FT Keogh Plans

Report
Special Measures Action Plan
Heatherwood and Wexham
Park Hospitals NHS Foundation
Trust
September 2014
KEY
Delivered
On Track to deliver
Some issues – narrative disclosure
Not on track to deliver
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Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan & our progress
What are we doing?
•
The Trust entered the Special Measures programme and was selected following a CQC inspection in February 2014 which rated the Trust as “inadequate.”
•
The Trust has to implement a range of recommendations, some of which are achievable in the short term and others which require a longer period of implementation to drive
sustainable change. The Trust is committed to making the changes as quickly as possible in the very best interests of our patients and has taken a realistic and prioritised
approach to the Improvement Plan.
•
The Trust has agreed a summary action plan to deal with these 18 recommendations. We envisage that improvements will be made on an ongoing basis throughout 2014 to
ensure that the Trust is ready when the Chief Inspector of Hospitals, Professor Sir Mike Richards, reinspects.
•
The key themes of these recommendations are summarised by the headings below:
• Patient Safety: the CQC found that there is a lack of ownership of problems with acceptance of sub-standard care and poor patient experience, poor cohesion of staff
groups, the existence of a ‘them and us’ culture, a safety culture is not embedded and there is a culture of poor incident reporting
• Patient Experience: the CQC found that staff are desensitised to patient experience being a priority, whilst complaints handling had improved considerably, awareness
of how to complain or raise a concern was still too slow and the estate is not universally fit for purpose nor maintained in a timely manner
• Workforce and Culture: the CQC found that there was a high turnover of middle and senior management, consultant engagement is an ongoing problem, reports of
bullying and harassment were widespread, performance management of consultants was inadequate, a lack of cohesive working between staff groups, concerns over
staffing levels, ongoing reliance upon agency staff due to struggles to recruit and retain staff and examples of non adherence with local induction policies
• Governance: the CQC found that governance structures were not standardised across the Trust including mortality and morbidity meetings and that fundamental
standards of care were not being met
• Patient Flow: the CQC found that there were significant problems with the flow of patients through the hospital and that the Trust is not meeting the 4 hour emergency
access standard.
• Elective Access: the CQC found that there was a high rate of cancelled operations and that the referral to treatment standards were not being met.
•
This document shows our plan for making these improvements and demonstrates our progress against the plan. While we take forward our plans to address the
recommendations, the Trust is in ‘special measures’.
•
Oversight and improvement arrangements have been put in place to support changes required. The Trust has a Quality Programme Board which meets twice a month to
consider progress and key actions. A formal Quality and Safety Executive Board meets monthly to review the Trust’s performance in key areas such as patient safety,
incidents, staffing and patient experience. External scrutiny will take place at a monthly Oversight and Assurance meeting chaired by NHS England which is also attended by
commissioners and the Trust’s regulator, Monitor.
•
The Trust has already benefited from the partnering arrangements with Frimley Park Hospital NHS Foundation Trust. Members of the Executive Team at Frimley Park have
had input to the Improvement Plan and have attended meetings with clinicians to support the engagement process.
•
The Trust has recognised the need for a sustainable organisational form as the key to addressing some of the longer standing issues and ensuring that there is a complete
approach to ensuring that the Trust can make the required improvements. The Board is supportive of and committed to the proposed acquisition by Frimley Park Hospital
NHS Foundation Trust. This will enable a longer term plan to be implemented to ensure that changes are fully embedded and sustainable.
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Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan & our progress
Who is responsible?
•
Our actions to address the CQC recommendations have been agreed by the Trust Board.
•
Our Acting Chief Executive, Grant MacDonald is ultimately responsible for implementing actions in this document. Other key staff include the Executive Team, the clinical
chairs and clinical leads in the organisation.
•
The Improvement Director assigned to Heatherwood and Wexham Park Hospitals NHS Foundation Trust is Mark Davies, who will be acting on behalf of Monitor and in
concert with the relevant Regional Team of Monitor to ensure delivery of the improvements and oversee the implementation of the action plan overleaf. Should you require
any further information on this role please contact [email protected]
•
Ultimately, our success in implementing the recommendations of the Improvement Plan will be assessed by the Chief Inspector of Hospitals, who will re-inspect our Trust
within 12 months after entering the Special Measures programme.
