Compliance ahead of time

1
Compliance ahead of time

• Transforming Care Delivery - Workshop Session
• Facilitator Dr Diana Hamilton-Fairley

2
Compliance ahead of time- Aims

• How to make changes quickly within an
  organisation to aid compliance
• Tips and techniques to engage staff
• How to maintain compliance in the run up to 2009
• Factual ideas on developing plans.

3
Content

• 4 Pilot sites
• 4 different approaches
• Physician-led assessment, GP in AE work streams
• Dr Jones, Dr Garnett and Dr Dimopoulos,
  Scarborough
• H_at_N 247
• Dr Diana Hamilton-Fairley, Guys and St Thomas
• MDT Support / surgeons supported
• Marion Waters, Dr Dimitri and Dr Ewins, Countess
  of Chester
• 4) Making changes quickly rotas
• Vanessa Read, West Dorset.

4
Agenda

• 4 Short presentations
• Split into 4 groups for QA
• 15 minutes
• 1 swap talk to maximum of 2 pilot sites.

5
SCARBOROUGH GP IN AE PILOT30th October to
4th December 2006

• DR. PHIL JONES and DR. PHIL GARNETT

6
The Service

• GPs in the AE department during the OOH periods
• Instigate appropriate investigation, rapid
  patient management plans, immediate
  admit/discharge decisions, improve communication
  to patients
• Aims
• Assess the effect of a GP on AE workload and
  admissions to hospital
• Practicable Application
• Employ GPs OOH, AE co-locate with GP OOH (Acute
  floor) to allow easy interchange of patients and
  GP opinion on suitability for discharge to
  Primary care.

7
Presenting Complaints
8
Waiting Times
9
Four Hour Trolley Breaches 2006
10
AE Admissions
11
Impact

• Shorter waiting times in AE
• Fewer four Hour breaches
• Senior clinician assessment
• Fewer investigations in AE
• Improved Patient Experience
• 12 reduction in hospital admission activity
• Closer primary/secondary care working.

12
SCARBOROUGH ACUTE PHYSICIAN ASSESSMENT
PILOT4th December 2006 to 7th March 2007

• DR. CHRISTOS DIMOPOULOS

13
The Service

• Adapted from Harrogates Clinical Assessment Team
  Model
• GP phone advice
• Primary senior assessment
• Early investigation - rapid access to diagnostics
• Immediate admit/discharge decisions - rapid
  feedback
• Early treatment plans/early discharge.

14
Acute Physician Pilot

• Data from 4th December 2006 7th March 2007
• Monday to Thursday service excluding B/H and
  Consultant A/L
• 09-00hrs to 17-00hrs
• 474 patients referred in total
• Age range 15 103
• Mean numbers per day 9 patients.

15
Referral Types
66 referred into service by GP
16
Outcomes
474 patients reviewed by an APU Consultant. 156
discharged therefore admission avoidance 33
17
Non Elective Medical Admissions
18
The Benefits

• Increased clinician engagement in front line
  care
• Patient satisfaction
• GP satisfaction
• Reduced admissions
• Shorter lengths of stay
• Reduced bed base
• Delivery of WTD in Medicine by August 2007.

19
Early Compliance

• Dr Diana Hamilton-Fairley
• Deputy Medical Director
• Guys and St. Thomas NHS Foundation Trust

20
Guys Hospital

• Non-acute site (except Urology and ENT)
• Complex cancer surgery
• Regional Cancer Centre Oncology
• Specialist Renal disease Renal Transplant
• Thoracic Surgery
• Orthopaedics
• OMFS / Head and Neck surgery
• Outpatients.

21
Current situation

• Hospital at night
• Site Nurse Practitioner
• Cross covering in surgery
• Minimal general medicine cover
• Hospital by Day
• Rapid surgical ward rounds
• Poor support of junior doctors by own team
• Problems being picked up too late
• Minimal general medicine cover.

22
Patients are safer at night
Not acceptable

• Need Hospital by Day
• Site Nurse Practitioners assess sick patients and
  support junior doctors
• POPS team
• Over 65 elective and acute orthopaedic admissions
• Optimise pre-op condition
• Optimise post-operative care
• Manage complex discharge
• Pairing of surgical specialties with medical
  specialty.

23
Pairing of Medical / Surgical teams

• Urology - Renal Medicine
• ENT / OMFS / Head and Neck surgery Oncology
• Thoracic Surgery Chest Medicine
• Orthopaedics Rheumatology.

24
Routine / Elective work

• Nurse led pre-assessment / Anaesthetist / POPS
• SNP Patient bed placement
• Surgical Admission Lounge
• Daily Surgical Post operative ward round
• Contact paired Medical SpR / Consultant
• Review and plan by Medical SpR / Consultant
• Liaison with POPS for complex discharge needs.

25
Acute Response Team (Guys)

• Nurse or FY1 / 2, ST1 identifies sick patient
• SNP called and assesses patient
• SNP treats patient / advises medical team
• SNP calls more senior medical help (paired
  medical SpR)
• SNP works with Clinical Technician and
  Physiotherapist.

