Ensuring services are effective Deliver the financial plan for revenue income and expenditure, capital expenditure and cash. Deliver the savings programme for each year. Develop the Estates and IM&T plans to support safe, effective and efficient service delivery Deliver the responsibilities within the transition programme as defined in the Transition plan
4 Delivery Plans 2015 - 2016 4.1 Key Operational Delivery initiatives 2015/16 Deliver clinically effective services which meet benchmarked best practice standards through implementation and audit of evidence based practice. Key work areas Key actions Key measurable and timescales Implement a culture of continuous clinical improvement and audit through evidenced based assessment of outcomes. Continue to embed the Model Ward concept across all wards. Service improvement through ED, RTT and emergency medicine pathways - Integrated Best Practice care Pathways- delivery of best practice clinical care across planned and unplanned care. Safe delivery of care 24/7 Continue to develop the functions and utilisation of the safety improvement hub. Through the Pathway Improvement Group continue to identify actions and deliver on improvements to the model ward. Utilise the Ambulatory rapid assessment and CDU elements of ED to deliver appropriate access at point of entry. Review the operation policy of these areas to support enhancing a reduction in inappropriate hospital admissions. Implement an audit and variation reduction approach to key clinical pathways Develop the use of International care pathways across the most common HRG/diagnostic codes. Improve productivity the RTT pathway Clear patient pathway process which focuses on diagnosis, care planning and EDD MDT ward rounding daily Improved timeliness and quality of communication to primary care colleagues concerning patients on discharge from hospital Programme of improvement projects presented at Q&G committee to report outcomes and improvement plans to the Trust Board across the next 12 months. programme in place to ensure the model ward is being fully implemented and delivering. Monthly data on average length of stay by ward and division to monitor performance. Reduced inappropriate hospital admissions, reduced LOS, readmissions and mortality (Effectiveness, Quality and outcome ) achievement of 4 hr target and RTT (patient flow) measures to be reported through IPR to Board. Improved patient experience to be measured through patient survey Quantitative measures including reduced inappropriate hospital admissions, reduced LOS, readmissions and mortality (Effectiveness, Quality and outcome ) achievement of 4 hr target and RTT (patient flow) across ED and access reported through the IPR and weekly performance reporting. Improved patient experience to be measured through patient survey. Improve delivery of eligible best practice tariffs to specified trajectories.
Introduce a Frailty Assessement Service to support early senior decision making and care plans for older patients. Review the Hospital at Night model to ensure that it is fit for purpose Work with the CCG to identify and the initiatives to be progressed with a focus on weekend and extended day working in key areas for implementation during 2016/17 Early care planning with the aim to avoid admissions into hospital if acute medical services will not benefit the patient and if admission required reduce the length of stay. Review the management of H@N and roles and responsibilities by March 2016. Five of the ten seven day standards to be implemented during 2016, subject to appropriate levels of funding Frailty Assessment Service established Embed clinical leadership providing clinicians sufficient time to lead together with clear, deliverable, objectives Key work areas Key actions Key measurable and timescales Organisational structure which defines the role of lead clinicians and puts clinical engagement at the centre of key decision making. Clear job descriptions for Clinical leads Defined time in job plans with a focus on continued professional development and leadership of clinical services Continue to improve engagement of all clinicians within the work of the Trust and the Transaction New Job description and objective setting to be completed and in place by the end of Q1. Improved staff survey response rate and feedback Deliver dignified care that is responsive to patients’ personal needs, ensures a positive experience of care and which meets CQUINs Family and Friend test standards Key work areas Key actions Key measurable and timescales Delivery of the Patient Experience Improvement strategy at delivering a caring and compassionate experience for all patients. . Effective and planned discharge to the community or social care settings utilising the green to go concept Implement Communication improvement project through the Improvement Hub the “Hello my name is” initiative Fully utilise Patient Council and Patient Experience Review Groups Review patient information leaflets Improve analysis of and feedback re complaints and incidents Improve communication relating to discharge Improvement programme which targets patients staying over 10 days and inherent delays in community and social care access. Clear escalation process for discharge delays to be introduced. Reporting of patient experience measures at Ward Wednesdays and through to the Quality and governance committee. All participating in Hello my name is ...... Improvements in Friends and Family response rate and results Reduced complaints concerning poor communication Patient Stories to meetings Reductions in LOS, inappropriate admissions and improved patient flow reported through IPR to Board.
