Aneurin Bevan Health Board Report on Ysbyty Ystrad … Ysbyty Ystrad Fawr... · Report on Ysbyty Ystrad Fawr Hospital’s ... combining 24 hour minor ... equating to an average of

Aneurin Bevan Health Board Wednesday 28 November 2012

Agenda Item: 3.7

Aneurin Bevan Health Board

Report on Ysbyty Ystrad Fawr Hospital’s first year of operation

1. Introduction

The purpose of this paper is to update the Board on Ysbyty Ystrad Fawr (YYF) Hospital’s first year of operation. It will provide an update against five key areas: unscheduled care, scheduled care, integrated care, women and children and Mental Health and will also outline some of the quality and patient safety improvements and issues. In addition, themes and actions from the lessons learnt process are detailed.

The Board is asked to consider the update.

Financial Assessment and link to Financial Recovery Plan

This paper does not provide a financial assessment of the ongoing revenue costs for YYF. Budgets for each of the key areas of service delivery are managed by the appropriate Division and variances to budget are reflected in the Health Board’s overall financial position.

Risk Assessment The paper highlights the key quality and safety issues and provides detail of the actions taken to mitigate the risks.

Annual Quality Framework

YYF supports the achievement of a number of priorities within the Annual Quality Framework. These include:

Improving the quality of patient experience – introducing Transforming Care methodology

Improving patient safety – with 1000 lives plus programme, NEWS, Sepsis bundle, falls risk assessments

Responding to capacity and demand by working in partnership to improve patient flow to the community

Utilising resources effectively

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Agenda Item: 3.7 Standards for Health Services Wales

YYF supports the achievement of a number of Standards for Health Services Wales. These include:

Governance (Std 1)

Citizen engagement and feedback (Std 5)

Quality improvement initiatives (Std 6)

Safe and clinically effective care (Std 7)

Care Planning and provision (Std 8)

Dignity and respect (Std 10)

Environment (Std 12)

Equality Impact Assessment

As this report is providing an update, there is no new equality impact

Child Impact Assessment

2 Background

Ysbyty Ystrad Fawr (YYF), a £172 million enhanced Local General hospital (eLGH), opened on 14th November 2011. It is the pathfinder for the Health Board’s Clinical Futures Programme and was commissioned with the following strategic objectives: • Improve access to services both in terms of time and location; • Ensure that services meet acceptable standards of safety and quality,

delivering the best possible outcomes for patients; • Improve the integration of care for patients between different

professionals, settings and providers; • Help people maintain their independence and support them in taking

more responsibility for their own health and social well being; • Develop an affordable and sustainable system of services that can

withstand future challenges.

As an eLGH, YYF was set up to maximise local access to services people use most often. The aim was to deliver as many services as practicable and safe in five key areas, illustrated in figure 1 below.

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Agenda Item: 3.7 Figure 1: eLGH Service delivery model

Local Emergency CentreEmergency admissions, rapid assessment,

minor injuries, GP out of hours

Diagnostic and Treatment CentreTests, investigations, CT scanner, MRI scanner, clinics, theatres, beds and

day places

Integrated Care CentreRehabilitation, step up/down care, palliative care,

therapies, hydrotherapy pool,

Mental Health ServicesDay care, outpatient & inpatient care for adults and older adults

Women and Children’s ServicesAntenatal & postnatal care, low risk birthing centre and

birthing pool, dedicated children’s clinic

Ysbyty Ystrad FawrLocal General Hospital

The initial Outline Business Case activity assumptions (as at September 2005) are as indicated below:

Local Emergency Centre

• 10,000 people using the primary care out of hours service

• 35,000 people with minor injuries • 7,474 emergency medical patients

Diagnostic and Treatment Centre

• 20,000 new outpatients • 4,300 operations

Children’s Clinic

• 2,500 Paediatric outpatient attendances • 1,200 attendances for the Child and Adolescent

Psychiatry, and Psychology Services

Integrated Care Centre

• Over 200 stroke patients • Over 2,000 patients requiring rehabilitation and sub

acute care

Midwifery Led Unit

• 2,200 outpatients • 500 births

Mental Health Unit

• 2,700 outpatient attendances (reprovision of current services in better facilities)

• 7,500 day hospital attendances (reprovision of current services in better facilities)

• 630 in patient admissions (increase in local service)

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Agenda Item: 3.7 This report will update the Board on each of the five key areas in YYF Hospital’s first year of operation, will outline key quality and patient safety improvements and issues and will detail the themes and actions from lessons learnt.

3 Unscheduled Care The unique Local Emergency Centre (LEC) model, combining 24 hour minor injury, medical assessment and GP Out of hour’s services, has been embedded since the inception of YYF.

3.1 Minor Injuries Unit (MIU) Unlike the previous service at Caerphilly District Minors Hospital (CDMH), the YYF MIU is open seven days per week and for 24 hours per day. Initially, doctors were provided at the YYF MIU until sufficient Emergency Nurse Practitioners (ENPs) were recruited. The service is now ENP-led and operates a ‘see and treat’ or ‘see and refer/signpost approach’. The ENP team is now well established, as are the links with the Medical Assessment Unit (MAU) and site Advanced Nurse Practitioners. Rotation of ENPs to the Royal Gwent Hospital assists in helping the YYF ENPs to maintain their skill set and deliver a comprehensive MIU service. Public perception continues regarding lack of doctors but the workforce is proactive in promoting the skills of the team to balance this. For the period 14th November 2011 to 31st October 2012, there have been 28,318 attendances, as shown in Figure 2 below, equating to an average of 2450 attendances per month. Figure 2: YYF MIU Monthly attendances

YYF MIU Monthly Attendances(NB Nov-11 data from 14 - 30 Nov)