•
If you have any questions about how we’re doing, contact us at [email protected]
How we will communicate our progress to you
•
We will update this progress report every month while we are in special measures.
•
There will be regular updates on NHS Choices and subsequent longer term actions may be included as part of a continuous process of improvement.
•
We will present our progress to the monthly Oversight and Assurance Group, chaired by NHS England and attended by our commissioners and regulators.
Chair / Chief Executive Approval (on behalf of the Board):
Chair Name:
Mike O’Donovan
Signature:
Date:11/9/14
Acting Chief Executive Name:
Grant MacDonald
Signature:
Date: 11/9/14
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Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan
Summary of
main concerns
Patient Safety
Summary of urgent actions required
Agreed timescale
for
implementation
1.1.1 We will communicate that completion of the WHO checklist is
mandatory and that repeated non-compliance will be addressed
through performance management.
End of May
1.1.2 We will appoint an accountable clinical lead for the WHO
checklist together with WHO champions in each theatre team.
End of May
1.1.3 We implement a mandatory field in the theatre management
system (IQTopia) that will enable near real time monitoring and audit.
In lieu of this development we will ensure that an incident must be
logged when the checklist is not completed and will monitor
compliance through weekly compliance checks and regular audits.
End of June
1.1.4 We will commission an expert external clinical advisor to
undertake a workshop with consultants on human factors that support
implementing the WHO checklist.
End of August
External
support/
assurance
Progress against original timescale
Revised
deadline
(if
required)
Acting CEO and MD have outlined the
requirement with the clinical leads.
Clinical lead and champions for the
WHO checklist identified.
Work on software for theatre system
has commenced but has been
delayed due to limited IT access in
the anaesthetics room. A compliance
process is ongoing in lieu of this
development.
Dr P McArdle,
Plymouth
Hospitals NHS
Trust
End Sept
Expert external clinical advisor
attended the Academic Half Day on
15 July. The debate led to significant
discussion about the need to move
the focus on the action plan onto
addressing the human factors in noncompliance with the checklist.
Firm engaged to run a workshop on
human factors for key theatre staff.
This is scheduled for December.
Quantitative audit process in place.
Qualitative audits developed and
introduced. The nurse in charge of
theatres observes the process three
times a week. A survey on staff
engagement with the WHO checklist
is planned to take place.
Theatre manager nominated to log
incidents on Datix.
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Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan
Summary of
main concerns
Patient Safety
Agreed timescale
for
implementation
External
support/
assurance
1.2.1 We will obtain external support from the Thames Valley
Academic Health Science Network – Patient Safety Academy to develop
and implement a programme to improve the patient safety culture in
the trust.
End of November
Thames Valley
Academic
Health Science
Network
1.2.2 We will undertake the Listening into Action (LiA) programme of
engagement with staff. This is a simple programme with a clear aim to
transform the way the Trust works, putting staff at the centre of
change. It is based on evidence about the link between engagement
and outcomes of care.
End of December
Listening into
Action
1.2.3 We will ensure that there are regular forums for clinical leads to
review quality improvement activity with the MD and CEO.
End of June
1.2.4 We will maintain a rolling programme for nurse leaders to
ensure a sound knowledge of care standards that can be cascaded to
others.
End of June
1.2.5 We will obtain expert clinical advice and implementation
support on our plans related to patient safety and clinical engagement
from Frimley Park Hospitals NHS Foundation Trust.
End of June
Summary of urgent actions required
Progress against original timescale
Revised
deadline
(if
required)
Seminar held with Patient Safety
Academy and senior clinical leaders
to explore how they can support the
Trust with cultural change. Trust to
nominate 4 individuals to attend
workshop in Autumn.
The Trust will join the Sign up to
Safety campaign upon acquisition by
Frimley Park. This will be led by the
Medical Director.
Phase 1 of LiA has been completed
and > 200 staff have taken part.
Project teams now working to
implement changes following launch
events. Quick wins identified,
implemented and communicated.
Clinical lead, MD, CEO forums are
ongoing and have identified how
specialities can work to inform and
implement this plan and a broader
improvement agenda.
Clinical advice agreed with FPH and
meetings between clinicians have
taken place.
Nurse development programme has
been extended due to positive
feedback.
