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Making Seven Day Services a
Reality
Hayley Mounsey
Locality Delivery Facilitator
NHSIQ Seven Day Services Improvement Programme
NHS | Presentation to [XXXX Company] | [Type Date] 2
“ At the end of last year, the research company Dr Foster found mortality rates rose by 10%
at weekends. Other studies have shown similar correlations.
” BBC News, Health
Five day service model not meeting
patient needs or expectations.
NHS | Presentation to [XXXX Company] | [Type Date]
3
Fewer people are admitted to hospital as an emergency at
the weekend but… chances of dying are noticeably higher
100
200
300
400
500
600
700
800
900
MON TUE WED THU FRI SAT SUN
Dis
char
ges
(000
's)
3.4%
3.5%
3.6%
3.7%
3.8%
3.9%
4.0%
4.1%
Emerency admissions
Percentage who are discharged dead
DH analysis of HES data 2010/11
National figures, England 2010/11
Variation in diagnostic services National self-assessment tool Standard 5 and 6
By 2020 the government commitment is to:
• ‘…ensure you can see a GP and receive the hospital care you need,
7 days a week by 2020’.
• ‘…with hospitals properly staffed, so that the quality of care is the
same every day of the week.’
Conservative Party Manifesto, 2015.
Seven Day Services
The 10 Clinical Standards
Patient Experience
Time to first consultant
review
MDT Review
Shift Handovers
Transfer to community and Primary
and social care
Mental Health
Quality Improvement Diagnostics
On-going review
Intervention /Key services
Context: • Following discussions with the Academy of Medical Royal Colleges the following four standards
have been identified as having the most impact on reducing weekend mortality Standard 2: Time to Consultant Review Standard 5: Access to Diagnostics Standard 6: Access to Consultant-directed Interventions Standard 8: On-going Review • Each Trust has been asked to support the establishment of a robust baseline showing the extent to
which these standards are being met, utilising the NHS Improving Quality Seven days Service Self-Assessment Tool (7DSAT) www.7daysat.nhs.uk
• Submission to the 7DSAT needs to be completed by Friday 4th September 2015
• Results of the baseline survey will be published nationally and will provide a baseline against which the progress of implementation can be measured on a quarterly basis
• This baseline will be used to track the progress against the roll-out of the standards nationally.
Early Adopter sites and role of NHSIQ team
1. Diagnostics: Spreading evidence-based models
2. Drive for spread: Engaging all healthcare communities in moving towards services that meet the clinical standards and identifying the top interventions
3. Designing new models of seven day services
Key lessons learned from early adopters
in first year • Workforce
– Weekend consultant reviews
– Staff group shortages
– Development of new and extended roles
• Shared whole health economy vision and governance
• Increasing use of networks and partnership arrangements
• The use of a hub approach for care outside hospitals.
• Information governance and data sharing
• Measurement of the clinical standards and improvements in seven day services
• Leadership for change and staff engagement
• Patient involvement and experience of care
• The importance of enlightened commissioning
Role of commissioner in delivering seven day services
• Approve the Service Delivery and Improvement Plans agreeing prioritised 5 Clinical Standards in year 1 and remaining in year 2.
• Monitor progress in partnership with TDA and Monitor
• Develop strong relationships across the pathway to support delivery of Clinical Standard 9 i.e. BCF, co-commissioning, commissioning of community services
• Ensure seven day services initiatives link with other transformational change programmes e.g. Prime Minister’s Challenge, Vanguards, Urgent and Emergency care
• Capture voice of patients and the public
Central Lancashire Health and Social Care – Whole
System Transformation Programme
Step Up Step Down
Jane Kitchen
Clinical Commissioning Group
• Outlier for delayed transfers of care
• Outlier for long term residential and nursing care admissions
• Under utilisation of intermediate care services
• Patient experience of discharge was poor
• Complex multi agency discharge arrangements –
and only Monday - Friday
Step Up Step Down - Why?
Step Up Step Down - How did we get buy in?
