Kent & Medway Stroke Review EKHUFT Deliverability Assessment - - PowerPoint PPT Presentation

Kent & Medway Stroke Review EKHUFT Deliverability Assessment

David Hargroves, Stroke Physician, EKHUFT Liz Shutler, Deputy Chief Executive, EKHUFT Phil Cave , Director of Finance EKHUFT Jim Cross, EK Patient Representative August, 2018

Appendix Wvi

Content

• Background and introduction
• East Kent plans for wider changes
• Track record of delivering sustainable patient centred innovation & change
• EKHUFT Stroke implementation plan & timeline
• EKHUFT Stroke implementation governance structure
• Capacity requirement for delivering HASU at WHH (estates and beds)
• Capacity requirement for delivering HASU at WHH (workforce)
• Key interdependencies and success factors for delivering HASU at WHH
• Communication and engagement
• Staff training
• Key risks and constraints
• Questions from panel

• The vision in east Kent is to create centres of excellence where specialist teams

have the equipment and expert staff they need to give patients the best chance of survival and quality of life. For stroke this means:

• A reduction in deaths from stroke;
• Fewer people living with long-term disability following a stroke;
• Fewer people losing their independence and being admitted to nursing/care

homes; and

• Shorter stays in hospital with better patient and staff experience as a result
• f excellent working practices.
• In order to achieve the above vision, we have worked with patients and health and

social care partners over the past few years, across Kent and Medway , to implement significant service improvement;

• A shortlist of five three-site HASU options (WHH is in all options) were publicly

consulted on in Spring 2018;

• Therefore we are presenting a single deliverability plan for all

shortlisted options.

Background & Introduction

East Kent is currently developing and engaging on plans for acute and specialist services: There are currently 2 potential

• ptions on the medium list for full evaluation

As part of this process, it has been agreed that the HASU would be located at the major emergency centre (MEC) with specialist services in both options.

Track record of delivering sustainable, patient centred stroke innovation

1) 24/7 thrombolysis using horizontal telemedicine – first in UK, 2008.

The Health Services Journal Award winner for Improving Healthcare with Technology, 2009

2) Rapid Access Carotid Endarterectomy (RACE) – top quartile in UK, 2008.

The South East Best of Health award for transforming stroke services within East Kent (runner up), 2009 and 2010

3) 7/7 TIA service using first line MRI and CEMRA imaging – first in UK, 2008.

The Dr Foster, highest UK performing acute secondary care stroke service award, 2010

4) Introduction of community stroke nurses to coordinate post discharge rehabilitation and life after stroke service development 2009

Care Quality Commission, best performing UK stroke rehabilitation service award, 2011

5) Introduction of advanced cerebral imaging to treat SUTO, 2010.

The Health Services Journal Patient safety Awards runner up 2013

6) First helicopter transfer for thrombectomy in England 2015.

https://www.stgeorges.nhs.uk/newsitem/stroke-patient-flown-to-st-georges-for-urgent-treatment/

Phase 2 (Post 10th Jan to Sept 2019) Phase 3 (Sept 2019 to December 2020) The objectives by December 2020:

• Prepare for the transition in alignment with the STP, agreeing the transition plan
• Continue the new build and purchase of equipment
• Continue implementation of new pathways based on feasibility
• Implement IT and Information systems as specified, incl. testing and training
• Implement staff benefits programme to ensure staff retention
• Continue recruitment as required
• Extend pilot to more patients to support agreement for funding to become the new thrombectomy centre

The objectives by September 2019:

• Agree funding locally for the new stroke service in alignment with the STP
• Commence the new build and purchase of new equipment
• Implement new pathways based on feasibility
• Develop and tender for IT and Information systems as specified
• Agree staff benefits programme to ensure retention of staff
• Undertake staff consultation for the new stroke service
• Recruit staff required into vacancies and new posts
• Perform 6 months thrombectomy pilot with 10 patients and full evaluation of expected outcomes.

Phase Objectives

EKHUFT Stroke Implementation Plan

Phase 1 (now till 10th Jan 2019) The objectives by January 2019:

• Obtain baseline KPI measures and agree target;
• Implementation plan drafted with mobilisation planning – workforce, IM&T, estates, capacity etc.
• Develop and agree model of care - Pre-hospital (Ambulance service and TIA Clinics), HASU and Rehabilitation
• Evidence and agree the optimal local stroke pathways for the purpose of quality assurance
• Ensure staff retention by gaining a better understanding of staff needs through 1-2-1 pre staff consultation
• Obtain Trust’s funding for and commence training of consultants for the thrombectomy pilot
• Bid for external funding to become a thrombectomy centre