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Agenda Item: 3.7 Although the attendances are below those assumed in the initial OBC, a comparison against CDMH activity based on its last 3 months of activity show that there has been a 42% increase in attendances for the new YYF MIU. Recent analysis of the pattern of MIU attendance shows that the extended daily and weekend service is well used. On average, more than 75 patients attend the department daily between 7 a.m. and midnight. Overnight, however, the MIU is less well used with an average of 2 patients attending daily between midnight and 7 a.m. Figures 3 shows the average volume and distribution of daily MIU attendances for the period 14th November 2011 to 6th November 2012. Figure 3: YYF MIU Average daily attendances YYF MIU Average Attends by Day of Week (14/11/11 to 6/11/12)

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Work has commenced, led by Senior Nurses, to address the safe transfer and clinical accountability of patients transferred between MIU and MAU.

3.2 Medical Assessment Unit (MAU) The MAU at YYF provides 10 dedicated examination trolleys. These are complimented by 28 short stay beds on Bedwas ward. For the period 14th November 2011 to 31st October 2012 the MAU assessed 5523 patients, equating to an average of 470 assessments per month. On average 41% of patients are assessed out. Figure 4 illustrates shows the total patients assessed each month and the percentage assessed out.

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Agenda Item: 3.7 Figure 4: YYF MAU total assessments and % assessed out

YYF - Medical Assessment UnitTotal Patients Seen and Percentage Assessed Out

52.4%

43.5%40.6%

42.3% 40.9% 39.8% 39.8%41.4%

43.8%

38.0%

41.6%40.2%

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MAU attendances for the last 3 months in CDMH were on average 278 assessments per month. There has, therefore, been a 70% increase in MAU assessments since the opening of YYF. In the first year of operation, there have been difficulties in managing within bed capacity with the main issue being an imbalance between admission and discharge/transfer activity. The increase in admissions to the MAU is within plan but it is acknowledged that to maintain patient flow through Bedwas Ward there needs to be at least 9 discharges per day to accommodate the admissions. In order to achieve this, targets were set for medical discharges (5 per day) and community transfers (4 per day). The following graph details achievement against this target in October 2012. Figure 5: Daily cumulative variance to medical discharge & community pull targets from MAU

YYF - Daily Cumulative Variance to Medical Discharge & Community Pull targets from MAU - 1 Oct 2012 to 31 Oct 2012

(Total cumulative variance of -61 made up of -2 medicine and -69 community)

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Agenda Item: 3.7 This shows a slight decrease in comparison to the previous month and

work is ongoing in relation to this. The YYF team are focusing on reducing length of stay in all areas, to not only promote flow throughout the hospital but to further enhance pull within and outside of the Health Board. The integrated model of working is key to achieving this.

The management and coordination of the assessment area is being

reviewed by the new senior nurse focusing on a dedicated team, triage and NEWS training, to ensure patient safety. This is in conjunction with the medical team and staff at Advanced Practitioner level.

3.3 GP Out of Hours (GP OOHs) The GP Out of Hours Service is an integral part of the LEC at YYF,

operating a 7 day service between the hours of 18:30 and 08:00. Call handling and nurse triage for the service is centralised at Vantage Point House.

For the period 14th November 2011 to 13th November 2012, there has been a total of 16,858 calls. The following graph illustrates the total call

volumes for the period and the daily average. Figure 6: GP OOH call volumes for the YYF

YYF GP OOH Call Volumes Nov 11 - Nov 12Nov 11 (14 - 30 Nov) Nov 12 (1 - 13 Nov)

45 59 50 46 49 53 44 52 45 36 38 37 41

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The co-location of the GP OOHs in the LEC is a positive advancement.

There is further work, however, to fully realise the benefits of this, in particular for those patients redirected from the MIU.

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Agenda Item: 3.7 4. Integrated Care 4.1 Integrated Care

The ethos of integrated care is a key area of development for the Hospital. It has been important to build on existing working practices in order to promote a team culture focussed around the patient to ensure they receive the appropriate interventions at the right time, in the right place by the right people. The following areas have been developed over the past 12 months:

There is a Community Resource Team presence on site daily with the aim of pulling patients into Frailty services or signposting into more appropriate services

Community Resource Advanced Nurse Practitioners now attend post take ward round thus promoting “pull” at the front door and avoiding inappropriate admissions. This initiative also promotes staff knowledge of community services. It also helps develop more effective working relationships which help invoke a change in the culture of “hospital admission” being the first mindset.

Closer working with Mental Health Team has been developed with a shared vision between Mental Health and General Wards that services would be centred on the patient regardless of setting e.g. providing palliative care directly to the patient on a Mental Health Ward rather than inappropriately moving the patient. This model of care is supported by the Advanced Nurse Practitioners and Mental Health Ward staff.

A Joint Hospital Discharge Team has a daily site presence. The team consists of Discharge Liaison Nurses and Hospital Social Workers who each have a site specific element to the role (e.g. RGH, UHW, PCH) as the team supports appropriate pull/ discharge of Caerphilly residents from neighbouring hospitals and Health boards as well as supporting the Wards at YYF to effectively discharge complex patients.

There are 12 GP Led beds at Redwood Hospital. The Discharge team work closely with Redwood Hospital and focus pull for Caerphilly residents outlying in Prince Charles Hospital. GPs will also utilise the beds to avoid an acute admission.

Direct admissions to palliative care beds to a dedicated ward area. The palliative care patients are managed by palliative care consultant and team.

