Transforming surgical services UHBristol

Andrew Hollowood PhD FRCSClinical Chair Division Surgery Head and Neck

University Hospitals Bristol NHS Foundation Trust

Bristol Acute Services Review

• 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

• 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

Optimising productivity & operational efficiency

Transforming the ways in which we deliver care

Making strategic choices that directly address the challenge• Disinvest• Reconfigure

STRATEGIC INTENT

A range of local and regional services

Developing our specialist

services

Promoting teaching & research -

and recruiting the

bestWorking in partnership

Supporting community provision

Patients at the centre

UHBristol Strategic intent

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

Ward HDU/Level 2 ITU/Level 3

16

21

7

0 01

9

5

Post-op Mortality Risk Prediction< 5 % 5-10 % > 10 %

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.

– 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)

Separate pathway models

Emergency Floor

STAU

Short Stay ward

Trauma and Orthopaedic

ITU Heygroves theatres

POD preop assessment

Standards & checklists

Divisional Escalation

• Implementation escalation rota

• Clear internal divisional support on a daily basis

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’

SCHEDULING

All teams working from

same list

ACTIVELY MANAGED BEDS

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 Ward 800Wards 700 & 800 PULL patients up

from Level 6

Level 6 – emergency floor

Emergency Department Divisional outliers

Benefits realisationSurgical Flow Dashboard

29/08/2014

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

Patient Access and Experience

1Number of patients on cancer pathway whose elective surgical procedure was cancelled on the same day (Non Clinical Reason).

Patient Access and Experience Medway Daily 0 1 7 12 8 4 10 7 17 8

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%

ED

4 Number of BRI Surgical Patients waiting over 4 hours in ED

ED Medway Daily 5% 5% 37% 43% 42% 27% 27% 26% 44% 38%

5 Number of Ambulance handovers taking more than 60 minutes

ED South West Ambulance Service

Monthly 0 15 4 4 5 3 5 1

Theatre

6 Number of in-patient elective surgical procedures on BRI site

Theatre 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% 10.7% 10.0% 8.8% 4.9% 16.7% 10.2% 18.8% 7.6%

9 Number of list changes <48 hours before procedure date

Theatre Medway Daily 0 1 0

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   Daily 98% 94% 25%

Recovery

14 Number of patients overnight in recovery Recovery     0 3

Critical Care

15 ITU daily checklist completion Critical Care   Daily 98% 94% 25%

16 % of patients transferred from ITU to the ward within 4 hours (from fit for discharge decision)

Critical Care Helen Dunderdale Monthy 45% 40% 34% 41% 18% 25% 35% 32% 6%

Wards

17 Wards daily checklist completion Wards   Daily 98% 94% 25%

18 STAU daily checklist completion Wards   Daily 98% 94% 25%

19 Number of patients in surgery beds with a stay of over 14 days

Wards Medway   30 36 38 42 42 36 35 41 35 42

20 Number of inter-specialty outliers on Ward 700 and 800

Wards Medway Daily 1 2 14

21Number of non-surgical outlier patients placed into protected, elective surgical beds on Ward 700 and 800 Wards Medway Daily 1 2 5

22 Bed Occupancy rate on ward 700 Wards Medway Daily 91% to 92.5%

 ≥95% and

≤85% 100.0%

23 Bed Occupancy rate on ward 800 Wards Medway Daily 91% to 92.5%

 ≥95% and

≤85% 103.1%

Discharge

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

Dashboard to measureDelivery of improvements to emergency and elective flow.

Reflects benefits to productivity, performance and patient experience

• 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

Critical Care Wards DischargeDivisional

Flow

Patient Access and Experience

ED Theatre Recovery

• 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

Summary

Strategic challenges

Optimise emergency care pathways

Transform the ways in which we deliver emergency care

Make strategic choices that reconfigure emergency services