Embed Size (px)
Citation preview
1
A further external review of the
Cardiac Surgery services at Morriston
Hospital Swansea
–the report of a follow up visit Sept 2014
Stephen Ramsden, on behalf of the external panel
report produced Nov 2014
2
Executive Summary
Since our last review in 2013, the cardiac surgery service has been moved into a dedicated clinical
directorate, as an interim measure, to both manage the service and also focus on the
implementation of the recommendations of our report. This has been a positive move, with the
directorate leadership being instrumental in building relationships and improving morale. One senior
interviewee told us that the interim directorate had concentrated on the “soft issues” and had
succeeded in laying the foundations to now address the “hard issues” around improvements in
efficiency and throughput. Our review team expert panel would concur with this and acknowledge
real progress in the development of more multi-disciplinary team working, communications and
addressing behaviours that we were critical of last year, with a new zero tolerance to bullying, for
example. This needs to be sustained as there are still some undercurrents, but it isn’t just leadership
who need to address this, the staff also need to play their part. However, it was refreshing for the
expert panel to hear about issues and ideas to improve the service, rather than the dominance of
poor relationships and behaviours we heard about last time.
The Health Board have made some substantial investments in response to last year’s report,
including on the new interim Directorate leadership and in a number of quality improvements. They
have also committed to more investment in staff resources to accompany the expansion in capacity
in 2015.
Improvements have particularly been realised in the Cardiac ITU(CITU), with a new CITU Director, an
increase in consultant anaesthetists/intensivists and developments in protocols to reinforce multi-
disciplinary team decision making, for example about end of life care.
The other service we emphasised needed significant improvement in our last review was the
operating theatres. The improvement noted in CITU has not been replicated in cardiac theatres and
we believe a more fundamental arrangement is going to be needed to achieve this. Therefore, on
balance, we recommend that the cardiac surgery theatre staff need to transfer into the Cardiac
Directorate to enable more control and focus on the improvements needed. In addition we
recommend that cardiology should also be part of a new Cardiac Services Directorate from April
2015. The two services are inextricably linked and including catheter labs in the Directorate may help
with the flexibility in theatre staffing needed. Including Cardiology will also ensure the two services
are planned strategically together.
The ward and outpatient services were not given a high profile in our last report. This time, there are
a number of issues brought to our attention in these services and we make new recommendations
to provide a more professional outpatient service including pre-operative assessment service. The
ward has some staffing issues, exacerbated by having to staff the outpatient clinics. Attention needs
to be given to the development of the level 1 service on Bracelet bay, as this would relieve pressure
on CITU/HDU and reduce cancellations and improve throughput.
Whilst we believe the work on team building and relationships needs to continue, it is now time to
focus on the “hard issues”, improvements to make the service more cost effective and efficient.
Based on the “albatross” benchmarking work, the cardiac surgery service is very inefficient both in
terms of length of stay and utilisation of theatres. But it is also significantly understaffed in several
3
areas as indicated by the NCBC benchmarking. This is not contradictory. Investing in staff in some
areas will help to improve the throughput in theatres and beds, and also reduce cancellation rates,
which is upsetting for both patients and staff. Skill mix reviews have been undertaken in the nursing
areas CITU/HDU, ward and theatres but the outcome has not been implemented as it would require
a further investment. The Directorate have been told that any further investment must be linked to
a capital business case for additional CITU/HDU beds. There may be economic arguments, as well as
quality improvements in the form of reduced cancellations, to bring forward some of these business
cases if they can be shown to be self financing or better. The formalisation of a level 1 unit in
Bracelet bay mentioned above may be an example of this.
The capital business case refers to the £4m + expansion of CITU to provide two extra CITU beds and
2 replacement HDU beds to improve the bed spacing in HDU later in 2015. We are pleased that this
is now happening to increase capacity but are disappointed that it is taking so long and that our
suggestion of an immediate move of HDU to adjacent to CITU could not be achieved. Even with the
new development, the separation of CITU and HDU remains a weakness in the service. There is also
the need to avoid a shift of the bottleneck to HDU/Ward and nursing skill mix is crucial to avoid this.
The directorate will need to review and improve the business intelligence to support the need for
major improvements in efficiency and throughput. Currently, there is a good monthly performance
pack but it does not yet have sufficient efficiency targets included (though the Directorate GM does
produce his own). Length of stay reductions for CITU/HDU and ward need to be set and owned by
the Anaesthetists, Intensivists, Surgeons and Nursing staff, and improved theatre utilisation likewise
needs to be devolved to the staff who can influence it.
In addition to the historical problems highlighted in our last report, there has been uncertainty
about the future of the Cardiac surgery service at Morriston hospital. WHSCC are very clear that
they wish to see two centres at Swansea and Cardiff continuing for the foreseeable future, albeit
with far more collaboration between the two. It is now important for the Health Board and
Directorate to create a positive vision and five year plus strategy for cardiac surgery, that reassures
staff and the public about the future, and incorporates improvement plans included in this report
and beyond.
We have assessed the progress made against all our Recommendations in last year’s report and
indicated which have been FULLY,PARTIALLY or NOT IMPLEMENTED. We have assessed that 17
recommendations have been fully implemented, 16 have been partially implemented (though in the
case of theatres there is a lot more to do) and 3 have not been implemented. We also suggested in
last year’s report, that 16 of those recommendations should have been implemented urgently. We
believe that 11 of these urgent recommendations have been fully implemented, 3 partially
implemented and 2 not implemented (relocation of HDU to adjacent CITU and skill mix review CITU).
We have made 12 new recommendations but also suggest that those only partially or not
implemented, need to be incorporated into a new Action Plan.
On the whole, the external panel believes that really good progress has been made in the last year
and hope that the implementation of this new Action Plan will continue this improvement journey.
Finally, in terms of sustainability, the creation of a new Cardiac Services Directorate with a
continuation of the strong leadership shown over the last 12 months, including from the cardiac
Surgeons and support from the Health Board; a new vision and 5 year plan for the service; plus
4
strong performance management of the Directorate and this new Action plan, there should be no
need to programme another external review. We were impressed by the rigour of the internal peer
review which was challenging and helpful to the Directorate and should be repeated periodically to
assure the Health Board that the Directorate are achieving the improvements required.
5
Introduction
In 2013, the Health Board commissioned a review of cardiac surgical services following some long
term clinical, operational and workforce problems in the Unit. The review was undertaken by an
expert panel and chaired by an independent chairman. A visit to site took place in July 2013 and a
report published in sept 2013 was accepted by the Health Board at their meeting on the 26 Sept
2013. One of the recommendations in response to previous reviews not resolving the problems was
to re-visit the Unit in Sept 2014 to assess what progress has been made. The same expert panel
agreed to undertake the re-visit and are listed below for completeness. The Terms of Reference
were largely based on the 2013 Review Terms of reference with an emphasis on assessing the
progress made on the Recommendations from the last visit. The Terms of reference are attached at
Appendix 1
Expert Panel
Dr Nick Fletcher, Consultant Anaesthetist &Intensivist, St Georges Hospital, London
Mr Philip Gamston, ChiefPerfusionist, St Bartholomews Hospital, London
Mr Leslie Hamilton, Consultant, Cardiac Surgeon Freeman Hospital, Newcastle
Mr Robert Harris-Mayes, Patient Representative
Dr Michael Norell, Consultant Cardiologist , Wolverhampton
Mr Paul Randall, Senior Cardiac Nurse, St Georges Hospital, London
and
Stephen Ramsden, Independent consultant and Chair of the Review Team
Process
The Chair held a number of planning calls with the new interim Directorate leadership in the months
before the re-visit. This enabled a documents list to be compiled and also determined the final
interview schedule. In addition it allowed an informal picture to be gained of progress made and
outstanding issues to test and focus attention on the re-visit. The re-visit took place on 15 & 16 Sept,
though the senior nurse member Paul Randall, had to re-schedule his visit and interviews to the 26
sept, when he was accompanied by Robert Harris-Mayes.