Nursing standards developed and
launched on Nurses Day.
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Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan
Summary of
main concerns
Patient Safety
Summary of urgent actions required
Agreed timescale
for
implementation
1.3.1 We will review the use of risk assessments in A&E and take
improvement actions where required.
End of May
1.3.2 We will meet the specific nutritional needs of patients who are
in the A&E department for prolonged periods.
End of May
External
support/
assurance
Progress against original timescale
Revised
deadline
(if
required)
The use of risk assessments in the ED
and the associated standards have
been reviewed and implemented.
Nutrition, waterlow and falls
assessments are to be completed for
all patients >75 years and others at
risk who will be admitted but are
awaiting a bed at four hours. If the
patient is still in the department after
6 hours, they will be transferred to a
bed and remaining assessments will
be completed.
Three audits have taken place in A&E
to review documentation of falls
assessments and fluid balance charts.
Compliance levels are improving.
Regular sample checks are now
taking place on assessments via
clinical compliance rounds. The
Associate Director of Nursing reviews
the outcomes of the audits quarterly.
Hostess rounds have been increased
in A&E to ensure that appropriate
nutrition is available to all patients,
including those attending for
prolonged periods.
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Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan
Summary of
main concerns
Patient Safety
Summary of urgent actions required
Agreed timescale
for
implementation
1.4.1 We will develop and communicate a programme of initiatives
aimed at developing an incident reporting culture, so that it is seen as
a mechanism to learn rather than attribute blame.
End of August
1.4.2 We will review the incident reporting process to identify how
learning can be better shared with the individuals reporting the
incident and throughout the wider organisation.
End of July
External
support/
assurance
Progress against original timescale
Revised
deadline
(if
required)
Feedback mechanism reviewed and
updated. All incidents classified as
moderate and above must now be
fedback to reporters. Guidance to
this effect has been updated and
released to all staff with clear
instructions on the mechanics of
using Datix.
Cleanse of Datix system to remove
duplicate incidents and users has
been completed. System upgrade to
facilitate feedback is on hold as an
outsourced solution is being jointly
progressed with Frimley
To support the Duty of Candour, the
Trust has amended Datix to capture
when a patient or relative has been
informed when something has gone
wrong for all incidents graded
moderate and above.
Plans in place to share learning via
monthly updates at all levels of the
Trust (e.g. all staff e-mail, Team Brief,
Bilaterals etc). Patient Safety and
Quality newsletter issued monthly.
Divisions are taking it in turns to
present a report on key themes from
complaints and incidents to the PSG.
Matrons slidepack has a placeholder
on key learning. A maternity
newsletter has been developed and
disseminated within the team to
highlight key learning points.
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Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan
Summary of
main concerns
Patient Safety
Summary of urgent actions required
1.5.1 We will review the investigation of incident process and
implement improvement actions. The scope will include consideration
of who is appointed to the investigating team, how the investigation is
conducted (including root cause analysis, data review and involvement
of those who use the service together with staff) and how the outcome
of the investigation is shared.
Agreed timescale
for
implementation
End of July
External
support/
assurance
Progress against original timescale
Revised
deadline
(if
required)
The investigation process has been
reviewed. Some clarification of roles
and responsibilities was required and
the Trust policy has been updated
and has been signed off.
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Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan
Summary of
main concerns
Patient Safety
Summary of urgent actions required
Agreed timescale
for
implementation
External
support/
assurance
Progress against original timescale
1.6.1 We will provide additional safeguarding training to staff to
ensure that they are able to respond to patients appropriately.
End of August
Capacity for training identified and
being programmed.
1.6.2 We will provide all staff with information on how to respond to
patients with a learning disability.
End of May
1.6.3 We will develop and embed initiatives to improve the care of
people with dementia.
End of October
DOLS to be included in level 2
safeguarding training. Awareness
increasing and more DOLs
applications are being made. DOLs
and safeguarding was included on the
agenda for the matrons meeting
inAug.
Revised
deadline
(if
required)
Plans for level 3 childrens
safeguarding training developed and
sessions (training up to 66
individuals) are due to take place in
November and December with
further phasing over an 18 month
period to ensure that relevant staff
are trained.
All staff provided with information on
people with learning disability at the
end of May via monthly payslip.
