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Urgent Care Improvement Board: 4 Hour Performance November 2014
Executive Summary
Improvement Trajectory
■ The target trajectory is to achieve between 96.5% and 98.3% for Q3. The trajectory
has been refreshed to reflect November 2014 actual performance and all types from
April 2014.
■ Clarification and confirmation of SRG plans in line with the expected trajectory
improvements is required.
■ Key performance measures for the Trust are improving since the introduction of the
Urgent Care Improvement Programme, specifically during the 4 hour step up
improvement period.
Key issues and root causes
■ ED admission rate decreased in month 37.3% (target 37.5%), further analysis required in
December due to change in clinical pathway with MAC direct admissions
■ Ambulance conveyance (+9% in FY14/15)
■ ED is performing well regarding time to treatment performance and patient feedback
■ Majority of 4 hour breaches remain attributable to bed availability
■ BaNES CCG root cause analysis for the weekend period of the 7th to 10th November
■ Impact of the community ORCP schemes to be quantified
Planning
■ The Trust is continuing to run its Urgent Care Improvement Programme
■ The Board initiated a three stage improvement plan
■ Key project for the 2014/15 Programme the development of both Medical and Surgical GP
direct admissions to the Medical and Surgical Assessment Units – operational 12th November.
■ The first stage, the 4 Hour Step Up Programme, focused on actions to be taken by RUH, the
aim to regain performance through September and October. Successfully completed and
reported to the November Board of Directors.
■ This second stage involves a medium term approach to support delivery from November 2014,
including sustaining all urgent care schemes, delivery of GP expected pathways as direct
admissions to both Medicine and Surgery and the delivery of CCG Operational Resilience and
Capacity plans (ORCP). ECIST visit planned 17th December 2014 to review progress,
■ The final stage involves the implementation of a community wide urgent care strategy across
the four CCGs.
■ Performance based upon no greater than 15 DTOC’s in total across all CCG’s.
Current Performance
■ November 4 hour performance was not achieved; 94% (All Types includes Urgent Care
Centre Activity)
■ Weekly green performance achieved since implementation of GP direct admission pathways
(Medical Assessment Unit Area C - MAC)
■ Q3 4 hour performance at risk
Governance and Assurance
■ The RUH Urgent Care Improvement Board is responsible for the programme and
reports monthly to both Management Board and Board of Directors
■ RUH requested from BaNES CCG System Resilience Group an RCA coordinated for
the period 7th – 10th November 2014
■ RUH seeking feedback from the Wiltshire CCG 100 Day Challenge as drawing to a
close
The graph to the right shows
the current trajectory.
RUH 4 hour step up
improvement plan commenced
8th September 2014 and stage 1
completed 31st October 2014.
Key action to continue to
review 4hr performance daily in
Stage 2, linking performance to
ongoing delivery of the Step up
plan operational actions.
Daily monitoring of the
Medically Expected and
Medical and Surgical Direct GP
admission pathways in place.
Ongoing metric review will
confirm that the actions taken
are supporting 4 hour Step up.
Reportable through the Urgent
Care Improvement Board.
Clarification and confirmation
of SRG ORCP plans in line with
the expected trajectory
improvements is required.
Current Trajectory
Week
Ending
Actual
Performance
Standard
06/04/2014 86.0% 95%
13/04/2014 92.7% 95%
20/04/2014 97.7% 95%
27/04/2014 96.8% 95%
04/05/2014 95.4% 95%
11/05/2014 97.1% 95%
18/05/2014 97.0% 95%
25/05/2014 94.9% 95%
01/06/2014 94.6% 95%
08/06/2014 88.1% 95%
15/06/2014 90.2% 95%
22/06/2014 93.5% 95%
29/06/2014 96.1% 95%
06/07/2014 98.0% 95%
13/07/2014 96.7% 95%
Week Ending Actual
Performance
Standard
20/07/2014 94.7% 95%
27/07/2014 94.5% 95%
03/08/2014 96.3% 95%
10/08/2014 92.6% 95%
17/08/2014 89.0% 95%
24/08/2014 90.8% 95%
31/08/2014 87.5% 95%
07/09/2014 91.4% 95%
14/09/2014 94.9% 95%
21/09/2014 95.5% 95%
28/09/2014 96.9% 95%
05/10/2014 96.5% 95%
12/10/2014 90.9% 95%
19/10/2014 87.7% 95%
26/10/2014 95.8% 95%
Week Ending Actual
Performance
Standard
02/11/2014 95.7% 95%
09/11/2014 90.1% 95%
16/11/2014 93.0% 95%
23/11/20014 97.0% 95%
30/11/2014 96.1% 95%
3
DRAFT FOR DISCUSSION PURPOSES ONLY Current Performance
94.0% of patients meeting the 4
hour performance target in
November.