The report is again divided into the sections of the terms of reference, and in each section we
produce an overview of our findings and a clear indication of our opinion on progress against the
original recommendations and make further recommendations as necessary.
6
i) Professional working relationships
Overview
It is evident that great efforts have been made to improve professional working relationships and
many commented on the positive impact that the new Directorate leadership had made on this,
including the appointment of a CITU Director soon after our last report. Increasing
Anaesthetic/Intensivist input to CITU enabling consultant presence for morning and afternoon
sessions every day has helped to achieve a shift to a more multi-disciplinary team decision making.
There are now agreed pathways for end of life care in use and there has been no incident of changes
to decisions since the last review. The Cardiac surgeons have played their part in this improvement
by their co-operation and participation in theatre briefings, team development and job planning and
the lead surgeon is actively involved in the Directorate leadership team.
We heard of a new zero tolerance to bullying and this, together with a number of examples of
activities to promote team working, has contributed to the overall improvements described above.
The Directorate and Health Board do need to maintain their efforts in this area.
Progress on 2013 Recommendations
R1 The lack of multi-disciplinary team decisions made on patients on CITU especially about end of
life care must end immediately ....
We found that this recommendation has been implemented and has made a positive contribution to
improved relations. The Directorate have used an Ethicist to help to implement the pathway and
discuss the issues generated. FULLY IMPLEMENTED
R2 A Director of CITU should be appointed immediately
This has been implemented and is having a very positive contribution to improved relations and
decision making. FULLY IMPLEMENTED
R3 The appropriate leadership of patients in CITU is with Anaesthetists/Intensivists and this should
be implemented as soon as the new CITU Director feels there are adequate numbers to cover
This is still evolving though the panel felt that the principle has been accepted by the surgeons and
will be implemented as soon as all the new consultants are in post. In addition the change in the
anaesthetic registrar rota to have one focussed on CITU is a good step forward.
Outside the normal weekdays 8.30 am – 5 pm, the surgical registrar provides the resident cover.
Formal handover is given by the daytime consultant to the anaesthetic registrar at 5 pm. The surgical
registrar does not attend but we felt strongly that protected bleep-free time should be given to the
surgical registrar to attend this handover. Service reconfigurations in anaesthesia have only slightly
increased the presence of junior anaesthetists on the CITU out of hours. Although limited by
reduction in trainee numbers, the Directorate should continue the development of the CITU medical
model and ultimately aim for 24/7 cover. Options would include introduction of Advanced Critical
7
Care Practitioners (ACCPs) and increased consultant delivered cover. We make a new
recommendation to continue the development of medical cover to the CITU. PARTIALLY
IMPLEMENTED
R4 Surgeons meetings should be instigated and held weekly ...
These are occurring and have helped to create some more standard approaches eg to discharge.
FULLY IMPLEMENTED
R5 There should be zero tolerance to incidents of bullying, abuse and intimidation
We heard that this had improved with only one ongoing Dignity at work case. Health Board- wide
initiatives have also been introduced to enable concerns to be raised confidentially. This includes the
“See it say it” and the “rumour line” whistleblowing and raising concerns initiatives which should
help. The Directorate leadership are also determined “not to brush issues under the carpet.”
However, we heard of a small number of examples where relations were still fragile and there is the
potential for these to escalate if the root causes are not addressed. We also heard from some staff
that using incident forms to report bad behaviour was discouraged as they “go to the Welsh office
and reflect badly on the reputation of the Unit”. Having said that, the Directorate provided data to
show an overall increase in reported incidents over the last year, and the biggest increase has come
from CITU.
There are still two formal grievance issues unresolved from our last visit but all parties are engaged
in resolving disputes with the assistance of external support such as mediation where necessary.
Unacceptable language being used at theatre team briefings needs to be stamped out immediately
and full engagement of all of the theatre team is essential. The staff surveys have also provided
some feedback on such concerns so there is still work to do. We make a further recommendation
about this later. PARTIALLY IMPLEMENTED
R6 Opportunities must be found to reinforce the multi-disciplinary team approach ..an example is
the clinical governance meetings...
Some deliberate small group multi-disciplinary meetings were held to air the issues between staff
and some more formal development has been undertaken including theatre staff and team
briefings. We heard that theatre briefings in cardiac surgery were now seen as an exemplar for the
whole Health Board. The weekly activity planning meeting has been a positive development that has
helped to improve efficiency, communications and relationships.
These developments are a start but need to be continued and added to. The clinical governance
meetings are not yet fully inclusive (eg of anaesthetists and nursing) but there are plans for this to
change later in 2014 with a full day per month .CITU ward rounds are now more multidisciplinary
with involvement of nursing staff now the norm.
There is some confusion about the Nursing leadership of the CITU with overlapping roles and
communication breakdowns. Communications with CITU/HDU and Cyril Evans ward were said to
have improved as a result of “Board meetings”, which was seen as an improvement by other
departments. PARTIALLY IMPLEMENTED
8
R7 The Cardiac service should have more control of the vital resources required to optimise care for
patients ....
The Health Board responded swiftly to this and created an interim Cardiothoracic Surgical Services
Directorate with its own Board including some new leaders. This has been an important
development to run the service and implement the recommendations of the last review. Praise for
the new Directorate leadership, including the lead Surgical and Anaesthetic consultants, was
widespread both within the service and more widely.
There have been improvements in the anaesthetics service to the Directorate but the panel felt that
more progress was needed to improve theatre services. Also, whilst it was sensible initially to focus
on cardiac surgery, the separation from Cardiology feels untenable in the medium term. We make a
further recommendation about future Directorate arrangements later. PARTIALLY IMPLEMENTED
R8...urgently review the proposals to increase anaesthetic sessions to cardiac surgery....
An additional 4 consultant anaesthetists have been appointed(one of these is still to take up post as
he has been funded by the Health Board to undertake a secondment at Papworth Hospital for skills
training and development) and additional resourcing is linked to the capital business plan. There is
still insufficient numbers to meet the FICM/ICS standards of split anaesthetic ICU/anaesthesia rotas
which is likely to become an NHS England commissioning requirement within 2 years time, albeit
there is no indication yet of whether this will be adopted in Wales. There is much improved
availability of TOE(transoesophageal echo) in theatre and all theatre sessions are covered though
“backfill” is still needed until a full complement of anaesthetists are in post. FULLY IMPLEMENTED
R9 The microbiologists should be encouraged to reinstate CITU ward rounds...
This is not possible in the way envisaged but there is more support now provided via daily telephone
support to everyone’s satisfaction. FULLY IMPLEMENTED
R10...formal job plan review with the cardiac surgeons immediately ...
This was implemented and new signed job plans are in place from April 2014 and due for review
after 6 months. In fact this has resolved a number of outstanding issues that have been in existence
for a number of years which previously prevented the agreement of job plans. FULLY IMPLEMENTED
R11...review the inequitable payment arrangements between staff groups....