Working version of LD protocol is in
place and is to be discussed at NMAC.
Plans in place to train a further 16
dementia champions in October
2014. 8 individuals are already
trained.
A dedicated dementia bay with four
beds on ward 5 has been established.
Dementia garden has been opened,
dementia awareness week has taken
place together with a workshop by a
dementia carer highlighting key
challenges. Individuals made
personal pledges around dementia
care.
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Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan
Summary of
main concerns
Patient
Experience
Agreed timescale
for
implementation
External
support/
assurance
2.1.1 We will implement and resource a co-ordinated programme of
activities aimed at improving the experience of patients and their
friends and family.
End of November
Picker Institute
2.1.2 We will develop and implement a customer care programme
which will be rolled out to all patient facing staff. This places the
patient experience at the centre of the training. The curriculum
includes a number of ‘always’ events that we expect from our staff
(e.g. Introducing yourself to patients, following hand hygiene protocols
etc).
End of November
Summary of urgent actions required
Progress against original timescale
Revised
deadline
(if
required)
Curricula and mobilisation
programme developed for
customer care programme. Roll
out has commenced. Since
February and at 10 Sept, 350
people had attended training and
a further 250 scheduled to
attend.
The Trust has developed and is
implementing a co-ordinated
programme of activities including:
• A workshop facilitated by a
patient with patient and clinical
involvement to develop top 5
priorities for the next 12 months
• Patient stories at the Trust Board
• Mystery shopper telephone calls
to wards and departments
assessing customer service skills
• “Hello – my name is..” was
successfully launched on 7 July.
• Bedside guide for patients
developed.
• HWP patient and advocate for
improved patient experience
involved in induction training for
new junior doctors in August. To
be filmed to facilitate ongoing
training.
Work is ongoing to consider the
organisational structure for
complaints.
A Complaints Newsletter has been
developed and circulated to all staff
with key learning points from each
division.
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Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan
Summary of
main concerns
Patient
Experience
Summary of urgent actions required
Agreed timescale
for
implementation
2.2.1 We will develop the estates management system as a way of
logging and responding to and monitoring planned and reactive
maintenance.
End of August
2.2.2 We will implement year one of a 5 year prioritised plan to
address circa £40m of estate issues identified in a 6 facet survey.
End of March
External
support/
assurance
Progress against original timescale
Revised
deadline
(if
required)
Revised system and process aimed at
improving the estate management
system being finalised. First phase of
training has been completed for
management, engineers and team
leaders. In total, 75% of staff have
been trained.
Scoping meeting held with Qube to
develop management information
and performance reports. This will
support more effective management
and decision making within estates.
Business process mapping is
complete and mobile devices have
been deployed to trained staff.
Comms to clinical staff on changes
has commenced at matrons mtg and
will be cascaded to all wards and
depts.
The backlog of outstanding jobs has
reduced by a third since March.
Capital plan and timeline has been
agreed with DoH. High level capital
plans for 14/15 agreed and work
commenced. Regular meetings held
with Frimley to prioritise plans.
The Trust has invested in two new
fully equipped and modern wards,
one of which is now fully operational.
Second ward will open in September.
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Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan
Summary of
main concerns
Workforce
and Culture
Agreed timescale
for
implementation
External
support/
assurance
3.1.1 We will work with ACAS to undertake a comprehensive review
of staff perspective on fairness in the workplace with a specific focus
on bullying and harassment.
End of August
ACAS
3.1.2 We will commission ACAS to undertake a programme of
development following the initial phase of the diagnostic work
described above.
End of August
3.1.3 We will commission ACAS to undertake training to prepare key
managers and leaders for difficult or crucial conversations, how to
manage and control the workplace discussion process and how to
ensure they are talking to employees in as productive a way as
possible.
End of July
3.1.4 We will complete an external assessment of the Trust’s
approach to longer standing employee relations issues.
End of May
Summary of urgent actions required
Progress against original timescale
Revised
deadline
(if
required)
ACAS have been jointly
commissioned between management
and staff side to undertake diagnostic
work on the culture of the
organisation with a specific focus on
bullying and harassment and training
on how to have a difficult
conversation.
ACAS have largely completed their
diagnostic work and anticipate that
their draft report will be available in
early October.
