southend university hospital foundation nhs trust risk summit
DESCRIPTION
Appendix A. Southend University Hospital Foundation NHS Trust Risk Summit NHS Southend CCG and NHS Castle Point & Rochford CCG The Commissioners’ Perspective. 31 st March 2014. Content. CCG role Performance trends across emergency care Actions taken by the commissioners - PowerPoint PPT PresentationTRANSCRIPT
Southend University Hospital Foundation NHS Trust
Risk Summit
NHS Southend CCG and NHS Castle Point & Rochford CCGThe Commissioners’ Perspective
31st March 2014
Appendix A
Content
• CCG role
• Performance trends across emergency care
• Actions taken by the commissioners
• Urgent Care Working Group
• How has the wider system responded?
Context
• Southend CCG is lead commissioner for services from SUHFT
• Responsibility to ensure we commission high quality, safe services on behalf of our population
• There has been inconsistent achievement of the A&E 4 hour standard since March 2012
• This has impacted on the ability to achieve other NHS Constitution standards and further reduced quality
A&E 4 Hour Standard since April 2011
Quarter 2011-12 2012-13 2013-142013-14
2014-15
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1
SUHFT A&E 4hr Performance (%) 97.0 96.3 96.9 95.3 94.8 95.2 93.8 89.6 91.0 96.5 94.2 87.9 92.4 93.4
Number of Weeks below Std. 0 0 0 4 4 3 6 13 12 3 4 12 31 4
Source: NHS England Weekly Situation Reports (published data only), Supplemented with Local Data from “Good Morning Southend” report
4/3/2
011
5/1/2
011
5/29/2
011
6/26/2
011
7/24/2
011
8/21/2
011
9/18/2
011
10/16/2
011
11/13/2
011
12/11/2
011
1/8/2
012
2/5/2
012
3/4/2
012
4/1/2
012
4/29/2
012
5/27/2
012
6/24/2
012
7/22/2
012
8/19/2
012
9/16/2
012
10/14/2
012
11/11/2
012
12/9/2
012
1/6/2
013
2/3/2
013
3/3/2
013
3/31/2
013
4/28/2
013
5/26/2
013
6/23/2
013
7/21/2
013
8/18/2
013
9/15/2
013
10/13/2
013
11/10/2
013
12/8/2
013
1/5/2
014
2/2/2
014
3/2/2
014
3/30/2
014
4/27/2
014
5/25/2
01475%
80%
85%
90%
95%
100%
4Hr Performance4wk Avg - 4Hr PerformanceStandard (95%)
4Hr P
erfo
rman
ce
A&E Attendances
4/3/2
011
5/1/2
011
5/29/2
011
6/26/2
011
7/24/2
011
8/21/2
011
9/18/2
011
10/16/2
011
11/13/2
011
12/11/2
011
1/8/2
012
2/5/2
012
3/4/2
012
4/1/2
012
4/29/2
012
5/27/2
012
6/24/2
012
7/22/2
012
8/19/2
012
9/16/2
012
10/14/2
012
11/11/2
012
12/9/2
012
1/6/2
013
2/3/2
013
3/3/2
013
3/31/2
013
4/28/2
013
5/26/2
013
6/23/2
013
7/21/2
013
8/18/2
013
9/15/2
013
10/13/2
013
11/10/2
013
12/8/2
013
1/5/2
014
2/2/2
014
3/2/2
014
3/30/2
014
4/27/2
014
5/25/2
01475%
80%
85%