Stage 1 of the Step Up
Improvement completed,
recommendations agreed through
the Urgent Care Improvement
Board and Trust Boards to further
improve performance.
RUH to focus on Medical
Ambulatory Care development
(MAU Area C GP expected
admissions) and Surgical
Ambulatory Care extension of
hours. Services went live 12th
November 2014 delivering 12 of 19
green performance days.
NHS England Type 1 performance
benchmarking RUH ranked 65 of
all NHS Trusts. In November 3
green weeks.
Diagnostic shows a month of two
halves; reduced performance due
to community’s ability to respond
and recovery from the 12th with
direct admission pathway
changes
Remain focused on direct
admission pathways, flow and
back door. No identified
Emergency Department Issues.
The Trust has not consistently met the 4 hour performance target
over the last 2 years, achieving 91.9% in FY12/13, 93.7% in
FY13/14 and is currently 94.2% FY 14/15 year to date.
As a result of this performance the Trust implemented the 2014/15
Urgent Care Improvement Plan which is overseen by the Board.
4 hour performance has been achieved for 2 of the first 8 months of
the year (see table above). The Trust therefore identified the need
for a Step Up Improvement plan to further improve performance.
NHS England benchmarking for November 2014, the RUH ranked
65 of all NHS England Trusts, improved compared to October
2014. Locally the RUH has performed better weekly than all other
trusts except Yeovil who equal 2 green weeks. Overall FY 14/15
year to date 1.6% above NHS England compliance (improved
compared to last month).
Performance below expected national compliance and currently
below RUH trajectory.
2014/15 ED 4 Hour Performance (All Types)
Diagnostic: Compared to trajectory assumptions DTOC and Green
to Go patients increased throughout the first part of the month
contributing to a reduced back door flow and an increase in patients
with a LoS > 14 days. Ambulance conveyance and batching /late
presentation – a daily pattern but significantly exacerbated on the
weekend of Friday 7th November which is under analysis by the
BaNES Urgent Care System Resilience Group; analysis pending
for most providers. RUH reported overall normal weekend activity,
admission to discharge imbalance on the approach to the weekend
reducing the Trusts resilience to respond; early analysis
demonstrates that the community was under pressure with regard
to sufficient capacity and an inability to respond specifically late
afternoon and early evening when HCP ambulance activity is at its
peak. Medical and Surgical pathways changes for GP direct
admissions as per ORCP has had a positive impact on
performance delivering 12 of 19 green performance days. Cycle of
Performance from 12th November improved.
Conclusion: Performance deteriorated in the first half of the month
due to the community's capacity to respond reducing RUH
resilience, which improved significantly from the 12th November
with the introduction of direct admission pathways. Continued
focus on these pathways to further increase performance
opportunity. RCA full outcome required and opportunity to review
providers response to HCP demand later in the day. No identified
issues with ED performance.
Financial Year Quarter Month Attendances 4 Hour Breaches Performance
April 6516 436 93.3%
May 7189 248 96.6%
June 7106 491 93.1%
July 7197 255 96.5%
August 6732 570 91.5%
September 6865 361 94.7%
October 7007 448 93.6%
November 6746 406 94.0%
2014/2015
1
2
3
4
DRAFT FOR DISCUSSION PURPOSES ONLY Impact of Medical Assessment Unit Area C (MAC)
GP direct admissions and Medically
Expected (unless clinically require ED
intervention) directly admitted to MAU
Area C. ECIST recommended pathway.
24 hour 7 day per week service.
Consultant presence; senior decision
makers.
Operational Wednesday 12th November
2014.
