Stroke Services Review Appendix Wiii Deliverability Panel th 4 - - PowerPoint PPT Presentation

Stroke Services Review

Deliverability Panel

4

th

September

Tunbridge Wells Site Options (D & E)

Appendix Wiii

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

• The estates solution required for Options D & E predominately consists of a new ward but

requires the relocation of the education centre outside of the main hospital on a car park area, which will also need to be re-provided

• The new 32 bed ward would be available March 2021 at the cost of 16.826m
• The current substantive workforce will largely cover safe staffing levels in Options D & E.

With the time required for the Estates solution we will have the opportunity to recruit to the ideal establishment.

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

having a positive effect at the Tunbridge Wells. The improvements are allowing the Trust to cope with a noticeable uplift in demand.

• Rolling out the solutions after the Maidstone site, it is possible to see the potential for

further gains with time.

• These improvements together with the new 32 bed ward at the site should allow:

– Access to the HASU beds when required – Ability to maintain patient flow and current hospital performance

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 of

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 Turnover for Kent Acute

Trusts: 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 Review

• Trust is fully supportive of case for change
• Started looking to consolidate its 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

Mar‘19 Mar’20 Sep‘20

Estates & Equipment

Implementation Plan Key Activities* – Options D & E

Sept’19 Mar’21 Sep‘21 Sept ‘18

New Car Park

New Ward

Education Centre Build & Resus

Comms and Engagement Operational Readiness

Workforce

Identify Transfers (1:1s)

Detailed implementation plans

involving key stakeholders

Ongoing drop

in sessions

Transition Updates (internal & externa) Corporate Readiness (incl Finance) and System Amendments

Operational Policies

& Procedures

Staff Familiarisation

Ward ready March 2021 Preferred Option Decision

Ongoing Recruitment Efforts Formal Consultation (TBC)

Facilities & Site Readiness Clinical Readiness incl. Support Services (internal and external) Readiness Comms System Implementation with key external stakeholders (inc. patients)

Service Checks &

Benefits Tracking

Oct‘20 Dec’20 Jan’21 Nov’20 Feb’21 Mar’21 Sept ‘20

Engage agencies

Staff Structures and Bank Provision

Go Live

Overview of Workstream Activities

• 1. Estates & Equipment

(Framework section – Timescales for implementation)

1. Refurbishment of existing stroke ward. 2. Redevelopment of a clinical offices and education centre into new ward (A), design to be similar to previous redevelopment. 3. Provision for 1no. new Resus cubicle. 4. New build for clinical offices/Education centre (B). 5. New car park (C).

Estate Solution Option D&E

Capital Reqt - £16,826,000 (see appendix for breakdown) Works required;

• Relocate education centre
• Heavy refurb to develop new 32 bed, based on existing design completed in 2016, incorporating 4 bed

bays.

Estates Option D&E (Ward)

For thresholds please see appendix

Timescales for implementation

• 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 will be required for the new building and car park
• New car park will be an extension of the existing car park area leased
• The building will be built on existing hardstanding, previously discussed with planners during

the hospital redevelopment scheme. It will require new utility services from main supplies

• PFI partner agreement required for new ward development, who has been approached and

informed

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

clinical engagement.

• Estates solutions are progressed as shown and have had clinical input

Overview of Workstream Activities

• 2. Workforce

(Framework section - Understanding Capacity)

Tunbridge Well’s Stroke Workforce

• Tunbridge Wells Stroke team has worked hard to improve its Stroke services. It is a C rated

SSNAP service largely to bed availability. It has managed to achieve B rating in the past. It consistently scores very 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

2.64 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

• 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

• For the TWH options the Trust will not need to move significantly beyond its current non

medical substantive staffing levels to open a new service safely and will have time to recruit to full establishment given the duration of the Estates work

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

Qualified Nursing

Requirement

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 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 and at establishment by the time the Estates solution is 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 CNSs on the ward.

• The CNSs also run bespoke SD 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

Options D & E

• The Estates solution requires a significant amount of change, particularly for non

Stroke staff, with the relocation of the Education Centre and opening of a new ward

• Careful planning will be required to avoid disruption to educational activities

although services will not be decanted until the new facilities are available

• The existing stroke unit will expand into a neighbouring ward and careful thought

will be needed around the higher number of HASU patients in the single room

• accommodation. Costs have been included to provide glass walls to these rooms,

as in ITU/HDU

• The processes used for the opening of the new ward at Tunbridge Wells in April

2016 will be followed, being in the comparable space one floor below

• In both these options, a sizeable number of patients will travel outside the Trust

for their Stroke care and MTW will need to work on information sharing and

repatriation processes with other providers to maintain a good level of Stroke care

for these patients.

