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  • 1. Project Initiation Document<br />Project Name: National Stroke Pathway Improvement Programme<br />Primary prevention, detection & access into services<br />Transfer of care and supported rehabilitation in the community<br />Project Sponsor: Dr Diane Gray<br />Document Owner: Dr Marianne Vinson<br />Contents<br /> TOC o "2-3" h z t "Heading 1,1" DOCUMENT PURPOSE AND STRUCTURE PAGEREF _Toc234812733 h 4<br />1project Definition PAGEREF _Toc234812734 h 5<br />1.1Background PAGEREF _Toc234812735 h 5<br />1.2Vision PAGEREF _Toc234812736 h 6<br />1.3Objectives PAGEREF _Toc234812737 h 7<br />1.4Scope PAGEREF _Toc234812738 h 7<br />1.5Out of scope PAGEREF _Toc234812739 h 7<br />1.6Deliverables PAGEREF _Toc234812740 h 7<br />1.7Evidence Base PAGEREF _Toc234812741 h 8<br />1.8Interfaces PAGEREF _Toc234812742 h 9<br />1.9Constraints and Assumptions PAGEREF _Toc234812743 h 10<br />1.9.1Schedule Requirements PAGEREF _Toc234812744 h 10<br />1.9.2Project Assumptions PAGEREF _Toc234812745 h 10<br />2OUTLINE business case PAGEREF _Toc234812746 h 12<br />2.1Benefits Analysis PAGEREF _Toc234812747 h 12<br />3Project Organisation PAGEREF _Toc234812748 h 15<br />3.1Key Roles and Project Structure PAGEREF _Toc234812749 h 15<br />4Project PLAN PAGEREF _Toc234812750 h 16<br />4.1Overall Approach PAGEREF _Toc234812751 h 16<br />4.1.1Implementation/Delivery Approach PAGEREF _Toc234812752 h 16<br />4.1.2Measures of Improvement PAGEREF _Toc234812753 h 16<br />4.1.3Change Management Approach PAGEREF _Toc234812754 h 19<br />4.2Communications Plan and Stakeholder Engagement PAGEREF _Toc234812755 h 19<br />4.3Product Plan PAGEREF _Toc234812756 h 19<br />4.4Resource Plan PAGEREF _Toc234812757 h 19<br />4.5Risks and Issues PAGEREF _Toc234812758 h 20<br />4.6Schedule and Key Milestones PAGEREF _Toc234812759 h 20<br />4.7Finance / Budget PAGEREF _Toc234812760 h 20<br />4.8Management Controls and Governance PAGEREF _Toc234812761 h 20<br />5APPENDIX A – Definitions PAGEREF _Toc234812762 h 22<br />6APPENDIX B - About this Document PAGEREF _Toc234812763 h 22<br />6.1Change Control PAGEREF _Toc234812764 h 22<br />6.2Approval Authorities (For Approval Versions Only) PAGEREF _Toc234812765 h 22<br />6.3Document Review Control (For Draft Versions Only) PAGEREF _Toc234812766 h 23<br />6.4Document Cross Reference PAGEREF _Toc234812767 h 23<br />7Appendix c – ‘where are we going’ maps PAGEREF _Toc234812768 h 24<br />8Appendix D - Stroke Project & Reporting Structure PAGEREF _Toc234812770 h 26<br />9Appendix E - involving patients & public in planning & commissioning stroke services PAGEREF _Toc234812771 h 27<br />DOCUMENT PURPOSE AND STRUCTURE<br />The purpose of this document is to define the Stroke Pathway Improvement project and to identify the plan for producing the deliverables. The document is divided into:<br />Definition and Business Case section which deals with what the project is required to deliver, when and why; and<br />Plan and Organisation section which deals with how it is intended to deliver and who will fill key roles.<br />This PID provides a summary of the following more detailed technical and management products for the project:<br />Business case<br />Requirements log;<br />Solution description;<br />Project plan;<br />Risks and issues log<br />Quality plan;<br />The PID supports the initiation of the project and its ongoing management, and may be updated to reflect changes in its definition or plan.<br />project Definition<br />Background<br />Long term conditions affect thousands of people in Milton Keynes, potentially reducing the quality of their lives and their life expectancy, with often missed opportunities for empowering and supporting patients to prevent deteriorations in their health. <br /> <br />There are three main diseases that, between them, are responsible for most of the premature deaths in the city and significant improvements in health would be achieved by preventing these diseases or mollifying their impact on quality of life: death rates from cardiovascular disease, cancer and respiratory disease are higher than they should be in a population like Milton Keynes. <br />Stroke management is included in the wider context of Long Term Management within the strategic plan. Nationally stroke;<br />is the 3rd largest cause of death in the UK<br />accounts for ~11% of all deaths<br />every 5 minutes someone in the UK suffers a stroke <br />there are 110,000 strokes each year – 25% are recurrent<br />is the main cause of adult disability<br />Within Milton Keynes approximately 300 people suffer from a Stroke. <br />Working with providers and clinicians, NHS Milton Keynes is reviewing the care pathways for stroke, and driving improvements in this pathway, using tools such as the Map of Medicine and local clinical and patient champions. This work needs to continue and accelerate to reach greater scale and systematisation of delivery, especially in more deprived areas with greater health needs.