5. Key Identified Risks The key five risks associated with achieving the objectives detailed within this plan are shown below together with the controls identified to mitigate each risk and the assurances sought that controls are mitigating each risk. Principal Risk CQC Ref Existing Key Controls Possible Sources of Assurance Results in Assurances on Controls Gaps in Controls & Assurances Exec Lead Current Risk Score LH Cons Score Risk that medical staffing will not be at the required numbers or skills to deliver safe and dignified care. Safe Domain Ongoing programme of international fellowship recruitment. Redesigned medical rota to ensure consistent medical across the wards. Continued use of NHS and Agency Locums. Active participation in BNSSG wide Urgent Care Groups in relation to demand management and health community wide management of emergency flow. Hospital OOHs Service. Regular review by EMG. Physicians Assistants Internal Locum spend. Recruitment monitoring. Risk management and reporting. Workforce review. CEO Clinical Sustainability Report to Board CQC internal monitoring Revalidation and appraisal processes Daily Quality Improvement Team situation report Divisional Governance Meetings Mortality review Service review Board Reporting External Deanery/GMC review NHS TDA dashboard doctor to bed ratio Vacancies in gastroenterology, respiratory/acute, community paediatrics, emergency department, upper GI, anaesthetics, oncology, gynaecology, radiology. Control Gaps National shortage of doctors Assurance Gaps Review of on call service with medical staffing at weekends Endoscopy ongoing capacity review Discharge planning & checklist usage below target (20%) Physician rota 1:11 with only 4 substantive maintaining this. Lack of visible Trust wide rota. Engagement with NICE TAG assessment. Medical Director 5 4 20 Risk that the Trust does not meet CQC requirements Board leadership Risk management QIT leadership and monitoring Internal Quarterly reporting to QGC Risk based CQC style visits IPR reports to Board CQC Intelligent Monitoring Report Dec 2014 – Control gaps Managerial and clinical staffing shortages. Director of Nursing 4 4 16
for a minimum of good rating Well led Domain Service leads coaching by ADG&PE Performance monitoring National Clinical Audit participation Daily Sitrep QGC monitoring Quality Hub mortality Theatre environment programme of improvement ORI support for patient flow Ward specific monitoring at EMG (Kewstoke, Uphill & Hutton) Infection Control management Medicines management Records management Patient flow management Safeguarding support Staffing escalation Equipment and Estates Management Review of Patient Experience Complaints Management NRLS reporting Daily sit rep report Weekly SIRI reporting Patient Experience Review monitoring Infection Control monitoring Quality Hub External CQC inspections NRLS reporting STEIS database Safety Thermometer Mortality data Inpatient survey DH databases NHS Staff survey GMC National Training Scheme Survey Cancer Patient Experience Survey PLACE assessment FFT score National Bereavement Survey NHS Choices Patient opinion website Qualitative CQC evidence Audit South West internal audit monitoring. Royal College of Paediatrics Peer Review and resultant Implementation Group CQC Intelligent Monitoring worsened to band 3 Oct 2014 - additional Never Event relating to application of WHO checklist. Non participation in some National Audits & NICE oversight. Oversight of medical records. Limited improvement narrative in support of Equality & Diversity Agenda. Limited capacity to support patient experience Gathering & sharing of learning from incidents. Impact of merger on senior staff retention Intranet remains under development affecting access to policies Domestic Champion role development. Assurance gaps Staff survey results – learning from incidents Readmissions data on CHKS Pressure and falls incidents Environmental issues in Theatre.
and Governance Committee. medicines optimisation strategy and annual action plan. Medicines risk register received at RMC. Medicines policy. Non medical prescribers policy and central register of prescribers. Medicines Reconciliation policy. Provision of out of hours discharge medicines policy. Ward and Theatre CD SOPs Homecare strategy and 12 month action plan approved. NHS Protect Security of Medicines Audit and action plan CD SOPs National prescribing safety test now compulsory for all medical graduates compliance monitoring - 38% temperature checks on drug fridges completed daily and auctioned. Assurance gaps Lengths of wait for TTOs– safety and security issue? Drug fridge compliance Timeliness of incidents closure Limited medicines reconciliation Annual medicines management report to Failure to support the improvement in Lead identified Health Informatics Committee Internal Unchanged Control gaps Director of Finance 4 (3) 4 16