforce plan development to meet service needs

*Bank management and regional working

CNS job planning Systems and process to manage temporary staffing (development of full use of bank)

Agency rates *Weekly pay Capacity identification for T&O

*Rota co-ordination *Grip and control Job planning for AHPs

Temporary staffing (agency market management)

Safecare live

Workforce planning/Medical & Nursing Establishment Review

Recruitment including new roles

ESR

*Resource Centre - rostering of substantive staff and management of temporary staffing

*Occupational Health (including Flu Vaccine CQUIN)

* Indicates work related to Resource Centre

Access and Flow

Planned Care Unplanned Care

Improving elective productivity (inc timed pathways, GIRFT, RTT and reduced 52 weeks, stabilising waiting lists, cancer and specifically colorectal and pain management)

Ambulatory care

Cancer: straight to test diagnostics Frailty

Endoscopy JAG accreditation Short stay

Radiology routine reporting outsourcing SAFER – red to green inc daily board rounds

Cancer: improve productivity Discharge – Home First approach

Theatres – culture and pre-assessment Hospital at Home

Home based delivery of IV fluids

Outpatients • Moving out into community • Facilities/estates – condition of existing areas

Step up/step down facility in community

GP streaming – linked to urgent care centre

Patient admin (ward clerks and trackers)

Internal professional standards

ECIP & ECIST GIRFT

Finance

Central grip and control Income Non-Clinical Service Re-design (‘Carter’)

PPIB/Procurement Income development Management Cost Optimisation

Pharmacy

Pathlinks Estates and Facilities Programme

Discretionary Spend Control

Central Budget Management

This workstream should be a mirror of all other relevant areas – e.g. LOS as a KPI related to unplanned care

Short term piece of work to find/develop ideas to close the financial gap

Strategy and Capital The Strategy Components Assurance

(NHS England national process)

1. Case for Change • Population Health Needs • Alignment CCG / NHSE

2. Scenarios explored and discounted

• Clinical Interdependencies • NHS England Assurance Stage 1

3. Place Based Care • Specialty Intelligence

• NHS England Assurance Stage 2

4. HASR / STP Care • Partnership Strategy

• NHS England Decision Outcome

• Comms & Engagement Strategy

• Progress to Consultation

• Scenario Development

• Impact Assessment

• Investment strategy

• Capital investment

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