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 FAQs 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

• Transition 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 . Tunbridge Wells hospital developed an Acute

Assessment Unit in 2015, the beginnings of an AEC in 2016 and FAU this year

• 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 maintaining patient flow at the Tunbridge Wells site in the

face of increasing demand as the following graphs demonstrate

• Further potential exists in the above improvements, particularly when the required

workforce can be sourced

• 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

• These improvements in combination with the new ward, allow the Trust to be

more confident that it will be able to maintain current hospital performance and

access to HASU beds when accommodating one of the three HASUs in Kent

• A site

Site Performance

• Despite increasing demand at the

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

Tunbridge Wells ED Attendances : Past 12 months have been 5.8% higher than the preceding 12 months Tunbridge Wells ED 4hr Score : Past 12 months have been 5.0 percentage points better than the preceding 12 months

Site Performance

• The increases in NE Admissions are

largely down to increases in zero LoS activity in decision & assessment units

• The NE LoS is a decreasing trend over

time

Tunbridge Wells NE Admissions : Past 12 months have been 13.6% higher than the preceding 12 months Tunbridge Wells Percent Zero LoS : Past 12 months have been 5.1 percentage points higher than the preceding 12 months Tunbridge Wells NE LoS : Past 12 months have been 0.37 days lower than the preceding 12 months

Maintaining Bed Availability for Stroke patients

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

requirement from stroke patients?

• TWH’s ITU is a busy unit and improved flow though the unit would be

required to meet a notable increase in demand.

• It is not felt, however, that such an increase in demand will materialise

with only a slightly busier Stroke Service than exists today and because Stroke patients rarely need ITU care and, when needed, it is for short periods of time

Additional NEL Activity and Bed Capacity

• 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?

• Two or three additional beds may be required if non TWH patients are

repatriated after 48hrs. Further analysis is required to confirm the exact number of additional NEL admissions. These additional beds could be mitigated by repatriating Maidstone patients back to MGH

• The A&E dept would experience an additional 1 or 2 NEL attendances a
• day. The acuity profile of patients at TWH’s front door is higher than at

Maidstone and another Resus bay has been requested. It is felt the site could manage the increase with this extra facility

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 LOS 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 Tunbridge Wells hospital would not be supportive
• f these plans and would require us to rethink our approach. This in turn may have

consequences for existing service configuration on which the Trust publicly consulted.

Risks and Interdependencies

(Framework sections – Understanding Key Risks

and Track Record)

Options D & E - Risks and Interdependencies

Risk Probability Impact Mitigating Action

Planning and PFI Permission issues for Estates solution Low Medium Previous discussions with planning about building on car park. PFI partners already engaged on potential developments. Bed modelling in incorrect and underestimates those coming from the Maidstone area Medium High There is no room for further expansion in this

• ption. Further beds could be freed on unit by

relocating some rehab patients to MGH. Bed modelling does not take account of ‘tail’ of NEL attendances and admissions High Low The additional beds have been estimated outside

• f the review. Work with the review to confirm
• analysis. Based on current predictions the tail is

small and be accommodated in this option. Site improvements and an additional ward may not be sufficient to adequately improve patient flow and secure a good Stroke service plus avoid worsening elective issues High High Maximise patient flow improvements and monitor closely for their increasing effectiveness. Ready plans to free beds at the TWH site by repatriating patients or moving services.

…cont’d

Options D & E - Risks and Interdependencies

Risk Probability Impact Mitigating Action

Poorer care for a sizeable number

• f Maidstone locality patients who

will travel out of the Trust catchment for their Stroke Acute Care High High Work with other providers to support Stroke services during transitional periods and then ensure sound pathways and communications between hospitals are in place to maximise care Efficiency risk due to the size of TWH units Medium Mediu m Work to calculate all costs to understand level of

• inefficiency. Already determined the smaller units

will be loss making as well as being unable to truly maximise care. Capital costs are insufficient for equipment required Low Mediu m 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 Maidstone 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 D&E

Q3-18 Q4-18 Q1-19 Q2-19 Q3-19 Q4-19 Q1-20 Q2-20 Q3-20 Q4-20

Planning Permission New Build Car Park New Build Ed. Centre Resus New Ward

March 2021

Capital Cost Model Option D&E

Item Option B (£ ‘000) Works subtotal 3,791 Fees 777 Equipment costs 569 Non-works 57 Planning contingency 519 Optimism Bias 1,607 VAT 1,309

Sub Total

8,629

Car Park & Education Centre 8,197

Total 16,826

Thresholds

Stroke Beds

Resus Beds

CT / MRI

Option D and E - TWH At maximum capacity Additional 1100 stroke patients for 2 resus bed

nd

additional 730 extra stroke would require a new CT . 1200 additional strokes would require a new 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 – ECG 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