<br />The need to review the current stroke management provision within Milton Keynes has gained more impetus, as the Department of Health National Stroke Strategy was published in 2007 and the National Clinical Guideline for Stroke was published in 2008. The National Stroke Strategy clearly sets out quality markers across the whole pathway, which demonstrates not only the level of care that should be provided, but also the quality.<br />The project has been split into two workstreams with the purpose of making the objectives more discrete and enabling a more focused management approach:<br />Primary prevention, early detection and access into services<br />Acute Stroke management including management of TIAs<br />Transfer of care and supported rehabilitation in the community<br />The workstreams will be taken forward by four Task and Finish Groups (TaF), however a TaF has not been established / decided upon to take forward the primary prevention, early detection and access into the service workstream:<br />Patient centred pathway planning TaF<br />Patient / communication information TaF<br />Workforce review / training and education TaF<br />Acute Hospital TaF<br />The Acute Stroke Management workstream is being managed by Milton Keynes Foundation Trust. <br />Therefore this document primarily focuses on the transfer of care and supported rehabilitation in the community. This was decided as a priority in terms of initial focus due to the conclusions that were drawn following a strategic review of community rehabilitation services (see document cross reference for further information). <br />It was concluded that when looking at the Milton Keynes community rehabilitation service in the light of mapping the patient pathway through them, it became apparent that there is no evidence of an appropriate, joined up rehabilitation service in Milton Keynes. This is in relation to all service users and not just stroke victims, as there are no formal pathways through the services<br />Operational performance is disjointed, with inefficiencies across the overall system and people’s needs (particularly older people) not being consistently met. The lack of clear governance for community based rehabilitation services is the root cause for the current problems.<br />This workstream has been accepted onto the National Stroke Improvement Programme which runs for a year.<br />The second phase of the project will focus on the primary prevention, early detection and access into the services workstream. This involves ensuring action is taken to improve public and professional awareness of stroke symptoms, as well as supporting healthier lifestyles, and taking action to tackle vascular checks; for example providing NHS Health Checks for our population aged 40-74 would assist in preventing the onset of this devastating condition.<br />Patients need to reach hospital early, be scanned and thrombolysis commenced to afford a reduction in strokes leading to dependency and the number of bed days reduced, this is being taken forward by the Acute Stroke management workstream. The early signs and symptoms of stroke and TIA are generally not as well known by the general population and may not be taken seriously enough to seek urgent medical care, resulting in many health professionals giving these conditions a lower priority than they should.<br />Vision<br />The overall vision is to<br />Empower patients and encourage control of their own care<br />Understanding their condition and how to control it<br />Knowing how and where to get help<br />Choice in the care they receive<br />Control how they interact with care providers<br />Provide a proactive, responsive and seamless service promoting and supporting all segments of the population:<br />Partnership working across all the agencies providing care<br />Equity of access for the whole population<br />High and consistent standards using the latest evidence-based care<br />Innovative menu of options for delivery of information, education and healthcare interventions<br />Empowered clinicians supporting self-care choices for patients<br />Make best use of NHS resources<br />Maximising access to community-based services supported by expert clinical teams<br />Minimising emergency admissions<br />Options tailored to the needs of the patient<br />Objectives<br />The objective of these projects is to ultimately improve the quality (safety, effectiveness and experience) of Stroke care within Milton Keynes in relation to primary prevention, and rehabilitation. Ensuring the recommendations set out in the National Clinical Guideline for Stroke are met, and the quality markers outlined in the National Stroke Strategy are achieved. The patient, their family and carers will be at the centre of the pathway developments, and will, subsequently ensure that the pathway is patient centred. Therefore the population of Milton Keynes will have better knowledge, awareness, and access, into services in addition those who unfortunately have a stroke receive a seamless transfer of care, excellent rehabilitation services, improved care, and greater support which will ultimately lead to improved medical outcomes, and an improved quality of lifestyle; ensuring that the Vision is achieved and delivered for each patient. Please see appendix C for ‘where we are going’ maps.