At 3 September, 123 people had
booked in for training, 53 people
were scheduled to attend a focus
group and 28 individuals had
requested a one to one interview. A
separate training session is being
scheduled for booking centre staff to
accommodate their workload and
opening hours.
Feedback on the training sessions to
date has been positive and additional
sessions have been arranged for
September and October.
A review of employee relations issues
undertaken and revised approach
agreed.
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Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan
Summary of
main concerns
Workforce
and Culture
Summary of urgent actions required
Agreed timescale
for
implementation
External
support/
assurance
Progress against original timescale
3.2.1 We will review, develop and implement our recruitment and
retention plans to drive an increase in substantive staff and reduce our
reliance on temporary agency staff.
End of July
Revised R&R plans have been
developed and are being
implemented.
3.2.2 We will enhance our monitoring of progress and report on
progress on a regular basis.
End of July
The Trust has attended overseas
recruitment events in Spain and Italy
to focus on increasing the numbers of
qualified nurses. Good progress has
been made at recent overseas events
and UK job fairs. Over 100 people
were interviewed and the Trust
expects staff to commence between
September and November.
Revised
deadline
(if
required)
The Trust has future plans to attend
further job fairs and additional
overseas recruitment.
Offers have been made to a number
of middle grade doctors, subject to
work permits and GMC registrations.
Revised reporting is being finalised
for the monthly resourcing group
meeting.
Roles and responsibilities between
HR and operations have been
clarified.
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Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan
Agreed timescale
for
implementation
Summary of
main concerns
Summary of urgent actions required
Workforce
and Culture
3.3.1 We will review our nursing establishments and adjust as
required.
End of May
3.3.2 We will implement governance and reporting systems to
monitor and report on safe nurse staffing levels.
End of May
3.3.3 We will publish their staffing fill rates (actual versus planned)
on the NHS Choices website.
End of June
3.3.4 We will review medical staff capacity to ensure that we can
meet the capacity required for planned and emergency care.
End of July
External
support/
assurance
Progress against original timescale
Revised
deadline
(if
required)
The Trust has reviewed nurse staffing
levels to inform budget setting and
increased nursing levels where
required. The Trust has agreed a
policy on nurse establishment and
skill mix.
The Trust has developed and
implemented a governance and
reporting system to monitor and
report on planned nurse staffing
levels. Further action is being taken
to provide assurance that remedial
actions for short staffed shifts are
being undertaken.
Data and accompanying narrative
posted on NHS Choices to
demonstrate key staffing metrics
such as fill rates
The Trust has reviewed the
requirements for consultant medical
staffing for unscheduled care and is
recruiting against this.
Demand and capacity work on
scheduled care is progressing. This
will provide clarity on the medical
staff required to deliver this capacity.
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Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan
Summary of
main concerns
Workforce
and Culture
Summary of urgent actions required
Agreed timescale
for
implementation
3.4.1 We will review the boarding passes used to induct agency staff
on the wards and reiterate the mandatory requirement of checking
identities and competencies when the agency member of staff arrives
at the ward.
End of May
3.4.2 We will monitor compliance with completion of the boarding
passes.
End of June
External
support/
assurance
Progress against original timescale
Revised
deadline
(if
required)
Boarding pass format finalised to
ensure consistent application.
Spot check audits have been
undertaken to monitor compliance.
Compliance with boarding passes is
also included as a question within the
clinical compliance rounds to ensure
sustained compliance.
Project team in place to agree
templates for boarding passes for
locum medics. Paper based process
has been designed (and is already in
use in A&E). Project plan is in place
to roll out across inpatient wards.
Frimley locum induction process and
templates obtained to progress
implementation at HWP.
15
Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan
Summary of
main concerns
Governance
Agreed timescale
for
implementation
External
support/
assurance
4.1.1 We will review and revise the existing governance structure
and submit the revised framework for review by the Good Governance
Institute (GGI).
End of May
Good Governance
Institute
4.1.2 We will implement the revised arrangement and processes
following initial feedback from the GGI.
End of June
4.1.3 We will ask the GGI to review the arrangements in practice
when established and undertake any ongoing improvements
recommended.
End of August
Summary of urgent actions required
Progress against original timescale
Revised
deadline
(if
required)
The GGI has examined the proposed
arrangements and are satisfied that
they will provide a framework for
adequate clinical governance system.
