Seven Day Services Regional Sharing and Learning Event - North Region, 15 September 2017

Meeting the challenge of
delivering 7 day therapy services
at Aintree
Angela McAvoy - Therapies Clinical Business Manager
Patricia Elmore - Clinical Lead Therapist

Who’s Already Taken the 7/7 Plunge?
• First Response Therapies
• Aintree at Home
• Stroke
• Orthopaedics
7/7
• Major Trauma
6/7
• General Medicine/Surgery
• DME
• Out-patients and clinics (all)
• Stroke ESD
5/7

CULTURE HR issues INTERNAL
infrastructure
EXTERNAL
infrastructure
4 Main Challenges

Examples
Resistance to change: “I didn’t come into therapies to work week
ends!”
“ It’s the only time I spend with my kids and
husband”
Lack of evidence of
success
“How do you know working week ends will
help?”
“Patients don’t want treatment every day”
Historical cynicism “ It won’t quicken discharges as no one else is
working over the week end”
Fear of failure
Feeling under valued in
5/5
“ It wont improve patient flow and we (therapy)
are always getting the blame for delaying
discharges”
“Why should we work over week ends when all
the others don’t?”
CULTURE

Examples
At the time many existing
staff not on 7/7 contracts
Covering B Hols and holiday
periods in 5/5: limited
numbers as voluntary basis,
difficult to co-ordinate
activity to make any real
difference
Impact of “on call” duties at
night covering 7/7 services
as rest period required
Mindful of staff moving
between 5/5 and 7/7
rotations (excess hours)
Job descriptions did not
meet service needs: car
driver
Maintaining safe service if
sickness at week ends with
reduced staff
HR Issues

Examples Not everyone else is 7/7 Reduces
the impact…….
Access to specialist
nursing staff
Providing therapy leadership
7/7
Dr cover at week ends
TTO’s
Managing the unexpected:
Covering Sickness on
reduced staffing
Internal Infrastructure

External Infrastructure
Doesn’t stop us delivering our service
but it can impact on patient discharges and experience
Acute
MSW’s
Equipment
stores
3 different
CCG’s
Different
resources
available
Community
Therapy
Community
MSW’s

• Deep down everyone knows 7/7 is better than
5/5!
• Deep down everyone is patient focussed and
do want the best for patients!
• Follow formal policies and procedures for
consultation and negotiation process with
Unions
But……
Engage with the staff +++++++++++++
Culture
HR Issues
External
Infra
structure
Internal
Infra
structure

• Be realistic on time scales: do it right, don’t
skimp on process: save time and stress for
all in the long term
• Invest the time and listen
• Face to face with management, unions and
grass roots : met with individual teams, one
to ones with individuals
• Sell the benefits to patients: LOS,
deconditioning, HAP etc
• Patient stories and feedback are better than
figures, compliments, FFT, celebrate
successes
Culture
HR Issues
External
Infra
structure
Internal
infra
structure

• Sell the benefits for staff: Champions: staff that
have been 5/7 and now 7/7
 The joys of M&S mid week!
 Long week ends without A/L
 Save up B/hol A/L to use when you want to
• Manage staff concerns e.g myth busting,
engagement sessions, Q&A on I drive
• Use engagement to hear other ideas/ suggestions:
don’t just focus on the staff issue, support
permission culture, learning environment
Culture
HR Issues
Internal
infra
structure
External
infra
structure

• Introduced new contracts and job descriptions: 7/7
& driving: 90% now on these
• Choose area carefully: early adopters AED/ A@H
• We rotate existing and all new staff between 5/5
and 7/7: bottom up influence
• Caution though: plan rotations with staff moving
between 7/7 and 5/5
Culture
HR issues Internal
infra
structure
External
Infra
structure

Principles we used were the same whether we were expanding
an existing service, or developing a new service
• Know the key drivers, collect appropriate evidence to back the
need
• Choose your outcomes:
Hard - Expand AED: Number of patients admitted at week ends
for therapy assessment on Monday
- Develop new A@H: Number of patients waiting in hospital
over week end as no therapy follow up available/ Number of
patients ready for discharge but waiting on a POC
Soft - patient stories/ videos, satisfaction, utilising complaints
Harness the power of patients!
Internal
Infra
structure
External
infrastructure
HR issues
Culture

• Introduced service one at a time, staged
approach
• PDSA approach to learn and imbed in
next area
• Utilising resource differently (additional
2/7 staffing not going to happen!!)
• Moving towards a patient focussed v
discipline approach
• Working with the staff on ways of working:
flexibility of roles, therapy assessment
(not OT/PT Ax), TA’s not OTA/PTA
Internal
Infra
structure
External
infra
structure
HR issues
Culture

• Strong leadership vital: Just do it,
permission to fail/ learn… no blame
• Persistence and perseverance: winter
pressures funding eventually became
substantive
• Champions at the top of the Trust
• Internal Stakeholders: no point having a
7/7 service if no one knows to refer to it!
Internal
Infra
structure
External
infra
structure
HR issues
Culture

