Appendix Wii Deliverability Panel 4 th September Maidstone Site - - PowerPoint PPT Presentation

Stroke Services Review

Deliverability Panel

4th September

Maidstone Site Options (B & C)

Appendix Wii

Contents

• Executive Summary
• Introduction to MTW and its Stroke

Services

• Timescales for Delivery (plans)
• Overview of workstream activities:

– Estates and Equipment – Workforce – Operational Readiness – Comms and Engagement

• Performance, Patient Flow and Bed Availability
• Confidence in Delivery
• Risks and Interdependencies

Executive Summary

Executive Summary

• MTW is fully supportive of improving Stroke services in Kent and regards its strong

Stroke teams as pivotal in this process

• The Trust has a clear track record and recognised approach for successfully

delivering sizeable service reconfigurations and accompanying capital projects

• MTW can confidently deliver the following relatively low risk

solutions:

– Option B by Oct 19 with £6.253m (Refurb and Office Build) – Option C by Jun 19 with £2.166m (Refurb)

• The current substantive workforce will largely cover safe staffing levels in Options

C, D & E

• Option B will require a larger expansion of nursing staff as well as medical staff.

However, the Trust is confident it can reach safe staffing levels to coincide with the refurbed ward being available. The Maidstone site easier to recruit to

Executive Summary

• Work around Acute Medicine, Ambulatory and Frailty pathways and Discharge

processes are seeing real progress at the Maidstone site. This work has released sufficient beds for both options whilst maintaining escalation capacity

• Further improvements are anticipated in these areas, minimising still further

the risk to the site of hosting a large HASU/ASU

• Maidstone hospital is a medically focused hospital, skilled at managing medically

sick patients and able to accommodate an increase in higher acuity patients. Its Medical take is equivalent in size to the trauma unit’s and is staffed similarly

• With vacant, serviceable accommodation the site could treat additional

Stroke patients faster should services elsewhere become unsustainable during the transition period

Introduction

MTW providing care for Kent and Sussex

• Sustainable, integrated modern services at two

well-established district hospitals in West Kent

• High levels of sub-specialisation
• Third largest Oncology Centre in the country,

serving 1.8 million people in Kent, Medway & East Sussex

• Largest specialised eye unit in the South-East
• f

England, serving one million people

• Stable platform to improve patient

care across Kent & East Sussex with a track record of delivering quality, safety and efficiency

Key: Red dots show A&Es Grey dots are sites without a front door

Catchment and T urnover for Kent Acute T rusts: Medway: Population 405,000 Budget £270m Dartford: Population 340,000 Budget £250m MTW: Population of 560,000 rising to 1m for eye care and 1.8m for cancer care Budget £450m East Kent: Population 695,000 Budget £560m

TWH Maidstone

MTW’s big commitment to care

MTW’s Support for Stroke Review

• Trust is fully supportive of case for

change

• Started looking to consolidate West Kent’s Stroke Services in 2014
• Have made significant improvement in its delivery of Stroke Services

in recent years

• Can build upon these achievements by consolidating the two strong

Stroke teams at MTW

• Strong basis on which to help improve Stroke Services across Kent

and Medway

• Clinical, Operational, Estates and HR

colleagues at the Trust are fully engaged in the Stroke Review process and are focused on maximising its benefits

Stroke - Local Trust results in the National Audit of Performance

Latest published quarterly SSNAP performance results Dec- Mar 2018

Timescales for Delivery

Implementation Plans

Jun‘19 Sep‘19

Estates & Equipment Comms and Engagement

Implementation Plan Key Activities – Option B

Planning

New Office Build, Ward Refurb and Resus

Workforce

Initial Recruitment Drive & Identify Transfers (1:1s)

Operational Readiness

Detailed implementation plans Staff Planning Sessions Ongoing drop in sessions/ 1:1s

Mar’19

Gym Re- location Transition Updates (internal & externa)