The Trust has rolled out the revised
system and associated processes.
An interim review has been
completed to identify any emerging
issues following a month of
operation. No significant issues
identified but some improvements to
be introduced as a result of the
findings.
The GGI has been on site and
performed a review of the
compliance with and operating
effectiveness of the new
arrangements. The Trust has
received positive verbal feedback and
anticipates that a draft report will be
received during September.
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Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan
Summary of
main concerns
Governance
Summary of urgent actions required
4.2.1 We will design robust and transparent structures and processes
to manage and improve individual and team clinical safety and quality.
Agreed timescale
for
implementation
External
support/
assurance
Progress against original timescale
End of July
KPMG
The review is complete.
Revised
deadline
(if
required)
A number of recommendations have
been made to improve the medical
governance arrangements at the
Trust. The recommendations are at
Trust-wide and specialty level and
have been drafted with the
acquisition in mind.
The project to do this is being carried out by KPMG in conjunction with
the Faculty of Medical Leadership and Management who have brought
in senior external medical expertise to work with the medical staff at
the Trust to understand how clinical governance currently operates
and help to design a robust new structure that can be rolled out across
the Trust.
The review is considering six areas incorporating a mix of medical,
surgical and diagnostic specialties. It includes a desktop review of
documentation (minutes, job descriptions, structure) followed by
observation of existing mortality & morbidity and multidisciplinary
meetings. The team will then work with divisional chairs to develop a
consistent approach to these meetings across the organisation.
4.2.2 We will implement the recommendations from this review
across the Trust.
End of September
17
Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan
Summary of
main concerns
Governance
Summary of urgent actions required
Agreed timescale
for
implementation
4.3.1 We will implement and embed a system for direct monitoring
of compliance with point of care standards.
End of May
4.3.2 We will fully embed ward dashboards and ensure that they are
understood and owned from ward to board as a tool to monitor point
of care standards by care area or by care issue.
End of July
4.3.3 We will embed a robust system to review the decision when a
caesarean section is performed.
End of June
External
support/
assurance
Progress against original timescale
Revised
deadline
(if
required)
The Trust has developed and
implemented a standard operating
procedure for compliance checking in
service areas.
Escalation procedure developed to
clarify to staff what action will be
taken if compliance rounds are not
undertaken or if scores are poor. This
is monitored weekly and has resulted
in significantly improved levels of
compliance.
The Trust has developed and is
embedding ward dashboards as a key
assurance product. The Trust has
progressed to using the data from the
reviews as a means of identifying
further areas for improvement.
C section meeting has taken place
with lead consultant and midwife and
CCG representatives. Agreed to do a
thrice weekly (Monday, Thursday and
Sunday) review of caesarean sections
with a focus on category 1 and 2
cases. Case notes are reviewed in
detail led by an alternating
consultant of the week. Meetings are
open to all. A monthly “Improving
Normal Births” meeting is also held.
18
Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan
Summary of
main concerns
Governance
Summary of urgent actions required
Agreed timescale
for
implementation
4.4.1 We will reinforce and communicate the standards required in
respect of documentation.
End of July
4.4.2 We will regularly review patient notes to ensure
documentation is of agreed standard.
End of August
External
support/
assurance
Progress against original timescale
Revised
deadline
(if
required)
Required standard of nursing
documentation has been
communicated.
Nursing documentation is reviewed
regularly, including as part of the
clinical compliance rounds.
Documentation standards workshop
held and an improvement campaign
took place in July. A reminder of
good clinical record keeping was
posted on the intranet for all staff.
Key tips on good care and recording
were also sent to all matrons. This
included tasks for all matrons to
complete with a focus on how
improvements could be made.
Proposal developed to introduce
personalised doctor’s stamps with
names and GMC numbers to provide
greater clarity in patient records.
Awaiting details of Frimley’s supplier
to place an order.
19
Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan
Summary of
main concerns
Governance
Summary of urgent actions required
4.5.1 We will maintain a system which enables us to monitor when
policies and guidelines are due for renewal and proactively review
them in advance of the due date.
Agreed timescale
for
implementation
End of July
External
support/
assurance
Progress against original timescale
Revised
deadline
(if
required)
The Trust has identified and is
working through a prioritised
schedule of polices requiring review.