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Agenda Item: 3.7 4.2 Therapy Services:

Community Therapy Services

Community Therapy Services are provided within the Multi-Therapy Unit, which is a fully integrated facility comprising Dietetics, Occupational Therapy, Physiotherapy and Speech and Language Therapy. This new facility is a much improved environment to those previously available within Caerphilly Borough, and enables the delivery of a wide range of clinical and therapeutic activities, including individual consultations and treatments and group-based programmes. Within the first year over 46,000 patient attendances took place within the Therapy Unit. The facility comprises six individual clinical consultation rooms, three multi-cubicle treatment areas, a treatment room with specialised equipment to support patients requiring intensive rehabilitation and a gym. One of the individual consultation rooms has been adapted for use by Speech and Language Therapists for voice therapy activities such as voice projection work, voice recording, relaxation and counselling, where privacy and dignity can be an issue. Two of the clinical consultation rooms are divided by a two-way mirror enabling observation of patient therapy and assessment of students. Patients have access to an outside Therapy Courtyard, which is a specialist area enabling assessment of walking on a variety of surfaces such as paving, steps and ramps. The Therapy Unit also includes a hydrotherapy pool, which is a new development within Caerphilly Borough. The philosophy of the hydrotherapy service is to maximise the therapeutic outcome of patients referred for rehabilitation using water as a treatment modality, thereby leading to optimal independence and health and social wellbeing. Podiatry and Orthotics community clinics are held in the main outpatient department. Circa 4,500 patient attendances have taken place since YYF opened, taking the total Community Therapy Services activity to over 51,000 within the first year. Patient group therapy education sessions also take place within the Education Centre, which is an excellent facility for this type of activity. Inpatient Therapy Services Therapy assessments and treatments (Dietetics, Occupational Therapy, Physiotherapy, Podiatry and Speech and language Therapy) are provided to inpatients within the single room environment. There is also a bespoke Therapy Inpatient Facility, which is an area suitable for when

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Agenda Item: 3.7 patients require Therapy treatment away from the ward. This enables joint assessments to take place across Physiotherapy and Occupational Therapy. The Therapy Inpatient Unit also contains a domestic kitchen, bedroom and bathroom that enable Occupational Therapists to assess a patient’s level of functioning within a home environment. Therapists working within YYF report a definite increased complexity of inpatients compared to those traditionally seen in CDMH and YMH. The YYF Food Interest Group has facilitated a number of improvements to the catering provision for inpatients. These include a more robust system for delivering meals to the single room environment and an improved two-week menu cycle which is compliant with the ‘All Wales Nutrition and Catering Food and Fluid Standards for Hospital Inpatients’.

5. Scheduled Care

The original business case assumed the development of several key areas for the Scheduled Care Division, as outlined below as part of the Diagnostic and Treatment Centre (only the Scheduled Care Division departments are highlighted from the original case below):

Service Unit

Key Clinical Facilities

Diagnostic and Treatment Centre

26 consultation/ examination rooms and 3 treatment rooms

Audiology facilities Cardiology investigation , ECG ,echo and lung function

testing (in main outpatients) 3 theatres 28 day care trolleys/short stay beds, further 14 beds

for future growth Radiology – including general, ultrasound, CT,

fluoroscopy, OPG space MRI ,future proofed to accommodate Mammography and 2nd CT

Pathology – including haematology and biochemistry near patient testing, consultation/ examination room

Medical Day Case facility 4 trolleys Dermatology PUVA unit

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Agenda Item: 3.7 5.1 Outpatients The outpatient department is fully utilised in fact so much so that space

is now at a premium. Instead of the planned 26 rooms, there are 21 consulting rooms. Some decisions were taken about alternative room usage such as blood rooms and pre-assessment for example. A robust exercise was done upfront to ensure that the rooms would be used appropriately, and rooms were not allocated to those who were not able to demonstrate effective utilisation.

The graph below shows the quarterly levels of Outpatient activity for the

Scheduled Care Division specialties, which represent the largest part of scheduled access in the Health Board. As is highlighted in the graph, there starts to be an increase from the opening time, and the baseline ahead of YYF was relatively low.

Figure 7: Outpatients seen in YYF – CDMH (Scheduled Care Division)

Outpatients seen in YYF . CDMH - Scheduled Care Division specialties - Apr 11 - Sept 12

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Repatriation of Rheumatology has commenced from the beginning of November 2012 with all of the adult service provision having been transferred from Cardiff and Vale. This includes usage of the Medical Day Case unit in YYF, as that has until now remained underutilised.

Further repatriation of work from Cardiff and Cwm Taf will be challenging within the space constraints of the department. This is a general issue for the Health Board across a number of outpatient departments, and we will need to think about challenge of traditional outpatient service delivery in order to take this work back.

A full reconciliation of activity being delivered against OBC plans is being undertaken.

A number of additional specialties have commenced clinics there that previously did not have any presence in CDMH, which is positive and step changes in activity levels across a number of specialties have been seen.

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Agenda Item: 3.7 5.2 Theatres

The development of the Foot and Ankle Unit has been very well received, and has been tested with patients via patient satisfaction surveys, and the feedback has been very positive in spite of any additional travelling.

Improvement in 3 session days usage remains a key focus for orthopaedics.

The ring-fenced ward is working well and as the rooms are single, robust screening allows all specialties to be mixed. This is a completely new model of care for the Health Board. It is also positive that ring-fencing has been maintained so far in spite of extreme bed pressure elsewhere.

