March 2016 - NHS Grampian · June 2016 Performance against the 4 hour A&E standard: for the year ending January 2016: The total number of attendances was 137,992. This is 2.7% lower

Improvement Programme

March 2016

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Contents

Section 1: Overview

Section 2: HIS Short Life Working Group report – Actions Outstanding

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Section 1: Overview

Introduction

1.1 This report summarises the progress that has been made to address the findings from the invited review of Quality and Safety at Aberdeen Royal Infirmary, the Royal College of Surgeons (England) report and the findings and recommendations from the unannounced Older People in Acute Hospitals inspection.

1.2 The Improvement Programme which was formally approved by the Board in April 2015 gave a commitment to delivering against high quality patient care based on:

Executive and senior management leadership

Engagement between the Board, staff and our patients in terms of planning for future services and the delivery of performance and quality outcomes

Clarity around management structures and operational effectiveness

Commitment to continuous improvement and learning from staff and patients

Supporting staff and building capability, capacity and resilience across all services.

1.3 The aim is not only to make improvements that will have an effect in the short term but also to have a long term impact in relation to the role of NHS Grampian as a partner in the north east of Scotland and north of Scotland health and care community Key findings from the Health Improvement Scotland (HIS) review

1.4 NHS Grampian has the ambition to be a high performing organisation - safe, effective, caring, responsive and well led. Performance against this ambition will be measured by clinical outcomes, patient experience and staff experience.

1.5 This report summarises how the Board have been addressing the key recommendations within the three reports issued on 2 December. The Board and Executive team remain committed to the implementation of all the recommendations in full and providing the leadership needed to deliver the vision, provide support to staff, promote staff engagement and effective team working and ensure that we fulfill our vision of delivering consistently high quality, compassionate and safe patient care.

1.6 A summary of the key outcomes achieved to date is noted overleaf, together with an overview of the status of the implementation of the recommendations arising from the Health Improvement Scotland review. In preparing this report we would wish to recognise the hard work and dedication of all our staff.

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Outcomes and Actions – delivered

Strategic Goal

Improve the health of the population within available resources

Outcomes and Actions

Leadership

We will ensure that effective leadership is established within all areas with clarity around the structure, roles and responsibilities and a sharp focus on the scrutiny of performance and risk mitigation. Nursing and medical staff and management will have equal responsibility and accountability for performance, patient safety and staff governance.

Implemented revised performance management arrangements at Board and Sector level and in support of new Integration Joint Boards

Organisational development plans in place

Commitment to ensuring our values are consistently applied

Established new Acute Sector Leadership Team

Implemented joint management and clinical accountability (pan Grampian)

Patient Welfare & Experience

We will listen and respond to feedback from patients and ensure a culture of learning and continuous improvement is embedded across all services

Improved response to patient feedback

Agreed operational policy

Responding to feedback real-time

Face to face meetings with patients

Changes in clinical practice and team working within General Surgery

Progress in improving care for elderly patients in acute hospitals

Access to Care

We will develop and implement robust and sustainable plans to ensure that patients can receive timely access to care that is high quality and patient-centred.

A sustainable plan for the staffing of the Emergency Department

Consistent and improved performance against the 4 hour A&E waiting times standard

Implemented an Acute Sector Access Times action plan – progress regularly monitored and close working relationship with Scottish Government

Fewer patients waiting with a delayed discharge and further progress planned for 2016/17

Joint responsibility with local authorities for patient discharge

Agreement to a fully integrated unscheduled care system – daily safety huddles in place as a key element of the winter plan

Workforce

We will ensure that the workforce challenges around recruitment, retention and sustainability are addressed and that appropriate mitigating actions are implemented to ensure we can deliver sustainable and resilient services. We will also ensure that all staff, including professional trainees, develop their skills and experience in a positive and supportive environment.

Fewer medical and nursing vacancies

Improved graduate conversion rates

Improved governance for ensuring safe and appropriate staffing cover

Significant increase in the number of consultants engaging in job planning

Evidenced improvement in trainee experience

Staff Engagement

We will ensure that there is a closer connection with all staff to enhance trust and confidence in the Board’s leadership. We will also ensure that the advisory structure is representative of health professions and professional staff and is connected to the Board with a common purpose and agenda.