• KPMG commissioned to complete analysis of what wasn’t working within urgent care across the health and social care economy (Clinical Senate) – the why
• Establishment of a programme board reporting into Clinical Senate – each project had a senior responsible officers reporting to board.
• 7 day services was core in every project, not a
separate one!
A ‘Single Point of Access’ will
coordinate access to the range of
available intermediate care services
with delegated authority to directly
access an agreed range of Social Care
services
3
Maximising local service provision to
enable patients to remain/regain
independence, preventing unnecessary
hospital admission and supporting safe
and timely discharge
1
Integrated Transitional Care and
Integrated Discharge /Admission
avoidance teams will provide a more
flexible and responsive service,
promoting continuity of care and fewer
hand-offs between professionals
2
Everyone has a bed – it’s in their own
home
“Discharge to Assess, not Assess to Discharge”
No long-term care decisions should be
made from a hospital bed
Promoting independence
for patients:
Better health and social care
outcomes
Improved experience for
services users and carers
Care closer to home
Reduced health and
social care costs
1
2
3
Step Up Step Down - Principles
Everyone has a bed – it’s in their own home
Discharge to Assess, not Assess to Discharge
No long-term care decisions should be made from a hospital bed
1
2
3
The first thing to consider is how we can safely
enable this person to go home
Agreed a working definition “what needs to happen
to enable this person can leave hospital”
We wanted to ensure that everybody had the
opportunity for a period of
rehabilitation/ recuperation prior to
making life changing decisions
Step Up Step Down - Principles
• Developed an economy wide project group
• Reported into programme board
• Step Up or Step Down – Concept, not a place
• Trusted assessor pathways into the following services
■ Low level VCFS support
■ Domiciliary Reablement (with or without therapy)
■ Community beds for recuperation, rehabilitation and assessment
• Medical cover embedded
• Pathways included exit routes
• Links with other projects .
Step Up Step Down - What we did
• Project leads from LCC and
CCG
• Weekly meeting
• Membership from all partners
• Devolved decision making
responsibilities
• No blame culture
• Working closely with social
care providers
• Project leads regularly
worked at the hospital to
affect culture change
• Critical friend
Step Up Step Down - How did we do it?
• Engaged with patient advisory groups
• Learning from what patients tell
us • Communications campaign
• Dashboard to show impact
• Hold our nerve
• Learning circles when it went wrong
• Celebrated the successes
• The support of Senate • Bribery – in the form of biscuits
and cake to the operational group
Step Up Step Down - How did we do it?
Monthly report and dashboard to
measure:
• Number of referrals received
• From where/who
• Which pathway utilised
• Delays and reasons
• Occupancy levels
• LOS in both acute & community beds
• Outcome for individuals
• Re-admission rates
• Patient experience
Step Up Step Down - How will we know it is working?
• Whole system integration: Patients see one service –
seamless care; part of their planned journey; offering flexibility. • Delayed access to Intermediate care has reduced from 8.6% • to 5% in first 9 months • Delays in discharge, attributed to social care, reduced from
13% to 7.8% in first 9 months. • There has been increased utilisation of community beds from
75% utilisation in 2012/13 to 91% in 2014/15. • Number of patients returning directly to home has increased • by approximately 20 extra patients a week. • Length of stay in community beds has reduced, on average
from 38.5 to 28.3 days. • Multiple assessments are no longer required leading to
improvements in patient experience. • Increased admission avoidance – right care, right place,
right time …. not always a hospital bed, care closer to home. • Better patient experience, with improved outcomes, for them
and their carers
Step Up Step Down - Key Outcomes
• CHC needs to be included
• Integrated discharge team under the day to day
management of one organisation
• Home of choice policy
• Wider than Preston, Chorley and South Ribble
• A shared vision
• Can't be done in isolation
• It is achievable
Step Up Step Down - Lessons
learned
Sustaining, Expanding and Enhancing
Healthcare Services for Older People,
Seven Days a Week
Stuart Ellis
Associate Director of Finance - Transformation
Claire Lambie–Fryer
Senior Clinical Transformation Manager
Common themes across Clinical Pathways prior
to becoming an early adopter site for 7 Day
Services
• Variation
• Availability of senior decision makers
• Access to clinical services and assessments
• Increased length of stay
• Pressures on bed base within the Trust
Or simply
Overall Approach
• Collaboration between 10 East Midlands Acute Providers
• Partnership working with CCG
• Supported by EM Clinical Senate
• Identifying key challenges
• Sharing good practice
• Supporting plans for future Improvement
• 21st Century joined up care
Capturing the Learning
• Worked closely with NHSIQ
• Pilots ongoing in Surgery, Medicine and Pediatric Areas
• Case Studies available on NHSIQ website
• One pilot that has since been funded and is providing
consistent patient care over 7 days across Chesterfield
Royal Hospital is the Acute Frailty Unit.