This has been resolved to some extent ie between the surgeons and anaesthetists. However, there
have been ongoing issues amongst theatre staff about on call arrangements, that has been resolved
with agreement over recurrent workforce patterns and investment in core cardiac staff. An intensity
payment is being applied for the period where on call working was over and above this agreed level
of work. FULLY IMPLEMENTED
New Recommendations
9
1. The directorate should continue to enhance the cover provided by the CITU medical rota.
Plans should be put in place to deliver weekly rotating consultant CITU cover with enhanced
out of hours cover. A multidisciplinary 5 pm handover should take place with the presence
of the surgical registrar in the interim.
2. Continue to seek ways of building a healthy multi-disciplinary team working spirit that does
not tolerate behaviours tantamount to bullying, abuse, intimidation and disrespect. This is
not just a leadership task, though they clearly have a role to play. It is also important that
staff themselves are not passive in this and also seek ways to improve working relationships
where necessary. Clarification on the use of formal incident reporting needs to be given as
some staff feel they are discouraged to use this process especially for issues relating to bad
behaviour. Also feedback from incident reports needs to be improved.
3. The external panel believe that the substantive Directorate arrangements should bring
Cardiology and cardiothoracic surgery together and, on balance, we also believe that
dedicated cardiac theatre staff should also transfer into the new Directorate. We are aware
of the potential difficulties this may cause but feel this is the best way of securing improved
staffing, staff morale and efficiency in the operating theatres. There may be scope in
flexibilities between the staffing of theatres and catheter labs. The Health board are
reviewing management arrangements generally across the organisation to make changes
from April 2015 and we hope this recommendation can help influence the nature of those
changes in that timeframe.
ii) The reasons for long waiting times to access the service and
measures that should be taken to address this
Overview
Waiting times are still long at around 13 months with 133 patients waiting over 36 weeks and real
pressure from WHSSC to reduce this to zero by 31 Mar 2015.The Directorate are confident of
achieving this with a combination of in house work and some outsourcing to the Brompton Hospital
etc. Clearly this is an expensive option and becoming self- sufficient is reliant on internal capacity
increases and efficiency improvements and possibly new ways of working, including in partnership
with the Cardiff centre. At the end of October the number has reduced to 100 over 36 weeks with
24 of those patients planned for treatment at the Royal Brompton. In addition the plan for the unit
to deliver 650 cases this year was on track to date which is an improvement on previous year.
Waiting list mortality is still an issue, though there is more attention now given to this through
monthly and quarterly validated reported to WHSCC from both Swansea and Cardiff. Nurse
practitioners now contact waiting list patients over 26 weeks to update on their progress and
arrange further review as necessary or expedite surgery. The Society of Cardiothoracic Surgery data
for post operative mortality remains low for Swansea with results in the upper quartile for the UK
centres.
10
Progress on 2013 Recommendations
R1 The Health Board should urgently receive a further analysis of the deaths on waiting lists in
recent years....
Work has been done to better understand the cause of death in patients who have died on the
waiting list and the Health Board/Directorate have worked with WHSSC on improvements to waiting
list management, and analysing those that die on the waiting list. Several have died for non cardiac
reasons. The WHSSC paper dated 14 Aug 2014 charts the numbers of deaths on the waiting list as
18 in 2013/14 and 5 in the first 4 months of 2014/15. Deaths on waiting list are therefore still an
issue, though efforts are being made to reduce the long waiting times by temporary outsourcing
some long waiters to the Brompton and other centres. FULLY IMPLEMENTED
R2 The Health Board should assess its capacity/performance to meet future demands ...
The long waiting times are a combination of insufficient capacity and inefficiencies. More analysis is
made in the next section but the Directorate are confident they will meet their overall targets by 31
March 2015, through a combination of the outsourcing and in house activity.
Questions have also been raised about the case mix of patients put on the waiting list at Morriston
Hospital relative to other centres. SCTS data suggests that patients referred for cardiac surgery in S
Wales tend to have more co-morbidity and tend to be more complex. Consideration is being given to
the use of a frailty index in MDT meetings, so that the responsibility for decisions that might decline
surgery can be shared and demonstrate transparency of decision making. . Alternatives to surgery
should be guided by the SYNTAX study which set clear guidelines for choosing surgery over PCI. The
long waiting lists may tip the balance in some patients in whom the Syntax Study suggested
equipoise(mid range Syntax score) towards PCI.
Attempts have been made to create a common pool for referrals to keep waiting times for surgeons
equal – this should be fully implemented. There is also a more proactive approach by the Directorate
involving telephoning long wait patients.
WHSCC have adopted a stronger performance management approach in its commissioning of
cardiac surgery services and are determined to reduce the long waiting times. They are very
supportive of maintaining two centres at Swansea and Cardiff and this is covered in more detail in
section vi) FULLY IMPLEMENTED
iii) To report on the efficiency and capacity of the service to meet
present and future demands
Overview
Much of the focus of this section in our last review was on CITU and Theatre efficiency. Some
progress has been made in improving theatre utilisation by focusing on start times and in reducing
11
the very long lengths of stay in ITU. Overall however more progress needs to be made on
implementing the recommendations to improve these and it was said to us that it is these “hard
issues” that now need to be addressed by the Directorate and the Health Board (acknowledging that
the “soft issues” around relationships and behaviours have had the initial priority).
The 2012/13 NCBC benchmarking data suggested that there is a relatively low throughput of cases
per theatre (2 per theatre compared to a UK range of 1.8 to 5.2). In addition it shows that Morriston
had one of the lowest throughputs per critical care bed in the UK, with 42 procedures per critical
care bed(compared to a range of 34 to 113). The cancellation rates at 42% were by far the highest in
the UK. On face value, these figures support the “Albatross” benchmarking undertaken by the
Finance team who estimate a potential saving of 55,000 minutes theatre time and 2400 bed days.
However, the NCBC data on staffing levels provided quite a different picture, and will be reported in
the next section.
It should be noted that the 13/14 NCBN data will be published in December providing a more up to
date benchmark for the first full year of the Directorate.
In addition to these two resource intensive units, the Directorate will need to also look at the
organisation of outpatient services including pre-assessment clinics, which do not gain a priority
currently, and which do seem to be contributing to inefficiencies. Out- patient services are poorly
organised, inadequately staffed, regularly start late by as much as an hour, and have very large
follow up to new ratios which could be reduced dramatically( to 1:1). This has led to clinic over-runs
and patients sometimes being sent home without being seen due to over-runs. The pre-assessment
clinic is not fit for purpose and the thoracic nurse specialist left the post a year ago, so this service
has virtually stopped.
We also heard some concerns about the lack of planning around ward capacity especially when the
new CITU capacity comes on stream, as there is a danger of moving the bottleneck to the HDU and
ward area. This will need to be carefully managed through changes to operational processes and
staffing levels.
We therefore make additional recommendations about outpatient services and ward capacity
planning.
Progress on 2013 Recommendations
R1 The surgical HDU should be relocated to adjacent to the CITU in place of the cardiology short
stay/day case unit...