<br />In order to achieve this there will be a need to clarify which elements are service developments across the whole pathway and which relate to transfer of care from inpatient to community and beyond.<br />Scope<br />This project is to review and develop services for stroke patients and their carers and families only. Pathways related to other related conditions do not form part of the initial scope but may be looked at a later date as a result of improvements in the care of stroke patients. The project will include an examination of pathways and processes related to primary, secondary and social care, in terms of primary prevention, early detection and access into services, as well as transfer of care and supported access to rehabilitation in the community<br />Out of scope<br />While the project in its entirety is being overseen by the Local Implementation Team (LIT), the acute stroke management is being managed by the hospital who will feedback to the LIT on progress. However as the acute stroke aspect spans across primary and secondary care, there will be a certain level of cross over that will be encouraged and fostered. This will be achieved through the formation of a task and finish group that will primarily focus on the acute care pathway and component services with representation from NHS Milton Keynes. While the acute stroke management aspect is mentioned in this document the full project initiation document is in development. <br />Deliverables <br />Across the three main workstreams the project will deliver the following final products. The quality markers referenced to (e.g. QM1) are taken from the National Stroke Strategy.<br />Primary prevention, early detection and access into services<br />Raise awareness – members of the public and health and care staff recognise and identify the main symptoms of stroke and know it should be treated as an emergency (QM1).<br />Managing risk – those at risk of stroke as well as those who have had a stroke are assessed for and given information and advice regarding risk factors and lifestyle management issues (QM2).<br />Assessment – referral to specialists. Ensure immediate referral for appropriately urgent specialist assessment and investigation is considered in all patients presenting with a recent TIA or minor stroke (QM5). <br />Improve detection, treatment and monitoring of blood pressure by ensuring that every GP can identify and treat patients at risk of stroke.<br />A well developed pathway for those who suffer a stroke, which is based on best practice, and has been developed not only in conjunction with the clinical teams but with patients, their carers and families.<br />Transfer of care and supported rehabilitation in the community<br />The implementation of the stroke community team; who will.<br />Support early discharge therefore reduces average length of stay in hospital, and numbers of outliers (patients in wards other than the stroke unit).<br />Reduce the number of therapy handovers following discharge.<br />Work across community and acute sectors seamlessly.<br />Every patient to have a care plan.<br />Signpost patients to the most effective and relative rehabilitation service for them.<br />Support and provide home-based assessment, rehabilitation and support to people who have suffered a stroke recently; for example, in the last six months whether or not hospitalised (QM12, QM14).<br />Operate across a five-day week with a weekend on-call service to ensure easy access for concerns raised by recently discharged patients and their carers. <br />All patients with TIA or minor stroke are followed up one month after the event, within the appropriate care setting (QM6).<br />A pathway that delivers the quality markers routinely, not as an exception or on an ad-hoc basis.<br />A clear service specification for the commissioning of stroke care that is based around patient outcomes, quality markers and supportive financial incentives (potentially with risk sharing).<br />Evidence Base<br />Primary prevention, early detection and access into services - There is evidence that rapid diagnosis of stroke, admission to a specialist stroke unit and immediate brain imaging and use of thrombolysis where indicated can all contribute to better outcomes for patients. For people who have had a TIA, rapid assessment for risk of subsequent stroke allows appropriate treatment to be initiated to reduce the likelihood of stroke occurring (ref NICE clinical guideline 68). <br />Transfer of care and supported rehabilitation in the community- There is emerging clinical evidence regarding the effectiveness of early supported discharge and community stroke rehabilitation schemes – including an average reduction of 8 inpatient bed days. The National Stroke Strategy (NSS) recommends that high quality stroke specialist rehabilitation should be available at all stages of the pathway and advocates early supported discharge.