The facilities have been very well received by the team, and they are enjoying their new work environment. The next specialty to move to the unit will be ENT, and this will assist with DOSA and day case performance, in addition to taking the pressure off the Royal Gwent site. The biggest challenge remains how we manage patients of higher ASA criteria via this site. Grade 1 and 2 patients currently attend YYF for surgery, and this we believe, impacts on backfilling of sessions due to the limited range of patients that are able to have their surgery on site. Increasing the pool of patients able to have their surgery done in YYF would be a significant improvement for all services. The table below shows the current session usage for YYF theatres for information. Table 1: Current session usage for YYF theatres Wk1 Wk2 WK3 Wk4

Day T1 T2 T3 Day T1 T2 T3 Day T1 T2 T3 Day T1 T2 T3

Mon AM KHA Mon AM KHA Mon AM KHA Mon AM KHA

17th Chamary Pandali 24th A/L Boyce Pandali 31st A/L Chamary Pandali 7th Boyce Pandali

KHA KHA KHA KHA

PM PM A/L PM A/L PM

KHA Chamary Boyce KHA Nutt Chamary KHA Chamary Boyce KHA Shute Nutt

A/L A/L

Tue AM YN GS Tue AM YN Tue AM YN GS Tue AM YN

18th El Garib 25th Feroz Ashraf 1st El Garib 8th Feroz Ashraf

YN YN YN YN

PM GS PM PM GS PM

YN Mclain YN Somasekar Ashraf YN Mclain YN Somasekar Ashraf

Wed AM SSK Wed AM Wed AM SSK Wed AM GS

19th G Williams 26th Chokkalingham El Garib 2nd 9th LA - Not Used El Garib

SSK SSK

PM PM ARO PM PM ARO

SSK Shute Feroz SSK Feroz Williams Feroz

Thu AM HTA Thu AM HTA Thu AM HTA Thu AM HTA

20th McKain Goddard 27th Boyce Goddard 3rd McKain Goddard 10th Boyce Goddard

HTA HTA REPAT A/L HTA HTA REPAT

PM GS PM PM GS PM GS

HTA Feroz HTA HTA Feroz HTA Feroz

Mr Feroz

Fri AM ORTHO GYNAE-LA Fri AM KHA Fri AM ORTHO GYNAE-LA Fri AM KHA

21st Boyce 28th Abdelmagied 4th Boyce 11th Abdelmagied

ORTHO Mr Feroz ORTHO Mr Feroz

PM PM ARO GS PM PM ARO GS

ORTHO Boyce ORTHO Boyce

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Agenda Item: 3.7

5.3 Radiology From a radiology perspective, the department has managed to support YYF on a 24/7 basis. Timely recruitment of staff was an issue. Some of the radiography staff did not start until the week of YYF opening. Although challenging, inpatient CT cover and the 24/7 service were running from the first day. CT and MRI services at YYF are covered by radiographers rotating from RGH - Nevill Hall. Out of hours cover for basic CT scans is covered by the on site radiographers who have been trained to undertake head and neck CT. Recruitment of Consultant Radiologists and a nursing post for the YYF model has been difficult. This has put considerable strain on the existing radiologists and meant that YYF had limited on site presence although reporting was covered via PACS by off site consultants. The consultants have now been recruited, which will ease some of the pressure of workload.

5.4 Pathology Workload has increased by 30% approx over the year. This is largely due to increased activity in unscheduled care and the general increase in bed numbers from other hospitals such as the former YMH and Mental Health Units. The onsite lab is being well used. There also appears to be increased activity associated with the frailty/CRT services. The workload was expected to increase but not as quickly as it did. The directorate feel that the service model is working well but a more robust workforce is needed. The directorate are making plans to do this via the current plan to reconfigure the pathology service across ABHB which is currently subject to staff consultation. The Directorate have identified that the overnight/weekend service is under increasing pressure and this is being closely monitored.

6. Women and Children 6.1 Gynaecology Services: All Gynaecology services previously undertaken at CDMH have been

successfully transferred across to YYF, namely: • Elective surgery including major operations • Gynaecology outpatients and Ring Pessary Clinics • Specialist Urogynaecology out-patients • Urodynamics, both medical and nursing delivered • Colposcopy and nurse-led smear clinics • Out-patient hysteroscopy • Early Pregnancy Assessment

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Agenda Item: 3.7 The following graph shows the quarterly level of total outpatient activity for gynaecology, including colposcopy. Figure 8: Gynaecology outpatients seen in YYF – CDMH

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There has been a marginal increase in outpatient activity since the opening of YYF of circa 3% compared to CDMH.

6.2 Midwifery Led Birth Centre:

The midwifery led Birth Centre at YYF provides holistic care for women on the normal birth pathway as a home from home environment, provision for pool birth (two pools), and family involvement in the birth process. There have been 348 births for the period 1st December 2011 to 31st October 2012. More babies have born in the new Birth Centre than the previous Caerphilly Birth centre, as the following graph illustrates.

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Agenda Item: 3.7 Figure 9: Total births in CDMH / YYF Jan 2011 to Oct 2012

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During periods of high activity in any 24 hour period, women are transferred to the RGH Obstetric Led Unit. The average transfer rate, since the opening of YYF to current day, is between 15%-20%, well below the accepted rate for free standing birth centres of 25%-30%. All transfers have been documented and are discussed through the risk transfer process on a monthly basis. The Birth centre also provides:

24 hour point contact for women Day Assessment Unit for Midwifery Led Care Women Parent Education, out of hours and at weekends to meet the needs of the women.

Larger, private rooms with double beds and en–suite enabling the women to have partner/ family support overnight.

Breast feeding support provided within a Baby Friendly accredited unit Student and preceptorship midwives with Midwifery led experience supported with experienced senior midwives.