We were disappointed that the Directorate and Health Board have been unable to progress a short
term solution to achieve this. This is because there would have been significant bed reductions in
the overall services. Subsequently the Directorate has just received support from WHSSC to a £4m+
capital development to expand the CITU giving additional beds (2 additional CITU ; 2 replacement
HDU) and now need to finalise a business case which will mean a start on site mid 2015. The scheme
does not relocate HDU alongside CITU so there are still issues of staffing , discharge of patients from
CITU and supervision of patients, even with the new investment. Of course there will be some
tangible benefits of the additional capacity as well as providing more bed space in HDU. Whilst a lot
of work has been done on this, no additional capacity has yet been created and even after the
12
capital investment in 2015 the CITU and HDU will still be left physically separate. NOT
IMPLEMENTED
R2 Thoracic patients could be accommodated in dedicated level 1 beds with enhanced nurse ratios
,in order to increase capacity for cardiac surgery cases...
This requires a change in practice by thoracic surgeons with more effective methods of analgesia and
not prolonged epidural analgesia. It also requires more equipment and staffing on Bracelet bay.
Neither have been progressed. The development has been linked to the capital and associated
revenue business case for CITU capacity expansion, but the panel think this could have progressed
earlier and achieved significant capacity release and efficiencies. The Directorate has developed a
plan for discussion with WHSCC as commissioners of the service to implement this recommendation.
NOT IMPLEMENTED
R3 Suitable fast track cardiac surgery patients should be identified pre-operatively and detailed to
an enhanced recovery type pathway....
ERAS has been introduced in thoracic surgery with enhanced pre-operative physiotherapy in place
which has positively impacted outcomes, recovery and length of stay. A fast track system has not
been introduced in cardiac surgery, but this has been hampered by lack of HDU capacity and
location. The term ERAS is not yet widely used in cardiac surgical practice. PARTIALLY
IMPLEMENTED
R4 CITU should ultimately move towards a weekly rota system to improve continuity of care...
This should be able to be fully implemented when the 4rd additional anaesthetist completes his
sabbatical at Papworth early 2015. PARTIALLY IMPLEMENTED
R5 Expedite the creation of protocols to standardise and speed up decision making. ....
The end of life pathway was mentioned earlier and some progress has been made on discharge
protocols and repatriation of patients back to their local hospital and also to Morriston general ITU.
More could be done on this and the process for escalation when protocols are breached needs to be
communicated. Occasional examples of disagreements over discharge/transfer were raised with the
expert panel on the site visit. PARTIALLY IMPLEMENTED
R6 The directorate should institute a system to regularly check patients who have stayed on CITU
for long periods....
The CITU Director has achieved a goal of no patient staying longer than 50 days and is now aiming to
reduce that to 30 days. This compares with an example of a patient staying over 200 days when we
last visited. FULLY IMPLEMENTED
R7 There needs to be further thought and careful planning of operating lists ...
The operational forum has been an important development for planning as mentioned earlier.
However as noted previously there may be an underlying capacity issue which affects performance.
13
However, we concluded that there are still many opportunities to improve efficiencies in the
utilisation of theatres:-
Although cancellations of the second case have reduced, they remain a challenge, possibly a
reaction to the major concern in the past about theatre overruns. Theatre staff are reluctant
to send for a second patient after 2/2.30 pm resulting in cancellation. With a start time of 8
am and projected finish of 6.30 pm it was not clear to the panel why 2 cases could not be
done, even allowing for case mix. We suggest that the “quickest” case be put first on the list,
so that the second patient is sent for long before 2 pm
It is important that the surgeons have no other commitments on theatre days. The new
surgical job plans have addressed this.
“in house patients” – the surgeons take these for a week at a time-the number is variable
and can be much in excess of their operating capacity for the next week. This is a challenge
for every unit but some allocate specific sessions in the weekly schedule for in-house cases
shared out amongst the surgeons.
The Directorate could consider modifying the “Priority days” i.e. if the priority list is over-
running with potential for cancelling the second case there should be communication with
the non-priority list to ensure full utilisation of theatre time. This would be an extension of
the current ”priority days”, introduced to give individual surgeons (by rotation)priority when
there is a shortage of CITU beds etc.
Thoracic surgery – at present the thoracic surgeons operate on Tuesday and Thursday which
results in a logjam later in the week. In addition to the changes in analgesia suggested
earlier, consideration should be given to changing the operating day .The “Tuesday surgeon”
has a main MDT meeting on a Thursday which means he cannot effectively use the Thursday
list when the other surgeon is on leave
TAVI- at present a full theatre team is on standby and a theatre kept empty when TAVIs are
being performed. This is not universal practice and some teams are moving to performing
the procedure under local anaesthetic and using Cath Lab if emergency conversion to
theatre is needed. We recognise there is variable practice across the UK.
Vital disposable and capital equipment is not being ordered, cardiac theatre is still
dependent on the main theatre budget to maintain stock of specific cardiac equipment and
it is perceived that cardiac are seen as a low priority for urgent replacement of equipment
We are aware of attempts by Trusts to improve efficiency around consultant intervention
into “training lists”. This is an extract from a protocol from Barts :-
Consultant involvement in training It is recognised that training is essential. However, training cannot be allowed to cause
overrun-related cancellations. To minimise the risk of cancellations and overrun the
following rules for Consultant intervention to assist or take over will apply:
o If the mammary artery has not been harvested one hour after the primary incision.
o If de-cannulation to sternal closure has not been completed within one hour.
If at any time when the theatre team feel that consultant input is required when junior surgeons are conducting cardiac or thoracic surgery.
14
Finally, the theatre management think that theatre efficiency is better but there is more room for improvement. They are funded for theatres operating 80 % of the year but in reality, theatres are now operating 90 % of the year and this contributes to the need for flexible staffing and last minute transfer of staff from cardiac theatres to main.
We make an additional recommendation on improving theatre efficiency
PARTIALLY IMPLEMENTED
R8 The long term capacity resolution may well need a major new build ...
The effort has gone into gaining commissioner support for the £4m development to create 4 beds rather than on the long term redevelopment of the cardiac Centre. The potential for a major new build is inextricably linked with the future strategy for Cardiac surgery in S Wales, which we raise in section v) below. PARTIALLY IMPLEMENTED
New Recommendations
4. A proper outpatient service review is undertaken and a more professional service established for this and for pre-assessment for both cardiac surgery and thoracic surgery. This should include proper staffing arrangements(nursing and medical) and modern templates for new:follow up clinics as well as agreed start/finish times.
5. In the capacity planning for the ward area, consider the following :-
Day of surgery admission(commonplace in many units).This would reinforce the requirement for a formal pre-assessment clinic where the patients could be seen by an anaesthetist as well as a nurse practitioner
Transfer of post-operative patients back to their referring hospital
Nursing skill mix review
6. The Directorate and Theatres management need to radically improve theatre efficiency and
we have listed some of the issues and ideas in R7 above. In addition we recommend that an audit of all the theatre times is performed to identify why cases take so long (we heard a variety of reasons so facts are needed). This should include - into anaesthetic room, intubation, into theatre, knife to skin, on bypass, off bypass, decannulation, sterna wires started, closure, leaving theatre.
iv) To report on the sustainability and cost effectiveness of the
workforce
Overview
Our report in 2013 majored on the CITU/HDU and called for a skill mix review to bring the Cardiac
critical care staffing into line with the rest of the UK and other ITU environments. That report did
15
also comment on other staffing issues but this was the main recommendation. The Health Board
have made substantial investments in the Cardiac surgery directorate, following last year’s review.