<br />Evidence for the need for this team is supported by:<br />Findings from the local strategic review of community rehabilitation.<br />Gap analysis by MK Stroke LIT (Stroke Strategy Group) against national stroke strategy.<br />Feedback from the Stroke Forum and patient focus groups undertaken in recent years support a community team.<br />The National Stroke Strategy QM12 relates to early supported care in the community it states that delivery with a similar level of intensity to stroke unit care can reduce long-term mortality and institutionalisation rates for up to 50% of patients and lower overall costs.<br />Evidence that co-coordinated community stroke teams prevent people from deteriorating once they return home. <br />The Map of Medicine has been utilised to test the existing pathway, which demonstrates that there are shortfalls and indeed gaps that need to be addressed. Therefore the Map will be applied when developing and agreeing the ideal pathway to ensure that it fits with the evidence based pathway. <br />Interfaces<br />The project will take place in the context of several other projects and service developments including, client interfaces, technical interfaces and the project must deliver. <br />The key interfaces will be with;<br />One local Foundation Trust with 26 designated beds on a stroke unit; hospital management, clinicians, stroke team representatives, Therapists including OT, SALT, Physiotherapists.<br />All of the rehabilitation services<br />Intermediate care team<br />Rapid access intervention team<br />Windsor intermediate care team<br />Orchard House<br />Inpatient Specialist rehabilitation centre at Rayners Hedge Aylesbury<br />Neurological rehabilitation unit based at Bletchley Community Hospital<br />Rehabilitation and falls service<br />Community occupational therapists<br />Speech and language therapists<br />Social work teams<br />Patients and carers<br />Voluntary organisations<br />MK Carers<br />Talkback MK<br />Age Concern<br />LINk MK<br />Different Strokes<br />Stroke Association<br />Clinical specialists – both in primary and secondary care<br />A&E clinicians<br />Ambulance service<br />General practioners<br />Joint commissioners<br />PCT providers<br />South Central Stroke Network<br />National Stroke Improvement Programme<br />Quality MK Programme<br />Service developments should be in agreement with and take a steer from the Stroke LIT and be presented to the Professional Executive Committee for ratification.<br />Constraints and Assumptions<br />The project will be subject to the following constraints:<br />Financial allocations are only certain until the end of 2010-11, therefore any significant change or development as a result of this programme must be in place by then and demonstrating benefits to people and financial return on investment during 2011/12 at the latest.<br />Double running, in terms of time and capacity of release staff that are already over burdened.<br />As the pathway spans across primary, secondary and health and social care cross organisational working will be required, strong working relationships will be essential as well as transparency. <br />Legal restraints for procurement and tenders if applicable.<br />Set within existing and amended specified contracts with the Primary Care Trust provider services and Milton Keynes Hospital Foundation Trust. <br />Schedule Requirements<br />The service specification should be developed with a view to the holistic new stroke pathways being operational during 2010/11 at the latest. The National Stroke Improvement Programme runs for a year, therefore the transfer of care and supported rehabilitation in the community workstream should be completed to meet the deadlines, for initial spend against the 2009/10 operational plan budget in quarter four 2009/10.<br />Project Assumptions<br />The project definition is based upon the following assumptions about the objectives, scope, requirements and benefits. <br />Funding for the transfer of care and supported rehabilitation in the community workstream will be invested in existing infrastructures, and is therefore considered as a service expansion / development, eliminating the need to go out to tender to procure a new service provider. <br />Sufficient resources (financial and workforce) will be available to undertake this programme.<br />Patient and public support for and involvement in the programme will be forthcoming<br />General practice and hospital-based specialists are prepared to work in the different culture that is likely to result from successful completion of the programme, and therefore that they are willing to engage in the programme from the outset<br />Sufficient timely and accurate information (especially financial) is available to allow construction of sensitive yet robust incentives for quality and good patient outcomes.<br />That there is agreement form all stakeholders for the direction of travel and eventual revised pathways.