90%
95%
100%
1400
1500
1600
1700
1800
1900
20004Hr Performance 4wk Avg - 4Hr Performance Standard (95%)Volume 4wk Avg - Volume
4Hr P
erfo
rman
ce
Volu
me
of A
&E
Atten
danc
es
Quarter 2011-12 2012-13 2013-142013-14
2014-15
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1
SUHFT A&E 4hr Performance (%) 97.0 96.3 96.9 95.3 94.8 95.2 93.8 89.6 91.0 96.5 94.2 87.9 92.4 93.4
Number of Weeks below Std. 0 0 0 4 4 3 6 13 12 3 4 12 31 4
Source: NHS England Weekly Situation Reports (published data only), Supplemented with Local Data from “Good Morning Southend” report
A&E Attendances – AMU removed
Source: SUS-SEM via MedeAnalytics, adjusted to remove AMU-pathwayCriteria: Southend UHFT as provider, NHS Southend CCG, NHS Castlepoint & Rochford CCG (Formerly SEE PCT) as commissioner only
4/3/2
011
5/1/2
011
5/29/2
011
6/26/2
011
7/24/2
011
8/21/2
011
9/18/2
011
10/16/2
011
11/13/2
011
12/11/2
011
1/8/2
012
2/5/2
012
3/4/2
012
4/1/2
012
4/29/2
012
5/27/2
012
6/24/2
012
7/22/2
012
8/19/2
012
9/16/2
012
10/14/2
012
11/11/2
012
12/9/2
012
1/6/2
013
2/3/2
013
3/3/2
013
3/31/2
013
4/28/2
013
5/26/2
013
6/23/2
013
7/21/2
013
8/18/2
013
9/15/2
013
10/13/2
013
11/10/2
013
12/8/2
013
1/5/2
014
2/2/2
014
3/2/2
014
3/30/2
014
4/27/2
014
5/25/2
01475%
80%
85%
90%
95%
100%
1300
1400
1500
1600
1700
1800
1900
20004Hr Performance 4wk Avg - 4Hr Performance Standard (95%)Volumes (Adjusted for AMU) Volumes (Adjusted for AMU) - 4wk Avg
4Hr P
erfo
rman
ce
Adju
sted
Aan
dE V
olum
es
Quarter 2011-12 2012-13 2013-142013-14
2014-15
Q1Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
SUHFT A&E 4hr Performance (%) 97.0 96.3 96.9 95.3 94.8 95.2 93.8 89.6 91.0 96.5 94.2 87.9 92.4 93.4
Number of Weeks below Std. 0 0 0 4 4 3 6 13 12 3 4 12 31 4
A&E Admissions
Source: SUS-SEM via MedeAnalytics, adjusted to remove AMU-pathwayCriteria: Southend UHFT as provider, NHS Southend CCG, NHS Castlepoint & Rochford CCG (Formerly SEE PCT) as commissioner onlyAttendances with Outcome as “Admitted” only
4/3/2
011
5/1/2
011
5/29/2
011
6/26/2
011
7/24/2
011
8/21/2
011
9/18/2
011
10/16/2
011
11/13/2
011
12/11/2
011
1/8/2
012
2/5/2
012
3/4/2
012
4/1/2
012
4/29/2
012
5/27/2
012
6/24/2
012
7/22/2
012
8/19/2
012
9/16/2
012
10/14/2
012
11/11/2
012
12/9/2
012
1/6/2
013
2/3/2
013
3/3/2
013
3/31/2
013
4/28/2
013
5/26/2
013
6/23/2
013
7/21/2
013
8/18/2
013
9/15/2
013
10/13/2
013
11/10/2
013
12/8/2
013
1/5/2
014
2/2/2
014
3/2/2
014
3/30/2
014
4/27/2
014
5/25/2
01475%
80%
85%
90%
95%
100%
300
320
340
360
380
400
420
440
460
480