This includes “Quality investments” on the interim Directorate leadership (£184k); CITU Nurse
educator(£45k); Theatres ( scheduled - £87k,intensity- £87k) ; perfusion intensity (£20k); ICNARC
clerk( £34k). In addition the Health Board have approved £575k for the activity levels to 728 cases
per annum and £483k for the extra 2 ITU beds. Even with these investments the CITU/HDU is light
on more senior nurses (2 X band 7 compared to 12 at St Georges, a similar size unit)and there are
also known staff shortfalls on Cyril Evans Ward and in theatres. The directorate have been told that
further investment can only be linked to the capital business case.
The NCBC benchmarking data for 2012/13 shows Morriston Cardiac surgery as significantly
UNDERSTAFFED against the rest of the UK :-
CITU – 4.54 wte per bed compared to a median of 5.23 and a range of 3.5 to 6.82.
(in addition re skill mix Morriston have 3% in bands 7&8 compared to median of 7%)
Theatres – 7.6 wte per theatre compared to a median of 10.1 and a range of 1.7 to 16.7
Ward – 1.22 wte per bed compared to a median of 1.3 and a range of 0.97 to 1.73
Surgeons – 7 compared to a median of 10.4 and a range of 5.8 to 19.2
(Morriston surgeons have the lowest number of theatre PAs per consultant at 2.4 compared
to a median of 4.8 range of 2.4 to 7.3). Note - Some caution should be exercised in benchmarking
surgeon’s PAs as they are measured differently in Wales to England.
It will be useful to see what the 2013/14 benchmark is when it is published in the next few weeks.
Our re-visit highlighted a number of other issues in staffing the key units in Cardiac surgery:-
i. Ward Nursing skill mix and staff numbers on the ward are cited as the reasons for problems
in patient flow between HDU and the ward. This could be addressed by the proper staffing of
level 1 beds (Bracelet ward) as previously recommended.
Ward nursing reported good opportunity for training and education, several are enrolled in
degree or masters programmes.
ii) CITU/HDU There have been high sickness rates on the CITU which were improving and being
managed well(reduced from 13 to 8 %). Retention of staff has remained a problem, up to 8
senior (band 6) staff have left in the last year, some to posts of a lower grade. Exit interviews
should be arranged to discover the causes. Band 6 nurses are routinely in charge of CITU and
occasionally band 5 nurses are in charge of the CITU. A band 5 nurse had developed a traffic light
system to to get an equal balance of experience between CITU and HDU, which was reported to
be working well. One Band 7 has started to take on the Education role which is a positive move
though she is concerned about the difficulties of freeing up staff for development. Finally, Core
standards for Intensive Care Units suggest that 50% of ICU/HDU staff should have a post
registration award in critical care but only 6 % of Morriston staff have this.
16
iii) Theatres Whilst there has been some investment in additional staff there is a perception that
much of this will benefit the general theatre pool and there has not been an improvement in
core cardiac theatre staff. Many of the staff feel “disenfranchised” and wish to move into a
Cardiac Directorate. They reported that staff are frequently pulled away from cardiac theatres
when main theatres are short, sometimes AFTER the day’s workload has been agreed. They feel
that staff are never pulled the other way, from main theatres to cardiac. They also report no
opportunity to take time back if they work late. Training opportunities for new cardiac scrub
staff are reduced, it was reported that this arose on 8 out of 10 days and this is unacceptable.
Overall cardiac theatre staff are frustrated that their area is not regarded as a speciality by the
general theatres. Clearly some of these points relate to the earlier section on working
relationships but it is also affecting the staffing of cardiac theatre lists.
iv) Surgical registrars – at present only 4 of the 9 posts are filled and there is also a vacant FY2
posts adding to the problem of ward cover. We heard of significant backlog of discharge letters
as a consequence of these shortages not to mention the affect on staff morale. 3 out of the 5
vacant posts have been filled and the other two have shortlisted candidates. The juniors would
appreciate more opportunity to meet with a lead consultant.
Progress on 2013 Recommendations
R1 Undertake a nursing skill mix review on the CITU/HDU....
It was reported that a skill mix review had been undertaken, and led to recommendations with cost
consequences but any additional costs could only be achieved through the capital business case as
mentioned in the Overview above. This means that there is no change from the situation in 2013.
NOT IMPLEMENTED
New Recommendations
7. We have set out these concerns about skill mix and staffing levels in some detail because
they are clearly affecting the efficiency (and morale) in the Unit. The potential savings
highlighted by the Finance team need to be seen in conjunction with the potential staff
shortages. It is not a contradiction to say that INCREASING staff costs can lead to improved
efficiency and throughput, enabling increased activity therefore LOWERING the unit costs.
So the new recommendation is to look at the total picture in planning ahead, not just one
dimension that looks at “potential savings”.
v) To report on the standards of care and the environment for
patients
Overview
We noted last time that, despite all the concerns raised in the report, the standard of care was of a
high standard though we did raise some specific issues about end of life care, infection control and
17
some serious clinical incidents. We have already noted the improvements evident in our re-visit
about end of life care and infection control. Since the original visit the Trusted to Care report into
hospital standards by Professor June Andrews has been published and the Health Board is in the
process of rolling out the recommendations to all services not just those that were subject to the
original visit. There was one “never event” reported this time, in connection some non- prescribed
medication left on a patient’s table on the ward( as the nurse had been interrupted on the drug
round). This was reportable as a “never event” following the Andrews report in Wales which
introduced a requirement for zero tolerance in relation to standards on medication, hydration,
continence, and sedation. There seems to be some confusion about these new “never events”
which appear to be important nursing standards, but which are quite hard to police and which don’t
get reported in the same way as the original set. Several interviewees did not regard the incident as
so important to be classed as a “never event”. This reflects that these recommendations are still in
the process of implementation across the Health Board.
In terms of the environment, the cramped conditions in both CITU and HDU are acknowledged and
should improve with the capital development next year. The ward environment is clean and well
organised considering its ageing estate.
Progress on 2013 Recommendations
R1 There were no recommendations in this section of the 2013 report that had not been covered in
earlier sections of the report.
New Recommendations
8. Improve communication and understanding of the the new list of “never events”
introduced with the Andrews report throughout the Directorate
vi) The priorities for developing the service
Overview
We were able to meet the WHSSC Director of Planning who made it clear that they see the two
centres at Swansea and Cardiff both continuing into the foreseeable future but with a more co-
operative approach between the two. This could include clearer sub-specialisation; joint audit and
outcome measures; other joint working; possibly even eventually a single service across two sites.
But it was clear that there is a desire to sustain both sites.
Last year and to some extent in this recent visit, there is an internal perception that the future of the
Morriston cardiac surgery service is uncertain and several staff expressed a fear that it may be
closed down.
18
There has been some progress on collaboration with Cardiff regarding subspecialisation MDTs
including for TAVI/SAVR and possibly mitral valve repair and aortic surgery. The two centres have
also collaborated on the development of an all Wales referral for cardiac surgery proforma.
The panel view is that the Directorate and Health Board should now work on a vision and a five year
plus strategy/business plan for the Cardiac Surgery centre that takes this into account but which
reassures the workforce(and public) that there is a secure and healthy future, with the positive news
around the capital development incorporated as well as the other workforce developments
recommended in this report. The workforce plan should include succession planning for the
consultant surgeons and any potential change in subspecialty could be linked to this eg should
Swansea continue to undertake major aortic surgery? (ie when the senior surgeon who undertakes
aortic surgery retires)
We need to identify clearly the potential for the planned 4 bed CITU expansion to be undermined by
a bottleneck occurring at the HDU and Cyril Evans ward level. The hoped for increases in cardiac
surgical volume may not be realised without ensuring a robust plan for patient flow through the
system are in place. Nursing skill mix in these 2 areas will be a key factor in implementation.