• Engage with external stakeholders: get them on
board with the benefits
A@H: GP’s, Commissioners , MSW’s, show case events
• Know what you can’t change
• Know what you can influence: acute MSW’s
working at week ends, educate patients and
families
• Change what you can:quick access to
equipment at week ends resolved with on site
equipment store
Internal
Infrastructure
External
infrastructure
HR issues
Culture

Next Steps
• Always asked to deliver 7/7 in areas of 5/7
(Bank holidays/ week ends)
• Additional temporary resources: Locums/
Volunteers……
• Opportunities to trial something different,
and build on existing flexibility within
therapies
• Consider best use productivity/ geography
for best outcomes

Next Steps
Ideas include:-
Criteria led week end discharges
Small discharge team in at
weekends(existing staff who get days off in
the week)
Extending evenings in AED
Look at different ways to deliver 7/7
Trust your instincts…. Leap of faith
Just do it, trial it, PDSA

angela.mcavoy@aintree.nhs.uk
patricia.elmore@aintree.nhs.uk

Better Emergency Surgical Care:
The Huddersfield Model
Mr Arin Saha, Mr Brian Dobbins
on behalf of the Department of General Surgery
Calderdale and Huddersfield NHS Foundation Trust
7DS Event, Manchester, 15 September 2017

A bit about us…
10 consultants
6 Colorectal
4 Upper GI / Bariatric
All on full acute rota
150-180 emergency laparotomies per year
25-29 acute admissions per day
Accredited colorectal cancer and NHS bariatric
units
Trainees from Yorkshire and the Humber Deanery

Aims of today
 To describe:
 The way we were
 Our Mission Statement
 Why we changed
 How we changed
 The way we are now
 What we’ve learnt and what we can teach

The way we were
Week Mon Tues Wed Thur Fri Sat Sun
1 48 hours on call CEPOD Elective Elective
2 Elective Elective Elective Elective Elective
4 Elective Elective Elective Elective 72 hours on call
5 CEPOD Elective 48 hours on call CEPOD

How we changed – our ‘Mission Statement’
Minimum standards
 Two complete consultant ward rounds of all acute
patients every day (8AM, 6-7PM)
 8PM consultant-to-consultant face-to-face handover of all
acute patients (day and night junior teams present)
 Patients with NEWS > 5 within the department discussed
 8AM and 8PM CEPOD theatre planning meeting
 Difficult patients reviewed together (UGI/LGI split)

How we changed – our ‘Mission Statement’
Minimum standards
 Consultant present at all laparotomies
 Investigations ordered when you need them
 All patients risk assessed
 HDU/ITU for any predicted mortality >5/10%
 Surgery performed when needed through the
night – 7 days a week
 Aim to satisfy minimum standards for sepsis
(source control)

The way we are now
Week Mon Tues Wed Thur Fri Sat Sun
1 Day Day Day CEPOD Night Night Night
2 Night Night Night Night Rest
3 Rest Rest Rest Elective Elective
6 Elective Elective Elective Day Day Day Day
7 CEPOD Post Take Elective Elective Elective

Before rota
change
After rota change P
Time to see consultant
(hours, median, IQR)
18.25 (8.4 – 78.4) 5.3 (2 – 10.6) <0.001
Time from decision to
operate to surgery
(hours, median, IQR)
4.4 (1.7 – 18.6) 2.8 (1.7 – 7.7) 0.048
Length of stay
(days, median, IQR)
17 (9 – 29) 13 (7 – 21) 0.036
Days on ITU
(days, median, IQR)
0 (0-2) 0 (0-1) NS
Days on HDU
(days, median IQR)
0 (0-0) 0 (0-0) NS
Results

Before rota change After rota change P
Grade of decision maker 96% 97% NS
Consultant Surgeon in
theatre
76% 91% 0.005
Consultant anaesthetist
in theatre
83% 76% NS
HDU/ITU post-op 41% 31% 0.068
Results

2013/2014
(Pre rota change)
2015/2016
(Post rota change)
Predicted mortality >5% 55% 54%
Return to theatre 3% 3%
Unplanned move to HDU/ITU 7% <1%
Post-operative 30 day death 12% 6.4% (P<0.001)
Observed:Expected Mortality
Ratio (SMR)
0.78 0.51 (P<0.001)
National average (NELA) 15% 11%
Results

Taking things further…
 Monthly M&M meetings
 Development of Mortality Surveillance Group
 Engaging with complaints and feedback
 Talking to other departments
 Talking to other hospitals
 Not accepting that ‘this is the way things are’

Results – unplanned effects
 Increase in acute laparoscopic cholecystectomy rate
 ‘Change in culture’
 Abscesses and appendixes are getting done
sooner
 Greater proportion of CEPOD theatre time used
 Greater consultant ‘presence’ drives things along

How we changed – what we didn’t have
 More money
 More consultants
 More infrastructure

How we changed – what we had
 A strong team ethic and a commitment to
excellent patient care
 Excellent communication and collaboration with
management
 A change in culture – we are all emergency
surgeons
 A clear mission statement

Why is this important?
 Every hospital takes acute admissions
 The greatest gains and the greatest costs are
associated with acutes
 We should demand the same standards of safety
and excellence for emergencies that we do from the
electives
 A single initiative is not enough
 A change in culture at CHFT has halved
mortality