Dec‘19 Mar‘20 Sept ‘18 Dec‘18

Corporate Readiness (incl Finance) and System Amendments Operational Policies & Procedures Staff Familiari sation System Planning Sessions with key external stakeholders (incl patients)

Ward ready end Oct Preferred Option Decision

Ongoing Recruitment Efforts Formal Consultation with Staff (TBC)

Engage agencies

Confirm Staff Structures and Bank Provision

Facilities & Site Readiness Clinical Readiness incl. Support Services (internal and external)

Readiness Comms

De-escalation end Apr (2018 Mar)

System Implementation with key external stakeholders (inc. patients) Service Checks & Benefits Tracking

Go Live

Jun‘19 Sep‘19

Estates & Equipment Comms and Engagement

Implementation Plan Key Activities* – Option C

Ward Refurb

Workforce

Initial Recruitment Drive & Identify Transfers (1:1s)

Operational Readiness

Detailed implementation plans Ongoing drop in sessions/ 1:1s

Mar’19

Transition Comms (int & ext)

Dec‘19 Mar‘20 Sept ‘18 Dec‘18

Corporate Readiness (incl Finance) and System Amendments Operational Policies & Procedures Staff Familiari sation Staff Planning Sessions System Planning key external stakeholders

Ward ready end Jun Preferred Option Decision

Ongoing Recruitment Efforts Formal Consultation with Staff (TBC) Confirm Staff Structures and Bank/Agencies

Facilities & Site Readiness Clinical Readiness incl. Support Services (internal and external)

De-escalation end Apr (2018 Mar)

System Implementation (incl patients) Service Checks & Benefits Tracking

Go Live

Overview of Workstream Activities

• 1. Estates & Equipment

(Framework section – Timescales for implementation)

1. Refurbishment of two co-located existing wards with some internal redesign (A). T

• include;

a) 38 bed HASU/ASU b) 9 Rehab c) New therapy gym d) Mix of 6 bed bays (existing) 4 bed bays (new) and single rooms (new) 2. Provision for 1no. new A&E majors cubicle. 3. New build for clinical offices (B).

Estate Solution Option B

Estates Option B (Ward)

Capital reqt – £6,253,000 (see appendix

for breakdown)

Works required; Phase 1 1. Removal of escalation beds 2. Light Refurb to ward 3. Heavy refurb to convert 2no. Bays to HASU. 4. Design and new staff base 5. Refurb to create TIA clinic Phase 2

• Relocate existing offices/Drs Mess
• New Therapy Gym
• Refurb offices

For thresholds please see appendix

Phase 1 Phase 2

Estate Solution Option C

1. Refurbishment of existing Stroke ward with expansion into a co-located ward (A).

Capital Reqt - £2,166,000 (see appendix

for breakdown)

Works required;

• Existing Stroke Ward
• Refurb of co-located ward to

provide the additional beds For thresholds please see appendix

Estates Option C (Ward)

• Qu. Is planning permission required and, if so, your assessment of the likely time this

will take? Outline of discussions to date with planning departments.

• Planning permission is needed for new office build (Option B). Previous similar requests have

been processed within the 12 week timeframe

• Qu. Confirmation of current status of estates plans i.e. architectural drawings and level
• f clinical

engagement.

• Estates solutions are progressed as shown and have had full clinical engagement

Other points to note:

• De-escalation of winter ward is required to enable refurb works to
• commence. De-escalated

March 2018 (Options B & C)

• MTW will work with neighbouring Trusts to maintain safe services during the transition phase.

Should an earlier transition of patients to a future HASU/ASU at Maidstone be required, this could be accommodated to ensure patient safety due to vacant accommodation

• See

Appendix for equipment details

Timescales for implementation

Overview of Workstream Activities

• 2. Workforce

(Framework section - Understanding Capacity)

Maidstone’s Stroke Workforce

• Maidstone's Stroke team has worked hard to improve its Stroke services. It was an A rated

SSN AP service until recently, missing out by only 1 point. It also scores consistently well on Friends and Family assessments.