First 19 days from operational start .
Aim to manage 20% of the medical take
through Area C – on average in
November 35.% achieved
Daily review of escalation and patient
flow – next steps to review trust wide
escalation policy with specific
reference to both MAU and SAU Area C
Next Steps; increase urgent clinic
availability Cardiology and Neurology
established, and meet with community
for next service development and links
to single point of access
Daily scorecard in place; too early to
draw definitive conclusions; early
indications show the positive effect
this service is having on ED treatment
times at the weekend, post post take
number and same day discharge
therefore a reduction in bed demand.
On the 12th November as per ECIST recommendations Medical
Assessment Unit Area C (MAC) launched; the principle that all GP
direct admissions and medically expected patients (unless clinically
requiring ED intervention) are admitted to MAC. Consequently ED
attendances will be reduced against plan.
From 12th November 2014 Medical Assessment Unit (MAU)
including MAC received 288 direct GP expected admissions
compared to an average of 40 in previous whole months. In
November ED attendances were -250 adverse to internal plan
demonstrating the impact of MAC.
On only two occasions did the % take through MAU Area C fall
below the target 20% for the project. This was at the weekend,
reflecting reduced senior review which has now led to a change in
senior review provision and timing to address senior reviews out of
hours.
20% of patients seen in MAU Area C is the target set to be
discharged the same day; the average for November was 32.1%
exceeding expectations. Only on two occasions did this fall below
20%. See chart.
Urgent clinics are being developed; weekly cardiology and
neurology clinics in place with a plan to extend to Gastroenterology
and Respiratory to facilitate early supportive discharge, in January
2015.
Friends and Family test results will be used as a marker of patient
experience and reported in December.
MAU Area C Activity : Admission and Same Day Discharge Activity
Diagnostic: Length of stay has been reduced on MAU, increased
same day discharge for medically and GP expected patients,
improved ED pathway, improved weekend ED treatment times
which was always elevated in Stage 1 and a reflection of the
pressure at the weekend due to a reduction in discharge; recovery
from Monday onwards and then performance deteriorating into the
weekend when flow is reduced. First three weeks show a change
in cycle and recovery more in line and rhythm with the community –
early indications internal processes improved – best outcome for
patients and contributes positively to 4 hour performance.
Conclusion: Continue to develop the assessment unit philosophy.
Review of Trust escalation plan to support MAU Area C flow to
maintain response and impact on ED.
Overview:
The Trust has created a low and high range target reduction per
week based on their calculation of how many breaches each
scheme will save.
The majority of the reduction in Q3 relates to the Trust’s step up
plan which was planned to take partial effect in October and full
effect from 1st November 2014. The impact of this is a forecast
trajectory of between 97.3% and 99.7% in December 2014.
Improvement Trajectory – 4 Hour Step Up Improvement Plan
The step up plan had three work
streams, front door, flow and
backdoor and twenty immediate
recovery actions were
identified.
Individual plans tracked using
the 4 Hour Step up Daily
Scorecard .
The trust anticipates that the
combined key actions will
reduce the number of breaches
in the Trust through a
combination of front door and
back door improvements.
The low range target is for a
reduction of 49 breaches a week
whilst the stretch target is for a
reduction of 105 breaches per
week.
The analysis shows that the
Trust will need internal and
external plans to deliver at 60-
70% of the stretch target in
order to achieve the 4 hour
standard in January and
February 2015.
Further schemes are anticipated to start to have an impact from
December (Sirona and Somerset CCG). The community ORCP
plans are anticipated to reduce breaches as per the forecast
trajectory.
Further system wide plans are anticipated to take effect in time for
winter. The Trajectory shows that all schemes (excluding the UCC
counting) will need to achieve 60-70% of the stretch target to
maintain performance during January and February.