Empowerment of staff to take decisions to improve care and address concerns

Commitment to an ongoing and meaningful engagement with staff.

Progressing towards stronger working relationships between management and clinical staff

Advisory structure, staff partnership and Board working to common purpose

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Status of progress against the recommendations within the Health and Improvement Scotland review

Recommendation Completed Ongoing

Action 1: NHS Grampian executive team with senior staff in emergency department and other key stakeholders should develop a plan for a sustainable emergency department service that provides patients with safe, effective and person-centred care

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Action 2: NHS Grampian executive team should work with senior clinical colleagues and local managers to review the management of unscheduled care across the hospital, with emphasis transfer of patients from ED to inpatient areas.

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Action 3: NHS Grampian should ensure that the escalation policy for patients whose Scottish Early Warning System score is high is implemented by clinical staff

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Action 4: NHS Grampian should continue to build on collecting real-time patient experience data ensuring this is done reliably and consistently across the services

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Action 5: NHS Grampian should improve the way it investigates, responds to and learns from complaints. 6 -

Action 6: NHS Grampian should carry out a fundamental review of the acute sector leadership with the emphasis on ensuring clear accountability of acute services

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Action 7: NHS Grampian should take urgent action to engage fully with all clinical and nonclinical staff 6 -

Action 8: NHS Grampian should introduce strong and effective governance mechanisms for the clinical, operational and managerial control of services at Aberdeen Royal Infirmary

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Action 9: NHS Grampian should develop and implement a robust nursing workforce plan using mandated national workforce tools.

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Action 10: NHS Grampian should develop & implement a robust medical workforce plan 1 3

Action 11: NHS Grampian should ensure that the training of trainee medical staff is given a sufficiently high priority, ensuring that the General Medical Council and National Training Survey results are reviewed by the Board

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Action 12 Recommendations made by the Royal College of Surgeons (England) All actions on track

Action 13: Recommendations in OPAH report All actions on track

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Section 2: HIS Short Life Working Group report – Actions outstanding at 31 March 2016

Recommendation Progress Responsible Officer Date

Action 1: NHS Grampian executive team with senior staff in emergency department and other key stakeholders should develop a plan for a

sustainable emergency department service that provides patients with safe, effective and person-centred care. The plan should be

Be sustainable in terms of ability to recruit and retain

medical staff and recognise

the reality that the emergency department requires

senior input from specialist emergency medicine

medical staff

that senior trainees will continue to be in short supply

that staff from other specialties whilst valuable in their

own roles cannot be used to substitute for the

expertise of senior emergency medicine medical staff

that senior trainees can make a valuable service

contribution, but are also entitled to expect support

and training that adheres to the appropriate GMC

mandatory regulatory standards2

Outcome – Recruitment to vacant posts

We continue to recruit to all approved posts and

monitor the workforce position on a regular basis,

reporting the position through the Acute Sector

management and performance arrangements.

Outcome – Long term sustainable plan

The ED rota has been reviewed and changes made

to ensure that there is a sustainable Emergency

Department. These arrangements will be further

strengthened by additional training grade staff in

August 2016 and by recruitment to the vacant

consultant posts.

Acute Sector General Manager


August 2016

August 2016

Explore the potentially valuable contribution that can be

made by non-medical staff, such as advanced nurse

practitioners, while recognising that senior doctors

leading care will always be required.

Outcome – Further development of front door model

The new front door model implemented as part of the

Board’s winter plan is being monitored throughout the

winter period and will be formally evaluated as part of

the debrief to be undertaken during May


June 2016

Performance against the 4 hour A&E standard: for the year ending January 2016:

The total number of attendances was 137,992. This is 2.7% lower than the previous year.

The percentage spending 4 hours or less in an A&E department was 96.0% up from 94.5% for the year ending January 2015. It was also well above the Scotland wide rate of 93.7%.

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Action 4: NHS Grampian should continue to build on collecting real-time patient experience data ensuring this is done reliably and consistently

across the services. This work should include the following

Continue to use patient feedback as a

resource for continuous improvement

Outcome – implementation of rolling programme of surveys

The aim is to have 90% of patients reporting a positive experience of

care. One full round of real-time patient feedback has been completed

across all inpatient areas and several outpatient departments across

NHS Grampian. The surveys have involved the collection of real-time patient and staff

experience information using a survey tool. The purpose of the tool is to

encourage a caring conversation between the interviewer and the

patient, carer or staff member.