• Highly committed individuals work well in strong multi disciplinary teams including

Orthoptists, as recommended by Royal College guidelines

• Frequently more than 50% of the Stroke clinical workforces in MNWK are from MTW
• Based on staff feedback to date, they are much more likely to move within rather than

between Trusts

Trust Maidstone & Tunbridge Wells NHS Trust Medway NHS Foundation Trust Dartford & Gravesham NHS Trust Nursing Registered 27.40 11.6 12.75 Nursing Unregistered 33.05 13.12 17.51 Physiotherapist 9.35 1.6* 1.9 Occupational Therapist 7.37 1* 2 S&LT Therapist 4.00 0.6* 2.3 Dietitian 0.50 0.2 0.5 Consultants 3.00 2.5 1.6 Staff Grades 4.00 1 Specialty Registrar 0.00 0.38 SHO, F2 & F1 7.00 3

*Staff supplied by Medway Community Health

Delivering the required workforce

Qualified Nursing Requireme nt Currently in Post Additional WTE Required Minimum to

• pen safely

Additional WTE to maintain safety Option B 69 27 42 54 27 Options C-E 52 27 25 36 9

• Qu. Outline your workforce gap and detail the strategy and plans to deliver the

required workforce

• The main areas of concern are Nursing and Medical
• In both Options the Trust will need to employ additional Stroke consultants, although the

Trust already employs four Stroke consultants and four Specialist doctors. The Trust also hopes to employ a further consultant shortly.

• Only Option B would require the Trust to move significantly beyond its current non medical

substantive staffing levels to open the new service safely

• The Trust has sufficient unqualified nursing staff to fully staff all of the options from day one

Qualified Nursing Requirements

Delivering the required workforce

• Qu. Outline your workforce gap and detail the strategy and plans to deliver the

required workforce Following the steps below and looking at the numbers of stroke staff at other Trusts locally, the Trust is confident it would have sufficient numbers to open the services safely by the time the Estates solutions are implemented.

• Engagement and retention of MTW Stroke workforce (by looking at hrs, travel time and costs,

development opportunities etc.)

• Understanding the likely scale of TUPE across all clinical groups and extending opportunities

and transition support to Stroke employees at other Trusts (in line with Kent wide relocation packages / incentives for Stroke workforce)

• Actively participating in recruitment campaigns at Kent &

Medway level as well as making Stroke recruitment part of MTW’s ongoing recruitment programme

• Early engagement with Bank and Agency staff for supply (if required). The Trust currently

uses a number of regular bank staff and frequently uses agency staff to cover roster gaps. It is envisaged that this could continue until the unit is fully staffed

Delivering the required workforce

• Qu. What is your training plan and how will you implement it? What are the

timescales associated with this?

• Longer term it is envisaged, as in London, that there will be a Kent

wide Competency Booklet, teaching programme and accreditation

• In the short term, the Trust will continue to support its own nurses completing

their competency documents, e.g. as a Stroke Assessor, and this is done by the C N S s

• n the ward.
• The CNSs also run bespoke S

D sessions

• MTW also has a more general, comprehensive training programme for its nurses

and is proactively rolling out programmes to train and grow its own staff

Overview of Workstream Activities

• 3. Operational Readiness

Operational Readiness Activities

Each of the MGH options has a varying degree of operational readiness activities required:

• Option B – The opening of a new, larger Stroke ward and interim use of the rehab

facilities in another part of the hospital will require close planning and

• preparation. Processes, policies and procedures, as well as patient information,

will need to be updated and approved. Clinical support services will need to be prepared along with corporate functions and facilities. The Trust will need to work with external stakeholders, including patients, to ensure readiness. Staff will need familiarisation sessions before the transition onto the new ward. After the transition, checks will be required to ensure safety and quality improvements.