We’re not perfect…
 Training
 Maintaining these standards
 Effect on colleagues

…but we’re trying to be!
 Genuine engagement with colleagues
 Regular analysis of data
 Open lines of communications
 Robust morbidity and mortality
reviews

What happened next…
National recognition of improvements in outcome

Valuestream #5
“I’ve started so I’ll finish – Eliminating Interruptions: A Service
Improvement Approach to achieve the 14 hour standard”

Current State
Future State
VS#5 - Time to First Consultant Review - High Level Value Stream Map
Seven Day Services –Time to First Consultant Review – Acute Medicine
Start: Patient admission/arrival on Acute Floor Finished: Start of First Consultant Review
Patient Arrival Clerking in
CSW/RN
Junior Dr
Review
First
Consultant
Review
00:17:00 03:43:00 18:18:00
00:04:00 00:20:00 00:15:00
CT: 00:04:00 CT: 00:20:00 CT: 00:15:00 CT: Lead Time 22:57:00
PT: 00:04:00 PT: 00:17:00 PT: 00:12:00 PT: Processing Time 00:33:00
COT: 00:00:00 COT: 00:00:00 COT: 00:00:00 COT: Change Over Time 00:00:00
VA: 00:00:00 VA: 00:10:00 VA: 00:07:30 VA: Value Added (VA) Time 00:17:30
NVA: 00:04:00 NVA: 00:10:00 NVA: 00:07:30 NVA:Non Value Added (NVA) Time 00:21:30
%VA: 0% %VA: 50% %VA: 50% %VA: % VA 1%
% NVA 2%
Patient arrives at the
Reception Desk of
the Ward.
Meet and greet.
Moved to bed or
designated corridor
position
Wipe Board Update
Obs and Swabs
Clinical Nurse
Review
Risk Assessment
Patient Paperwork
Initial Ward Clinical
Review
Patient Care Plan
Further test
requests
Consultant arrives
for the First
Consultant Review
71
Consultant
Review
Admissions
Process
Consultant
Review
Meet and Greet by
appropriate
consultant
Review diagnostic
testing
Produce a working
diagnosis and plan
Patient clinical
admission
supported by mutli-
disciplinary team
Clinical prioritisation for
patients review .
Ward Rounding
Allocation of most
appropriate consultant
for patient need
Seven Day Services –Time to First Consultant Review – Acute Medicine
Start: Patient Admission/arrival on Acute Floor Finished: Start of First Consultant Review

Rapid Process Improvement Workshop
• 6 weeks planning:
– structured focus and targets, senior leadership
support
• 1 week event:
– Learning of Lean theory for RPIW team
– Representation of all roles involved
– Improvement ideas come from the team
– Quick changes tested & implemented immediately
• Follow-up to embed and spread successful ideas
– Standardized Report Outs at 30, 60 and 90 days.

Interruptions in Flow
Dr in Training is interrupted every 00:08:51
L

Interruptions in Flow
Category
No. of
occurrences
Patient 20
General Advice 12
Prescribing 9
Administration 3
Bleep Holder 3
Priority - URGENT 1
Test Results 1
TOTAL 49

Targets
Metric Baseline Target
1
Lead Time
Medical Clerking: clinical record
removed until returned following
77mins
18secs
45mins
4
Quality (defects)
Number of times the patient is not
ready
4/5 = 80% 0%
5
Quality (defects)
Number of times the clinician is
interrupted
49/5 =
10 per pt
0 per pt
7
Environmental, Health & Safety (5S)
The Ops Room on J27 & J29
Level 1 Level4

Changes we made
Issue Action Status
Unclear roles and
responsibilities
• Staffing board
• Process board
Medical notes not always
available
• Priority list
• Kanban cards
Patient not always available
for clerking
• Short discussion with patient
prior to clerking
Repetition of information
during clerking e.g.
medications/patient history
• Making better use of
information in PPM
• MDT sharing knowledge
Disorganised clinical areas • 5S J27 and J29
Unsure of benefits of an
Integrated Clinical
assessment team
• Trial an integrated clinical
assessment team on 3
Wednesday afternoons

Successful Initiatives – Improving information

Multidisciplinary Clerking Team
We trialled an MDT team consisting of Consultant, Junior Doctor/AP,
Pharmacy, EDAT and a Nurse.