5004Hr Performance 4wk Avg - 4Hr Performance Standard (95%) Admissions Admissions - 4wk Avg
4Hr P
erfo
rman
ce
Num
ber o
f A&
E Ad
mis
sion
s
Quarter 2011-12 2012-13 2013-142013-14
2014-15
Q1Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
SUHFT A&E 4hr Performance (%) 97.0 96.3 96.9 95.3 94.8 95.2 93.8 89.6 91.0 96.5 94.2 87.9 92.4 93.4
Number of Weeks below Std. 0 0 0 4 4 3 6 13 12 3 4 12 31 4
Non-Elective Conversion
Source: SUS-SEM Via MedeAnalytics, adjusted to remove AMU-pathway A&E Attendances
4/3/2
011
5/1/2
011
5/29/2
011
6/26/2
011
7/24/2
011
8/21/2
011
9/18/2
011
10/16/2
011
11/13/2
011
12/11/2
011
1/8/2
012
2/5/2
012
3/4/2
012
4/1/2
012
4/29/2
012
5/27/2
012
6/24/2
012
7/22/2
012
8/19/2
012
9/16/2
012
10/14/2
012
11/11/2
012
12/9/2
012
1/6/2
013
2/3/2
013
3/3/2
013
3/31/2
013
4/28/2
013
5/26/2
013
6/23/2
013
7/21/2
013
8/18/2
013
9/15/2
013
10/13/2
013
11/10/2
013
12/8/2
013
1/5/2
014
2/2/2
014
3/2/2
014
3/30/2
014
4/27/2
014
5/25/2
01475%
80%
85%
90%
95%
100%
15%
17%
19%
21%
23%
25%
27%
29%
31%
33%
35%4Hr Performance 4wk Avg - 4Hr Performance Standard (95%) Conversion to NEL rateConversion to NEL rate - 4wk Avg
4Hr P
erfo
rman
ce
% o
f A&
E Att
enda
nces
Adm
itted
Quarter 2011-12 2012-13 2013-142013-14
2014-15
Q1Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
SUHFT A&E 4hr Performance (%) 97.0 96.3 96.9 95.3 94.8 95.2 93.8 89.6 91.0 96.5 94.2 87.9 92.4 93.4
Number of Weeks below Std. 0 0 0 4 4 3 6 13 12 3 4 12 31 4
11/1/2011 12/5/2011 1/12/2012 2/15/2012 11/16/2012 12/20/2012 1/29/2013 11/4/2013 12/6/2013 1/14/2014 2/17/2014 3/21/201480.0%
82.0%
84.0%
86.0%
88.0%
90.0%
92.0%
94.0%
96.0%
98.0%
100.0%Southend UHFT Rest of Essex National
SitRep Period Start (to next SitRep Period)
Bed Occupancy
Source: NHS England Sitreps, 4 years of collections, 7 day rolling average
2011-12Nov-Feb
2012-13Nov-Feb
2013-14Nov-Mar
Quarter 2011-12 2012-13 2013-142013-14
YTDQ3 Q4 Q3 Q4 Q3 Q4
SUHFT A&E 4hr Performance 96.9% 95.3% 93.8% 89.6% 94.2% 88.7% 92.8%
Number of Weeks below Std.
0 4 6 13 4 10 29
11/1/2011 12/2/2011 1/10/2012 2/10/2012 11/12/2012 12/13/2012 1/21/2013 2/21/2013 11/26/2013 12/31/2013 2/3/2014 3/6/20140.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
3.5%
4.0%
Southend UHFT Rest of Essex National
Source: NHS England Sitreps, as a percentage of occupied beds, 4 years of collections, 7 day rolling average
2011-12Nov-Feb
2012-13Nov-Feb
2013-14Nov-Mar
Delayed Transfers of Care
Quarter 2011-12 2012-13 2013-142013-14
YTDQ3 Q4 Q3 Q4 Q3 Q4
SUHFT A&E 4hr Performance 96.9% 95.3% 93.8% 89.6% 94.2% 88.7% 92.8%
Number of Weeks below Std.
