Transcript Document

Transforming surgical services UHBristol
Andrew Hollowood PhD FRCS
Clinical Chair Division Surgery Head and Neck
University Hospitals Bristol NHS Foundation Trust
Bristol Acute Services Review
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UHB and NBT with significant clinical engagement
Assisted by PWC
Financial Challenge to Bristol of £230M next 5 years
Scale of change needs ambitious wide ranging solutions, integrated
with health and social care
• Service Review inc T&O and general surgery
• Urgent Care Pathways in medicine, ED and stroke
Bristol Acute Services Review
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Centralisation of Specialist Paediatrics
Head and Neck, Breast & Urology
Vascular reconfiguration
Cleft
• Benefit for further rationalisation of services was not recommended
through the review
Strategic challenges
Transforming
the ways in
Optimising which we
productivity & deliver care
operational
efficiency
Making
strategic
choices that
directly
address the
challenge
• Disinvest
• Reconfigure
UHBristol Strategic intent
A range of local
and regional
services
Developing our
specialist
services
Patients at the
centre
STRATEGIC INTENT
Promoting
teaching &
research - and
recruiting the
best
Supporting
community
provision
Working in
partnership
ICNARC data Jan-Mar 2014
UHBristol Data
• Inpatient mortality (locked data) was 4/41 (9.7%)
• Predicted mortality 14.3%
• NELA overall mortality 13.4%
Post-op Destination By Post op Risk Prediction
- UHBristol
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Post-op Mortality Risk Prediction
<5%
5-10 %
> 10 %
9
7
5
1
Ward
2
0
HDU/Level 2
1
0
ITU/Level 3
The Challenge
• Agreed protocols to assess and manage risk.
• Timely input of senior decision makers according to the needs of the
patient.
• Appropriate facilities, laid out in such a way as to provide safe and
expeditions patient care in a acute setting.
• Careful planning and provision of adequate resources to enable sufficient
and timely access to emergency theatres.
• Appropriate pre-and post-operative arrangements, including the early
involvement of anaesthetists and critical care specialists and resources
where required.
• A focus on patient centred care, which involves consultant-led
communication with patients and supporters.
Separate pathway models
– Emergency
• Surgical and Trauma Admissions Unit
– 23 beds , 7 chairs, 4 assessment rooms
– USS in assessment unit – radiographer 5 days a week
• Short stay emergency ward
– 18 bed
• Trauma and Orthopaedic ward
– 40 Beds, #NOF bay to rehab
• Co-located on same floor with ICU and theatres
• Dedicated NECOPD staffed separately
– Local Networks - OG, HPB, Thoracics (on call rota)
Emergency Floor
ITU
Heygroves theatres
STAU
Short
Stay
ward
Trauma and
Orthopaedic
POD preop
assessment
Standards & checklists
Divisional Escalation
• Implementation escalation
rota
• Clear internal divisional
support on a daily basis
SCHEDULING
WLO allocates
TCI date
Weekly scheduling
meeting & list ‘sign off’
Elective surgical bed allocation.
EDD based on procedure norms
Daily checkpoint
meeting
Next day list
‘sign off’
ACTIVELY MANAGED BEDS
All teams
working from
same list
Critical care and ward beds
pre-allocated so theatres
can start on time
Critical care, Wards & CSMs
are expecting patient
EDD – patient transferred to
discharge lounge by 12pm
Home
ESCALATION
Ward 700
Wards 700 & 800
PULL patients up
from Level 6
Ward 800
Level 6 – emergency floor
Emergency Department
Divisional outliers
Benefits realisation
Surgical Flow Dashboard
29/08/201
4
ID No
Report Item
Train Track Category Generated by
Frequency
Green
Red
Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14
Daily
0
1
7
12
8
4
10
7
Patient Access and Experience
1
Number of patients on cancer pathway whose
elective surgical procedure was cancelled on the
same day (Non Clinical Reason).
