Summary of Actions Action Owner Timeline Action Timeline 3.1 CAPACITY - Optimising Existing Hospital and Community Capacity 3.1.1 Reducing Delayed Discharges Agree what is meant by a delayed discharge so that it can be appropriately measured and targeted at hospital and community level HSE, Social Care Immediate Set and maintain NHSS wait time of 4 weeks through the provision of adequate funding in 2015 HSE, Social Care Q2 2015 Enforce regulatory guidelines for submission of financial and CSAR information to NHSS HSE, Social Care in conjunction with AHD Immediate Set and enforce timelines for processing of financial information by Nursing Home Section HSE, Social Care Immediate Set and oversee individual Hospital targets to ensure that the total number of Delayed Discharges does not exceed 500 in 2015 and that no hospitals delayed discharges are in excess of 10% of its available beds. This should include individual Hospital weekly discharge targets for Social/Primary Care as identified by the SDU. HSE Social Care/Primary Care in conjunction with AHD Immediate Set targets, by Hospital, for delivery of Home Support services to ensure minimum delay for patients in Hospitals accessing appropriate supports. It is recognised that home support is not a demand led scheme but is budget capped and must meet the requirements of those in hospital and in the community HSE, Social Care Immediate Define and implement a menu of appropriate clinical pathways using the information that is already available i.e. 27 Clinical Programmes each of which describe in detail an evidence based clinical pathway HSE Care Q4 2015 Define Community/Acute Hospital Catchment Areas for older person’s services specifically HSE AHD & Social Care& DOH Q2 2015 Develop and implement agreed metrics to ensure that agreed targets for delayed discharges are being met consistently at national and hospital level HSE AHD/Social Care/Primary Care Q2 2015 Develop Integrated care pathways across the acute hospitals/community interface in the context of the newly created Divisional structures HSE AHD/CCP Q4 2015
Review resource requirements for G.P OOH’s services and CITs should the campaign result in an increased number of patients presenting at these services HSE AHD/Primary Care Immediate Each CHO provide a live electronic contacts register of primary care and social care clinical and admin contacts (phone and email) to local hospitals for ease of communication HSE CHO’s Immediate Make greater use of electronic communication, including references to the usage of “healthmail” which allows all hospitals to communicate clinical information securely to GPs HSE Primary Care Immediate Commence discussions with relevant stakeholders including representative bodies to develop the expanded roles of nurses in areas of prescrbing, IV fluids and antibiotic therapy within the long terms care facilties, inclduing the potential for training and/or recruitment of Nurse Prescribers/ANPs in community to work collaboratively of GPs and Out-of Hours services, good examples of similar nurse-led walk-in treatment centres in UK. HSE Primary Care Immediate 3.2.2 Effective management of patients within ED Implement and oversee agreed target timelines for patients to be seen within ED and by admitting teams. For ED, 3.2.1 as per EMP. For admitting team/s – patient assessment should commence within 1 hour of referral. CEO’s/Hospitals Immediate Ensure appropriate level of senior clinical decision making in ED. There is a requirement to ensure that there is a senior decision making presence in ED during peak hours with consultant availability on 8am-8pm basis, subject to resource. CEO’s - Immediate Immediate The HSE National Service Plan 2015 provides for 4 additional Consultants in Emergency Medicine and 4 AMAU physicians. This is a first step in addressing the requirement to enable extended day provision particularly in Model 3 and 4 hospitals. HSE AHD/Group CEO’s Immediate with appointment by Qtr. 3, 2015) Determination of nurse staffing and skill mix should be made using a robust evidence based methodology, applicable to the ED andAMAU context. The Taskforce on Staffing and Skill Mix in Nursing to develop a Framework for Nurse Staffing and Skill Mix in Emergency Nursing Care, as Phase II of its programme of work. DOH/AHD,CCP Q3, 2015
Shorter average length of stay (approximately 2 day reduction) Prompt effective discharge – with no adverse increased readmission 3.2.4 Access to diagnostics Access to diagnostics- Ensure full implementation of 8-8 working day for laboratory and radiology services in line with the national protocol in all sites for diagnostic services, and having regard to additional resource requirements. Within context of extended day, seek to optimise access for emergency serviceshaving regard to resources. It is recognised that there is a need to develop additional consultant manpower to meet additional reporting requirements Group CEO/ Hospital Mgr Immediate Target 7 day radiography service initially on pilot basis using overtime. Evaluate impact on ED and AMAU performance and length of stay with emphasis on timelines for access for inpatient and emergency patients. Capital constraints need to be borne in mind. HSE AHD Qtr. 2 2015 In the short term, the options for developing additional diagnostic capacity may be considered particularly for outpatient workloads in order to improve overall bed utilisation and patient flow. This should be progressed in consultation with relevant stakeholders in recognition of pre-existing protocols and agreements. HSE AHD/Group CEO Q2 2015 Develop a plan for targeted increase in diagnostic capacity (MRI/CT) to ensure that GP and consultant access is appropriate (-) HSE AHD 2016 The prioritisation of inpatients access to diagnostics should be a core principle to effect reductions in length of stay. Requirement to implement agreed metrics to measure specific impact of extended day on wait for diagnostics for emergency patients Group CEOs, Hospital Managers Q 4, 2015 Seek to secure the necessary additional consultant manpower to meet the additional reporting requirements associated with extended day and 7 day service. HSE AHD, National HR 2016/2017