Forecast Trajectory
Month Low Range Stretch Target
Apr-14 92.7% 92.7%
May-14 96.3% 96.3%
Jun-14 92.4% 92.4%
Jul-14 96.1% 96.1%
Aug-14 90.5% 90.5%
Sep-14 94.3% 94.3% Oct-14 95.2% 96.3%
Nov-14 96.8% 98.7% Dec-14 97.3% 99.7%
Jan-15 94.1% 97.5%
Feb-15 93.7% 96.8%
Mar-15 96.0% 99.5%
Impact on 4 hour wait performance
Month
RUH Sirona Wiltshire Somerset SWAST Dorothy House Primary Care UCC Total
Low High Low High Low High Low High Low High Low High Low High Low High Low High
Oct-14 1.1% 2.2% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 1.1% 2.2%
Nov-14 2.3% 4.4% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.5% 0.2% 2.8% 4.6%
Dec-14 2.2% 4.3% 0.5% 0.9% 0.0% 0.0% 0.0% 0.2% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.4% 0.0% 3.1% 5.5%
Jan-15 2.2% 4.3% 0.5% 0.9% 0.6% 1.5% 0.0% 0.2% 0.1% 0.2% 0.0% 0.1% 0.0% 0.1% 0.9% 0.4% 4.3% 7.6%
Feb-15 2.0% 3.9% 0.4% 0.8% 0.6% 1.4% 0.0% 0.2% 0.1% 0.2% 0.0% 0.1% 0.0% 0.1% 0.8% 0.4% 3.9% 7.0%
Mar-15 2.3% 4.4% 0.5% 0.9% 0.6% 1.6% 0.0% 0.2% 0.1% 0.2% 0.0% 0.1% 0.0% 0.1% 0.6% 0.1% 4.1% 7.6%
Appendix 1 November 2014 System Resilience Group Bath and North East Somerset CCG
4 Hour Improvement Trajectory
■ The RUH target trajectory is to achieve between 96.5% and 98.3% for Q3. The
trajectory has been refreshed to reflect November 2014 actual performance and all
types from April 2014.
■ Clarification and confirmation of SRG plans in line with the expected trajectory
improvement of between 7 and 14 breaches avoided per week for BaNES CCG
SRG.
Key issues and Root Causes
■ ED attendance has increased by 2.2% compared to 13/14
■ Non-elective ED admissions has increased by 2.6% compared to 13/14
■ Trust wide average numbers of Green to Go total 95 and 165 > 14 days length of stay
■ Trust wide average number of complex discharge daily average 7
■ High level of delayed transfers of care (DTOC) – monthly snapshot 2.4%
Planning
■ The Trust is continuing to run its Urgent Care Improvement Programme
■ The Board initiated an improvement plan to regain performance through September
and October 2014, stage 1 evaluated
■ Medium term approach to support delivery from November 2014 in place, including
care system planning and the delivery of CCG Operational Resilience and Capacity
plans (ORCP)
■ Based upon no greater than 5 DTOC’s
■ Final stage involves the implementation of a community wide urgent care strategy
across the four CCGs supporting 4 hour position
Current Performance
■ November 4 hour performance was not achieved; 94.0% (All Types)
■ Year to date 4 hour performance has been achieved for 2 of the first 8 months
■ CCG contribution to adverse performance (all DTOC and complex patients) equivalent to
13 x 4 hour breaches = 0.17%
Governance and Assurance
■ BaNES CCG System Resilience Group (SRG) KPI monitoring
■ RUH Urgent Care Improvement Board and Management Board
■ Urgent Care Provider Forum Key Projects and overview of progress
Diagnostic Exception Reporting
■ Early analysis of RCA indicates DTOC pressures at the beginning and end of month
Low Stretch
Step down beds x20↑ Discharge 3 3 Investment ORCP/Recruitment/Staffing
Night sitting service
Admission avoidance
↑Discharge
0 1 Recruitment
DN clinics at the weekend
↑ Discharge 0 1 Transport
Discharge at the weekend↑ Discharge 3 4 Investment ORCP/Recruitment/Staffing
IV Therapy↑ Discharge 1 2 Investment ORCP/Recruitment/Staffing
SWASFT Mobile rapid response/fallers Admission avoidance 0 1Investment ORCP/Recruitment/Staffing
Dorothy House Hospice at Home↑ Discharge
0 1Investment ORCP
Primary Care Extra GP Sessions
ED Attendance Avoidance
Admission avoidance 0 1
Investment ORCP/Recruitment/Staffing
Sirona
Scheme Potential Benefit Per Week Breach
Avoidance
Risks to Delivery
Appendix 2 November 2014 System Resilience Group Wiltshire CCG
4 Hour Improvement Trajectory
■ The RUH target trajectory is to achieve between 96.5% and 98.3% for Q3. The
trajectory has been refreshed to reflect November 2014 actual performance and all
types from April 2014.