Patient Access and
Experience
Medway
2
Number of patients breaching a cancer standard as
a result of theatre cancellation
Patient Access and
Experience
Hannah Marder
Monthly
0
1
5
6
3
3
2
4
3
% of patient complaints related to elective surgical
cancellations
Patient Access and
Experience
Bev Fitzjohn
Monthly
0%
3%
0%
2%
3%
6%
2%
5%
0%
Daily
5%
5%
37%
43%
42%
27%
27%
26%
44%
0
15
4
4
5
3
5
1
17
8
ED
4
Number of BRI Surgical Patients waiting over 4 hours
ED
in ED
5
Number of Ambulance handovers taking more than
60 minutes
6
Number of in-patient elective surgical procedures on
Theatre
BRI site
Medway
Daily
1%
5%
192
175
227
192
195
185
178
147
7
% of same day cancellations for elective surgical
procedures (non-clinical reason)
Theatre
Medway
Daily
0.80%
1.50%
1.6%
1.8%
1.6%
0.8%
1.7%
1.5% 2.1%
2.9%
8
% of same day cancellations for elective thoracic
surgical procedures (non-clinical reason)
Theatre
Medway
Daily
5%
8%
9
Number of list changes <48 hours before procedure
Theatre
date
Medway
Daily
0
1
10
List start time (% lists starting ≤15 mins of start time) Theatre
Medway
Daily
≥95% <95%
54%
47%
64%
65%
62%
66%
66% 53.8%
11
List Utilisation
Theatre
Medway
Daily
≥85% <75%
79%
75%
81%
81%
82%
81%
82% 69.9%
12
List Picked Up
Theatre
Medway
Daily
≥96% <94%
93%
87%
92%
90%
94%
92%
92% 91.7%
13
Theatres daily checklist completion
Theatres
ED
Medway
South West
Monthly
Ambulance Service
38%
Theatre
Daily
98%
94%
0
3
Daily
98%
94%
Monthy
45%
40%
10.7% 10.0% 8.8%
4.9% 16.7% 10.2% 18.8% 7.6%
0
Dashboard to measure
Delivery of improvements to
emergency and elective flow.
Reflects benefits to
productivity, performance and
patient experience
25%
Recovery
14
Number of patients overnight in recovery
Recovery
Critical Care
15
ITU daily checklist completion
Critical Care
16
% of patients transferred from ITU to the ward within
Critical Care
4 hours (from fit for discharge decision)
Helen Dunderdale
25%
34%
41%
18%
25%
35%
32%
6%
Wards
25%
25%
17
Wards daily checklist completion
Wards
Daily
98%
94%
18
STAU daily checklist completion
Wards
Daily
98%
94%
19
Number of patients in surgery beds with a stay of
over 14 days
Wards
Medway
30
36
20
Number of inter-specialty outliers on Ward 700 and
800
Wards
Medway
Daily
1
2
14
21
Number of non-surgical outlier patients placed into
protected, elective surgical beds on Ward 700 and
800
Wards
Medway
Daily
1
2
5
91% to
92.5%
≥95%
and
≤85%
100.0%
Daily
91% to
92.5%
≥95%
and
≤85%
103.1%
22
Bed Occupancy rate on ward 700
Wards
Medway
Daily
38
42
42
36
35
41
35
42
23
Bed Occupancy rate on ward 800
Wards
Medway
24
Number of patients to the discharge lounge before
12am
Discharge
Medway
Daily
90
70
69
102
102
93
70
91
83
53
25
Number of Patients on Green to go List
Discharge
Site team
Daily
4
8
10
8
17
17
6
11
11
13
Discharge
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4hour flow
ITU discharge
Complaints due to cancellations
List utilisation list pick up
Start time
Completion of checklists.
Specific divisional targets to deliver
operating plan
Measurement - Are we on time?
Surgical Flow Dashboard - Improvements in real time flow
measures
Divisional
Flow
Patient
Access and
Experience
ED
Theatre
Recovery
Critical Care
Wards
Discharge
Summary
• Define the emergency service/patient pathway
• Assess deliverability against standards
• Review data against standards
• Supporting Networks for local hospitals
• Cross trust service reconfiguration where
evidence
• Develop local networks for speciality care
– OG, HPB, Vascular, ITU
Strategic challenges
Transform the
ways in which
we deliver
emergency care
Optimise
emergency
care pathways
Make strategic
choices that
reconfigure
emergency
services