With the focus on cardiac surgery development there is a risk that important developments required
in Cardiology are not considered in parallel, as the two services are currently in separate
directorates. It is important that the unit is seen as a whole entity and any plans for CITU/HDU
expansion need to be cognisant of the future need to refurbish the two existing cardiac catheter
laboratories. In addition, other cardiology developments will include the expansion of TAVI and
other structural interventions as well as the extended application of primary angioplasty into those
patients with out of hospital arrest. This particularly will have impact on ITU capacity and needs to
be factored into any developments in that area.
The strategy for thoracic surgery should also be determined as part of this work, as they too are
being encouraged to collaborate with the Cardiff Surgeons.
Many staff we interviewed expressed frustration that there is no overarching plan for cardiac
surgical services in S Wales. With the information gleaned from WHSSC, the capital development
proceeding (subject to final business case) and the recommendations in our two reviews, it is timely
to now produce a clear plan. We make an additional recommendation about the creation of an over-
arching strategic plan as a high priority for the Directorate and Health Board.
Progress on 2013 Recommendations
R1The Health Board need to build these development opportunities into their service planning
processes …..
There have been ongoing discussions with WHSSC and Cardiff about subspecialisation and
cooperation, and also as part of the capital plan discussion. We consolidate this recommendation
19
and several others into a new recommendation for a formal strategic plan and vision to be created
and communicated. PARTIALLY IMPLEMENTED
R2 Review MDT arrangements to try to discuss all patients accepted for elective and semi elective
and other non- surgical priority patients..
There is a well attended MDT by all Swansea, Bridgend and Hywel Dda cardiologists with a formal
terms of reference, focusing on non complex cases and we recognise it is difficult to review all
patients at MDT meetings. Ideally all elective patients in which revascularisation is considered should
be discussed at an MDT. If there is insufficient time, the Directorate should consider expanding their
MDT sessions to accommodate this. In the meantime, an agreed set of criteria could be developed
taht would direct which elective cases should be discussed eg LMS,MVD with proximal LAD
involvement, high risk for PCI etc. Discussion of inpatients (and therefore urgent cases) may pose
practical problems in terms of timing of meetings. Ideally these patients should also be discussed if
the disease is widespread or complex, and if there is no mandate to proceed with PCI at the same
sitting. It is recognised that in the above scenarios ad hoc discussion between cardiologist and
surgeon is entirely reasonable, the substance of which being documented in terms of both the
decision reached and its priority. Guidance is available on the BCS,SCTS and BCIS websites and the
Directorate need to agree a future policy for this. PARTIALLY IMPLEMENTED
New Recommendations
9. The Directorate and Health Board should now create a positive vision and 5 year plus
strategy for cardiac surgery services that takes into account the clear views of WHSSC and
reflects the need to sub-specialise in collaboration with the centre at Cardiff, It should
incorporate the workforce improvements sought in this and our last report and plan for the
succession of surgeons over the medium term. The exercise can be a very positive
opportunity for staff and stakeholder engagement in the creation of a compelling vision for
the future and we recommend this should be progressed as soon as possible ie over the next
6 months.
vii) The appropriateness of clinical audit and benchmarking
arrangements
Overview
It was disappointing that approval for the appointment of an audit clerk only happened just before
this re-visit took place. We didn’t feel that improvements had been made in the collection of data
and then the use of benchmarking reports. Some staff reported to us that they had been
discouraged from submitting incident reports about poor behaviour, as it may reflect badly on the
unit. However, it should be noted that there are new processes in place Health board wide, intended
20
to make it easier for all staff, patients and carers to raise concerns and issues. The Directorate
needs to reinforce the messages and processes to make a clear statement about the importance of
incident reporting, its purpose and use and the availability of other avenues on raising concerns.
Progress on 2013 Recommendations
R1 Utilise existing NCBC database with more directorate staff exposed and to influence service
plans … and utilise the SCTS database to benchmark quality standards …
The internal Action plan update states “Attendance from CD, DGM, Nurse, Chief Pharmacist and
Surgeon at annual NCBC Benchmarking day on 5/12/13” and that it had been used alongside the
Albatross costing model to benchmark performance. However, none of the nursing staff we
interviewed were aware of the contents of the NCBC database. This applies to a lot of the internally
generated performance metrics and even waiting list figures. PARTIALLY IMPLEMENTED
R2 Expedite the appointment of an audit clerk… clinical governance meetings to involve
anaesthetists and nurses…
There has been a recent decision to approve the appointment of an ICNARC clerk for 16 hours a
week on the CITU. This is quite low compared to most units who also often use an audit nurse to
validate the data. The surgical data including that for SCTS is entered by the surgical registrars when
doing the discharge letter, which is a significant job. Would it not be possible to enter the data as the
patient moves through the pathway and then checked by the registrar at the time of discharge. This
would also enable a verification process, which seems to be absent.
There are excellent standards incorporated in the terms of reference for the clinical governance
meetings, which are soon to move to a whole day per month (currently 3 hour session)and will
enable the anaesthetists to attend and allow time for multi-disciplinary teaching and learning. It is
important that nursing staff are enabled to attend these meetings. It is also important that the
results of audits and clinical governance meetings are shared with staff who do not attend the
meetings. PARTIALLY IMPLEMENTED
R3 Mortality cases could be presented by a consultant not responsible for the patient … and use
NCEPOD grading …
The NCEPOD grading isn’t yet used. This would standardise the process of achieving agreement on
the standard of care and highlight areas for improvement. Another suggestion would be to
categorise each death into one of three groups – technical/surgical; failure to rescue; and multi-
factorial/patient co-morbidities. This would take the spotlight off the surgeon and their concern that
all deaths are their responsibility.
Trust-wide templates are in use – to be completed by the doctor completing the death certificate
and the consultant giving details of the care- these are used at the clinical governance meeting. It is
good practice for a consultant not involved in the case to present the findings. PARTIALLY
IMPLEMENTED
R4 Consider a culture climate survey with staff ….and seek to improve the culture..
21
Two Pulse surveys have been undertaken in March 2014 and July 2014 and important themes have
emerged from the responses. It was acknowledged that this was too little time between the two
surveys to show any meaningful progress though the second was slightly more positive feedback. A
reasonable response rate was achieved(46 % in march;62 % in July). Linked into the surveys a
number of development sessions have been undertaken with some staff groups including a “well-
being workshop” and “in your shoes” exercises. Some of these are broader than the cardiac surgery
directorate. It was pointed out that 8 staff from cardiac surgery have been included in the
Chairman’s awards which is a very positive development for the recognition of staff. The team won
the category of “outstanding tutor/mentor”
It is acknowledged that this is very much “work in progress” but a good start has been taken by the
Health Board and directorate on trying to change the culture in cardiac surgery. FULLY
IMPLEMENTED
R5 Ensure the deficiencies and risks in the report are on the risk register and it is used as a live
document
The new Cardiothoracic Surgery Directorate acted quickly to disaggregate the old Risk Register and
establish their own, which is regularly reviewed and updated. There was a multi-disciplinary
workshop early 2014 and also root cause analysis training/refresher course. FULLY IMPLEMENTED
R6 Insist upon the regular reporting of serious incidents such as overturned end of life care
decisions , ensuring management action is taken and escalated if necessary
The external panel were told there had been no serious incidents reported, though the Andrews
“never event” was then shared with us. Several staff told us they were being discouraged from
reporting of poor behaviour on incident reports. There would be merit in the Directorate stating
explicitly its philosophy around incident reporting and running some multi-disciplinary workshops to
ensure clarity around the purpose and process of incident reporting, and also the other avenues
available to staff to raise concerns. PARTIALLY IMPLEMENTED
viii) Appraise the sustainability of improvements made
Overview
This section in the last report was headed “Why Recommendations from previous reviews had not
been implemented” and we heard of several reports over the last 10+ years that had not been
implemented. The progress against last year’s recommendations in this has been quite impressive
but inevitably the theme of future leadership arrangements tended to dominate the discussions we
held. We have already made a new recommendation about this in section i) to propose a new
Cardiac services Directorate comprising Cardiac Surgery, Cardiology and the appropriate dedicated
theatre staff, which we believe, with the right leadership, will help with the sustainability of
improvements made. The creation of a positive vision, long term strategy and business development
22
has also already been recommended earlier in section vi) and this too will act as a powerful positive
stimulus for further improvements.