We aim to have 80% of staff report a positive experience of care

delivery or work. Where patient/carer experience is being collected we

aim to collect staff experience data also.

The use of improvement trees for the capture of real time feedback has

expanded rapidly across Grampian with sixty trees displayed in clinical

areas and a further twenty mobile trees being used by staff who move

around the region. A total of 1084 improvements have been recorded as

a result of feedback posted on trees.

Patient Opinion is a website where the public can report their

experience of care. We are currently moving to the second level of

registration with Patient Opinion which will allow more staff to have

responding rights, bringing the responsibility for responding closer to

those staff responsible for service delivery. A video of our real-time

patient and staff experience work is available as an example of good

practice on the NHS Scotland Staff Governance website

Director of Nursing

and Midwifery

Completed1

1 Date for completion – originally 30 June 2015

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Action 4: NHS Grampian should continue to build on collecting real-time patient experience data ensuring this is done reliably and consistently

across the services. This work should include the following

Continue to use patient feedback as a

resource for continuous improvement

Outcome – enhanced pool of trained survey workers

The Person-centred Team profile has changed and there are now

more staff trained and participating in the collection of real-time

feedback.

There is a part-time member of staff who has been seconded to carry

out five surveys per ward per week at Dr Gray's Hospital. This is being

achieved most weeks for most wards. Recently we have adapted and

are testing the survey tool to include questions relating to the five must

do with me components of person-centred care

Director of Nursing

and Midwifery

Completed2

2 Date for completion – originally 30 June 2015

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Action 9: NHS Grampian should develop and implement a robust nursing workforce plan using mandated national workforce tools. These plans

should include the following

Detail on how to ensure that there are sufficient

numbers of nurses with the appropriate skill mix

at all times in all wards

Detail on how to fill the gaps, with defined dates

and hierarchical ordering of wards be based on

assessed priority. Through this process, nursing

staff should be made aware of the most recent

results of the national nursing workforce and

workload tool

Consideration of the current bed model in the

context of a 20% gap between staff

establishment in-post and establishment-

assessed-as-being-required, especially in the

absence of a robust plan to successfully recruit

and retain nursing staff

Opportunities to create learning and

communication sessions with senior charge

nurses regarding workforce requirements. This

should include positive communication regarding

the funded skill mix and patients-per-registered

nurse per-shift ratio

Outcome – re-assessment of acute nursing workforce

We have reviewed the acute nursing workforce

encompassing Nursing and Midwifery Workload and

Workforce Planning (NMWWP) tools, professional

judgement, registered nurse:patient ratios, registered

nurse:non-registered nurse ratios, quality data,

supplementary staffing (for example ward house keepers

and bed busters), roster management, senior charge nurse

(SCN) supervisory time, senior professional judgement and

triangulation.

Workforce risks are articulated on the risk register to enable

an overarching view that will support the prioritisation of any

redesign requirements.

Significant work is being undertaken to improve recruitment

and retention.

Outcome – review and challenge of assessment of

workforce

We are embedding consistent governance and assurance

mechanisms across the Acute Sector that focus on safe

staffing models that enable high quality care delivery and

build nursing confidence and capability.

We are in the process of establishing an escalation process

that includes roles and responsibilities that promptly address

concerns raised by nurses about a risk of delays

or omissions of care

Developing and supporting the organisational and Nursing &

Midwifery workforce of the professional responsibility to

assure robust workforce planning.

ADN Modernisation

ADN Modernisation

Completed

30 June

2016

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Action 10: NHS Grampian should develop and implement a robust medical workforce plan. This plan should:

Have a significant focus on securing full

recruitment, including anticipating

retirals and proactively working to

prevent gaps

Outcome – focus on recruiting to vacant posts

Steps that have been taken towards development of a medical workforce

plan are as follows:

Work to develop a full Medical Workforce Plan is progressing,

concentrating on key risk specialities. The final Plan will identify the

risks and gaps for each clinical specialty reviewed, including locum

spend to identify the actions needed to ensure service resilience. This

initial plan will be available by April 2016, with a wider plan for all

specialities developed during 2016-17.

