East Lancashire Hospitals NHS Trust : Our improvement plan & our progress

Personal statement from the Chairman of East Lancashire Hospitals NHS Trust:

“I am pleased to share with you the latest update on our plans to improve the quality of care the Trust provides to our local community. The Board welcomes the findings of the Keogh review, which was as a result of higher than expected mortality rates at the Trust. We, together with our staff, are wholeheartedly committed to continuing to improve the quality of our services. The Board believes we have made significant progress in addressing the findings of the Review, though we know there is still more to do. Once the actions identified within the Keogh action plan have been completed, we will set out a longer-term plan to maintain our progress and ensure that the actions lead to measurable improvements in the quality and safety of care for patients. These will address the findings from our forthcoming Chief Inspector of Hospitals visit at the end of April 2014. There will be regular updates on NHS Choices and subsequent longer term actions will be included as part of a continuous process of improvement.

Our staff were rightly seen by the Keogh review as our biggest asset and we will work together, and support our staff, to ensure we provide compassionate care that places our patients at the heart of everything we do.

We are committed to improving as an organisation and our plan is fundamental to helping us on this journey.”

Professor Eileen Fairhurst, Chairman

East Lancashire Hospitals NHS Trust : Our improvement plan & our progress

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What are we doing?

The Keogh review made 30 urgent recommendations on the 16 th July 2013 which, if implemented, would improve the quality of our services. Specifically, Keogh said that we need to: - Improve the way in which the Board seeks to ensure high quality services are delivered every time, all of the time. This is important

because the Board need to be aware of risks to the quality of our services , to promote patient safety and react swiftly to any emerging issues.

In our response to the Keogh review we emphasised the need to put sustainable, safe and high quality care for our patients at the heart of everything we do. We simplified our vision to set out a clear ambition : ‘ To be widely recognised for providing safe, personal and effective care’. This is supported by five improvement priorities.

One of our key improvement priorities is to reduce mortality. Following the Keogh review we reviewed how we look at mortality in the hospital, particularly how we learn from patient deaths. Now all patient deaths are formally reviewed by a senior clinician and are discussed at weekly departmental meetings attended by all clinical staff. We have a mortality reduction plan, overseen by a steering group of senior clinical staff from a variety of professions. We monitor actual (crude) mortality on a week by week basis so that any unexpected peaks are identified and investigated immediately. We have introduced a number of clinical care bundles, which are best practice packages of care for specific conditions, for example pneumonia and acute kidney injury. There is now clear evidence that our actions have reduced mortality for our patients with specific conditions. Our Summary Hospital Mortality Indicator (SHMI) has been within the ‘expected’ range for the last two months. The SHMI at the weekend has also been within the ‘expected’ range during this period. We are also piloting the use of an electronic clinical Early Warning System on four wards.

A group of senior clinicians have developed a set of professional internal standards to support improvements in our emergency pathway e.g.

how quickly we initially assess patients, response times for diagnostic procedures.

Our performance against the 4 hour maximum wait time in Accident and Emergency services dropped following the Review, whilst actions were being taken to address poor patient experience. Our performance is now improving with the 4 hour standard achieved in February at 95.4%, although performance dipped in March, performance in April is much improved, we achieved over 97% in the week commencing 7 th April. We also now escalate into agreed non core clinical capacity on considerably fewer occasions.

We have a dedicated email address for our local GPs to feedback any concerns. This information will help us to improve services and provides GPs with a central point to ask questions.

- Improve the information that the Board receives about savings plans and their impact on the quality of our services. This is important

because, although we have to make savings each year so that we don’t spend more money than we receive, we need to be better at checking that the savings we make will not have a detrimental effect on the care we give our patients.

The process by which our savings plans are approved has been strengthened to ensure there is no detrimental impact on the quality of care we provide. Plans are now reviewed and signed off by both our Medical Director and Chief Nurse. We are also sharing our savings plans with our Clinical Commissioning Groups .

- Improve the way we use our beds across all of our sites. We will also work more closely with other NHS organisations and the Local Authorities to ensure alternative services can be accessed by patients in a community setting. Both of these points are important because we need to ensure that we can continue to provide high quality care to the increasing number of patients who need to access emergency care.

We have developed an ambulatory care service. This is a service where people coming in to hospital as emergency patients can have investigations, exploratory examinations and receive a treatment plan without the need for an overnight stay. We have also introduced an Outpatient Parenteral Antibiotic Therapy service (OPAT). This services allows patients who are medically stable and whose only reason for hospital admission is the requirement for intravenous (IV) antibiotic therapy to go home and be treated in an outpatient or community setting. Our new Urgent Care Centre building on the Burnley General Hospital site opened at the end of January 2014. The building is purpose built, offering much improved privacy for patients. There is also a separate waiting area for children and their parents.