Go live date of January 2021 anticipated. The Trust hold s a detailed programme timeline with key milestones identified which include the 18 months new build timeline for inpatient ward at WHH HASU opens to patients at MEC site

Sep 2018 October 2018 November 2018 Obtain baseline KPIs measure and agree targets December 2018 January 2019 Pre-Hospital HASU Rehabilitation Workforce IT/Information Plan Quality Assurance of pre-hosp. Triage Raise awareness & train staff Event

EKHUFT Stroke Implementation Plan Timeline: Phase 1

Undertake Quality Assurance Test QA Outcome Report

Optimal Pathway & model of care

Plan Quality Assurance of pre-hosp. triage & Door to Needle Pathway Raise awareness & train staff Undertake Quality Assurance Test QA Outcome Report

Optimal Pathway & model of care

Commence thrombectomy training

SIG Thrombectomy Business Case

Set Up thrombectomy training programme with St. Georges Hospital

SGH Training Programme

Develop 1-2-1 Pre- Staff Consultation Raise awareness with management Undertake 1-2-1 Pre Staff Consultation Plan Stroke Vision Day

Stroke Vision Day

Pre Staff Consultation Outcome Report

Staff Benefits Programme

Feedback Stroke Vision Day Outcome Develop local requirement specification for information portal aligned to STP

Information Portal

Develop Capture Stroke Business Case Purchase and Plan Implementation

Capture Stroke Business Case

Obtain agreement ‘Model of Care’ from STP Develop localised model of care & pathways

Optimal Pathway & model of care

Milestone

Agree targets

IM&T Appraisal

IM&T Appraisal

EKHUFT Stroke implementation governance structure

• EKHUFT has a good reputation of delivering sustainable change to time and

forecasted budget. Example: moved acute medicine (including stroke services)

• ut from K&CH to WHH and QEQMH June 2017
• The Trust has established project resources for stroke programme with key

members of staff actively taking the following roles and responsibilities:

• Executive Sponsor (Deputy Chief Executive);
• Programme Owner (General Manager Medicine);
• Clinical Lead (Lead Stroke Physician);
• Project Manager; and
• Project team members which includes patient representatives, stroke

consultants, ward teams, SECAmb pathway lead, local clinical resource manager (SKC & Thanet UC), inpatient therapy lead, Director of information, etc.

• EK patient representative: Jim Cross
• Project and programme management arrangements for stroke at

EKHUFT is a well established with a clear governance structure and vision to provide thrombectomy

Full time – with focus on developing and delivering stroke implementation plan including transition element

EKHUFT Stroke Implementation Governance Structure

Capacity requirement for delivering HASU at WHH (estate & beds)

• Historically WHH has received 450 ‘confirmed strokes’ per year;
• Following the medicine move from K&CH in June 2017, WHH site has seen
• an increase of 7,062 emergency attendances (an average of 9% increase);
• an average 100 ambulances per day;
• an increase of 130 stroke patients per year (578 currently).
• In order to ensure the quality of care that will meet the required standards for

approximately 1,200 stroke patients , additional capacity is required for A&E (inc. resuscitation), ITU, MRI, CT and ward capacity . For example, there are currently only 4 resuscitation bays within the department and there have been regular instances of stroke patients having to wait for a bay which is clinically not safe. In addition additional patients are expected to attend A&E because of the HASU therefore additional majors capacity is required.

• The table on the next slide summarises the additional capacity required:

Capacity requirement for delivering HASU at WHH (estates & beds)

The Trust has submitted a bid for emergency capital for the A&E if this is successful it will not require this element

• f funding but if it isn’t it will

be required. The Trust engaged closely with MC Consult Ltd an independent estate reviewer working with all Trusts on K&M stroke review. All figures was signed off at the last K&M STP Finance Group meeting on 24 August 2018.

SOURCE: K&M Trust estates returns (August 2018); Gleeds analysis (August 2017); MC Consult analysis (August 2018); Carnall Farrar analysis August 2018.

Capacity requirement for delivering HASU at WHH (estates: proposed site plan)

Inpatient ward accommodation at WHH

NB: The plans will be scaled down to accommodate the right number of beds

Inpatient ITU expansion at WHH

Source: EKHUFT Stroke Services Baseline at 30/04/2018

Capacity requirement for delivering HASU at WHH (workforce)

The current Therapy service is only funded for a 5 day service – the requirement to move to a 7 day service will be considered as part of the future workforce plan. This will reflect the SEC recommendation

Capacity requirement for delivering HASU at WHH (workforce)

Source: Trust Current Staff in Post Lists (July 2018) and Funded Establishment List (July 2018)