Target Progress Report
Team Name: Acute & Elderly Medicine Date: 26th July – 28th August 2017
Department: Acute Floor, Wards J27 & J29 Takt Time: J27: 1440min/19=76mins J29: 1440min/14=103min
Product/Process Summary: Interruptions in the medical
clerking process
Team Leader: Helen Gilbert Workshop Leader: Jimmy Parvin
Process Owner: Beverly Brown & Adam Cole
#
Metric (units of measurement) Baseline
Target
Final
30 days
28/07/17
60 days
25/08/17
1
Lead Time
Time measured in minutes or seconds as appropriate to the process
being studied
From: Medical record removed from trolley for Medical
Clerking
To: Medical record returned to trolley following Medical
Clerking
77mins
18secs
45mins
Simulated
48mins
20secs
48Mins
32 Secs
43 Mins 16
Secs
(Including
frailty)
2
Work in Process (WIP)
Counted number of work within the process at a specific point in
time (document time) 15:41 Thurs 15th June 17
3 1 1 1
3
Standard Work In Process (SWIP)
Lead time divided by takt time. Percent target should be the same
as lead time target. Must be a WHOLE number. J27 / J29
1/1 1/1 1 1/1 1/1
4
Quality (defects)(%)
Defects measured as a percent of total products/services produced.
You must include specific data (e.g., “3 defects of 12 products) in
this box.
Number of times the patient is not ready for their Medical
Clerking interview
4/5 = 80% 0%
Simulated
0/1
0%
1/12 =
8%
0/5 = 0%
5
Quality (defects)(%)
Defects measured as a percent of total products/services produced.
You must include specific data (e.g., “3 defects of 12 products) in
this box.
Number of times the clinician is interrupted during the
Medical Clerking Process
49/5 =
10 per pt
0 per pt
Simulated
0 per pt
39/12 =
3.25 per pt
7/5 = 1.4
per pt
6
Productivity Gain
Productivity Gain as calculated in FTE’s using Option B.
Time spent completing Medical Clerking except time spent
with the patient during their Review (Cycle boxes 1,3&4)
J27:2.9
J29:2.14
FTE
J27:1.69
J29:1.25
FTE
J27:1.3
J29:0.96
FTE
NA NA
7
Environmental, Health & Safety (5S)
Measured as a Level from 1 to 5 (there is no level 0), as described
in the 5S Audit Tool.
The Ops Room on J27 & J29
Level 1 Level4 Level 1 Level 1 Level 3

Interruptions
Previously: Doctor in training interrupted every 8 mins 51 secs
Now: Doctor in training interrupted every 30 mins

Next steps
• Further embed current changes on pilot wards
• Spread ideas to other Acute Floor Wards
• Create protected space clerking doctor
• Break down interruptions into necessary and unnecessary
for next report out
• Use 5S concept with wider ward team to increase
ownership
• Improve communication with Junior Doctors and
Advanced Practitioners so they understand why we are
doing it - Particularly hard with Junior Doctor turnover.
• Extend the Clinical Assessment team trial sessions

Key Learning
• Sharing information is a respectful behaviour.
• Difficult to ensure staff don’t revert back to old methods on a
busy acute floor – someone needs to take ownership to
embed changes. For us this was the senior sisters.
• Continual conversation with those on the ‘shop floor’ is a
must to ensure buy in
• Create dedicated time for ward teams use the 5S concept.
Ensure clear expectation and local ownership.
• Evolving ideas and keeping momentum needs the original
RPIW team to meet regularly.
• Make extra time for re-measures of selected metrics.

Leadership to Support
7 Day Services
Dr Chris Dipper
Clinical Director Medicine

The Standards
Standard 2: Time to first consultant review
(14 hours from admission)
Standard 5: Access to diagnostics
Standard 6: Access to consultant-directed
interventions
Standard 8: On-going review
(Twice daily in certain areas (ICU, CCU, Acute
Admissions, Daily in other areas)

What have we done since April 2016?
• Established a 7 Day Services Steering Group
membership includes 3 Executive Directors
• Established a 7 Day Services Delivery Group
tasked with identifying solutions to achieve
compliance
Membership: I/T Director, clinicians, support
services…
• Clinical leaders identified and engaged in programme
of work: each Directorate has a lead

Background
• From March 2016 audit – of 280 case notes -
over 100 from Medical Assessment Suite
– Compliance low for twice daily reviews (but not all
patients require twice daily reviews!)
• An electronic solution was suggested
– I/T team, with AS consultants designed the system
Why an Electronic Review Board in
Assessment Suite?

• Main route of admission for medical patients
admitted as an emergency to Newcastle Hospitals
• 50 bedded unit
• 60-80 emergency admissions a day
• Consultant presence 0800-2200, 7 days a week
with 35 consultants providing input
RVI Acute Admissions Unit

Assessment Suite – Electronic Review Board
•Refocused consultant activity
•Identify which patients need to be reviewed by length of time in hospital
•Ongoing clinical review based on clinical need identified by consultants
Purpose of the system?
•Developed July and August 2016
•Implemented 30th August 2016
When was it introduced?
•I/T design
•Chris Gibbins- Clinical lead for AS reviewed options and advised on development with support
from Clinical Director Medicine
•Shown at Clinical Governance meetings , emails, face to face discussions
•Floor walkers on Assessment Suite from I/T for one week
What resource/workforce
required for
implementation and
support?
•Improved the compliance with 14 hour standard and ongoing reviews
•Consultant feedback- helps to inform where to start ward rounds, a good way of handing over
patients, those that require a second review get one
•Likely patient flow improvements
What were the benefits?