East Lancashire Hospitals NHS Trust : Our improvement plan & our progress

What are we doing?

- Improve our understanding of the reasons why we have a relatively high number of patients who are readmitted to hospital unnecessarily. This is important because we are now able to move some services into the local community so that they are closer to home which means patients don’t have to go into hospital. This improves the experience for our patients.

We have undertaken a comprehensive audit of our readmissions to establish the reasons why they occurred. We are working with our partner organisations to address the issues highlighted. We have doubled the capacity in our virtual ward, which supports 300 patients, 7 days a week to be cared for in their own home rather than having to come into hospital. We have introduced paediatric hot clinics. Our readmission rate for adults is now within the expected range and the rate for paediatrics is 2% lower than this time last year.

- Engage more effectively with our patients and their carers and provide an increased opportunity for them to improve our services.

We have implemented a more comprehensive walk round programme by our Board members, the focus of which is patient safety and quality. We have held listening events, where members of the public can ask questions or raise concerns directly with members of our Board. We are holding regular events with our members and shadow Governors, for example we held a member event on the 15 January 2014 to share our improvement plans. Governors have been allocated to divisions and are having introductory meetings with key staff and undertaking tours of the areas A new initiative to encourage more feedback from users of our emergency department and urgent care centres through the use of text messaging has begun. There are already signs of significant improvements in response rates and positive feedback. We have launched an extensive public engagement campaign, ‘Tell Ellie’. Changes made as a result of feedback from the campaign will be fed back to the public using a ‘you said, we did’ approach.

- We will listen to patients’ concerns and respond compassionately and quickly and we will listen to what our patients are telling us. It is important to learn from things which don’t go well so that they don’t happen again. We need to support our staff to continue to learn and develop in order to provide the best possible care for our patients

We have extensively communicated with staff in a variety of ways on the importance of complaints and concerns raised by patients and relatives as a mechanism of learning and improving care. We’ve introduced a new education and training programme on how to respond to and learn from complaints. A new complaints handling process is in place that changes emphasis from investigation and formal response to understanding complaint/concern, offering an early meeting, responding empathetically and learning to improve care. Executive directors review all new complaints and clinical teams are invited to discuss what lessons should be learned focussing on the issues from the patient’s perspective. Patient stories have become a feature of Trust Board. We also use patient stories at a variety of meetings as a learning tool. For example a patient’s relative attended our joint clinical leaders’ forum in early February to share their experience and describe the impact of staff behaviours. Our Chief Nurse and interim Director of HR and OD have also been ‘back to the floor’ where they are working alongside staff across the organisation to learn and understand the issues our staff are facing on a day-to-day basis. A monthly quality report produced by Medical Director / Chief Nurse incorporating ‘lessons learnt’ from engagement activities and complaints is shared with the Board

- Constantly review our workforce numbers and work hard to meet the changing needs of patients in our care. This is important to ensure all the needs of our patients are met and that the care that we give is safe and effective.

We commissioned an external review of nurse and midwifery staffing levels, which has resulted in range of actions taken including the introduction of a daily staffing template, daily staffing teleconference, roll out of the publication of daily staffing numbers and the introduction of a monthly ward scorecard.

We have significantly increased the number of nurses on duty at nights and are continuing to recruit additional trained nurses, health care assistants and midwives. We have improved our recruitment processes and initiated a major innovative recruitment campaign. This has also included the recruitment of nurses from Portugal and Italy. Our sickness absence levels are improving and levels are significantly below the North West average and below the national average. We now employ 12 more consultants, 118 more qualified nurses, 172 more nurse support posts than we did on the 1 April 2013.

East Lancashire Hospitals NHS Trust : Our improvement plan & our progress

What are we doing?

- Strengthen the leadership and support to our nursing staff. This is important so that our nurses and midwives feel valued and

ensures excellent and consistent nursing is provided throughout the Trust.

We have reviewed our organisational development strategy and cascaded our leadership development programme to our matrons and specialist nurses. Our Nursing and Midwifery Strategy , which nurses and midwives from across the organisation contributed to, has been published and sets the direction for our nurses focussing on the 6Cs, the nationally recognised nursing values of Care, Compassion, Competence , Communication , Courage and Commitment, with patients firmly at the centre of all that we do.