26
Achieving Compliance

• Minimises need for medical staff overnight
• Better coordination of care
• Everybody learns and supports
• Frees surgeons and physicians from double
  covering
• SAFER for PATIENTS.

27

• Countess of Chester Hospital
• Mrs Marion Waters, Dr David Ewins
• Mr Sameh Dimitri

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Countess of Chester Hospital WTD 2009 Pilot Site
remit

• Work to deliver WTD 2009 targets through
• H_at_N implementation
• Cross boundary multidisciplinary team working
• Multi-specialty handover and bleep filtering
• Robust communication strategy
• (24/7 Team Approach).

29
MDT Support

• Multi-specialty implementation group
• Multi-specialty handover
• Bleep filtering
• Defined roles and responsibilities
• Operational policy
• Escalation policy
• Generic clerking document
• Rota redesign
• Leadership training.

30
Multi-disciplinary H_at_N Implementation Group

• Broad membership - chaired by project lead
• CD leads, SpR and F2/SHO reps
• Senior hospital managers and executive leads
• Medical director
• Medical staffing
• Finance department
• Risk / clinical governance manager
• Invited / co-opted members as required
• IT, Telecommunications..
• Fortnightly meetings
• Well attended
• Motivated group, can do attitude.

31
Multi-specialty Handover

• Learning from others
• 9pm, by MAU, records kept, Handover Policy,
  attendance
• Consultant Physician on call
• all incoming and outgoing junior medical staff
  (except Paeds and OG)
• Clinical Site Co-ordinators with CCO input
• Process
• led by Medical SpR (H_at_N team leader)
• Surgical and Anaesthetic handovers first
• Critical care outreach handover
• Culture change

32
Bleep Filtering

• Bleep Policy
• Available on Intranet (H_at_N website)
• Ward based calls to CSC first with subsequent
  assessment and triage (exceptions)
• Medicine and Surgery
• AE bleeps direct to relevant medical staff
• Baseline and follow-up bleep monitoring
• Switchboard and IT input, 1 week per month
• Reduction in F2 and SHO night-time bleeps
• Anecdotes / anaesthetics SHOs.

33
Supporting Documentation

• Operational Policy
• Roles and Responsibilities
• Handover Policy
• Bleep Policy
• Escalation Policy
• Critical Care Outreach Policy
• .

34
Generic Clerking Document
35
Rota Redesign
36
Leadership Training

• Myers Briggs
• Leadership courses for local SpRs and CSCs
• Terema study Day.

37
Lessons Learnt

• Project Leader
• Need early buy-in from all stakeholders
• Redefine and clarify roles
• Listen, listen and listen
• Negotiate
• Communicate
• Accept culture change
• Overall patient care does benefit.

38
West Dorset Whole Systems Approach

• Vanessa Read
• Project Manager

39
West Dorset Whole Systems Approach

• Patient focused
• Multi-agency
• Multiprofessional.

40
Aspects of the project

• Ambulance contact
• General Practice
• AE/CDU
• Hospital at Night
• MMC and EWTD 2009
• Patient pathways
• New roles and responsibilities

• Community Hospital
• Community response teams
• Adult services Dorset County Council.

41
All at once?

• Some non-compliant rotas from 2004 changes
• Need to introduce MMC
• Need to achieve 2007 and 2009 EWTD compliance
• Long lead time to successfully implement small
  changes
• Change from 6 month to 4 month rotations for many
  posts.
• Decision was to target single change in August
  2007.

42
How did we do it?

• Lead by Medical HR committee
• Medical director
• Head of personnel
• Medical staffing
• General managers
• Consultant representatives
• Meets monthly about all medical staffing issues.

43
How did we do it?

• Sub-group to implement this set up
• Medical lead for junior doctors hours (WW)
• Medical lead for MMC
• Clinical tutor
• Medical staffing
• Project junior doctor.

44
Process

• One day to meet all specialities in turn
• Monitoring data, 2009 compliance info available
• Listened to issues for them
• Highlighted current problems
• Brief discussion of possible solutions
• Allowed a global view of the problems/solutions
• Result was action plan for change.

45
Process

• Tackling EWTD 2009 means savings from re-banding
• Extra F1/F2 posts available from MMC means we can
  convert trust doctor posts to training posts
• Consider where are juniors are not useful
  (OG/Ophth)
• Consider capacity issues at the same time (WLI).

46
Outcomes

• Minor changes to several rotas allowed
  down-banding
• Planned changes to most other rotas agreed with
  specialities, with advance re-banding in process
• Some specialities will have transition period to
  2009 compliance (surgical MG)
• Some work still outstanding
• Plans will employ more juniors and increase
  capacity for the same cost.

47
Problem areas

• Anaesthetics having enough doctors, no
  cross-cover (ACCS)
• Surgery keeping quality of training
• Paediatrics no cross-cover (GP VTS)
• GP VTS keeping balanced programmes
• Balance of junior/senior trainees
• Risk of FTSA posts.

48
Question time

• Pick a pilot of interest and sit around their
  table to ask direct questions
• Well move round after 15 minutes so you get to
  have detailed discussion with two pilot sites.