<br />That learning groups established through the National Stroke Improvement Programme projects will benefit local development and provide partners outside Milton Keynes with whom the project team can collaborate and learn from their experiences.<br />OUTLINE business case<br />Benefits Analysis<br />The deliverables and changes being produced by this project deliver benefits as follows.<br />Benefit DescriptionHow benefit arisesMeasurement of SuccessMonitoring method (who when, how ?)Improved primary prevention skills and awareness which will lead to prompt diagnosis and care which will contribute to better outcomesEducating the public and GP practicesIntroducing Vascular Checks and therefore identifying those at riskIncrease in number of the public presenting to GP practices for Stroke or indeed vascular health checkNumber of Vascular Checks completedNumber of people identified as high risk, and therefore have tailored primary prevention plans in placeLinks to Acute and Ambulance data on a quarterly basis – see metric section 4.1.2Appropriately skilled staffThrough effective workforce review and subsequent planning.Ongoing education and training.Staff meet the core competencies detailed in the National FrameworkAppraisals and benchmarking once a year by the providersA well defined pathway that delivers care based on and meets best practice and evidenceReviewing the current pathway, identifying gaps / shortfalls. Developing improvements in line with the Guidance.Benchmark revised pathway against the Stroke National Strategy and the Map of Medicine to ensure compliance and highlight if there are any gapsBenchmark quarterly for the first year, assess the frequency after year oneA pathway that meets the patients, and their families and carers expectations and needsInvolvement of the public, and voluntary organisations in the development of the pathway improvementsIncreased patient, carer and family satisfactionPatient, families and carer satisfaction surveys, patient stories and diaries. This will be an ongoing exercise, to ensure that the patients needs are being metImproved patient outcomes, therefore an improved quality of lifestyle and support to achieve personal goals i.e. training, education or return to workTime spent on the Stroke Unit is appropriate.Prompt care by specialist team.Improved access to services i.e. TIA and ThrombolysisPatient reported outcome measuresNumber of patients that achieved their personal goalsSupport from National ProgrammeIncrease proportion of time spent on the acute stroke unit and reduced average length of stayEarly supported discharge facilitated through the community stroke teamIncrease clinicians confidence in early discharge due to knowledge that the patient is being supported at home with access to specialist advice and interventionWell developed and strong links between the community and acute servicesImproved access and appropriateness to the rehabilitation services Increase in % of time spent on the acute stroke unitReduction in average length of stayAverage % of time spent on the stroke ward, and average length of stay. Quarterly reports, provided by the Acute sectorA responsive rehabilitation service that is based on patients needsIntroduction of the community stroke team to facilitate placement Increased patient satisfactionPatient, families and carers satisfaction surveys, patient stories and diaries. This will be an ongoing exercise, to ensure that the patients needs are being metSeamless transfer of careIntroduction of the community stroke team to facilitate the transition and onward care and supportStrong patient support and informationEducating the staff to ensure they are well informed to signpost and assist patients, their families and carers.The introduction of the community stroke team who will be available 7 days a week to provide support and informationHigher level of information available that is tailored to patients, carers and families needs Patient questionnaires / interviewsImproved continuity of careReduce the number of handovers and improve the clinical handover process Early introduction to the community support teamReduced clinical riskTBCImprove the likelihood of patients being discharged to their usual place of residence and remain longer outside residential careIntroduction of the community support team to facilitate appropriate care and rehabilitation within a home settingHome assessments and equipment provision prior ro discharge including support to carer assessment of their needs and teaching of skills to them to manage the patients needs at home% of people discharged to UPRReferral rate to residential homes due to strokeAcute to provide place of discharge statistics on a quarterly basis.TBCIncrease self careAccess to improved specialist rehabilitation Reduction in co-morbidities, readmission and long term support requirementsTBCEmbedded Quality:MK practicesEvidence based, clinician led, patient driven commissioningGetting it right first time more of the timeBuy-in from key stakeholders from the outsetTBC<br />Project Organisation<br />Key Roles and Project Structure<br />The following key management role assignments apply to this project: <br />NameResourcing OrganisationRoleResponsibilitiesProject Board – Local Implementation Team for StrokeSponsor – Dr Diane GrayProject TeamDr Marianne VinsonNHS Milton KeynesProject LeadTo give a strategic overview with links to NHS Milton Keynes’ corporate requirementsDr Asma AliNHS Milton KeynesProgramme Manager for Long Term ConditionsTo provide an advisory role, as holistic view of all long term condition projects and potential links, lessons learnt. Responsible for tracking the demand management schemes that arise from this project.Lynn KentMilton Keynes CouncilJoint CommissionerTo provide the commissioning link, and an overview of how the funding streams should be managed. Driving the project forward utilising a whole systems approach.Sandra Harrison-MooreMilton Keynes PCT - ProviderStroke Clinical SpecialistTo provide expert knowledge on the provider side, giving real clarity as to what is achievable and realistic. Stephen CaffreyMilton Keynes PCT - ProviderPhysical Disability ServicesTo provide expert knowledge on the provider side, giving real clarity as to what is achievable and realistic.Claire McGillycuddyNHS Milton KeynesProject ManagerTo drive and track progress of the workstreams to ensure the project board, the National Stroke Improvement Programme, and the NHS Milton Keynes Programme Board receive the information they require to monitor progress against the overall project objectives<br />Project PLAN<br />This section of the PID states how and when the project’s objectives will be achieved and requirements delivered, showing the major products, activities and resources required. The Plan identifies the overall approach and drills down into various key aspects of this such as the technical processes to be used, key management stages and other the management controls. This plan section is supported by more detailed documentation as referenced.<br />The plan will be used as a baseline against which to monitor progress and cost, stage by stage.<br />Overall Approach<br />Implementation/Delivery Approach<br />This project will be managed broadly using PRINCE2 methodology in that it will have a defined beginning, middle and end. As described, the project has been split into two workstreams with the purpose of making the objectives more discrete and enabling a more focused management approach:<br />Primary prevention, early detection and access into services<br />Acute Stroke Management and TIA Management<br />Transfer of care and supported rehabilitation in the community<br />A Project Manager will be assigned to monitor the progress of the project; more specifically with the first and third workstream. This role should not just be about scoping and reporting on any issues but should identify the way forward and should instigate service developments and changes with the agreement of Stroke LIT. <br />The Acute Management workstream will be managed by MKFH, but will report to the Stroke LIT in terms of progress. However as the acute stroke aspect spans across primary and secondary care, there will be a certain level of cross over that will be encouraged and fostered. This will be achieved through the formation of a task and finish group that will primarily focus on the acute with representation from the PCT.<br />See appendix D for Project Structure and reporting.<br />Measures of Improvement<br />The following measures will be utilised to assess the success of the final product and ultimately the success of the project. <br />The targets will not be achieved immediately, as there will be an implementation settling down period to be expected, and time required for the community team to start to take effect. Therefore the expectation is that a through the first year of start up a review of the data will be taken and an assessment made and then again at the end of the year. Where there is no current baseline, one needs be agreed or assumed, or agreement that this information is collected over a three month time period and strapulated to gain a full year effect to use as a baseline.<br />The following table details the measures that will be used for the Primary prevention, Detection & Access workstream:<br />MeasureBaselineTarget% of patients assessed using stratification tool (e.g. ABCD2 scoring) to determine the patients risk groupTBC% of patients admitted to A&E within 2 hours from onset of symptoms, via ambulance service (A&E data)TBCAverage time of stroke to admissionTBCEducation and training across the pathwayWidespread use of the scoring tool for TIA risk analysis to assess requirement for early referral to hospitalTBCDependent on caseloadNumber of health checks completedTBC100%<br />The following table details the measures that will be used for the Transfer of care and supported rehabiliation workstream:<br />MeasureBaselineTarget% time spent by hospital physiotherapists and occupational therapists on the Acute Stroke UnitIncreased staff satisfactionAverage number of hours of therapy per patient% discharged to independent living from Acute and Rehabilitation servicesReduction in referrals to residential homes after stroke (to include a specific lead time?)