■ Clarification and confirmation of SRG plans in line with the expected trajectory
improvement of between 9 and 22 breaches avoided per week for Wiltshire CCG
SRG.
Key issues and Root Causes
■ ED attendance has increased by 1.3% compared to 13/14
■ Non-elective ED admission increased by 3.9% compared to 13/14
■ Trust wide average numbers of green to go total 96 and 165 > 14 days length of stay
■ Trust wide average daily number of complex discharges total 16
■ High level of delayed transfers of care (DTOC) – monthly snapshot 5.4%
Planning
■ The Trust is continuing to run its Urgent Care Improvement Programme
■ The Board initiated an improvement plan to regain performance through September
and October 2014, stage 1 evaluated
■ Medium term approach to support delivery from November 2014, including care system
planning and the delivery of CCG Operational Resilience and Capacity plans (ORCP)
■ Final stage involves the implementation of a community wide urgent care strategy
across the four CCGs supporting 4 hour position
■ Based upon no greater than 5 DTOC’s
Current Performance
■ November 4 hour performance was not achieved; 94.0% (All Types)
■ Year to date 4 hour performance has been achieved for 2 of the first 8 months
■ CCG contribution to adverse performance (all DTOC and complex patients) equivalent
to 59 x 4 hour breaches = 0.85%
Governance and Assurance
■ Wiltshire CCG System Resilience Group (SRG) KPI monitoring
■ RUH Urgent Care Improvement Board and Management Board
Diagnostic Exception Reporting
■ RUH seeking feedback from 100 Day Challenge as drawing to a close
■ Early analysis of RCA indicates DTOC pressures at the beginning of the month,
continued from October
Low Stretch
Community Escalation CapaictyAdmission avoidance
?Discharge
1 3 Staff capacity
Overnight community support Admission avoidance 0 0 Recruitment
GWH community cluster teams Admission avoidance 1 3 Recruitment
Healthcare professional l ine Admission avoidance 0 0 None
Help to live at home brokerageAdmission avoidance
?Discharge
1 2 Care Home Capaicty
Step up and step down capacity ?Discharge 5 7 New model not tested
Simple point of access and rapid
response
Admission avoidance
?Discharge
1 3 None
Additional POC ? Discharge 0 1 Care Home Capaicty
Domicill iary Care Support ? Discharge 0 1 Staff capacity
Additional Hospital Social Care
Capacity
? Discharge 0 1 Staff capacity
Primary Care Nursing Home
Initiative Admission avoidance0 1 Primary Care Capacity
Wiltshire
Scheme Potential Benefit Per Week Breach
Avoidance
Risks to Delivery
Appendix 3 November 2014 System Resilience Group Somerset CCG
4 Hour Improvement Trajectory
■ The RUH target trajectory is to achieve between 96.5% and 98.3% for Q3. The
trajectory has been refreshed to reflect November 2014 actual performance and all
types from April 2014.
■ Clarification and confirmation of SRG plans in line with the expected trajectory
improvement of between 1 and 5 breaches avoided per week.