Time to Review Column Colour
0 – 1 Hours Red
1 – 2 Hours Amber
2 – 14 Hours Green
Over 14 Hours White
N/A (Review Not Applicable) White

• Another IT system
• “I go where I’m told to”
• “Most patients don’t need to be seen twice a
day”
• Does it matter whether they are seen within
14 hours?
Challenges to Implementation

• Clinical engagement with IT team
• Consultants leading the acute take
• Feeling of control and having a safety net
• You don’t always need evidence that
something is better – sometimes it just is!
• Clearly identified patients requiring review
and provided a useful, defined and clear role
for the Acute Medicine SpR
What worked well

• Roll out a similar, adapted software for use on the
basewards, particularly to assess weekend working
• Make it useful to clinicians using it as well as an
audit/monitoring tool
• Electronic handover incorporated
• Simple colour coded “Stable, Watch, Unstable,
Discharging” descriptors
• Incorporate EDD
• Audit can be done with the click of a button, rather
than searching through hundreds of casenotes
Future Plans

7 day working at Northumbria
Improving patient care and staff experience
Putting patients first
Making 7 Day Diagnostics work
Dr Jeremy Rushmer, Executive Medical Director
Dr Rahul Dharmadhikari, Business Unit Director
Clinical Support and Cancer Services
Jeremy.Rushmer@northumbria-healthcare.nhs.uk
@JeremyRushmer

500,300 pop 2,500 sq ml 85/15%
85 ml A1 65:35 Em : El
9,300 staff 500 Docs +/-1,000 beds
9 I/P sites £ 480 mill 83, 84
9/13 Adult SS
Northumbria’s numbers…

Culture
Behaviour
Workforce
Incentives
Geography , history , economics & politics
Influencing clinical change

3 into 1, 1998
Financial & service pressures
Clinically led
FT, 2006
Business units
= Clinically led control with responsibility &
accountability
History

Open & honest
“This is the way we do business”
No back door deals
Compact of behaviours
Clinical leadership development
Health as a business
CPG ‘ a safe place’
Consultant recruitment
Culture

Used as drivers for every change
Recognition of variance
Commitment to act
Safety panels
Quality panels
Patient safety Fridays
Safety & quality

Bringing Sites together using ‘Standard ways’ = the
Northumbria way
Handover + SBAR
Shared ownership in TEAMs eg post-op care
Fast track hip and knee
POW = POD = PO ½ D
Ambulatory care
New ways of working

O&G ( 3 to 1 ),Surgery , Ortho , ITU Endoscopy Rota
Extended working day 8am to 8pm
On call = work
Sole commitment to emergency stream and theatres
Rolling rounds
Rapid assessment clinics
Every patient seen every day
Medicine
Foundation programme pilot
Single door point of entry
Consultant led acute care stream
Develop H@N teams – night nurse practitioners
All clinically driven on safety and quality
7/7 2004: On 21/2 SITES
,

Safety & quality consistent
Patient satisfaction
Complaints
‘How much easier is it to work with consultant
colleagues?”
Bed use
Elective capacity / diagnostics
Teaching & training
Team spirit
Benefits

Collectiveness & pride
Doing the best for our patients
A better way of working
Better support of trainees
No surprises
YCTM IPOAU
What will it mean for me?
On call = work
Diminishing private practice
+ / -

Advanced neonatal nurse practitioners, level II
Night nurse & nurse practitioners
Advanced critical care practitioners
Surgeons assistants
Specialist nurses
Clinical pharmacists
Co-located out of hours service
GP clinical directors 2013
Grow a new workforce

What to do if you can’t merge rotas onto on site
……….sort your emergency diagnostics

The Driver
Royal College of Radiologists (Standards for
providing a 24-hour diagnostic radiology
service): “Clinical radiology is now so central
to the management of so many patients
that its delivery can no longer be confined
to ‘office hours’”

- Year on Year increasing demand.
• Increase in absolute patient numbers
• more reliance on Radiology i.e more scans per
patient.
• Increasing risk averseness.
- National / International shortage of Radiology
workforce.
- Geography – Making recruitment difficult.
The Challenge

• Unlikely to be able to recruit many more Radiologists,
Sonographers or Radiographers.
• Will need to innovate and work differently.
• Reconfigure/Re-prioritise/Up skill available staff.
• Have better understanding and communication with
referrers.
• Supervise trainees better and help them to be more
independent and productive.
The Realisation

• Open & honest discussion with the team
• Focussed patient centred approach
• Laying down clear goals and boundaries
• Empowerment of the team
• Support from senior management - alignment of vision
• Room for negotiation and recognition of apprehension
within the team.
The Solution - Culture change

• Separation of Acute and Chronic care and refocusing of
priorities.
• Availability of senior Clinicians for discussion and
decision making.
• Better understanding and appreciation between the
Radiology and clinical teams.
• Attempt to recruit more Radiologists/Sonographers
locally, nationally and Internationally.
• Up Skill Radiographers and Sonographers.
The Solution

• Presence of Consultant Radiologist Onsite the
Northumbria 12 hrs a day – 365 days a year.
• Presence of Sonographers 12 hrs a day 365 days a
week.
• 24/365 on site Radiographers.
• Two CT scanners/ Two US machines and an MRI scan
at the Northumbria with NO pre-booked patients.
The Service

Turnaround times ( Request to Report )
• CT scans
 Heads within 30 mins to 1 hour.
 Rest the CT scans within 2-3 hrs.
• US scan turnaround times- Couple of hrs.
• MRI turnaround times between 1-4 hrs based on
Clinical information and urgency.
All scans can be prioritised for faster turnarounds if
required.
The Service