One person suggested this external expert panel should be asked to visit again in 12 months to
maintain the pressure on improvements and sustaining the focus and attention. We don’t think this
is necessary but do agree there has been great merit in having this external stimulus. The internal
peer review process was very impressive and challenged the Directorate in terms of their self-
assessment on progress and we suggest this should be repeated regularly.
Progress on 2013 Recommendations
R1 Make this report available to all staff
The report was reported to a public Health Board meeting, several open staff forum were
established to present the report and listen to staff reaction, and these open staff forum have
continued since its publication, to review progress. FULLY IMPLEMENTED
R2 In addition to the Project Steering team, we believe that dedicated project management will be
needed to oversee the implementation of our Recommendations…..
The Health Board’s response to this was to create a dedicated Cardiothoracic Surgery Directorate,
initially on an interim basis, in order both to run the service and also to focus on implementing the
review report’s recommendations. The new interim leadership have achieved a lot and have quickly
established respect from staff and the rest of the organisation, as well as external stakeholders such
as WHSSC. The emphasis of the interim Directorate leadership’s early work was described (by an
interviewee)to have been on “soft issues” meaning some of the team working and behavioural
aspects, and has made real progress on these. However, they went on to say, it is now time to
address the “hard issues”, meaning performance and business improvements, having established
these foundations. The expert panel would agree with this statement, though wouldn’t
underestimate the challenges of the so-called “soft issues”.
The Directorate have to pull together business intelligence from a variety of different sources,
though the monthly performance report is quite good, it does lack some basic efficiency and quality
targets. Such basic improvement priorities should be devolved throughout the Directorate so that
ward sisters, theatres, CITU all can see both the wider directorate priorities and their own
contribution to this. Priorities such as cancellation rates, length of stay reductions in CITU/Ward ;
long waiting lists etc were not widely known or owned in the directorate outside of the directorate
leadership. The CITU Director has worked hard on reducing the number of the long stayers in CITU
and should, with the team, seek to achieve a median stay of 1 day as an aspirational target.
We make an additional recommendation about the “hard issues”.
The Health Board have invested substantially in the interim directorate leadership and this was a
good decision. However, as this new review report highlights, there is still a lot to do and dedicated
project management would still be useful to oversee discrete elements of the recommendations and
work plan eg theatre improvements. PARTIALLY IMPLEMENTED
23
R3 There needs to be clear lines of accountability ..and regular progress reports…
The Health Board quickly established a Cardiac Surgery Review Action Plan that incorporated the
2013 Report’s recommendations. Progress reports and regular reviews of this Action Plan have been
through monthly performance review meetings to hold the cardiothoracic directorate to account.
An additional step was taken with a challenging internal peer review process in April 2014, which
was a really useful process and could be repeated regularly (see new Recommendations)FULLY
IMPLEMENTED
R4 This external review panel should be re commissioned to visit again in 12 months to see and
report what progress has been made.
The Health board immediately commissioned a re-review to take place in Sept 2014 and this report
summarises the outcome of that further external review. FULLY IMPLEMENTED
R5 There is a need for courageous leadership ….
The Health Board CEO, other Health Board Directors and the new interim directorate leadership
have all stated and demonstrated their determination to address the issues raised and the “zero
tolerance to bullying” for example has shown that courageous leadership. This has been further
reinforced with the transparency to the public and to staff by making the last report freely available.
FULLY IMPLEMENTED
R6 ….Build on progress made eg by Dr Dafydd Thomas in CITU ..and not jeopardise the progress made …. There was certainly a risk of jeopardising the progress being made and the Cardiac surgeons were
understandably “bruised” by some of the contents of the last report. The first few weeks following
the publication of the last report led to reduced surgical activity whilst discussions progressed and
new arrangements were put in place, including a new lead surgeon. The working relationships and
better engagement in the improvements needed have been handled with a leadership style that has
been collaborative and respectful, but also not accepting of poor behaviour. FULLY IMPLEMENTED
New Recommendations
10. Review the current monthly performance report to ensure it contains all the
Directorate/Health board priorities and then this is built up from ward/departments in the
directorate so they can see their share of the improvement required and progress they are
making on this, as well as understanding the wider performance of the Directorate. An
example would be setting an aspirational target median length of stay on CITU of 1 day.
11. Repeat the internal peer review challenge process regularly to supplement the normal
existing performance management arrangements.
12. Ensure a robust legacy plan is in place to continue the leadership provided by Dafydd
Thomas is in place when he retires from his current role(this point about succession planning
is also pertinent to other key senior people but the CITU Director role is particularly
sensitive).
24
ix) Any other issues that the panel feel are relevant, highlighting
any new issue that have arisen since the Review in 2013
Overview
In this section last year, we raised points about the CCU managing acute strokes (they are
increasingly managed in hyper-acute stroke units in England); we acknowledged that we had not
spent much time looking at Cyril Evans ward; highlighted that little training and development is done
aside statutory training; and the need to raise the profile of patient and family involvement.
In this follow up review we have not looked at the CCU managing strokes situation but have formed
a view on the other issues:-
Cyril Evans ward. In contrast to the last review, the ward has had a much higher profile in
terms of our recent visit and review findings. We have already commented on the need for a
formal level 1 unit with appropriate skill mix to be funded and the nurse staffing did seem to
be more pressured, partly due to the need for them to run the outpatient service, which we
have been critical of earlier.
There have been a number of development processes established and recently a part time
clinical educator has been appointed on CITU, but both developments have suffered from
the ability to free up staff to attend. This is linked to the overall staffing levels referred to in
earlier sections of this report.
It is impressive that the Directorate Board has a patient representative as a full member and
he provided the panel with an article showing how patient representation had been used in
the cardiac surgery service. We heard that there had been patient involvement in the P.D.U
but we were still left with a view that more could be done to gauge patient/relative
feedback following their stay in hospital and more could also be done to enable patients and
family to influence the treatment and service they receive.
25
Summary of all Recommendations
Progress against 2013 Recommendations
Of the 36 recommendations made in the last report our analysis of the Health
Board/Directorate’s progress against these is that:-
17 have been fully implemented
16 have been partially implemented
3 have not been implemented
We indicated in the last report which recommendations we considered to be urgent. There were 16
of these. We believe that 11 of these have been fully implemented; 3 partially implemented and 2
have not been implemented - relocate HDU to adjacent to CITU; and undertake skill mix review on
CITU/HDU( the review was done but not acted upon).