% of patients with care plans% of “correctly” completed referrals (handover information) from the MDT to the community% of patient, families and or carers involved in the care planning% of carers aware of what support is available on discharge% of carers accessing support services after discharge – by a certain number of weeksAverage length of stay of all patients27.4118.41 Average length of stay of those discharged to usual place of residence% of admission spent on the Acute Stroke UnitPatient satisfaction with the their LOS% of patients with home visits before discharge% of patients with a record of patient led goals% of carers with assessment of needs% of carers reporting teaching skills to manage patients needs at home% of patients with a record of 6 week and 6 month assessments% of staff that meet the core competencies as detailed in the National FrameworkIncrease in patient, family and carer satisfactionReduction in co-morbiditiesReduction in preventable re-admissionsReduction in appropriate long term support requirementsReduction in the number of therapy handovers following dischargeNumber of patients with TIA or minor stroke who are followed up when after the eventWhereWithin one month and in the most appropriate care setting<br />Change Management Approach<br />There is a high level of commitment from both NHS Milton Keynes and Milton Keynes Hospital Foundation Trust. However it is expected that the barriers to change could arise as follows:<br />BarrierActions to MitigateThe pace of change may not be sufficient to hold the stakeholders attention, and therefore they become disengagedEnsure that the project plan is realistic and share the timescales with stakeholders therefore setting out the expectations and timeframes. In addition they will be kept up to date of progress and any slippage. Timeframes should be realistic and achievable and set at a reasonable paceImplementing change at grass root level could be met with resistance, as the staff involved are not only fatigued with change but also busy with delivering the day to day careEarly engagement is key, ensure that the individuals feel included and part of the decision making process. A communication strategy should be robust and detail not only initial engagement but ongoingPatient engagement, in terms of level of time commitment needed, and therefore keeping them engaged The mitigating actions to address this will be included in the stakeholder engagement strategy, which reflects and takes into consideration the constraints in not only the engagement issue, but the language issues. Patients should be briefed ahead of meetings, and an assessment made in terms of whether it is mutually beneficial for them to attend etc.<br />Communications Plan and Stakeholder Engagement<br />A user involvement strategy has been developed for specifically for this project, in relation to communication and stakeholder engagement see appendix E. <br />Please see appendix D for the Project Structure and reporting. Each group has detailed terms of reference, which can be accessed for review.<br />Product Plan<br />The detailed project plan in appendix F reflects the relationships between the Deliverables and Key Products to be produced by the project.<br />Resource Plan<br />The human resource requirements for the project are as follows:<br />The Project Board (Stroke LIT) and Project Team membership needs to have sufficient decision making authority to support the progress of the project at various stages or to halt the project if required.<br />The skills of the TaF groups need to reflect the requirements of the project and the make up of each group will be determined by the project manager with the TaF chair.<br />Risks and Issues<br />An initial risk assessment has indicated the following potential risks to the success of the project. However a rolling / active risk log will be kept and managed for each of the workstreams.<br />Red = High RiskAmber = Medium riskGreen = Low risk<br />RiskRAGActions to MitigateLack of robust information / data to assist the decision making processStock take of data needed vs what is available, develop action plan to address not only the gaps but the quality of the data. The Acute could develop their processes to quickly or too slowly to respondWork closely with the acute team to ensure projects are kept cohesive and progress is sharedStaff recruitment and retention. Training and specialist skillsFinancial spend against allocated moneyFunding to implement the ideal solution is not available Looking at skill mix, and existing teams to build on current resourcesEngagement with provider services Engagement and buy in has been gained from the beginning of the project, and is further strengthened through the multi disciplinary approach of the LIT. Where barriers are faced a pragmatic approach will be taken in terms of resolution. NHS MK are represented at the Acute project meetings.