0 4 6 13 4 10 29
Delayed Transfers of Care
Total Social Health0
2
4
6
8
10
12
2012/13 population weighted Delays per 100,000
Southend England Eastern Region Comparators
Social Health0
5
10
15
20
25
30
35
40
45
Number of Delays
2012-13 Delays2013/14 YTD Delays
Friends and Family Test
Source: Unify2
4/1/2013 5/1/2013 6/1/2013 7/1/2013 8/1/2013 9/1/2013 10/1/2013 11/1/2013 12/1/2013 1/1/2014 2/1/2014 3/1/20140
10
20
30
40
50
60
70
80
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
41 41
60
66
51
70
55
66
51
47
54
23
Eng Score SUHFT Score Eng Response Rate SUHFT Response Rate
F&F
Scor
e
Resp
onse
Rat
e
Ambulance Handover Times
Source: Local Feed from Southend UHFT (‘Daily 9am Sitrep’)Period: July to latest
7/7/2
013
7/21/2
013
8/4/2
013
8/18/2
013
9/1/2
013
9/15/2
013
9/29/2
013
10/13/2
013
10/27/2
013
11/10/2
013
11/24/2
013
12/8/2
013
12/22/2
013
1/5/2
014
1/19/2
014
2/2/2
014
2/16/2
014
3/2/2
014
3/16/2
014
3/30/2
014
4/13/2
014
4/27/2
014
5/11/2
014
5/25/2
014
6/8/2
0140
100
200
300
400
500
600
70%
75%
80%
85%
90%
95%
100%
Under 15mins 15-30mins 30-60mins Over 60mins 4Hr Performance Standard (95%)
Num
ber o
f Am
bula
nce
Han
dove
rs
4Hr P
erfo
rman
ce
Ambulance Handover Times – expressed of % of total
Source: Local Feed from Southend UHFT (‘Daily 9am Sitrep’)Period: July to latest
7/7/2
013
7/21/2
013
8/4/2
013
8/18/2
013
9/1/2
013
9/15/2
013
9/29/2
013
10/13/2
013
10/27/2
013
11/10/2
013
11/24/2
013
12/8/2
013
12/22/2
013
1/5/2
014
1/19/2
014
2/2/2
014
2/16/2
014
3/2/2
014
3/16/2
014
3/30/2
014
4/13/2
014
4/27/2
014
5/11/2
014
5/25/2
014
6/8/2
0140%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
70%
75%
80%
85%
90%
95%
100%
Under 15mins 15-30mins 30-60mins Over 60mins 4Hr Performance Standard (95%)
Perc
enta
ge o
f Am
bula
nce
Han
dove
rs
4Hr P
erfo
rman
ce
Ambulance Handover Times – over 30mins
Source: Local Feed from Southend UHFT (‘Daily 9am Sitrep’)Period: July to latest
7/7/2
013
7/21/2
013
8/4/2
013
8/18/2
013
9/1/2
013
9/15/2
013
9/29/2
013
10/13/2
013
10/27/2
013
11/10/2
013
11/24/2
013
12/8/2
013
12/22/2
013
1/5/2
014
1/19/2
014
2/2/2
014
2/16/2
014
3/2/2
014
3/16/2
014
3/30/2
014
4/13/2
014
4/27/2
014
5/11/2
014
5/25/2
014
6/8/2
01470%
75%
80%
85%
90%
95%
100%
0%
5%
10%
15%
20%
25%
% over 30mins 4Hr Performance Standard (95%)
4Hr P
erfo
rman
ce
Perc
enta
ge o
f Han
dove
rs
Ambulance Handover Times – over 60mins
Source: Local Feed from Southend UHFT (‘Daily 9am Sitrep’)Period: July to latest
7/7/2
013
7/21/2
013
8/4/2
013
8/18/2
013
9/1/2
013
9/15/2
013
9/29/2
013
10/13/2
013
10/27/2
013
11/10/2
013
11/24/2
013
12/8/2
013
12/22/2
013
1/5/2
014
1/19/2
014
2/2/2
014
2/16/2
014
3/2/2
014
3/16/2
014
3/30/2
014
4/13/2
014
4/27/2
014
5/11/2
014
5/25/2
014
6/8/2
01470%
75%
80%
85%
90%
95%
100%
0%
2%
4%
6%
8%
10%
12%
14%
16%
% over 60mins 4Hr Performance Standard (95%)
4Hr P
erfo
rman
ce
Perc
enta
ge o
f Han
dove
rs
Themes from the Data
• A&E standard has been met in only one quarter since Q3 2011/12
• A&E attendance has not increased significantly
• A&E conversion rates have increased
• DToC are small
• Ambulance handovers have remained constant but recently higher number of ambulance waits over 30 and 60 minutes
What does this mean for patients?