20
Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan
Summary of
main concerns
Patient Flow
Summary of urgent actions required
5.1.1 We will review existing plans to improve the emergency care
pathway and develop a focused recovery plan. This will include
enhancing the role of ambulatory care, developing further seven day
working plans and earlier initiation of patient treatment in the most
clinically appropriate location.
Agreed timescale
for
implementation
External
support/
assurance
End of June
5.1.2 We will obtain expert clinical advice and implementation
support on our plans as part of the partnering arrangements from
Frimley Park Hospitals NHS Foundation Trust.
End of June
5.1.3 We will engage the expert external support of the NHS
Emergency Care Intensive Support Team in relation to the delivery of
our recovery plans.
End of June
Progress against original timescale
Revised
deadline
(if
required)
Final draft of recovery plan being
agreed following extensive clinical
engagement.
Frimley Park
Hospital NHS FT
Emergency Care
Intensive Support
Team
ECIST have conducted an initial
review and have developed a series
of recommendations which are being
incorporated into the recovery plan.
Ambulatory care has progressed well
and has been embraced by the
surgical teams. This was enhanced by
an open day held in the area at the
end of June.
Clinical advice agreed with FPH.
Initial meetings have taken place
between clinicians. Individuals have
been tasked with working in small
teams to develop a plan to achieve an
outstanding rating in each of the CQC
domains at the next inspection. This
will be developed with input from
FPH.
Additional resource secured for x-ray
to operate a third machine. This
commenced 7 days a week from 4
July to reduce A&E diagnostic waits.
Meeting between key clinicians and
managers from A&E and radiology is
being set up to facilitate improved
communication and team working.
21
Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan
Summary of
main concerns
Patient Flow
Summary of urgent actions required
5.2.1 We will minimise the number of patient moves by improving
the emergency care pathway and specifically by undertaking the
‘Spring to Green’ initiative aimed at generating energy for change by
doing things differently for a defined week to support patient flow;
Right Patient – Right Bed and consequently improve patient care.
Agreed timescale
for
implementation
End of July
External
support/
assurance
Progress against original timescale
Revised
deadline
(if
required)
Spring to Green event took place w/c
30 June. Significant levels of clinical
engagement throughout the Trust at
all levels.
Escalation status improved
throughout the week (from red to
green).
Sustainable changes identified
including additional radiology and
OT/Pt resource.
There were a number of quick wins
identified in Spring to Green which
have been implemented by
Executives immediately. This
includes the provision of additional
staff within radiology and
rehabilitation.
22
Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan
Summary of
main concerns
Patient Flow
Summary of urgent actions required
5.3.1 The Trust will monitor escalation areas on a daily basis. This
will include consideration of the mix of substantive/bank & agency
staff. Clinical compliance rounds will incorporate a review of the
documentation to ensure that patients meet the admission criteria.
Agreed timescale
for
implementation
End of May
External
support/
assurance
Progress against original timescale
Revised
deadline
(if
required)
Snowdrop escalation area has been
closed and is only being used when
the escalation policy is implemented.
Admission criteria has been agreed
and communicated to staff.
Compliance is monitored and
discussed at daily bed meetings when
escalation beds are open.
Escalation beds were opened w/c 25
August and an audit of adherence to
admission criteria has been
performed. Further action to ensure
adherence to the Escalation Policy all
of the time has been implemented.
The Trust has nominated substantive
members of staff to cover escalation
areas.
An escalation methodology has been
agreed. This includes agreement of
key actions to be completed within 6
hours when escalation areas are open
by 9am in the morning. Action cards
are also being developed for
escalation areas when they are
opened. This includes actions for
nursing staff, pharmacy, catering etc.
23
Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan
Summary of
main concerns
Elective Access
Summary of urgent actions required
Agreed timescale
for
implementation
6.1.1 We will undertake detailed capacity and demand work for
prioritised surgical specialties and implement a robust recovery plan.
End of July
6.1.2 We will obtain expert clinical advice and implementation
support on our plans as part of the partnering arrangements from
Frimley Park Hospitals NHS Foundation Trust.
End of August
6.1.3 We will get external assurance from the NHS Elective Care
Intensive Support Team on the sustainability of our plans.