6.3 Children’s Outpatients Additional services are now provided from the dedicated Children’s

Outpatient Unit, including those services transferred from CDMH and Ystrad Mynach Hospital (YMH), including:

• General and Community Paediatric Outpatients • Paediatric asthma and allergy clinics • Diabetes clinics • Public Health enuresis clinics • Continence clinics • Neonatal Outpatient clinics • Child & Family Psychological Health clinics

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Agenda Item: 3.7

An analysis of the data pre and post opening for YYF shows that paediatric new outpatient activity for residents of Caerphilly Borough GPs in Caerphilly Hospital sites has doubled since the opening of YYF, as shown in the graph below. It should be noted that this coincided with the appointment to a Community Paediatrician vacancy. Also the new accommodation at YYF has enabled the service to hold more sub-specialty clinics than previously, such as Diabetes, Asthma and Allergy clinics. This increased activity is a positive indicator of access to services for the local population improving. Figure 10: Paediatric outpatient activity pre and post YYF opening

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Child and Family Psychological Health provide outpatient clinics from YYF Children’s Outpatient Unit and the following graph indicates activity for the Caerphilly team. It should be noted that whilst the majority of contacts take place in YYF, some patients are also seen at home or in other outpatient locations as appropriate. Figure 11: Child & Family Psychological Health Services Caerphilly activity November 2011 – September 2012

CFPHS Caerphilly Locality Activity

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Agenda Item: 3.7 7. Mental Health Services The move of the Adult Mental Health unit from Ty Sirhowy Blackwood to

Ty Cyfannol had provided the Mental Health division with an opportunity to develop positive relationships with the physicians in unscheduled care. A lead Consultant physician has been identified to provide direct clinical input and advice with Mental Health inpatients that have complex and longstanding physical conditions. This has enabled a service more responsive to the needs of inpatients, and reduced the, at times, unnecessary transfer of patients from Mental Health to unscheduled care beds. Equally there is much improved access to diagnostic testing and results for a client group that has high rates of concomitant pathologies.

While there is still at present no substantive Mental Health Liaison

service, both Older Adult and Adult services provide a nurse lead response to requests for advice and support for urgent assessment and management of unsettled and disturbed patients. The Senior Mental Health Nursing teams and Advanced Nurse Practitioners routinely share information via daily site meetings minimising the communication shortfalls that can delay transfer and discharge.

Since August 2012 the adult inpatient unit now provides inpatient

provision for Child and Adolescent Mental Health service users who are in need of acute inpatient support prior to transfer to specialist Tier 4 accommodation. The single occupancy layout and contained environment far better meets the needs of vulnerable young people and the inpatient Team have all undertaken a programme of training lead by the HEalth Board CAMHS specialist staff.

With increased policing demands in the local area there has been

provision of a Community Support Officer out of hours in order to increase the awareness of the Hospital community to the support provided by the Police service. The Adult Inpatient Team has developed a forum for regular discussion and case review with local senior police officers. This local relationship has minimised the need to unduly escalate concerns enable a more timely and proactive response to concerns and an increased understanding of the processes that guide the decision making for both Police and Mental Health teams.

The provision of the suite of consulting and Treatment rooms has

enabled the Service to consolidate links with Gwent Specialist Substance Misuse Services who provide have developed an enhanced clinic monitoring concordance with treatment and general health needs. The Treatment room resource has also allowed the development of a specialist Clozapine blood monitoring service, with "one stop shop" point of contact monitoring and dispensing that has had extremely positive

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Agenda Item: 3.7 feedback from carers and service users, and has provided considerable cost savings in relation to dispensing and delivery of medication.

8. Quality and Patient Safety 8.1 The single room environment

The single bedroom model presented an opportunity to address key issues raised as priorities for both patients and staff. The single room ensuite facility provides flexibility and enhanced dignity in care, meeting the expectations of the public and government policy.

The new hospital design addresses key issues such as: • Patient privacy and dignity The single bedroom offers flexibility in bed usage, breaking down confines in the management of bed usage with male and female wards and bays restrictions. This in itself provides more privacy for the patient with mixed sexed wards eliminated and multi-occupancy bays a thing of the past. The single bedrooms are gender sensitive and offer the patient and family freedom for private conversations and the licence to follow religious beliefs.

The room provides a reduction in noise levels, especially at night, to improve the quality of rest and sleep, thought to have a positive impact on pain control with a potential reduction on the reliance for analgesia and night sedation.

Evaluation by both the CHC and GAVO has shown that patients are enjoying the single room environments but isolation can be an issue. This is being addressed through Transforming Care and hourly Intentional Rounding. In addition, Volunteers are helping with social activities in Ysbyty Aneurin Bevan and it is hoped that this model will be extended in YYF, with a Big Lottery Bid.

• Reducing hospital acquired infection There is a considerable amount of evidence to support the single room concept with regards to infection control.

Single-bed rooms have a positive impact on the pro-active isolation of patients with infection on admission; single rooms are easier to decontaminate and clean on patient discharge; and are vastly superior in managing air changes, pressure and clean air flow.

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Agenda Item: 3.7 The single bedroom means patients have their own bathrooms, so any risk of cross contamination from shared facilities is reduced. The positioning of the clinical hand wash basins at the entrance of the room promotes hand washing by the health care teams and visitors, with a further reduction in the risk of cross contamination.

Health Care Associated Infection rates for Ysbyty Ystrad Fawr over the past year have shown a significant improvement, when compared to the previous Caerphilly Hospital rates. For Clostridium Difficile there has been a 44.1% reduction, as shown in the following table: Table 2: C.diff cases in YYF compared to CDMH and YMH Hospital(s) Period No.of C.diff

Cases CDMH / YMH Nov 10 – Oct 11 43 YYF Nov 11 – Oct 12 24

• Individualised patient care

The single bedroom is acuity-adaptable. Patients do not have to move bed space to have the appropriate environment for their needs, whether that is for infection control, isolation or the end of life pathway. The rooms provide an environment for holistic, individualised patient care. Treatments can be delivered in the privacy of their own room, where conversations are private, encouraging and promoting open communications between the patient, their family and healthcare professionals.