Current Position

Staff group Staff in post Current Establishment Vacancy (Gap in workforce) Medical - Consultant 6.9 WTE 7.9 WTE 1 WTE Nursing 50.16 WTE 64.76 WTE 14.6 WTE Admin and Clerical 13.1 WTE TBC TBC Clinical Support - Ward 52.6 WTE 51.26 WTE (TBC) Therapy 14.7 WTE 14.7 WTE

With consideration to the number of beds required, the Trust is working to deliver a future workforce that consider the SEC recommendation above and wider multidisciplinary team. This work is currently underway

Future workforce requirement and the South East Coast Stroke workforce service specification (2017)

Source: South East Coast Cardiovascular Strategic Clinical Network Hyper Acute Stroke and TIA Service and Quality Standards ( as quoted by Carnall Farrar for stroke workforce model, stroke CRG 16th August 2017)

Key interdependencies and success factors for delivering HASU at WHH

Key factor Consideration in Trust plans for implementation

Sufficient capital for the required investment An agreed capital requirement of £23.6m has been submitted for additional beds, ED capacity, additional diagnostics and a critical care bed Planning permission requirement for new build for inpatient ward expansion required to accommodate growth in Stroke activity at the WHH The Trust is aware of this requirement and an initial informal discussions have been held with local Councils with positive outcome. Discussions are ongoing . Sufficient staffing levels sustained Staff engagement – events, stroke vision days, etc, 1-2-1 pre-staff consultation currently

• ngoing, Implementation of staff benefit programme to be developed

K&M stroke consultation outcome aligned with EK plans for wider change It has been clinically agreed that HASU would be located at the major emergency centre (MEC) with specialist services Dedicated project resources Dedicated resources are assigned to the project enabling a succesfull delivery of the HASU at EKHUFT Sufficient beds capacity, estates, staffing level, support services Detailed demand and capacity modelling completed with the associated workforce, estate and financial modelling work. 56 beds is required with additional A&E, CT/MRI and critical care capacity. The Trust participated in challenge session with the DMBC regulator and reflected the above in the revised capital plan submitted to Carnall Farrar for the development of the DMBC Future models of care, pathways, workforce and IT requirements Working with the STP and developing local work streams to implement the future models of care, pathways, workforce and IT requirements inline with plan Clinically agreed patient pathways (pre-hospital, HASU, Rehabilitation, life after stroke) Work streams established and leads identified with clear objectives and key milestones for delivery inline with plan. Although model of care for rehabilitation is not yet agreed by the STP rehabilitation work stream which is currently a risk that has been highlighted Interdependency and co-location of the proposed thrombectomy with PpCI/ITU It has been clinically agreed that HASU would be located at the major emergency centre (MEC) with specialist services. Clinical support systems and processes required for PpCI service which at WHH are similar to the requirements for a thrombectomy service. Trust performance position and impact on scrutiny/permission to proceed from regulators The Trust is currently on an improvement journey with performance and we are engaging with regulators and partners on our plans for internal improvements and wider changes to acute and specialist services.

Key interdependencies and success factors for delivering HASU at WHH

Key factor Consideration in Trust plans for implementation Model of new build (traditional /modular unit) The Trust is currently considering a traditional built inpatient ward expansion at WHH with an 18 months delivering timeline planned. Although, it has been identified that a modular unit would have a shorter delivery timeline. However, this is currently not being considered by the Trust as costs are similar Likely variations from Standard Contract Will be procured under the Procure 22 framework using the NEC form of contract Design Team Capabilities Using Devereux/Ryder Architecture who are a well renowned national healthcare practice. Their stroke ward design is based on best practice. Cost advise from a very experienced healthcare cost advisor Contractor's Capabilities (excluding design team covered above) Under the Procure 22 there are six supply chain partners selected by DOH. A selection process for this scheme is required from those six supply chain partners Capability and capacity of Trust The Trust would be using very experienced in house capability with a proven track record of delivering capital projects of this size. Robustness of Output Specification High Level discussions have taken place with consultants Involvement of stakeholders including Public, Patients and staff The Trust continue to engage with key stakeholders across patch including patients, public and staff External stakeholders (e.g. KCHFT, CCGs, SECAmb) engagement and time commitment Working closely with partners to ensure co-design of clinical pathways and gain commitment to ensure its successful delivery

Communication and engagement – 2015 to date

2015 2016 2016 - 17 2017 2018

June/July Healthwatch led public engagement Jan/Feb June/July Public listening Second series of events consider public listening case for change events on clinical and hurdle Stroke and Vascular Targeted engagem ent with patients and carers Summer Targeted engagement work with with renal, stroke and vascular patients and carers