• Options C - Stroke services will remain in situ with an expansion into a

neighbouring ward area. Processes to incorporate the extra floor space and manage the displaced patients will be required as a well as familiarisation sessions for new staff. However, the degree of planning and clinical/corporate readiness activities will be significantly less vs. a new ward

Overview of Workstream Activities

• 4. Comms and Engagement

(Framework section - Understanding Capacity)

Comms and Engagement

• Qu. Please outline the communications which have happened to date with your

existing staff, specifically with employees who may need to work on a different site

• Written Comms – an overview for MTW staff of the Review process was distributed last

month and a F AQs is being regularly updated

• Staff Drop In Sessions – These regular sessions at handover and lunchtime have

been running on the wards since the end of January 2018 and will continue

• Engagement Events – Staff have been encouraged to also attend wider Kent and

Medway Staff Engagement Events as well as complete the questionnaire etc.

• Staff Planning Activities – once a preferred option is identified, staff beyond the ‘MTW

Stroke Group’ will also be asked to participate in activities to plan the new service

• One to one meetings - once a preferred option is identified, one to one staff sessions will be

held to understand individuals’ concerns, questions and possible plans for the future

• Formal staff consultation process – this will commence in line with other Trusts across the

county when the site option is finalised

• T

ransition and readiness comms – these will take place and keep staff informed as the services are prepared for transition

• System planning and implementation – the Trust will also work proactively with

external parties, including patients, to prepare and ensure a smooth handover of services

Performance, patient flow and bed availability

(Framework sections - Understanding Capacity & Track Record)

Site Performance

• Qu. What is the current performance position of the trust? How will current

performance be maintained?

• The Trust has taken proactive steps in recent years to improve patient flow and

maximise hospital performance Maidstone hospital developed an Acute Assessment Unit in 2013, an A E C in 2015 and F AU in 2017

• In parallel, GPs

have been increasingly effective in A&E, an integrated discharge team has been established and initiatives such as Home First and Pathway 3 have been implemented

• All have contributed to improving patient flow at the Maidstone site as the

following graphs demonstrate

• Further potential exists in the above improvements. In addition the Trust has

advanced plans to roll out a virtual ward of 30 beds as well as continuing work with the system to reduce stranded patients

• The Trust is therefore confident it

can maintain, if not improve, site performance despite accommodating one of the three HASUs in Kent

• A site with improving patient flow will also help ensure HASU beds are available

when required

Site Performance

Maidstone ED 4hr Score : Past 12 months have been 1.8 percentage points better than the preceding 12 months Maidstone ED Attendances : Past 12 months have been 3.1% higher than the preceding 12 months

• Despite increasing demand at the

front door, Maidstone hospital has managed to improve its A&E performance

Site Performance

Maidstone NE Admissions : Past 12 months have been 15.9% higher than the preceding 12 months Maidstone Percent Zero LoS : Past 12 months have been 10.6 percentage points higher than the preceding 12 months Maidstone NE LoS : Past 12 months have been 0.70 days lower than the preceding 12 months

• The increases in NE

Admissions are almost entirely down to increases in zero LoS activity in decision & assessment units

• Non zero activity has also dropped by

4.2%, further demonstrating the beneficial improvements

Bed Availability for Stroke patients

• Qu. Do you have critical care bed capacity to accommodate any potential

requirement from stroke patients?

• Stroke patients rarely need ITU care and only for short periods of

time

• MGH’s ITU could easily increase its physical capacity if required, with the support
• f additional staffing

Bed Availability for Additional NEL Activity

• Qu. Do you have capacity in your medical beds to accommodate a potential increase

in NEL admissions as a result of being a HASU/ASU? Option C

• High level work undertaken locally suggests an increase in NEL

admissions will not be an issue for Option C due to the relatively small unit and bed capacity at Maidstone hospital Option B

• In Option B a handful of additional beds may be required if non MGH patients are

repatriated after 48hrs. Further analysis is required to confirm the exact number

• The double ward in Option B can accommodate up to five further beds. Additional

bed usage may eat into winter escalation capacity at the Maidstone site but could be accommodated

• A&E feel able to cope with an increase in higher acuity patients at the front door

due to the generally lower acuity profile of attendances at Maidstone

Confidence in Delivery

(Framework section -Track Record)

Confidence in Delivery

• Qu. What is your track record in delivering change and was it done to the planned go

live date?