External
support/
assurance
Frimley Park
Hospital NHS FT
Elective Care
Intensive Support
Team
Progress against original timescale
Revised
deadline
(if
required)
The Trust has undertaken detailed
capacity and demand work and
agreed a recovery plan with
specialities, which is being
implemented.
The Trust has increased capacity
(through additional sessions and
outsourcing) to undertake activity to
reduce the number of patients with
long waits. This has had a significant
impact and the RTT >18 weeks has
reduced by 53% since February 2014.
No patients have breached the 52
week guidelines.
The Trust has agreed an external
review with the NHS Elective Care
Intensive Support Team. The review
took place during August 2014. A
wide range of staff were interviewed
and verbal feedback has been
provided to senior operational staff.
Clinical advice agreed with FPH.
Initial meetings have taken place
between clinicians.
24
Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan
Summary of
main concerns
Elective Access
Summary of urgent actions required
Agreed timescale
for
implementation
6.2.1 We will implement a radiology improvement plan which will
factor in the forecast demand and capacity and enhanced performance
standards to reduce waiting and turnaround times.
End of September
6.2.2 We will review and implement an improved radiology
reporting tool.
End of August
External
support/
assurance
Newton Europe
Ltd
Progress against original timescale
Revised
deadline
(if
required)
A radiology improvement plan
developed, signed off and being
implemented. A visioning event held
to develop the plan.
The department is working towards
achieving a 2 day turnaround,
including reporting, for inpatients for
all modalities.
For outpatients the national standard
for diagnostics is 6 weeks from
referral to exam. The Trust is working
towards a 14 day turnaround,
including reporting.
Performance has improved
significantly. The additional staffing
provided as a result of Spring to
Green is having a positive impact on
performance.
The radiology team is recruiting
additional consultants to deliver 7
day working and there is progress
and momentum to the plan.
25
Heatherwood and Wexham Park Hospitals NHS FT - Our improvement plan
Summary of
main concerns
Elective Access
Summary of urgent actions required
Agreed timescale
for
implementation
6.3.1 We will review options to improve the booking centre and
related functions and implement the preferred option.
End of November
6.3.2 The booking centre will work to agreed key performance
indicators and ten operational service standards.
End of November
External
support/
assurance
Progress against original timescale
Revised
deadline
(if
required)
Executive received an option
appraisal and agreed that a clustered
model of outpatient scheduling
should be adopted.
Operational changes identified and
two phase project developed:1 - devolvement of the booking
centre functions to specialities
2 - work around improvement
themes and supporting projects to
improve each service area.
Management structure set up and
staff in post using the cluster model.
26
Heatherwood and Wexham Park Hospitals NHS FT- How our progress is being monitored and
supported
Agreed timescale for
implementation
Action owner
Progress
Monthly Oversight and Assurance Group chaired by NHS England and attended by
commissioners and Monitor to track delivery of the improvement plan.
Implemented
NHS England
Regular meetings held
Appointment of an Improvement Director (Mark Davies) by Monitor who will
provide expertise to the Trust Board on how to improve our services and check
that we’re meeting our promises to deliver our improvement plan.
Commenced May 2014
Monitor
Mark Davies appointed and
has provided input and
support
Partnership working with Frimley Park Hospitals NHS Foundation Trust as a high
performing provider organisation. This will provide best practice guidance, peer
support and challenge.
Commenced June 2014
Acting Chief Executive
Buddying plan agreed and
being implemented
Agreement and regular monitoring of quality measures at the Quality Programme
Board to demonstrate that the actions are leading to improved quality of care for
patients.
Monthly from end June 2014
Acting Chief Executive
Reports prepared in
accordance with the agreed
timescales
Review and refresh of the Trust’s governance structure to facilitate improved
visibility and reporting from the ward to Board.
End May 2014
Director of Corporate Affairs
Review complete.
Oversight and improvement action
GGI report on operating
effectiveness has taken
place. Report awaited
External specialised communication support engaged. Communication with the
public via NHS choices and development of a communication plan as actions are
implemented.
Monthly
Acting Chief Executive
Comms on progress issued
to all staff by CEO.
Posters printed and
displayed on wards. To be
issued bi-monthly.
Re-inspection.
2015
CQC
To be scheduled
27

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