• The Customer Care Strategy has also been reviewed. A revised customer care training programme, aligned to providing Safe, Personal, Effective has been developed. The Customer Care training approach includes face to face sessions , using interactive group discussions/use of case studies. In addition an on-line Customer Care programme is now available to all staff. Staff can access the on-line training at any workstation. ‘Hotspot’ areas within Divisions have been identified using complaints information.

We have also significantly improved levels of staff attending their required core and safeguarding training This has been achieved through providing additional training sessions, evening sessions being particularly well attended, and on-line facilitated e-learning sessions.

This document shows our plan for making these changes and our progress. It builds on the ‘Key findings and action plan following risk summit’ document which we agreed immediately after the review was published. This can be found at: http://www.nhs.uk/nhsengland/bruce-keogh-review/pages/published-reports.aspx

• Whilst we make these changes to address the Keogh recommendations, the Trust is in ‘special measures’. More information about special measures can be found at measures http://www.ntda.nhs.uk/blog/2013/07/16/nhs-tda-places-five-trusts-in-special . The Trust Development Authority are working with us to ensure we have the right support in place to make these changes as quickly as possible.

East Lancashire Hospitals NHS Trust : Our improvement plan and our progress

Who is responsible?

Our actions to address the Keogh recommendations have been agreed by the Trust Board.

With the Board our Interim Chief Executive, Jim Birrell, is ultimately responsible for implementing actions in this document. Other key staff are our Medical Director, Ian Stanley and our Chief Nurse, Christine Pearson, who are tasked with implementing many of the key actions described, which will help improve the quality of care delivered by our staff and enhance patient experience.

Nicky O’Connor from the Trust Development Authority is helping us to implement our actions by supporting and challenging the process by which we will ensure we deliver on our action plan.

We will also be assessed by the Chief Inspector of Hospitals, who is due to re-inspect our Trust in April 2014.

If you have any questions about how we’re doing, please ring Chris Hughes our Interim Director of Communications on 01254 732160, or if you wish to contact Nicky O’Connor, as an external expert, you can reach her on [email protected]

How our progress is being monitored and supported

We will update this progress report on the first day of every month while we are in special measures.

• We will work with our Shadow Council of Governors, members and Healthwatch to ensure that the improvements we are putting in place are effective. We will also hold public meetings and attend listening events, where we will update, face to face, our local community on our progress. We will also produce monthly press briefings which describe how are delivering against our improvement plan. Further details will be announced in updates of this progress report.

• Marie-Noelle Orzel has been appointed as the Trust’s Improvement Director by the Trust Development Authority. Improvement Directors are appointed to provide expertise to the Trust Board on how to improve services and to check that we are meeting our promises to deliver our improvement plan • We will access support from partnership working as appropriate with the Academic Health Science Network, NHS Improving Quality and the NHS Leadership Academy. (Timescale: By April 2014; Owner: NHS England).

Professor Eileen Fairhurst Chairman of the Trust (on behalf of the Board)

Our improvement plan

This table shows the actions we’re taking to address the concerns about the quality of our services which were raised in the Keogh report. It also shows how we are progressing against our actions.

Summary of Keogh Concerns Summary of Urgent Actions Required Agreed Timescale External Support/ Assurance Progress B/G/R/ narrative

Improve the way in which the Board seeks to ensure high quality services are delivered every time, all of the time Improve the information that the Board receives about savings plans and their impact on the quality of our services Improve the way we use our beds across all of our sites The Board will undertake a specific development programme which focusses on quality and safety. This has helped us to emphasis the need to be safe personal and effective.

We will work through the information from the listening events carried out by the Keogh Review Team to look very carefully at the issues raised and make sure wherever possible we don’t repeat the same failings. We will share this learning with our CCG colleagues.

We will increase the number of spot checks in clinical areas to ensure that the care being provided is of the highest standard.

We will work harder to understand the priorities of our patients, their carers and our staff. This will support us in being more personal in our approach.

We will target and address specific areas of concern to drive clinical quality and safety improvements across our organisation. This is embedded within our ‘share-to-care’ communications for cross organisational learning, allowing us to be more effective. The Board will put in place triggers for all patient safety and quality issues to make it clear to our staff when they need to notify the Board of issues which need closer review.

Our Medical Director and Chief Nurse will review all of our savings plans to ensure there isn’t a detrimental impact on the clinical services we deliver.

Agree our plans for winter and ensure that all of the beds that we use are in environments which support the privacy and dignity of our patients.

Continued spot checks on escalation areas when in use.