In considering what action the Directorate and Health Board should now take, it is important to
study our analysis of the progress against the recommendations and consider what further action
they need to take to improve the arrangements. In particular where we have suggested only
PARTIALLY IMPLEMENTED, the outstanding actions need to be taken forward. A good example of
this is in the improvements we recommended in Theatres. We have marked this PARTIALLY
IMPLEMENTED but much still needs to be done and is a more urgent and more important
recommendation than the PARTIALLY IMPLEMENTED recommendation about NCBC data for
example.
A summary of new Recommendations.
1. The directorate should continue to enhance the care provided by the CITU medical rota.
Plans should be put in place to deliver weekly rotating consultant CITU cover with enhanced
out of hours cover. A multidisciplinary 5 pm handover should take place with the presence
of the surgical registrar in the interim.
2. Continue to seek ways of building a healthy multi-disciplinary team working spirit that does
not tolerate behaviours tantamount to bullying, abuse, intimidation and disrespect. This is
not just a leadership task, though they clearly have a role to play. It is also important that
staff are not passive in this and also seek ways to improve working relationships where
necessary. Clarification on the use of formal incident reporting needs to be given as some
staff feel they are discouraged to use this process for such issues. Also feedback from
incident reports needs to be improved.
3. The panel believe that the substantive Directorate arrangements should bring Cardiology
and cardiothoracic surgery together and, on balance, we also believe some dedicated
cardiac theatre staff should also transfer into the new Directorate. We are aware of the
potential difficulties this may cause but feel this is the best way of securing improved
staffing, staff morale and efficiency. There may be scope in flexibilities between the staffing
of theatres and catheter labs. The Health board are reviewing management arrangements
26
generally across the organisation to make changes from april 2015 and we hope this
recommendation can help influence the nature of those changes in that timeframe.
4. A proper outpatient service review is undertaken and a more professional service
established for this and for pre-assessment for both cardiac surgery and thoracic surgery.
This should include proper staffing arrangements(nursing and medical) and modern
templates for new:follow up clinics as well as agreed start/finish times.
5. In the capacity planning for the ward area, consider the following :-
Day of surgery admission(commonplace in many units).This would reinforce
the requirement for a formal pre-assessment clinic where the patients could
be seen by an anaesthetist as well as a nurse practitioner
Transfer of post-operative patients back to their referring hospital
Nursing skill mix review
6. The Directorate and Theatres management need to radically improve theatre efficiency
and we have listed some of the issues and ideas to improve. In addition we recommend that
an audit of all the theatre times is performed to identify why cases take so long (we heard
a variety of reasons so facts are needed). This should include - into anaesthetic room,
intubation, into theatre, knife to skin, on bypass, off bypass, decannulation, sterna wires
started, closure, leaving theatre.
7. We have set out these concerns about skill mix and staffing levels in some detail because
they are clearly affecting the efficiency (and morale) in the Unit. The potential savings
highlighted by the Finance team need to be seen in conjunction with the potential staff
shortages. It is not a contradiction to say that INCREASING staff costs can lead to improved
efficiency and throughput, enabling increased activity therefore LOWERING the unit costs.
So the new recommendation is to look at the total picture in planning ahead, not just one
dimension that looks at “potential savings”.
8. Clarify the status of the new list of “never events” introduced with the Andrews report.
9. The Directorate and Health Board should now create a positive vision and 5 year strategy
for cardiac surgery services that takes into account the clear views of WHSSC and reflects
the need to sub-specialise in collaboration with the centre at Cardiff, It should incorporate
the workforce improvements sought in this and our last report and plan for the succession
of surgeons over the medium term. The exercise can be a very positive opportunity for staff
and stakeholder engagement in the creation of a compelling vision for the future and we
recommend this should be progressed as soon as possible ie over the next 6 months.
10. Review the current monthly performance report to ensure it contains all the
Directorate/Health board priorities and then this is built up from ward/departments in the
directorate so they can see their share of the improvement required and progress they are
making on this, as well as understanding the wider performance of the Directorate.
11. Repeat the internal peer review challenge process regularly to supplement the normal
existing performance management arrangements.
12. Ensure a robust legacy plan is in place to continue the leadership provided by Dafydd
Thomas is in place when he retires from his current role(this point about succession
planning is also pertinent to other key senior people but the CITU Director role is
particularly sensitive).
27
Appendix 1
External re-Review of the Cardiac Surgery Services at Morriston Hospital, Swansea.
Background and Context
In 2013, the Health board commissioned a review of cardiac surgical services following
some long term clinical, operational and workforce problems in the Unit. The review was
undertaken by an expert panel and chaired by an independent chairman. A visit to site took
place in July 2013 and a report published in sept 2013 was accepted by the Health Board at
their meeting on the 26 Sept 2013. One of the recommendations in response to previous
reviews not resolving the problems , was to re-visit the Unit in Sept 2014 to assess what
progress has been made. These terms of reference for the re-visit have been adapted from
the original review Terms of reference approved by the Health Board.
Membership
The panel and independent Chair will be the same as that established and appointed by the
Health Board in 2013 :-
Dr Nick Fletcher, Consultant Anaesthetist &Intensivist, St Georges Hospital, London
Mr Philip Gamston, Chief Perfusionist, St Bartholomews Hospital, London
Mr Leslie Hamilton, Consultant, Cardiac Surgeon Freeman Hospital, Newcastle
Mr Robert Harris-Mayes, Patient Representative
Dr Michael Norell, Consultant Cardiologist , Wolverhampton
Mr Paul Randall, Senior Cardiac Nurse, St Georges Hospital, London
And
Stephen Ramsden, Independent consultant and Chair of the Review Team
28
Approach
The date of the re-visit has been agreed as 15 & 16 Sept 2014. The panel will interview key
personnel in the Cardiac Surgery Unit and senior corporate officers as necessary.
In advance of the visit, the panel will have access, through the Chair, to new documentation
generated since the 2013 Review and any others from before, if necessary. The external
panel will use the 2013 Report as a firm basis to measure progress against the same criteria
determined in 2013 (set out below)
The Chair will create a cohesive formal written report synthesising reports produced by
individual panel members.
Presentation of the Report’s findings will be determined with the Review sponsors, Alex
Howells and Hamish Laing.
Terms of Reference
The external panel will , in the main, use the same headings as required in 2013 to present
the progress made against the recommendations and actions in relation to:-
i) the effectiveness of professional working relationships and multi disciplinary team working along key components of the cardiac surgical patient pathway, and to outline what additional measures may be required to improve this .
ii) Referral to Treatment Times performance and long waiting times in particular and additional measures that should be taken to address this.
iii) the efficiency and capacity of the service to meet present and projected demand, in the context of current plans
iv) thesustainability and cost-effectiveness of the workforce model and arrangements within the cardiothoracic centre.
v) thestandards of care and the environment for patients.
29
vi) The priorities for developing the service for the future.
vii) The appropriateness of current clinical audit and benchmarking arrangements.
viii) Appraise the sustainability of improvements made.
ix) Any other issues that the panel might feel are relevant, highlighting any new issues that have arisen since the Review in 2013.
Timescale It is envisaged that a report will be drafted in Oct for the Review sponsors to comment and a final report presented to the Health Board by Dec 2014.