7-day services: Business as usual?
Jeff Perring
Deputy Medical Director

Patient Safety / Quality of Care
Safety:
Avoiding harm from
the care that is
intended to help
Patient-
experience:
Including patient-
centeredness,
timeliness and
equity
Effectiveness:
Aligning care with
science and
ensuring
efficiency

Narrative
7-day services part of wider developments in
patient safety:
 SAFE initiative
 Electronic PEWS
 Prescribe 4
 Guardrail for infusions
 Patient Safety induction and briefings

Implementation
 Based on local need
 Not just introduction of 7-day services
 Risk management of change
 Considerations
 Specialist v general paediatrics
 Job planning - change in on call rotas
 Recruitment (5 general paediatricians so far)
 Phased implementation

Phasing
 Phase 1
 Second consultant for morning ward rounds
 Phase 2
 Twilight shift x 5 days / week
 Phase 3
 Twilight shift x 7 days / week

Considerations
 Cost
 Narrative
 Consistent – communicated?
 Documentation
 Technology Stamps
 Monitoring
 How do we show the changes make a difference?
 Wider system
 South Yorkshire and Bassetlaw Accountable Care
System (ACS)
 Acutely ill child managed clinical network

ACS / STP
 Whole system approach
 Cost / efficiency
 Activity / staff experience
 Options
 e.g. SSPAU
 08:00-22:00
 Consultant cover
 Admissions travel to
nearest inpatient unit
 Better or worse?
 Co-dependencies
 Neonates / Obstetrics/
Ambulance
 Monitoring activity

Conclusions
 7-day services as part of wider quality
improvement / patient safety initiative
 Extension of ‘business as usual’  building on
quality agenda
 Takes time to implement fully
 Monitoring
 Need to consider wider system

Seven Day Services at STHFT
Dr A Gibson
Dr H Stewart

PROUD TO MAKE A DIFFERENCE
SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST
Overview
• Context
• Engagement Journey
• What are 7DS?
• What we did
• If we had a time machine
• Where are we now?
• Reprise: What are 7DS?
• Next Steps

Context
• Industrial Relations
• Workforce
– GP retirements
– FY2 leavers
– Nursing Numbers
– Shape of Training
– Advanced care practice
• Fiscal Pressures
• Competing Priorities
• Focus

STHFT Engagement Journey
• 2013 Right First Time (NHSIQ)
• 2014 7DS Launch
• 2014 HiSLAC
• 2014-17 Survey iterations
• 2014-17 CS Working Group
• 2014-17 National Engagement

So that…….

A 2020 Vision……
• Time
• Energy
• Resource
• Champions
• Planning
• Leadership

What are 7DS?
• 10 Acute Standards
• Delivered in context
• 4 Priority Standards
• Timely delivery of:
– Acute Care
– Tests
– Interventions
– On going Care

What we did
• BAU versus Dedicated Project team
• CMB/Executive/Board Engagement
• DOF Engagement ( “The right thing to do” )
• Survey team
• Job Plans and increased PA’s at the weekends
• “Safety Net” Out of Hours ( see the sickest quickest)
• Spread/Share best practice ( Renal/Gastro )
• Excellent Emergency Care
• Consultant of the day/week

Where are we now……

Characteristics of Success
• Identifying Leaders and Champions
• Develop a “Can do attitude”
• Empower to try something different ( “Give it
a Go” weeks)
• Coproduction with trainees
• Supporting “the right thing to do”

Next Steps
• NHSI Supported Trust event in Nov 2017
• Build a Ward to Board ethic
• Ensure that at STHFT 7DS is synonymous with:
“ the timely delivery of all aspects of high quality
acute care to those that need it…….. all day and
every day”

Region-wide Collaboration
to Deliver the Standards
Dr Des Breen
Medical Director
Working Together Partnership ACC Vanguard
September 2017

In this session
• Background
• List common themes
• Managed clinical networks
• Give examples of services
• Each illustrates different issues, solutions
• Generic enablers
• Infrastructure

“…..what can we achieve collectively that we
cannot achieve on our own?.......”
Sheffield
Children’s
Mid
Yorkshire
Chesterfield
Barnsley
Rotherham
Sheffield Teaching
Hospitals
Doncaster
and
Bassetlaw
The Working Together Trusts

Working Together Partnership Vanguard Population approx. 2.3m
15 hospital sites, 45,000 staff, £2.5bn turnover
Dewsbury and
District

Committee in Common Model
Proposed contractual
joint ventures
Barnsley
Hospital NHS
Foundation
Trust
Chesterfield
Royal
Hospital NHS
Foundation
Trust
Doncaster
and
Bassetlaw
Hospitals NHS
Foundation
Trust
The Mid
Yorkshire
Hospitals NHS
Trust
The
Rotherham
NHS
Foundation
Trust
Sheffield
Children’s
NHS
Foundation
Trust
Sheffield
Teaching
Hospitals NHS
Foundation
Trust
Joint working arrangements of the 7 committees working in common model
Commissioners
Contracted service provided to Trusts through sub-contacting arrangements

Common issues
• Escalating demand (i.e. radiology)
• Workforce shortage
o Vacancies across the region
o High locum usage, outsourcing
• Arduous frequency of on-call
• Variation in skills (i.e. paediatric surgery)
• No co-ordination/sharing of subspecialist expertise (i.e. ENT)
• Variation in safety, quality & compliance of standards
• Variation in access
o Elective
o Out of hours
• Often very few patients present out of hours
• Underuse of alternative workforces
• Underuse of technology/technology solutions

Managed Clinical Networks
“………….Linked groups of health professionals and
organisations working in a co-ordinated manner,
unconstrained by existing professional and organisational
boundaries, to ensure equitable provision of high quality
clinically effective and sustainable services throughout a
region………..”