The ensuite provision promotes independence, with shorter walking distances to the bathroom and an area they can personalise for their individual requirements. Allied Health Professionals can utilise the area for assessments of the patient aids to daily living, assessing progress in a private environment.

The overall objective is to provide an environment of care that promotes the well being of the patient in recovery, health maintenance or to a peaceful death.

The environment of care has been challenging from a nursing perspective, due to requirement for a different model of care. Transforming Care has enabled this, as it provides a structured, patient-focussed approach, but it has taken time for changes to embed and for the true benefits of the single bedroom environment to embed.

The single bedroom environment has generally been a positive advance but it should be noted that there have been some concerns from both patients and relatives and staff around the environment. Staff, however,

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Agenda Item: 3.7 are now getting used to working in this environment and the issues of patient isolation, particularly of elderly patients, are being addressed through the GAVO volunteers who offer a befriending service. The number of falls has increased compared to CDMH and one of the contributing factors is the visibility of both patients and staff. To address this, intentional rounding has been implemented, ensuring healthcare professionals carry out regular checks at set intervals; risk assessments are undertaken; and falls alarms are provided to patients at risk of falls. A falls audit has been undertaken, the results of which are due mid November.

8.2 Workforce

The new hospital has provided a challenge in a number of workforce related areas, namely:

Initially, the required number of substantive staffing resource was not available to support a number of services in YYF including the Medical assessment Unit and therapies. The MAU was fully commissioned earlier than originally planned and initially resulted in a high usage of variable pay – particularly agency nursing. This was addressed with the recruitment of substantive staff.

The eLGH at YYF is a very different operating environment compared to the former hospitals from which many of the services and staff were transferred. The physical environment, increased acuity of patients and pace and new ways of working has offered a challenge for some of the workforce. This is being addressed by ensuring staff are appropriately skilled and supported and embedding the principles of transforming care and other quality initiatives. Closing working across divisions is enabling the team to embed multi-professional integration.

8.3 The Management of Deteriorating Patients

There have been 5 cases highlighted as part of the Intensive Care Audit of deteriorating patients transferred inappropriately to critical care services at the RGH. To address the issue, improve the process and ensure the safe and rapid transfer of deteriorating patients, a number of actions have been taken: • The Exclusion Criteria for YYF has been ratified and applied; • The Escalation process has been revised and implemented –

consultant to consultant level – with most appropriate area of transfer determined;

• A lactate testing facility to help measure the patient’s condition commenced on site in MAU on 12th November 2012;

• Welsh Ambulance Services Trust has been engaged to support a time critical transfer;

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Agenda Item: 3.7 • NEWS and sepsis training for a dedicated MAU team has been

initiated. A report of the outcome of the audit and actions taken will be considered

formally by the Quality and Patient Safety Committee at its next meeting.

8.4 Medicines Management

The original model of pharmaceutical care for Ysbyty Ystrad Fawr was approved in principle by the Clinical Model Group in February 2011 but has not been implemented in full. The model and funding for Medicines Management for Mental Health was approved in May 2012 and is now in place, providing a positive contribution to patient care. The remainder of the case to improve support to areas other than Mental Health has required the pharmacy team to revisit the model. This has included remodelling of the staff required to deliver the service and service reconfiguration in other areas of pharmacy to enable resources to be released to contribute towards the YYF model. The revised model for YYF has now been agreed and it is anticipated that additional resource will be in place in the first three months of 2013.

8.5 Complaints The total number of formal complaints received for YYF, for the period

November 2011 to the 31st October 2012, is 106. The following graph illustrates the total number received each month.

Figure 12: Total number of formal complaints received for YYF Nov 2011 to 31 Oct 2012

YYF - Formal Complaints Monthly Total - 1.11.11 to 30.10.12

0

2

4

6

8

10

12

14

16

18

20

2011 12 2012 01 2012 02 2012 03 2012 04 2012 05 2012 06 2012 07 2012 08 2012 09 2012 10

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Agenda Item: 3.7 A high number of complaints were received between January to March, with these three months representing 40% of the total. Of the complaints received during this specific period, 56% related to complaints received for the Local Emergency Centre (LEC). The high number of complaints received for one of the three LEC areas is also true for the overall period and, as the graph illustrates below, formal complaints received for the MAU, MIU and GP OOHs are higher than other areas. Complaints received for the LEC total 55 for the period, representing just over half of the total complaints. Figure 13: Total number of formal complaints received for YYF Nov 2011 to 31 Oct 2012 by location

Total No of Formal Complaints Received from 1.11.2011 to 31.10.12 by Location

0

5

10

15

20

25

30

35

Antena

tal C

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Birthing

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nit

CMHT Base -

Older

Adult -

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Day Surge

ry Unit

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servi

ce

Minor In

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nit

Outpatie

nts - C

ommun

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Physio

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Pre-Admiss

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Therap

ies U

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ents)

Ty Cyfa

nnol

Women's H

ealth

Unit

Radiolog

y/X-ra

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ommunit

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Bedwas

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1/1 M

AU

Oakda

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2/1

Bargoe

d Ward

2/2

Rhymne

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Risca W

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Penall

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An analysis of the LEC complaints received show that 62% of the complaints relate to three themes – length of time the patient had to wait to be seen; unhappiness with the treatment received and, for MAU, concerns about nursing care. These reflect a number of issues – the single room environment; workforce related quality and patient safety issues; and patient expectation of the nature of the services provided.

8.6 Community Health Council feedback

In October 2012, there was a further unannounced visit from the Community Health Council. The general feedback was that there had been a visible improvement of all areas since their last visit.

