7 day services practical tips for achieving consultant review of patients within 14 hours clinical...

Seven Day Hospital Services Webinar Connect, Share and Learn Hosted by Sustainable Improvement NHS England South Region

January 2017

Establishing a Virtual Community for All to

Connect, Share and Learn

• Series of National and Local webinars

• Share practical examples – discuss barriers and generate improvement solutions

• NHS E Specialist Support Team - Sustainable Improvement

• Work in collaboration with NHS Improvement and the UEC Programme Board, South Region

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7 Day Hospitals – Virtual Learning

Webinar objectives

This webinar aims to provide you with:

• An overview of the updated guidance for the priority clinical standards and timing of the forthcoming self assessment survey

• Practical examples of how commissioners and acute providers are working together to support delivery of timely Consultant assessment (clinical standard 2) – their successes, challenges and opportunities

• An opportunity to ask questions of your colleagues and identify key areas of support required

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7 Day Hospitals – session objectives

Our guest speakers today are:

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7 Day Hospitals – Guest Speakers

• Sue Cottle, Programme Lead, 7 Day Services, Sustainable Improvement, NHS England South

• Celia Ingham Clark, MBE, Medical Director for Clinical Effectiveness, NHS England

• Claire Gorzanski, Head of Clinical Effectiveness, Salisbury NHS Foundation Trust

• Sam Burrows, Director of Strategy, NHS Wokingham CCG

Seven Day

Hospital

Services Clinical Standard 2 – Time to first

consultant review Celia Ingham Clark, Medical Director for Clinical Effectiveness, NHS England

The four priority clinical standards for 7 day hospital services

ensure that patients receive the same high quality assessment,

diagnosis, treatment and review in hospital on any day of the week

• Standard 2: Time to first consultant review

• Standard 5: Diagnostics

• Standard 6: Consultant directed interventions

• Standard 8: On-going review

Priority clinical

standards

Standard 2: All emergency admissions must be seen and have a thorough clinical

assessment by a suitable consultant as soon as possible but at the latest within 14

hours from the time of admission to hospital.

There is a large body of evidence associating timely consultant input to patient care with

improved outcomes. This meets with patients’ expectations and their care becomes more

effective and efficient. The Royal College of Physicians’ Acute Care Toolkit 4 suggests that

all patients admitted in an emergency should be seen promptly by a suitable consultant and

at the latest within 14 hours of admission.

Following extensive engagement with clinicians, standard 2 has

been clarified to ensure best clinical practice is supported

Time to first consultant

review

• Measured from the time of

admission to hospital rather than

the time of arrival at hospital.

• Reflects the original source

document for this standard (Royal

College of Physicians acute care

toolkit number 4).

• Aligns with pattern of emergency

patient admissions and associated

consultant staffing rosters.

• The definition of consultant remains

a doctor who has completed all of

their specialist training and been

placed on the GMC’s specialist

register

Pathways that are not

consultant-led

Patients with a clear diagnosis on a

well-defined pathway (e.g. midwife-led

maternity, simple superficial abscess

management) may have their clinical

care delegated from a consultant to

another clinician under the following

circumstances:

• A clear written local protocol agreed

within the Trust clinical governance

system and by commissioners.

• Protocol must describe actions to

take in the event of clinical concern

including rapid escalation to a

consultant where appropriate.

• Patient's care is still recorded as

being under a named consultant

(excluding patients specifically on

midwife-led care pathways)

When measured from time of admission, results from the

September 2016 7DS self-assessment survey showed that meeting

standard 2 presented the greatest challenge to trusts

Table 1: Achievement of the four individual clinical standards

Number of

trusts achieving

the standard

% of trusts

achieving the

standard

% of national

population

these trusts

serve

Standard 2: Time to

consultant review

9 6% 6%

Standard 5: Access to

diagnostic tests

8 5% 3%


consultant directed

interventions

80 54% 63%

Standard 8: Ongoing review 49 33% 31%

Table 2: Achievement of the four standards at different thresholds

Over 90% 70-90% 50-70% Under 50%

Standard 2: Time to

consultant review 6% 30% 53% 11%


diagnostic tests 3% 71% 26% 0%


consultant directed

interventions 63% 27% 8% 2%

Standard 8: Ongoing review 31% 45% 21% 2%

Staff rotas and working practices

Ensure acute take consultant presence from 8am to 8pm every day (especially for high volume specialties such as medicine).