2017 - 18

Summer Focussed seldom heard voices groups Throughout Ongoing engagement with campaign groups e.g. CHEK, Faversham Health Matters Spring Strategy event - Trust clinicians and divisions discuss new ways of working

Ongoing staff engagement: Divisions, Staff forums, Clinical forums, Trust Board, QII Hubs, Leadership forums Ongoing partner engagement - PPAG (monthly), CCGs lay members, Partnership Board (including local councils), MPs, HOSC, EK

Delivery Board, SE Clinical Senate, H&WBs, NHSE and NHSI

Ongoing media activity – sharing stories and information at each stage *Please refer to East Kent communication & engagement log for more information – hosted by PMO

March Kent and Medway case for change launched K&M STP criteria published model and evaluation criteria Summer Voluntary sector engagement event October K&M STP

• ne year on

conference brings together 300+ stakeholders Jan/Feb Online survey asks staff and public to rank evaluation criteria

Summer Focus groups test

‘thresholds of acceptability’ for change Spring East Kent case for change ‘Better health and care’ launched October Winter

• nline

survey

• c. 2000

replies Summer Health- watch Red Bus Tour asks public’s health priorities November Widespread communicati

• n (staff,

stakeholders media) of the medium list

• ptions

January Strategy Week - Trust clinicians / staff discuss

• ptions

to inform PCBC Feb-April EK

• ptions

discussed in all stroke public consultati

• n events

in east Kent Wider Health economy clinical pathway workshop – task and finish groups

EKHUFT Engagement – local stroke staff and patients

Staff Stroke Vision Brochure is being distributed face-face to all EKHUFT acute stroke staff providing opportunity for all staff to discuss the content and continue staff engagement Listening sessions: the Trust continues to hold informal listening sessions for staff on all sites, to answer any questions they may have and gather further feedback; 1-2-1 meetings with stroke staff prior to staff consultation: continue with initial, informal meeting with stroke staff to better understand their current circumstances, the impact of the proposed change and what support may be required Stroke Staff Survey: to ensure that stroke staff have a say on what staff support is needed now and once any decisions have been made Stroke staff engagement sessions (13th Aug – 25th Sept) from an East Kent perspective and for staff to gain further understanding of the project and its impact across Kent and Medway 4 Stroke vision away days over last 2 yrs, which brings together the MDT staff and patients working in all aspects of stroke care, in and outside of hospital, social care and the third sector to improve patient care  Thursday, 11 October 2018 (upcoming next away day)  Thursday, 22 March 2018  Thursday, 14 September 2017  Thursday, 11 May 2017  Thursday, 9 February 2017

Staff training requirement and implementation plan

• A comprehensive assessment of staff competencies has been undertaken with the University
• f Keele to refresh elements of intervention across the stroke pathway and staff roles and

responsibilities to inform and mitigate duplication and staff vacancies.

• It is currently anticipated that staff would require a level of training to ensure successful

delivery of the new clinical pathways. This is anticipated to include:  Pre-hospital pathways  HASU pathways, including thrombectomy  Rehabilitation pathways  Life after stroke pathways  IT and information system - enabler

• The Trust is currently developing the future pathways and undertaking quality assurance

which would help to positively inform the training required; and

• Based on the output of the above, each workstream lead will work with their team to make

necessary planning to deliver the required training e.g.

• Comprehensive annualised job planning assessments have commenced for the new

consultant workforce with presentation to a joint BASP and NHSI vision day on 21.9.18.

• Vision to align neurology and stroke out of hours rota’s with 24/7 dedicated

neurology and stroke middle grade cover for out of hours assessments supported by telemedicine.

Key risks/constraints

• Inability to be successful at funding application would negatively impact implementation:
• capital requirement of £23.6m submitted for additional beds, ED capacity, additional

diagnostics and a critical care bed

• estimated £5m - £6m funding to become thrombectomy centre
• Existing staff retention and staff recruitment may not be achieved to required standard due to

national shortage of stroke trained staff leading to a challenge in achieving 7 day service rota required to run HASU;

• The stroke services at QEQM may be forced to close earlier than planned if the current staffing

levels cannot be sustained, because of the challenge to retain staff during the transition and to recruit stroke trained staff as there is a national shortage.

• The outcome from the public consultation may recommend further investigations on a hybrid
• ptions, if they cannot conclude and recommend implementation of one of the options

consulted on.

• The external partners i.e. KCHFT, CCGs, SECAmb, may not have the ability to engage and

deliver at the required pace to enable a timely implementation of the HASU; and

• If the local community rehabilitation services cannot be implemented at the

required pace ensuring flow on the HASU site, ability to discharge patients, from HASU at EKHUFT would be negatively impacted .

Thank you for listening