Key issues and Root Causes
■ ED attendance has increased by 1.13% compared to 13/14
■ Non-elective ED admission increased by 7.4% compared to 13/14
■ Trust wide average numbers of Green to Go total 95 and 165> 14 days length of stay
■ High level of delayed transfers of care (DTOC) 4.6% monthly snapshot
Planning
■ The Trust is continuing to run its Urgent Care Improvement Programme
■ The Board initiated an improvement plan to regain performance through September
and October 2014, stage 1 evaluated
■ Medium term approach to support delivery from November 2014, including care system
planning and the delivery of CCG Operational Resilience and Capacity plans (ORCP)
■ Final stage involves the implementation of a community wide urgent care strategy
across the four CCGs supporting 4 hour position
■ Based upon no greater than 3 DTOC’s
Current Performance
■ November 4 hour performance was not achieved; 94.0% (All Types)
■ Year to date 4 hour performance has been achieved for 2 of the first 8 months
■ CCG contribution to adverse performance (all DTOC and complex patients) equivalent
to 4 x 4 hour breaches = 0.4%
Governance and Assurance
■ Somerset CCG System Resilience Group (SRG) KPI monitoring
■ RUH Urgent Care Improvement Board and Management Board
Diagnostic Exception Reporting
■ Early analysis indicates DTOC pressures increasing towards the end of the month
Low Stretch
Enchanced out of Hospital Care Admission avoidance 0 1 None
Home Care Packages ?Discharge 0 1 None
Crisis Support Night Sitting Admission avoidance 0 1 Recruitment
GP Weekend Response Admission avoidance 1 2 GP Capacity
Mental Health Admission avoidance 0 0 Recruitment
Somerset
SWASFT
Scheme Potential Benefit Per Week Breach
Avoidance
Risks to Delivery
Appendix 4 RUH Operational Resilience and Capacity Summary of Assurance November 2014
RUH Key Performance Indicators
Key issues and Root Causes
■ Non-emergency patient transport
Planning
■ The Trust is continuing to run its Urgent Care Improvement
Programme
■ The Board initiated an improvement plan to regain 4 hour
performance through September and October 2014. Stage 1
completed and reported.
■ Medium term approach to support delivery from November 2014,
including care system planning and the delivery of CCG
Operational Resilience and Capacity plans (ORCP)
■ Final stage involves the implementation of a community wide urgent
care strategy across the four CCGs
Current Performance
■ All RUH schemes on plan
Governance and Assurance
■ RUH Urgent Care Improvement Board and Management Board
■ BaNES and Wiltshire CCG formal contract review of NPTS (Arriva) due 1st
December 2014
■ KPI’s for all community ORCP schemes required to determine impact upon
4 hour trajectory
Core ORCP Funding - Summary of plan to achieve requirement
Provider
Estimated
Costs in
2014/15
BaNES
Agreed
ORCP
Funding
(41.3%)
Wiltshire
Agreed
ORCP
Funding
(44.3%)
Somerset
Agreed
ORCP
Funding
(14.4%)
KPI Oct-14 Nov-14 Comments
95% 4 Hour Performance
(all types) 93.6% 94.0%
Step up improvement plan in place as part of RUH
Urgent Care programme including SRG
contributions to performance
Total Trust Wide Beds Open
(monthly daily average).
Plan to open 22
9 6 Monthly average escalation beds open
Increased radiology capacity CT/MRI/US to support ED, MAU,
SAU, ESAC and Medical Ambulatory Care.
£389,870 £161,016 £173,000 £0
% CT/MRI inpatient
requests completed in 24
hours (target 80%)
85.6% 87.9%CT/MRI scans completed within 24 hours of
request (inpatient)
Scheme A: Weekend discharge registrar (10am to 6pm
Saturday and Sunday).
Scheme B: Acute Oncology. Increase the service to 7 days per
week -
Scheme A: Evening ward rounds Medical Assessment Unit.
Scheme B: Increasing Medical Ambulatory Care Capacity until
8pm Monday to Friday (Medical Assessment Unit Area C -
MAC)
Weekend and Evening
Consultant MAU Ward
Rounds (target average 7
patient reviews per round)
N/A 14 November 2014 start
% of Medical direct
admissions to MAU Area C
discharged on the same
day. Target 20%
N/A 32.10% November 2014 start
4 Hour Performance (all
types) Target 95%93.6% 94.0%
Step up improvement plan in place as part of
Urgent Care programme
Total Trust Wide Beds Open
(month average). Plan to
open 10
N/A N/ACapital works commenced on plan. Beds due to
open 15th December 2014
Additional non-emergency patient transport to support
patient flow during periods of high discharges and if discharge
needs to be less than the 4 hour NSL and Arriva contracted
response times. Piloted in 2013/14 programme and very
successful with x2 crews. Plan to use x1 crew 11:00-20:00 day
seven days per week which will be managed by the RUH
transport lead who will maximise activity.
£49,500 £20,444 £0 £0 4 per day 32 40
Additional capacity to support discharge.