On high volume units such as most AMUs use rolling ward rounds through the day to keep up with the new patients arriving.

Best clinical practice

Write into policy the expectation that patients admitted before 8pm will be seen by the evening take consultant before he/she goes home.

Ensure that handover lists used for take ward rounds include time of arrival, admission and ward for all patients to support the on take consultant to prioritise the order in which they see patients on the ward rounds.

Effective recording

Ensure that entry in the medical notes makes clear that consultant is assessing the patient and the time.

Ensure patients assessed by an appropriate consultant in ED or in clinic prior to admission to hospital are recorded as meeting the standard.

Clinical Engagement

Ensure that all team members, particularly junior doctors and senior ward nurses know the importance of a prompt consultant assessment for new and undifferentiated patients

Senior staff demonstrate commitment to the aims of the 7DS programme

Trusts could take the following steps to support delivery of

clinical standard 2, taking into account the recently published

clarifications

1

0

Northumbria NHS Trust organise their own transport for patients admitted from

home after the afternoon GP home visit so that the patient has more opportunity

to arrive at hospital before the specialty consultants leave for the day at 8pm.

When issues with flow occur the Trust adopts the following strategies: calling

specialty consultants into ED to support early assessment with a view to

reducing conversion rates and proactively sending patients from ED to specialty

wards at 11 am and 4pm to reduce congestion in A&E. This means at the

busiest times patients are still reviewed by the appropriate specialist.

Buckinghamshire Healthcare NHS Trust are making ongoing significant

efforts to improve flow, admission avoidance and rapid front door management

at Stoke Mandeville Hospital, meaning a high proportion of their patients were

admitted and reviewed within 4 hours of attendance. They also use a tracking

system and real time dashboard to ensure patients who have not been seen are

flagged.

There are examples of trusts that have implemented new ways of

working which have led to improved performance and more

patients being seen by a consultant in a timely fashion

Discussion

Please raise your hand if you have a question or comment- or write it in the chat box to ‘all participants’. When speaking please let everyone know your name, and your organisation

7 Day Hospitals – Discussion

Patient-Centred & Safe Friendly Professional Responsive

NHS 7 Day Services

Standard 2 – Time to Consultant review

Claire Gorzanski, Head of Clinical Effectiveness

27 January 2017

An outstanding experience

for every patient


Standard 2 – Time to consultant review

• All emergency admissions must be seen and have a thorough clinical assessment by a suitable consultant as soon as possible but at the latest within 14 hours of arrival at hospital

• Next survey – within 14 hours of admission


Standard 2 – Suitable consultant

A suitable consultant is one who is trained and competent in dealing with emergency and acute presentations in the speciality concerned and is able to initiate a diagnostic and treatment plan

• 89% within 14 hours of arrival

• 95% within 14 hours of admission


Standard 2 – time to consultant review (arrival) within 14 hours


Standard 2 – time to consultant review (admission) within 14 hours


Standard 2 – Results – are they credible?

• Clinical engagement – 2 workshops

• Culture of 7 day working accepted & good leadership

• Consultant delivered models in ED, AMU and SAU & resident paediatric consultant led model 24/7.

• Separate consultants for acute take & acute wards at weekends

• Ambulatory care pathways – VTE, TWOCs, gynaecology emergencies, plastics trauma


Standard 2 – Results – are they credible?

• Understand & streamline clinical processes on admission

• Chairs & trollies in AMU/SAU

• Train nurses to take bloods & ECGs

• Laboratory turnaround for AMU/SAU 1 hour

• Consultant presence AMU 12 hrs weekday, 6 hours weekends. SAU – surgeon of the day

• AMU/SAU dashboard


Standard 2 – AMU dashboard


Standard 2 – SAU dashboard


Standard 2 – Survey top tips

• Plan the audit

• Same auditors (all clinical) for each survey & time set aside to complete it

• Shared interpretation of a suitable consultant

• Logical paper data collection form – later validation/further analysis

• Pre-populated with date & time of arrival & admission – check against notes

• 4 week interval between sample & audit to allow for coding & reduced notes chasing (80% available)