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Agenda Item: 3.7 Positive feedback received was as follows:

• Staff they encountered were friendly and helpful • Patients gave very good feedback about the care they received on

the wards • Staffing levels appeared better than last visit and staff attitude

very positive • Nurses were all wearing their name badges • Mealtime processes was good and positive comments about the

meals provided • Pleased to see increasing number of daily attendances at MIU • Commended the Loop system in place at reception • Coffee shop and ATM machine were all considered positive

additions to the reception area giving the public a welcoming approach

They did note a number of areas requiring further improvement:

• Signage remains an issue, suggested more "You are here” maps in key locations.

• Linen shortage was flagged as a concern, particularly on weekends • Lighting on level 2 was an issue, • Seating areas in the Outpatient Department needs improvement

with more mixed height or chairs with two arms required • Although it was generally clean in all areas, the state of the

external windows was raised • Concerns raised about no-one in reception areas on wards • Non-nursing staff not wearing ID badges observed • Concerns about general security. An evening visit was conducted

(just external) where the member was able to walk around unchallenged.

The above concerns are being addressed via the local environment group

9. Lessons learnt As part of the YYF Capital project, a lesson learnt process was

established, the second part of which focused on the development and implementation of the eLGH service model for YYF and how well these were currently working in practice. The report, finalised in September 2012, collated the lesson learnt under six key themes:

Service model development and user involvement Staff recruitment, training and induction Patient experience Clinical effectiveness Maximising opportunities for integrated care / multi-disciplinary and multi-agency working

eLGH unit performance

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Agenda Item: 3.7

24

11. Recommendation

10. Summary

The Clinical Futures Programme Board is overseeing an action plan on the lessons learnt. The key recommendations and progress against the agreed actions is contained in Appendix 1.

The Board is asked to consider the update on YYF.

There have been a number of challenges to overcome in the first year of operation but the services and teams have and will continue to address these to ensure improvements are ongoing.

However, communication of these improvements and extension of services remains an issue. There needs to be an ongoing focus using local community groups, politicians, the CHC, newsletters and local media to demonstrate the development of the services over the last year and to share the further plans for bringing back more local services.

The model that the Health Board set out to deliver in the original business case for YYF has largely been achieved. Access to services for the local population has improved, demonstrated by both an increase in activity in a number of the services in YYF compared to its predecessor hospitals and in the range of services now provided in the new hospital. There have been positive advancements in both key quality and patient safety areas and in the integration of care for patients between different professionals.

Paper sponsored by: Judith Paget, Chief Operating Officer/ Deputy Chief Executive Denise Llewellyn, Director of Nursing

Date: 19th November 2012


Agenda Item: 3.7 Clinical Futures Programme Board

Ysbyty Ystrad Fawr Lessons Learned on eLGH Model

Action Plan

Key Recommendation Actioned to Required By (Date)

Status

Theme: SERVICE MODEL DEVELOPMENT AND USER INVOLVEMENT Clinical service models need to be developed (and regularly reviewed) in as much detail as practical, at all stages of the project including OBC, FBC, pre- and post-implementation. Appropriate capacity and support is required to achieve this.

Divisional Directors

2013-2017 Liz King Karen Jones have agreed regular meetings with Clinicians to review capacity /workforce/service model assumptions.

The Design Team needs to look at ways to improve both the original statement of need to be provided by end users and ways of re-testing design solutions to meet those needs.

Liz King April 2013 User groups will be set up to develop the design post OBC approval with agreed protocol in place for attendance, expectation of role etc.

While SCP clinical planners can act as support, undue reliance on them has the potential to create increased conflict between affordability and clinical team acceptance of the end results. Internal equivalent capacity needs to be adequate.

Andrew Walker Completed The health Planner role has been reviewed and we will commission them for specific pieces of work. Project clinicians in place

ABHB Annual Plan and 3 year rolling plans at both divisional and directorate level should be aligned with OBC and FBC clinical service plans to ensure that appropriate performance and capacity assumptions are achieved.

Richard Bowen, Hannah Evans and Judith Paget

Dec 2012 Processes to be established to ensure integration of Annual Plans with overall service, workforce and capacity plans

Workforce plans need to be developed in parallel to this work rather than in sequence to it. They need to be as detailed as possible, demonstrating numbers and skill mix by speciality and profession.

Julie Chappelle Completed JC retained as part of project structure

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Agenda Item: 3.7


Status

Repatriation assumptions should be integral to workforce plans and operational preparedness from the day of opening.

Alan Brace/ Judith Paget/ Anne Phillimore

2013-2018

Senior clinical leaders need to be supported to ensure that appropriate clinical input (into service models and infrastructure plans) is forthcoming and that this happens: □ at all levels (particularly with front-line staff) □ between Directorates/ Divisions □ without over-reliance on senior staff (who also

have to review and evolve the initial, high level service plan visioning).

Divisional Directors Ongoing

Existing mechanisms to be further developed for cascading and consistency of clinical involvement including: - Delivery Group - Directorate & Divisional meetings - SMDG - project clinicians

That appropriate balance between operational and planning activity is made. While understandable, excessive attention to immediate pressures impairs medium term solutions and service modernisation.

Exec Team Divisional Directors

2013-2018

Theme: STAFF RECRUITMENT, TRAINING AND INDUCTION Single site working brings opportunities for integrated, cross divisional and organisational working. Time used in building up these relationships and allowing staff to talk through alternative ways of working prior to opening would be a good investment.

Julie Chappelle – lead for change management

March 2013

Similarly allowing staff to walk through the new infrastructure/IT systems will help solve problems in advance.