End Aug 2013 End Aug 2013 End July 2013 End July 2013 End Sept 2013 End July 2013 End July 2013 End Aug 2013 NHS Improving Quality Improve our understanding of the reasons why we have a relatively high number of patients who are readmitted to hospital unnecessarily We will comprehensively analyse the data on patients who have been readmitted unnecessarily and put in place an action plan to address any issues identified. Our Board will look at the learning from this work to ensure our discharge processes are safe and effective. End Sept 2013

Our improvement plan

This table shows the actions we’re taking to address the concerns about the quality of our services which were raised in the Keogh report. It also shows how we are progressing against our actions.

Summary of Keogh Concerns

Engage more effectively with our patients and their carers and provide an increased opportunity for them to improve our services

Summary of Urgent Actions Required Agreed Timescale

Our Medical Director will oversee patients’ concerns alongside the newly appointed Complaints Manager.

We will work with our key health partners to share learning and improve the care we provide for our community.

End July 2013 End Aug 2013

External Support/ Assurance Progress B/G/R/ narrative

Constantly review our workforce numbers and work hard to meet the changing needs of patients in our care We have obtained support to help us better understand our nurse staffing levels and how our nursing staff can best meet the care needs of our patients.

Develop a process to constantly review the skills of our nursing teams and better understand the impact of vacancies.

Review the workforce information which is provided across our organisation and develop reporting on recruitment activity levels, by area and staff group.

End Sept 2013 End Sept 2013 End Aug 2013 External reviewer Strengthen the leadership and support to our nursing staff.

We will place particular emphasis on our senior nurses and midwives participating in our Leadership Programme. This programme focusses on the values and behaviours we want to see shown in our organisation and will help to ensure we are consistent in how we deliver high quality care.

End Aug 2013

How we’re checking that our improvement plan is working

This table shows how and when we are checking that the actions we’re taking are making a real difference on our wards, in our operating theatres and in our community services. It also highlights how we will be communicating our progress to our local community.

Oversight and improvement action Timescale Action owner Progress

Monthly accountability meetings with Trust Development Authority and our Clinical Commissioning Groups to track delivery of action plan. The Clinical Commissioning Groups are working closely with us to provide assurance to their governing body that we are delivering appropriate actions to make a difference.

We will use the partnership working with Salford Royal Hospitals NHS Foundation Trust to learn how we can strengthen our leadership, governance processes and make improvements to the quality of services that we provide. Appointment of an Improvement Director (Marie-Noelle Orzel) by TDA, who will provide expertise to the Trust Board on how to improve our services and check that we’re meeting our promises to deliver our improvement plan .

The monthly meetings of the Trust Board and the Executive Management Board will review evidence about how the trust action plan is improving our services and changing the way we work for the better. There will also be bi-weekly Keogh Action Plan Meetings attended by our Executive Directors who have lead responsibility for implementing the action plan.

Trust Reporting to the public about how our trust is improving through Healthwatch, our Shadow Council of Governors, members, our website, listening events and the local media. We will further develop our communications plan over time Agreement and regular reporting of quality measures to demonstrate that the actions are leading to improved quality of care for patients.. Our performance will be published on our website.

Aug 2013 to July 2014 Aug 2013 onwards October 2013 2 weekly Sept 2013 to July 2014 Monthly Monthly Trust Interim Chief Executive/Special Measures Director Trust Interim Chief Executive TDA Trust Chairman Trust Interim Chief Executive Trust Interim Chief Executive/TDA

How we’re checking that our improvement plan is working

This table shows how and when we are checking that the actions we’re taking are making a real difference on our wards, in our operating theatres and in our community services. It also highlights how we will be communicating our progress to our local community.

Oversight and improvement action

We aim to complete an independent review of the quality and governance systems at the Trust. We aim to have this completed within the next six months .

Timescale

Sept 2013 to Feb 2014

Action owner

Trust Interim Chief Executive

Progress

An independent review of our quality and governance systems was carried out in November 2013. We have subsequently undertaken a self-assessment against the Board Governance Assurance Framework. The draft self-assessment against the Quality Governance Assurance Framework will be reviewed by the Board at their meeting in April. We agreed with the TDA to commission a further independent review of our quality and governance systems at the Trust at an agreed point after our Chief Inspector of Hospitals visit.

External scrutiny of our new ways of working and of the quality of our services by a Quality Surveillance Group (QSG) composed of the Trust CE, Trust Medical Director, NHS England Area Team and CCGs.

Re-inspection.

Sept 2013 to July 2014 April 2014 Trust Interim Chief Executive /Special Measures Director/AT/CCGs CQC

Key for progress reports

Blue -delivered Green – on track to deliver Narrative – disclose delays/risks/plan to recover Red – not on track to deliver