<br />Schedule and Key Milestones<br />A detailed schedule is documented in the detailed project plan and Gantt chart, located in appendix F. <br />Finance / Budget<br />The budgetary allocation for the project are as follows.<br />Primary prevention, early detection and access into services<br />£5k year 1 and £15k year 2<br />Transfer of care and supported rehabilitation in the community<br />£50k year 1 and £272K year 2<br />Management Controls and Governance<br />The approach to management controls that will be applied to this project will be as defined by the standard Milton Keynes PCT Project Control framework. <br />This approach will include:<br />The establishment of the TaFs and agreed reporting mechanisms.<br />Meeting schedules that are published in advance with agendas and minutes produced for each meeting.<br />A file on the G drive will be set up for storage. Documents will be sent out by email to those who don’t have access. <br />Monthly RAG highlight reports produced and sent to the LIT on a monthly basis, to ensure progress can be tracked and monitored.<br />APPENDIX A – Definitions<br />AbbreviationDefinitionLITLocal Implementation TeamTIATransient ischemic attackQMQuality MarkerALOSAverage Length of StayMKMilton KeynesLINkLocal Involvement NetworkA&EAccident & EmergencyRAGRed Amber GreenTaFTask and Finish MDTMulti-Disciplinary TeamABCD2AgeBlood PressureClinical FeaturesDuration of TIA symptoms2 – presence of diabetes<br />APPENDIX B - About this Document<br />Change Control<br />Version:Date:Author(s):Summary of Changes:Draft1st April 2009Sent for comments from key stakeholders<br />Approval Authorities (For Approval Versions Only)<br />Name:Position:Organisation:Signature:Date:<br />Document Review Control (For Draft Versions Only)<br />Review Comments by:<Date by which comments are due>Review Comments to:<Either the Author or their nominated representative who is organising the document review><br />Mandatory Review Authorities<Individuals/stakeholders who the author believes are mandated to respond>NameRoleOptional Review / Issued for Information<Those chosen to review the material who might have an interest but are not necessarily stakeholders><br />Document Cross Reference<br />Document Ref:Document Title:Version:Date:Source:Strategic Service Review of Milton Keynes Community Rehabilitation Services FinalMarch 2009Local Implementation Team terms of Reference<br />*Unless a specific version/date is referred to above, reference should be made to the current approved versions of the documents.<br />Appendix c – ‘where are we going’ maps<br />Appendix D - Stroke Project & Reporting Structure <br />Appendix E - involving patients & public in planning & commissioning stroke services<br />Assess needs – fact finding Get information We intend to obtain information from Local communities Users and local interest groups Relevant health professionals Relevant voluntary organisations LINks Review current service provision – looking at where the gaps are and finding out the local issues We have: Undertaken a stakeholder analysis Identified the right people to involve, people who have not been involved before We intend to:Use innovative ways of reaching out to people who are ‘seldom heard groups’Give information Where appropriate we have disseminated information on the ‘givens’ - what we have been told to deliver and why, and provide information on what can be influenced and how people will be able to get involved. Get information Forums for debate We have: Used workshops to gather patient and public views on the gaps and issues within the current service provision.Involved relevant organisations, networks and partnerships Work with professionals in primary, secondary and social care Work with voluntary organizationsWe intend to:Use a range of techniques such as, informal discussions, structured interviews, feedback forms, case studies and patient’s stories to get feedback (gather experiences) to find out what’s working well or not so well within the ‘new’ pathwayReview user’s experiences using existing information from the PCT and local NHS trusts’ and NHS foundation trust’s complaints and PALS Decide priorities – plan the provision of services Forums for debate Participation We have: Arranged opportunities to discuss priorities and/or for users to get involved in agreeing to priorities Recruited patient and public members to sit on the LIT and TaFs to enrich the process and give advice Re/design services Give information We have:: Kept people informed throughout the process, through shadow LITs whereby the agenda items and documents are circulated and walked therough Forums for debate Participation Hold forums for debate and provide opportunities for user participation Involve specialist teams and medical and clinical teams Identify the trigger points for wider involvement. Consult on options that have been developed with users - building on the initial workshop to share the ‘vision’ to a wider audience to gain views.Manage demand and ensure appropriate access to careGet information We intend to use a range of techniques to get information on patient’s experiences, including those who are ‘easy to overlook’<br />