• Leads to a crowded department with patients both waiting to be seen and waiting for beds
• Overall poor patient experience and safety• Evidence has shown that patients admitted through a crowded
A/E have a 43% increase in mortality at 10 days• Patients admitted after 4-8 hours in A/E stay on average 1.3 days
longer in hospital and 2.35 days when this reaches 12 hours• Treatment initiation is often delayed in a crowded department• FINALLY for patients seen and discharged from A/E there is a
direct correlation between the length of time waited and a higher chance of dying in the next 7 days
Action taken by the CCG since April 2013
• Performance management and contractual action
• System co-ordination and winter planning
• Managing demand
• Quality visits and external reviews
Performance management and contractual action during 2013/14
• Weekly performance meetings COO- COO since July 2013
• Two letters of serious concern to CEO
• Required formal root cause analyses and exception reports
• Action under the contract
• Contract Query – 7th March 2013
• 1st Exception Report – 29th May 2013
• 2nd Exception Report – 27th September 2013
• Closure Notice – 15th November 2013
• Contract Query – 21st January 2014
• 1st Exception Report – 13th March 2014
System co-ordination and winter planning
• System conference calls – daily since November 2013
• Winter plan developed through two stakeholder half day workshops and full evaluation of demand management schemes
• Scenario testing (Exercise Eskimo) to ensure effective escalation and production of escalation guide
• Winter money allocated to the hospital (£0.9m out of £1.4m)
Managing Demand
• Full evaluation of schemes over summer which identified sub-optimal performance in schemes and took corrective measures
• Implemented a successful programme to increase GP referrals to the Single Point of Referral
• Extended hours for hospital Day Assessment Unit
• Increased GP practice MDTs
• Implemented strengthened model of GPs supporting care homes
• Public education – local campaigns to use NHS 111 and avoid A&E
• Commissioned system bed capacity review – due April 2014
External reviews and quality visits
Emergency Care Intensive Support Team visited twice with recommendations which has formed basis of recovery plans
Themes from CCG-led quality visits – unannounced and announced:00hrs:• Potential patient safety risk from delayed offloading of patients from ambulances • Inappropriate attendees in minors• Slow triage of patients in waiting area• Slow transfers from A&E to wards• Inappropriate skill mix and staffing levels for nursing and medical staff in A&E• Lack of senior decision makers on the emergency floor• High use of agency medical & nursing staff• A&E department size too small
In Summary
• Significant problem in meeting A&E 4 hour standard for last 24 months
• Demand, discharges and bed capacity has remained constant across the system
• Unable to recover quickly from periods of surge prolonging impact
• Main underlying issue is staffing shortages in the A&E department – consultant, middle grade doctors and nursing
• Size of the department is a limiting factor
• Process management has not been fully embedded with clear leadership
.
Further action required for the hospital• To appoint a performance director for emergency care.• To establish a senior consultant rota of permanent clinicians to provide
senior leadership in the department.• Revise A&E recovery plan to incorporate KPIs and clear and accountable
actions for implementation and delivery.• Implement a medical, nursing and service manager recruitment plan.• To establish minors see and treat.• To establish majors rapid assessment.• To embed process for escalation to specialist teams.• To embed internal and external escalation processes.• To achieve earlier patient discharge.• To ensure 3x daily site visits take place.• To develop a clear plan to deliver the paediatric pathway.
.
Further action for the wider system
• Urgent Care Working Group meeting fortnightly moving to weekly
• Review pathway for minors across system
• Implement our frail elderly pathway in line with the integrated pioneer plan
• Better management of patients with long term conditions in the community
• Implement system-wide A&E recovery plan.