Subject to ongoing audit (led by RUH transport
Lead with BaNES CCG)
Number of Discharge
reviews reported via the
Discharge Registrar (target
24)
28 47November 2014 start as per ORCP; October start
in line with identified operational requirement
Flexible non-elective medical bed capacity. 12 beds have
been identified to be used during periods of escalation and 10
beds overnight
£1,191,051 £491,904 £264,000 £100,000
£43,913 £18,136 £19,000 £0
£102,124 £42,177 £45,000 £0
£97,000 £0£219,623 £90,704
Additional capacity on core specialty wards to support flexible
capacity modeling. Detailed bed modeling has been
completed by the RUH BIU team, in addition to demand
predictions (based upon 5 year averages) supporting flexible
capacity during periods of highest demand. 4 beds to open
mid December 2014 and a further 6 by the end of December.
10
DRAFT FOR DISCUSSION PURPOSES ONLY Appendix 5 November 2014 RUH Urgent Care Improvement Programme
Overall assessment of the Urgent Care
Programme in November is AMBER.
Front Door. Medical ambulatory care activity
decreased in month, direct impact of MAC
from 12th November 2014. Median wait to
treatment target sustained and improving.
Continued focus on Medical Ambulatory Care
development (MAU Area C GP expected
admissions) and Surgical Ambulatory Care
extension of hours.
Introduction of MAC has lowered the post
post take ward round number to below target
(i.e. reduced MAU length of stay)
Flow. Increased adult bed occupancy,
increased medical outliers. All markers of the
trust in escalation, increased ED admission
rate and increased acuity. All seen at the start
of the month.
Backdoor. Adult non-elective LoS in line with
target. Non-elective geriatric LoS average
and non-elective discharges from ACE-OPU
recovered.
Overall decrease in bed days lost due to
DTOC and complex discharges.
Remain focused on Flow and Back Door as no
identified Emergency Department Issues.
ECIST visit planned for the 17th December
2015 – MAC/SAU and Trauma Pathway review.
The Trust has not consistently met the 4 hour performance target in
2014/15. Diagnostic: Diagnostic: Compared to trajectory
assumptions DTOC and Green to Go patients increasing
throughout the first part of the month contributing to a reduced back
door flow and an increase in patients with a LoS > 14 days.
Ambulance conveyance and batching /late presentation – a daily
pattern but significantly exacerbated on the weekend of Friday 7th
November which is under analysis by the BaNES Urgent Care
System Resilience Group; analysis pending for most providers.
RUH reported overall normal weekend activity, admission to
discharge imbalance on the approach to the weekend reducing the
Trusts resilience to respond; early analysis demonstrates that the
community was under pressure with regard to sufficient capacity
and an inability to respond specifically late afternoon and early
evening when HCP ambulance activity is at its peak. Medical and
Surgical pathways changes for medically expected and GP direct
admission as per ORCP has had a positive impact on performance
delivering 12 of 19 green performance days.
Conclusion: Continued focus on Flow and Backdoor actions and
improvement as per the step up improvement evaluation
recommendations to the Board of directors in November. ECIST
team to review the GP direct admission services on the 17th
December 2014.
.
2014/15 Urgent Care Programme Trust Metrics
Key Actions;
1) From the 12th November 2014 direct pathway to the Medical
Assessment Unit (MAU) Area C for GP expected patients. GP
referred patients, unless clinically an emergency no longer.
assessed in the Emergency Department. Aim to assess one third
of the medical take through MAC. KPI monitoring through UCIB
refer to page 4.
2) SAU Area C now operational 7am to 7pm Monday to Friday.
Further work required to collect robust metric data and determine
% surgical take through the ESAC service. KPI monitoring through
UCIB.
3) 4 hour step up improvement scorecard integrating MAC and ESAC
performance measures in place.
4) RUH ORCP scheme implementation and KPI monitoring in place
5) Wiltshire CCG ED attendance audit and anticipatory care planning
to support ED attendance avoidance.
6) Integrated Transfer Team implementation.
7) ECIST recommendation implementation.
8) Focus on “sustain” work streams.
9) Four Hour Step Up Improvement recommendations and actions to
implement