• The organisation has major experience in service reconfiguration including a major

consolidation of acute hospital services into a new singular hospital in 2011. Moves commended by the Patient Safety Agency as “Exemplar”.

• Other notable projects include:

– a relocation of 1000m2 of offices to alternative hospital locations and the works to develop the offices into a new 4 bed bays and single room ward (AMU), delivered within a 48 week programme – Significant ward refurbishment programme at Maidstone hospital to create a new Respiratory Unit – The new acute Frailty Unit works, undertaken within an operational setting and completed 13 days ahead of schedule

• The Trust has undertaken a number of other significant service alterations run by in-

house project teams who are well versed in service change and the stakeholders who need to be involved

• Equally ward staff are not unfamiliar with the movement of services and their

patients to allow for a series of deep cleaning sessions at Maidstone hospital

Confidence in Delivery

• Qu. Do you have programme resource allocated for managing the implementation and

the transition?

• The Trust is in the process of developing a more clinically led organisation. It sees

clinical leadership and engagement as a prerequisite of successful change. Our Stroke Clinical leads will be at the forefront of delivering a new Stroke service on the ground at MTW.

• They will be supported by a Senior Programme Manager from the Transformation /

Project Management Office (PMO) which supports the Trust’s Transformation work.

• The experienced team of 13 consists of 6 Senior Programme Managers, (clinical and

non-clinical backgrounds, from both public and private sector) and 6 Project Managers.

• The team utilises all national methodologies and standard approaches to ensure best
• practice. Based on experience, the team has defined ‘step by step’ approaches for

delivering clinical service changes.

Confidence in Delivery

• Qu. Have you got any other strategies / programmes underway in your organisation

that might cut across this?

• We have an ongoing improvement programme called Best Care. The reconfiguration
• f the Stroke services would be a priority programme for the Trust. As such, other

programmes of work would not impact on its delivery and instead would work in tandem to support its delivery, e.g. winter de-escalation, reduced L O S activities

• The Trust is closely looking at transformational plans to overcome issues and

improve its emergency surgery service as well as maximising capacity for elective

• work. Siting the Stroke service at Maidstone hospital would be supportive of these

plans.

Risks and Interdependencies

(Framework sections –Understanding Key Risks and Track Record)

Option B Risks and Interdependencies

Risk Probability Impact Mitigating Action Planning Permission issues for Office Block Low Medium Previous permission granted for hard standing area so refusal unlikely. Early application to avoid impactful delay Ward not vacated following winter escalation Low High Ward was vacated in March this year. Review winter plans & consider part vacating ward to avoid delay to refurb Bed modelling in incorrect and underestimates those coming from East Sussex and Sevenoaks areas Medium Medium Double ward does have capacity for an additional 5beds. Further beds could be freed by relocating East Sussex rehab patients to TWH Bed modelling does not take account of ‘tail’ of NEL admissions High Low The additional beds have been estimated outside of the review. Work with the review to confirm analysis. Based on current predictions the tail can be accommodated in this option. Unable to ramp up to staffing levels required to open service. Medium High Regularly review effectiveness of plan and work with agencies early to secure cover if required.

Option B Risks and Interdependencies

Risk Probability Impact Mitigating Action MGH does not have some key clinical adjacencies Low Low The site has the important clinical adjacencies for Stroke services. Those seen as ideal but not necessary are networked within the Trust with robust and exercised emergency and elective referral and transfer protocols in the unlikely event they are needed for Stroke patients. Capital costs are insufficient for equipment required Low Medium Confirm costs as quickly as possible. Levels of contingency and optimism bias are higher than we would use for an internal business case so should be low risk. Self presenters and inpatients will encounter delays in treatment when Stroke services are no longer in Tunbridge Wells hospital Medium High Have clear Trust protocols in place to either transfer patients or have means to provide effective remote support that can lead to immediate treatment if required.