Summary

• Clinical engagement & leadership

• Culture of improvement

• Plan the audit/keep it simple

• Share the results & learning

Discussion



7 Day Services in

Berkshire West –

Benefits to Collaborative

Approaches

24

Berkshire West – Background & Context

• Self contained health economy covering the area between the Berkshire /

Wiltshire border (West of Newbury) and the East of Wokingham

• Population of approx. 500,000 people

• One major acute provider – Royal Berkshire Hospital Foundation Trust

and one major Community / Mental Health provider – Berkshire

Healthcare Foundation Trust

• Four CCGs work in a very tight Federation covering this whole area

• Strong benchmark data – three of the four CCGs are in the top 5

nationally for NEL admission rate

• Receive one of the lowest funding allocations in the country – South

Reading CCG is the only CCG in England which receives less than

£1,000 per head of population

Really positive conditions for the delivery of change programmes –

including 7 Day Services

25

7 Day Services – Current Performance

Royal Berkshire Hospital – Self-certification

• Priority 1 (Std 2 – Time to First Consultant Review): Above national & regional mean

• Priority 2 (Std 5 – Access to Diagnostics): Partial Compliance

• Priority 3 (Std 6 – Access to Consultant Interventions): Fully Compliant

• Priority 4 (Std 8 – Ongoing Review): Partial Compliance

With clear trajectory agreed to full compliance by end of the current year.

26

Our overall approach to working together

• Significant cultural change underway within our local health economy

• History of joint working – Berkshire West Integration Programme

established three years ago and continues to deliver benefit

• April 2016: Established the Berkshire West Accountable Care System

• Not an ACO / vertical integration of functions

• Greater collaboration, planning over contracting, joint governance

• Deriving the maximum value from the ‘Berkshire West £’

• System wide recognition that we cannot afford constant and continued

improvement but need to delivery 5YFV priorities

• Cultural change is already delivering benefit and 7DS programme fits

within this overall framework

• Regard 7DS as a collaborative programme between the CCGs and the

Provider – not one party having primacy over the other and not the

commissioner ‘assuring’ the provider

27

Joint approach to delivery of 7 Day Services

• Recognise that our simple structure helps drive delivery of these sorts of

programmes

• Meet regularly – dependent on current challenges either monthly or

quarterly

• Defined a contractual mechanism early on but now ‘left in the drawer’ with

focus on collaboration yielding far more positive engagement and

outcomes

• Open and honest collaboration – recognise challenges and priorities

within the context of overall health economy / financial performance

• Use NHS England team wherever we can – supportive and informative

discussion – particularly where there is lack of clarity (i.e. threshold for

compliance

28

Challenges

• Lack of clarity around data, benchmarking, compliance thresholds

• Finance becoming even more scarce – investments being reserved for

maintaining the system rather than improving it

• No clear Return on Investment – appetite for incurring ‘cost’ is severely

limited

• Competing priorities for CCGs and Trust – 7DS has to fight for airtime at

an executive level

• Whole system problem – currently not coming at this with a whole system

solution (but have the structures in place should we need to)

29

Questions?

30

Discussion



Thank you for joining the South Region Webinar the links to the recording will be sent out shortly For more information: [email protected] Programme Lead [email protected] Senior Improvement Manager (South Central & Wessex) [email protected] Improvement Manager (South East) [email protected] Improvement Manager (South West)

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7 Day Hospitals – Information

mailto:[email protected]




Future NHS England Sustainable Improvement Team webinars: • 7th February 2017 (National) 13:00 – 14:00: The importance of clinical

leadership in establishing seven day services

• 27th February 2017 (South Region) 12:30 – 13:30: 7DS Practical examples of ensuring access to diagnostics and interventions Clinical Standards 5 & 6

• 7th March 2017 (National) 13:00 – 14:00: 7 Day Services: Top tips to engage your stakeholders

• 29th March 2017 (South Region) 12:30 – 13:30: 7DS Practical examples and models for achieving ongoing review-planning and processes to meet Clinical Standard 8

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7 Day Hospitals – Future webinars