Managed Clinical Networks
Pilots in:
Ophthalmology, ENT , OMFS, Radiology, Children’s Surgery and Anaesthesia,
Acutely unwell child, Pathology
Benefits:
• Unified clinical protocols
o Compliance with national quality standards
o Reduced variation in quality, safety
• Regional planning of service
• Equity of access
• Increase resilience
• Better recruitment, retention
• Decrease agency, locum usage
• Development of workforce solutions,
o Alternative ways of working/workforce
o Professional development, training

Radiology- The Challenge
Workforce:
• Variable radiologist vacancy rate across WTP footprint
• 0 – 50%
• Variable in-house access to out of hours reporting
• 0-100% outsourcing
• No significant increase in radiologist numbers nationally
• Ad hoc use of alternative solutions
Increased demand, widening gap:
0
500,000
1,000,000
1,500,000
2,000,000
2,500,000
Y0 Y1 Y2 Y3 Y4 Y5
Gap

MCN - Radiology
Areas for consideration:
• Increase the reporting and image capturing workforce
o Radiographers, radiography technicians, sonographers
o Radiologists
• Decrease inequalities of access – One NHS Institution
o Remove barriers to staff movement
o Technical solution
o Co-ordinated regional approach
• Demand management

MCN - Radiology
Workforce:
• Radiography Academy Pilot
o 1st cohort September 2017 (8)
- MSK
o Linked to Bradford University – Established course
o Dedicated IT room – Rotherham FT
- Full workstations with access to PACS/RIS
o Clinical educator – Academy
o Educational supervisor – Own Trust
o MDT faculty – University and Academy
o Backfill and course fees funded (HEE)
o Three aspects to evaluation

MCN - Radiology
Radiography Academy Pilot:
• Benefits
o Train as a regional cohort
- Peer support
- Decreased burden on trainers
- Minimises impact on service delivery
o Critical mass for University and Academy
o Protected time out of workplace
o Linked to University Advanced Practice modules
o Regional standardisation of scope of practice
o Replicable
o Coordinates the current ad hoc approach

MCN - Radiology
Workforce:
• Radiography technicians
o LWAB
o Apprentice schemes
• Direct entry sonography
o Course developing
• Radiologists
o Recruitment, retention
o Different ways of working
o Regional approach in some areas
-i.e. Interventional radiology hubs

MCN - Radiology
• Technical solution for regional connectivity
o PACS & RIS independent
o Possibilities for workflow management
-Image capture and reporting – competency based
- Automated
- In and out of hours
• Regional approach to service
o Interventional radiology hubs – in existence
o Service resilience
o Regionalised specialist reporting
o Regional workflow, in and out of hours
o Insourcing

Ophthalmology – The challenge
• Seven non-sustainable rotas
• Consultant, middle grade
• Small consultant numbers in some areas
• Variable vacancy rate
• Reliance on locums
• Quality, safety issues
• Adverse events
• Non standardised pathways
• Variable patients numbers out of hours
• Multiple data analysis

• Standardised Operating guidance/pathways completed for all A&E’s
• Staged approach to regional ophthalmology out of hours cover:
• Implementing 3 hub model October 2017
• On-going data analysis
• Proposed 2 hub model
• Day- case only units – non hubs
• Emergency slots in morning clinics – non-hubs
• Capacity for repatriation, H@N in non-hubs
• Future workforce proposal being developed to expand alternative
roles:
• Orthoptists, ANP’s
o Intraocular injections, glaucoma, eye casualty/eye triage
• Regional approach to education
MCN - Ophthalmology

ENT, OMFS – The challenge
• Non-sustainable rotas
• Consultant, middle grade
• Small consultant numbers in some areas
• Variable vacancy rate
• Reliance on locums
• Quality, safety issues
• Inequitable access
• Non standardised pathways
• Training issues
• Variable patients numbers out of hours
• Multiple data analysis

• ENT
• Three hub out of hours model for ENT at weekends (from 18:00)
• In-patient operating moved to Monday-Thursday only for non-hubs
• No in-patients in non-hubs at weekends
• Separate Children’s hospital consultant on-call for the first time
• Sustainable regionalised rotas (all consultants)
• Future – Transferring activity from theatres to out-patients
• OMFS
• One regional trauma on-call (1:12 or 1:15)
• 24/7
• Separate free flap rota
• Centralised trauma service
• Maximise use of existing trauma lists
• ‘Hot weeks’ for consultants
• Backfill
MCN – ENT, OMFS