Implement target of 40% agreed target) of patients to be discharged before 11 a.m. on a day to ensure required capacity is available for admission. A whole system approach is require to achieve this including communication with families and development of appropriate waiting areas for discharged patients (e.g. discharge lounges) to ensure that there is appropriate clinical oversight of both discharged and newly admitted patients. Group CEO’s/Hospitals Immediate Ensure 7 day ward rounds by senior decision makers are an integral part of the discharge process and task Clinical Director with oversight of compliance with this requirement. Group bodies Immediate Undertake weekly systematic review of all patients with extended length of stay (>14 days) to identify issues and actions required. CEO’s/Hospitals Immediate Enable delegated discharge between clinical teams within agreed parameters. bodies Immediate Delegated authority to senior nurses to support discharge based on agreed criteria and having regard to the consultant’s ongoing responsibility for the patient. Group bodies/Unions Immediate Report and publish and weekly discharges by hospital and Group to ensure consistent application of weekend and daily ward rounds by senior decision makers SDU/Hospitals Immediate Active regular review of non compliance with PDD SDU/Hospitals Immediate Ensure that appropriate systems are in place to enable effective discharge planning in collaboration with community partners. These should be formal with regular structured engagement to address any blockages or delays. CHO’S/Group CEO’s Immediate Weekly reporting mechanisms to be developed to identify and/or discharges and to communicate same to community partners CHO/Group CEO’s Immediate Facilitate bi-directional flow and appropriate use of Model 2/3 Hospitals through expansion of NAS Intermediate Care service, subject to resource availability NAS 2015/2016
3.2.7 Chronic Disease Management Measure impact of existing funded chronic disease programmes to date in terms of reducing LOS Quantify reduction in length of stay for chronic diseases (e.g. COPD, Heart Failure) where speciality ambulatory care services have been developed under the clinical programmes. Maximise the national effect on length of stay reduction by filling geographical gaps in these services in the 2016 NSP HSE CCP’s Immediate Implement and evaluate Service Plan 2015 requirements for Integrated Care pathways and Frail Elderly. Examine opportunity to develop community based ANPs which can provide an effective model and pathway of care specific for older patients to expedite their care and treatment both inward and outward. This would extend the current proposal on geriatrician led services to include ANP delivered services in collaboration. HSE, Acute Hospitals Division and CCP Q4 2015 Development of ANP model of care for low acuity chronic illness, both in the ED and AMAU to assess, treat and discharge low acuity chronic illness, with the option for return clinics at the ED & AMAU for ongoing assessment and treatment similar to the current ED Minor Injuries model of care CNO DOH and HSE Q4 2015 Increase coverage of Clinical Nurse Specialist (CNS) and AHPs for chronic disease support to General Practice in the 2016 Service Plan (commenced in 2015) Primary Care 2016 Commence implementation of the chronic disease self management support strategy in 2016 NSP Primary Care / CCP 2016 3.3. CONTROL - Leadership, Governance, Planning and Oversight 3.3.1 Leadership and Governance
Establish clear lines of accountability within the hospital for the management of patient flow within each Hospital CEO’s/Each Hospital Immediate Establish leads for scheduled and unscheduled care in all Groups with clear reporting lines to COO for each Group Group CEO Q2 2015 Develop and maintain centralised bed management to ensure consistent oversight of scheduled and unscheduled workloads Group CEO/Each Hospital Immediate Group and Hospital Clinical Directors to drive discharge planning and ward rounds Group CEO/Each Hospital Immediate Empower and enable delegated discharge in accordance with National agreements and cross team discharge, having regard for the consultant’s ongoing responsibility for their patient CEO/Each Directors Immediate and systematiccally review whole system escalation / de-escalation processes Group CEOs and CHOs Immediate 3.3.2 Operational Planning and Predictive Modelling Match services with need. E.g. team on call working in EDs and out of hours service options. Solutions may be subject to resource. CEO/EMP Immediate Develop a greater range of services in community settings on a planned basis in the evenings and at weekends subject to resource availability e.g. wound care clinics, IV services, catheterization HSE Primary Care Q4 2015 Optimise use of the human resource, transfer of duties to other grades/ professionals, e.g. delegated discharging in accordance with the HRA Hospitals supported by National Division Immediate Operational grip – develop capability within COO function to enable reduction in numbers and wait within 12 hour period of escalation and recovery within 48-72 hours and to manage balance between scheduled and unscheduled care. Hospitals Immediate Develop flexible rosters to meet demand requirements and ensure consistent access to Senior Decision makers Group SDU Immediate Develop appropriate (weekly, monthly and annual) elective schedules in line with assessed need, seasonal requirements and having regard to overall capacity requirements Hospitals/SDU Immediate
with the delivery system through the CHO and Hospital Group’s. 4. Enabling consistent improvement across all Hospitals In the term these Hospitals, working with the SDU and community partners, must prioritise the escalation responses that are known to assist with patient flow. Each of the actions recommended meets the SMART criteria, which can be applied by local management. AHD, Group CEOs, SDU – Immediate Immediate Development of additional consultant and NCHD manpower in line with international norms and recommendations AHD 2016/2017 Requirement for medium term investment to develop the required residential care capacity to meet assessed needs. This will be a mix of public and private provision and therefore will also require an assessment of pricing and contractual arrangements with private providers to ensure their effectiveness in meeting assessed needs. This will be enabled once the report on the review of NHSS is published by the DOH. Social Care 2016/2017 Hospital Groups to drive reconfiguration of services and structuring of posts to attract and retain consultant and NCHDs AHD, Hospital Groups 2015/2016 4.1 Service Improvement and Re-design Hospital Redesign Program The Solution Design phase for Tallaght completed in April 2015. Implementation phase Tallaght 10-12 weeks - Implementation phase for solutions identified as high impact but relatively easy to implement. Extend the program in 2015 to 4/5 additional hospitals. HSE AHD/SDU 2015