JC/Steve Harding Completed

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Agenda Item: 3.7


Status

A Workforce transition plan needs to be developed at the planning stage which aims to phase in and repeat training sessions to synchronise issues such as recruitment, equipping, training and team building. This will help to ensure staff are properly inducted in a timely way on the new environment and new ways of working.

Julie Chappelle March 2013

Theme: PATIENT EXPERIENCE CHC and lay involvement is maximised at all levels

Karen Newman and Comms Team

Ongoing

CHC embedded in project structure Patient Involvement group / Stakeholder Reference Group communicated and involved

Some practical adaptations suggested by the CHC to support working in the new single room environment should be considered to maintain positive experiences for patients.

Karen Jones Completed (YYF) Ongoing (for SCCC)

CHC part of evaluation process and Design review

Local perceptions of what clinical services will be provided need to be continually tested and revisited. In particular, previous consensus (e.g. as at OBC stage) may require ongoing dialogue and reinforcement.

Communication and engagement plan Karen Newman

Completed (YYF) Ongoing (for SCCC)

Engagement Plan in place

The language used to describe what unscheduled, walk-in services are provided, warrants careful review and consideration.

Karen Newman/Hannah Evans



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Agenda Item: 3.7


Status

Communication around service models is equally important both internally (e.g. to GPs and hospital clinical teams) and externally (e.g. to WAST), in order to maximise intended referral routes.

Karen Newman/Hannah Evans



Theme: CLINICAL EFFECTIVENESS Safety critical infrastructure systems warrant robust trialling in a real-life situation (or realistic virtual simulation), prior to reliance on them. Back up systems should be clearly defined and walked-through in order to ensure they are practical and workable.

Steve Harding- Completed (YYF) Ongoing (for SCCC)

Ongoing audit of patients transferred within the hospital network warrants active support, with learning being spread via current clinical governance and Divisional operational systems (as well as for future planning purposes).

Grant Robinson Divisional Directors USC, SC, Community (YAB)

Mid Nov 2012

Service models can be expected to change and evolve. Outcome based clinical audit is an integral part of this evolution testing planning assumptions and informing evolution of the service models. There are opportunities for this work to be a formal part of service improvement/ audit programmes.

Grant Robinson Divisional Directors

March 2013

Theme: MAXIMISING OPPORTUNITIES FOR INTEGRATED CARE/ MULTI-DISCIPLINARY AND MULTI-AGENCY WORKING That the opportunities that are being realised in YYF to increase integrated working practices (between Primary and Secondary Care, between Directorates, between physical and Mental Health and between Health and Local Authorities), be detailed and progressed as part of both Clinical Futures and annual directorate /service plans.

CFPB Ongoing

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Agenda Item: 3.7


Status

Performance data to clarify that these relationships are achieving YYF/ eLGH CF Performance requirements should be live, visible and constantly monitored.

Jayne Harding and CFPB 2013-2018

Efforts to reduce unnecessary hospital admissions will be enhanced by a move to 7 day working and considering enhanced access (for GPs, CRT and Palliative Care) to the Frailty ward.

CFPB DDs USC/ Community Care

TBC 2013

Theme: eLGH UNIT PERFORMANCE Overall site management and accountabilities should be clearly defined.

Judith Paget March 2013

Performance expectations for individual Directorates and teams (Primary, Community/CRTs and Divisions) and for partnership organisations (e.g. WAST, LAs) should be as visible as possible.

Allan Davies March 2013

Clarity on activity expectations/achievement is integral to this, particularly relating to: □ Impact of Frailty □ eLGH ward flow □ USC Local Emergency Centre activity (and

onward referrals to RGH) □ Effective, maximal use of OPD/theatres

Allan Davies March 2013

Ownership of performance achievement for the YYF eLGH unit should be made clear and progress monitored regularly. The role of Divisions and the cross-functionality at HMG- eLGH unit/ Divisional level warrants definition.

Judith Paget & Allan Davies March 2013

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Agenda Item: 3.7


Status

There should be effective arrangements in place to engage with external providers and then manage and monitor the activity of any repatriation agreements.

Angela Jones March 2013

Critically, in relationship to the overall eLGH CF model (and for success of the SCCC model), it is essential that the ‘Pull’/early rehabilitation in YYF (e.g. for #NOF and stroke) happens and is balanced with internal (RGH) and external (e.g. PCH) repatriation pressures. Excessive use of YYF for failed/complex discharges will not allow achievement of the performance and capacity plan.

Judith Paget & YYF HMG March 2013

The YYF eLGH unit performance could be monitored via a dashboard/ balanced scorecard approach with appropriate categories e.g. □ Patient experience / access □ Provision of appropriate, safe, effective care as

locally as possible □ Efficiency in matching demand with local

capacity and resource

CFPB March 2013

Whatever themes are decided, overall eLGH unit functionality should also be reviewed, as part of CF implementation, at CF Programme Board.

CFPB

Ongoing Annual clinical review

Theme: SHARING THE LEARNING AND CHANGING PRACTICE The Recommendations in this report should be shared with other projects in an accessible format.

Andrew Walker Completed

Presentations on the lessons learned should be offered to SCCC Project Board, the Clinical Futures Service Model Design Group and other appropriate

Hannah Evans & Angela Fry

Completed

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Agenda Item: 3.7 fora


Status

Key Recommendations should be revisited periodically (by the SCCC Project Board) in order to ensure compliance with lessons learnt

Karen Jones Arrangements in place

Consideration should be given to the development of other learning tools and presentations for training programmes and other learning events.

Hannah Evans & Angela Fry

Ongoing

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Documents

Aneurin Bevan Health Board Report on Ysbyty Ystrad … Ysbyty Ystrad Fawr... · Report on Ysbyty Ystrad Fawr Hospital’s ... combining 24 hour minor ... equating to an average of