Acute Re-enablement Unit (ARU)
Frailty Unit Project Timeline
• January 2014 CRHFT redesigned its care pathway for frail
older people to improve access to high quality patient
centred acute care, increase flow through the hospital and
reduce avoidable harm to patients by reducing length of stay
• Initially as a pilot project partially funded by commissioners.
• Patients are admitted directly from ED or the Emergency
Admissions Unit to the Frailty Unit. There is as yet no direct
GP access although this is planned for the future.
Key Challenges
• At the beginning, there was some anxiety from staff about working in
this new way.
• Providing access from and advice to primary and community services.
• Making sure the Frailty Unit is optimised and used appropriately so
flow is maintained.
• Implementing the model using a phased approach with limited staffing
resources.
• Providing access from and advice to primary and community services.
• Maintaining a safe, calm, dementia friendly environment for patients
Key performance indicators
Number of admissions (KPI: Minimum 80 per month during first year of operation)
KPI - Re-admission rates less than the average
for non-elective medicine
KPI-ALOS 4 nights during first year of operation
KPI - >50% of patients to return to their
pre-admission place of residence
Potential savings on reduction of bed days
• With this model, Chesterfield Royal Hospital is now one of ten pilot sites participating in the National Acute Frailty Network programme, part of NHS
Elect, which aims to support the widespread adoption and improvement of
Frailty Services in England
• In addition to the Frailty Service, a ‘Discharge to assess-and-manage’ (D2AM)
model has been commissioned and is now in use since June 2015 for Frailty Unit patients, seven days a week.
• Falls Partnership Service (joint enterprise) - FPS is a seven day service
working from 6am to 6pm consisting of a paramedic and therapist who are called out acutely in an ambulance to patients who have fallen
and do real time assessments in the patient’s own environment
Rules of Engagement
• Get started! Identify enthusiastic staff
members, agree a date and start with your first
patient. Don’t worry about having all of your internal
processes perfect first.
• Attend the PDSA meetings, bring your patient’s
information and be prepared to honestly discuss
how it has gone.
• Speak to staff that have started this work to hear
and learn from their experiences.
Managing the process
• Remember the risk of keeping someone in hospital
can be far greater than the risk of them being at
home even when they are not 100% back to how
they were pre-admission.
• Think discharge when a patient is admitted.
• Get others involved at the earliest possible stage.
• Make sure any difficulties or successes are taken
to the PDSA meetings.
Moving Forward for ARU
• Providing an enhanced “front door” frailty service outreaching to
ED, EMU and CDU.
• Use of new technologies to provide timely access to the specialist
team and ultimately to enable people to remain safely supported
in their own homes where appropriate.
• Integrating the existing outpatient falls clinic into the Frailty Unit,
as well as rapid access MDT clinics in order to avoid
unnecessary hospital admission
• Greater integration with Falls, Dementia and Palliative care
services under the umbrella of the 21st Century Acute
Frailty Services Workstream.
Next Steps in our 7 Day Services Journey
• Development of a 7 Day Services Matrix across all
specialities
• Building on existing partnerships and building new ones
• Development and agreement on metrics for 7DS
• Making 7DS part of the Annual Trust Audit Programme
• Translating enthusiasm into care.
• Sustaining the momentum
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