Option C - Risks and Interdependencies

Risk Probability Impact Mitigating Action Ward not vacated following winter escalation Low Low Ward was vacated in March this year. Review winter plans & consider part vacating ward to avoid delay to refurb Bed modelling in incorrect and underestimates those coming from East Sussex and Sevenoaks areas Medium High There is no room for further expansion in this option. Further beds could be freed on unit by relocating East Sussex rehab patients to TWH. Bed modelling does not take account of ‘tail’ of NEL admissions High Low The additional beds have been estimated outside of the review. Work with the review to confirm analysis. Based on current predictions the tail can be accommodated in this option. Unable to ramp up to staffing levels required to open service. Low High The low increment in staffing numbers makes this risk unlikely.

Option C - Risks and Interdependencies

Risk Probability Impact Mitigating Action MGH does not have some key clinical adjacencies Low Low The site has the important clinical adjacencies for Stroke services. Those seen as ideal but not necessary are networked within the Trust with robust and exercised emergency and elective referral and transfer protocols in place in the unlikely event they are needed for Stroke patients. Capital costs are insufficient for equipment required Low Medium Confirm costs as quickly as possible. Levels of contingency and optimism bias are higher than we would use for an internal business case so should be low risk. Self presenters and inpatients will encounter delays in treatment when Stroke services are no longer in Tunbridge Wells hospital Medium High Have clear Trust protocols in place to either transfer patients or have means to provide effective remote support that can lead to immediate treatment if required.

Appendix

Programme Phasing Option B

Planning Permission

Oct

• 1

8 Nov

• 1

8 Dec

• 1

8 Jan

• 1

9 Feb

• 1

9 Mar

• 1

9 Apr

• 1

9 May

• 1

9 Jun

• 1

9 Jul

• 1

9 Aug

• 1

9 Sep

• 1

9 Oct

• 1

9 Nov

• 1

9 Dec

• 1

9

New Build Offices Ward Refurb (P1) Resus Therapy Gym (P2)

Capital Cost Model Option B

Item Option B (£ ‘000) Works subtotal 2,970 Fees 535 Equipment costs 445 Non-works 45 Planning contingency 399 Optimism Bias 906 VAT 953 Total 6,253

Programme Phasing Option C

Ward Refurb

Oct

• 1

8 Nov

• 1

8 Dec

• 1

8 Jan

• 1

9 Feb

• 1

9 Mar

• 1

9 Apr

• 1

9 May

• 1

9 Jun

• 1

9 Jul

• 1

9 Aug

• 1

9 Sep

• 1

9 Oct

• 1

9 Nov

• 1

9 Dec

• 1

9

Resus

Capital Cost Model Option C

Item Option B (£ ‘000) Works subtotal 1,029 Fees 185 Equipment costs 154 Non-works 15 Planning contingency 138 Optimism Bias 314 VAT 330 Total 2,166

Thresholds

Stroke Beds Resus Beds CT / MRI Option B - MGH Can fit up to 5 additional beds Additional 400 stroke No extra C T

• r MRI

patients would required 1 extra resus bed needed, would need additional 730 stroke Option C

• MGH

At maximum capacity patients for C T and 1200 stroke patients for MRI

Equipment

• 15% of capital costs are allocated for equipment
• This should be sufficient in both options to

cover any additional items from the below:

– Wall mounted cardiac monitors for all HASU beds – Portable INR monitor – E C G machines – IPCD loan costs will increase & purchase of sleeves – Tympanic’s (taking temperature) – Electronic observation machine – NG Pumps – Infusion pumps – Ophthalmoscope – More IPads for Nerve Centre – Computers, printers and appropriate screens – Additional therapy equipment including hoists – Bladder scanner – Notice board & Patient status board – Filing cabinets, Notes & drug trolleys