• ENT/OMFS
• Standardised Operating guidance/pathways completed for all
A&E’s
• Repatriation pathways
• Unified head and neck cancer service
• Proposed Regional approach to workforce management:
• Proposal for a regional approach to recruitment
• Matrix of sub-specialism
• Different contracting model (ENT)
MCN – ENT, OMFS

• Potential contracting models
• Status quo
• Status quo + MCN
• As we are now
• +/- regional recruitment
• Lead provider model
• Multiple variants
• Lead provider has ownership of all/parts of service
• Regional institution
• All Trusts have ownership
• Tied to one Trust for back office function only
• Separate NHS PLC
MCN – ENT

Children’s Surgery & Anaesthesia – The challenge
“……...depending on which anaesthetist and surgeon are on-call,
you might be lucky!….……”

MCN – Children’s Surgery & Anaesthesia
Implementation 2017/18 network model for Children’s surgery and
anaesthetics
• Joint commissioner/provider project
• First strategic commissioning decision
• JCCCG
• ‘Phone-a-friend’ network formalised
• Beyond the WTP footprint
• Compliance with national standards
• 24/7 or set times
• Tiered approach to provision of service
• Clinical thresholds
• Unified care pathways

MCN – Children’s Surgery & Anaesthesia
Tiered approach to provision of service
• Single hub
• Tertiary services
• Age < 3
• Complex medical
• Three hubs
• In patient services
• Age > 3 (> 8 for general surgery)
• Seven hubs
• Day case paediatric services

Enablers for clinical networks
• PMO support
• Removing barriers to staff movement
• Human Resources
o Passport mechanism
o Standardising terms and conditions
o Different models of employment
• IT
o NHS Roam for WiFi
o ICE OpenNet for results reporting
o Tear 1 & 2 data sharing agreements
• Estates
o i.e ‘car parking’

Other infrastructure
• Supporting workstreams:-
• Informatics
• Procurement
• Back office
• Supporting senior groups:-
• Clinical reference group
• Medical Directors
• Directors of Finance
• Directors of Human Resources
• Communications team
• Strategic commissioning
• JCCCG

“…….A collaborative regional approach is the only way
to deliver a seven day service in some specialities…...”

Working Together
Partnership
www.workingtogethernhs.co.uk
des.breen@nhs.net
@WTPVanguard

Making it Relevant & Making it
Resilient
Mr Richard Montague
Deputy Medical Director/
Consultant Urologist/Executive lead for 7DS

UHSM - Background
Wythenshawe Hospital - a major acute teaching hospital, recognised as a centre of clinical
excellence and provides district general hospital services and specialist tertiary services to
our local community. Specialist expertise – including cardiology and cardiothoracic surgery,
heart and lung transplantation, respiratory conditions, burns and plastics, cancer and
breast care services. Recognised in the region and nationally for the quality of our
teaching, research and development.
Withington Community Hospital - provides specialist care to those patients requiring
diagnostic treatment, day surgery and community services via the main hospital,
Buccleuch Lodge and Dermott Murphy Centre.
Community Services - provide care in patient’s own home and other locations including
nursing homes, health clinics, Withington Community Hospital and GP surgeries to make
sure you get healthcare which is coordinated and meets your needs. Services are provided
locally, so patients get the support and care that fits them.

UHSM - Statics
• Number of beds at – 899 (including 22 day case beds)
• Emergency admissions in 2016/17 – 36,949
• Length of stay in 2016/17 for emergency admissions – 4.8 days

How are we performing nationally
and regionally – Standard 2 …
Proportion of patients reviewed by a consultant with 14 hours of admission – survey
comparison
Proportion of patients reviewed by a consultant with 14 hours of admission –
March 2017 audit

How are we performing Nationally
and Regionally – Standard 8 …
Proportion of patients receiving once or twice daily consultant reviews – survey comparison
Proportion of patients receiving twice daily review – March 2017 audit

How are we performing Nationally
and Regionally – Standard 8 …
Proportion of patients receiving once daily review – March 2017 audit

Making it Relevant
• Clinically lead not corporately lead to cultivate the
need for change, with robust PMO & operational lead
support
• A whole system approach
• Pathway changes evidence based and clinically led
• Benefits to patients measured & celebrated following
the implementation of new clinical models/pathways
• 7DS included within Trust and Divisional strategic and
transformation plans

Making it Resilient
• Implementation of new clinical pathways –
• AMU
• SACRU
• URO-ACRU
• Surgical hot weeks
• Gastroenterology hot weeks
• Gynaecology hot weeks
• 7DS integrated within job planning process –
• Thrice/Twice daily ward rounds (am/pm)
• Extended days on Acute Medical Receiving Unit
• 7DS for all diagnostic and intervention suites

Key Benefits
 Improved understand of what diagnostic and
interventional services are available 24/7
 Faster time to diagnostics to diagnosis to
treatment
 Reduced length of stay
 Improved patient flow leading to improved ED
performance
 Reduction in our readmission rates
 Reduction in our mortality rates
Ultimately, it is the right approach
for our patients

Seven Day Services Regional Sharing and Learning Event - North Region, 15 September 2017

Seven Day Services Regional Sharing and Learning Event - North Region, 15 September 2017

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Seven Day Services Regional Sharing and Learning Event - North Region, 15 September 2017