A joint health board and university group has been established, and

continues to meet. Joint workforce opportunities continue to be

investigated, including joint posts.

We have empowered clinical leads to take action (with support) to take

forward any innovative solutions to address gaps in clinical capacity,

including proleptic appointments.

Development of new roles, including Clinical Development Fellows to

support service delivery and education, aimed at recruitment and

retention.

A revised framework for Medical leadership was approved by the

Remuneration Committee in November and will be rolled out in April.

This extends the number of clinical leader roles.

The action plan from the GP workforce summit is progressing well.

The GP lead to support workforce planning has established a live blog

and face book page for vacancies, which has been positively received.

A number of GPs have supported attendance at Career fairs.

Director of Workforce

and Medical Director

30 April

2016 for

first section

of Plan.

Full Plan

for all

Specialities

by

December

2016.

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Ensure that the experience of trainees in

their training is consistently good so that

they will be attracted to work in NHS

Grampian after completing training

Outcome – positive experience for trainees

The Associate Medical Director – Education and Training within the

new medical directorate structure has been appointed.

The Director of Medical Education (DME) structure, with divisional

leads for Education and training in acute, has been established.

We have established Medical & Dental Education Governance Group

(MDEGG) to ensure appropriate governance around medical & dental

education. We hosted a successful Medical education Conference in

November 2015, with 100+ participants, including GMC.

Development of new roles, including Clinical Development Fellows to

support service delivery and education, aimed at recruitment and

retention.

e-rostering system for Doctors in Training (DiT) implemented in

Emergency Medicine, Acute Medical Initial Assessment (AMIA) and

rolled out in anaesthesia for DiT & consultants and for DiT in surgery.

Plan to begin roll-out during 2016-17, across acute.

Medical Director and

Director of Workforce

31

December

2016

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Ensure all consultants and specialty doctors

complete a job plan review annually, and

have an up-to-date job plan that explicitly

and fairly outlines what is expected of them,

and

Outcome – confirmed and agreed job plans for all consultants

We have defined how engagement and non-engagement with

revalidation and job planning will be measured and support clinical

leads to ensure that there is mandatory application of the need for

all consultants to engage in an annual formal appraisal and job

planning process.

We are liaising with the GMC enquires in relation to the historic

processes for revalidation of posts, clarity regarding the current

position and how we intend to move forward with stronger links

between job planning and revalidation.

NHS Grampian achieved an 86% Job Plan return rate across all

specialties for the year 2014/15. There is a clear picture of the

status for each individual, including under negotiation, on

secondment/leave and non engagement for all individuals. Work

has commenced to improve the quality of job planning, linked to

service requirements and educational and research commitments

in each job plan.

For 2015/16, the number of Job Plans agreed at beginning of

March 2016 is 61%, although a much higher number (88%) are in

the process of being signed off by the Medical Lead – Acute.

Work continues on improving the Job planning process and

electronic templates are being used to simplify the process. This

will allow direct upload into personal files and reduce the

administrative tasks on medical and admin staff. NHS Grampian is

represented on the national work to review job planning.

In consultation with the Job Planning Steering Group, a

specification for the introduction of an electronic job planning

system has been developed. Work will continue this year to further

and improve the quality of the Job Plans and simplify the process.

NHS Grampian is also represented on the national Job Planning

group established in partnership with the BMA.

Medical Director 30 June

2016

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Action 11: NHS Grampian should ensure that the training of trainee medical staff is given a sufficiently high priority, ensuring that the

General Medical Council and National Training Survey results are reviewed by the Board. This arrangement should

Ensure that particular attention is paid to the

current training experience in general

surgery and emergency medicine

Outcome - specific improvement plan for ED and General

Surgery

We will seek to eliminate all red flags in both services by the

2016/17 General Medical Council National Training Survey. The

plan will be presented to the new Medical and Dental Education

Committee in June 2015.

Medical Director 31 March

2017

Documents

March 2016 - NHS Grampian · June 2016 Performance against the 4 hour A&E standard: for the year ending January 2016: The total number of attendances was 137,992. This is 2.7% lower